Joint statement on ear and hair covering

In February 2018, APIC President, Janet Haas, APIC Immediate Past President, Linda Greene, and APIC CEO, Katrina Crist, participated in a collaborative meeting involving seven national organizations representing surgery, nursing, anesthesia, infection prevention, and patient safety. The purpose of the meeting was to better understand the basis for hair and ear covering recommendations in nationally accepted guidelines, particularly the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) and Association for peri-Operative Registered Nurses (AORN) guidelines. Over the past couple of years, the interpretation and compliance with these recommendations have created controversy as it relates to the type of head coverings that should be used, the extent of hair on the neck that can be exposed, and whether ears must be covered.

The Centers for Medicare and Medicaid Services (CMS) has cited hospitals to the degree of “immediate jeopardy” status based on a strict interpretation and an expectation of adherence to the strictest interpretation as policy. 

This prompted interest in a multi-disciplinary group reviewing the literature to better understand the evidence base for covering hair and ears in the operating room. The American College of Surgeons (ACS) convened a meeting of seven relevant organizations including APIC. All organizations were provided an opportunity to provide literature for review during the meeting. More than 100 published papers, case studies, and opinion-based editorials were compiled and reviewed.

The consensus of the group was that there was no evidence base to support covering of the ears. Regarding hair covering, there was wide variation and no evidence to support a link between hair covering and surgical site infections. However, it was agreed that this requires further study and review. AORN is undertaking this review as part of their regular guideline revision process with an anticipated update published in 2019. AORN has previously emphasized that their 2014 guidelines recommended that hair should be covered, but did not specify the type of head covering that should be used. In their recent release that accompanied the joint consensus statement, AORN stated again, “In the 2014 AORN Guideline for Surgical Attire, the recommendation is that hair should be covered, though there is not a recommendation on which head covering as it can vary with the individual practitioners.”

What to do in the meantime? Convene the relevant stakeholders – surgery, nursing, anesthesia, and infection prevention. APIC believes this is a great leadership opportunity for IPs. Take the lead on convening a meeting at your facility and discuss the pros and cons of your policy. Confirm that your policy will remain the same or recommend changes based on the consensus of your group. Keeping in mind that whether your policy remains the same or is modified, it is important to ensure compliance with your facility’s policy.

APIC will be reaching out to CMS to better understand their position on this issue and to discuss the recently released consensus statement by ACS, AORN, American Society of Anesthesiologists (ASA), APIC, Association for Surgical Technologists (AST), Council on Surgical and Perioperative Safety (CSPS), and The Joint Commission (TJC). We recommend taking a conservative approach to any changes until we have more information.



A Statement from the Meeting of ACS, AORN, ASA, APIC, AST, and TJC

The American College of Surgeons (ACS), the American Society of Anesthesiologists (ASA), the Association of peri-Operative Registered Nurses (AORN), the Association for Professionals in Infection Control and Epidemiology (APIC), the Association of Surgical Technologists (AST), the Council on Surgical and Perioperative Safety (CSPS); and The Joint Commission (TJC) met on February 27, 2018, to review and discuss the literature related to recommendations for operating room (OR) attire, specifically ear and hair covering.

Over the past two years, as recommendations were implemented, it became increasingly apparent that in practice, covering the ears is not practical for surgeons and anesthesiologists and in many cases counterproductive to their ability to perform optimally in the OR.  Furthermore, in reassessing the strength of the evidence for this narrowly defined recommendation, the group concluded the following: 

  • Evidence-based recommendations on surgical attire developed for perioperative policies and procedures are best created collaboratively, with a multi-disciplinary team representing surgery, anesthesia, nursing, and infection prevention. 
  • The requirement for ear coverage is not supported by sufficient evidence. 
  • At present, available scientific evidence does not demonstrate any association between the type of hat or extent of hair coverage and SSI rates. One recent study1 on head coverings (disposable bouffant or skullcap, cloth cap), identified that the commonly available disposable bouffant hat is the least effective barrier to transmission of particles.
  • Other issues regarding areas of surgical attire need further evaluation.


1. Markel TA, Gormley T, Greeley D, Ostojic J, Wise A, Rajala J, Bharadwaj R, Wagner J. Hats Off: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators. JACS, 225(5): 573-581, 2017.