Environmental sustainability resources: Cloth caps

Abstract
Introduction: While several patient and operative variables have been shown to be associated with an increased risk of postoperative wound events, the association between surgical hat type worn by surgeons and postoperative wound events remains controversial. The purpose of this study is to investigate the association between type of surgical hat worn by surgeons and the incidence of postoperative wound events following ventral hernia repair using the Americas Hernia Society Quality Collaborative database.

Methods: All surgeons who input at least ten patients with 30-day follow-up into the AHSQC were identified. These surgeons were sent a survey asking them to identify the type of surgical hat they wear in the operating room. The association of the type of surgical hat worn, patient variables, and operative factors with 30-day wound events was investigated using multivariate logistic regression.

Results: A total of 68 surgeons responded to the survey, resulting in 6210 cases available for analysis. The type of surgical hat worn by surgeons was not found to be associated with an increased risk of 30-day surgical site infections or surgical site occurrences requiring procedural intervention.

Conclusion: Our study is the first study to directly compare the association of surgical hat type with postoperative wound events. There is no association between the type of surgical hat worn and the incidence of postoperative wound events following ventral hernia repair. Our findings suggest that surgical hate type may be chosen at the discretion of operating room personnel without fear of detriment to their patients.

Keywords: Surgical hat; Surgical site infection; Surgical site occurrence requiring procedural intervention; Wound events.

Abstract
Background: The effectiveness of operating room headgear in preventing airborne contamination has been called into question. We hypothesized that bouffant style hats would be as effective in preventing bacterial and particulate contamination in the operating room compared with disposable or cloth skull caps, and bouffant style hats would have similar permeability, particle penetration, and porosity compared with skull caps.

Study design: Disposable bouffant and skull cap hats and newly laundered cloth skull caps were tested. A mock surgical procedure was used in a dynamic operating room environment. Airborne particulate and microbial contaminants were sampled. Hat fabric was tested for permeability, particle transmission, and pore sizes.

Results: No significant differences were observed between disposable bouffant and disposable skull caps with regard to particle or actively sampled microbial contamination. However, when compared with disposable skull caps, disposable bouffant hats did have significantly higher microbial shed at the sterile field, as measured by passive settle plate analysis (p < 0.05). When compared with cloth skull caps, disposable bouffants yielded higher levels of 0.5 μm and 1.0 μm particles and significantly higher microbial shed detected with passive analysis. Fabric assessment determined that disposable bouffant hats had larger average and maximum pore sizes compared with cloth skull caps, and were significantly more permeable than either disposable or cloth skull caps.

Conclusions: Disposable bouffant hats had greater permeability, penetration, and greater microbial shed, as assessed by passive microbial analysis compared with disposable skull caps. When compared with cloth skull caps, disposable bouffants yielded greater permeability, greater particulate contamination, and greater passive microbial shed. Disposable style bouffant hats should not be considered superior to skull caps in preventing airborne contamination in the operating room.

Abstract
Objective: Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste.

Methods: We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed.

Results: We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions.

Conclusion: Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Keywords: Anaesthesia; Disposable equipment; Durable medical equipment; Environment; Life cycle; Nosocomial infection.

Abstract
Objective: To provide guidelines for the choice of items of clothing (except sterile surgical gown) for staff working in the operating theatre.

Design: A committee of nine experts from SFAR and the SF2H learned societies was convened. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The authors were required to follow the rules of the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

Methods: We aimed to formulate recommendations according to the GRADE® methodology for four different fields: operating theatre suits, operating theatre hats, masks, and shoes/over-shoes. Each question was formulated according to the PICO format (Patient, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

Results: The experts' synthesis work and their application of the GRADE® method resulted in 13 recommendations. As the GRADE® method could not be integrally applied to all questions, some recommendations were formulated as expert opinions.

Conclusion: Based on strong agreement between experts, we produced 13 recommendations to guide the choice of operating theatre attire.

Keywords: Dress code; Environmental impact; Guidelines; Operating theatre; Risk of infection.

Abstract
Background: Infection prevention measures are widely used in operating rooms (ORs). However, the extent to which they are at odds with ambitions to reduce the health sector's carbon footprint remains unclear.

Aim: To synthesize the evidence base for the carbon footprint of commonly used infection prevention measures in the OR, namely medical devices and instruments, surgical attire and air treatment systems.

Methods: A scoping review of the international scientific literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search was performed in PubMed and Google Scholar. Articles published between 2010 and June 2021 on infection prevention measures, their impact on the health sector's carbon footprint, and risk for surgical site infections (SSIs) were included.

Findings: Although hospitals strive to reduce their carbon footprint, many infection prevention measures result in increased emissions. Evidence suggests that the use of disposable items instead of reusable items generally increases the carbon footprint, depending on sources of electricity. Controversy exists regarding the correlation between air treatment systems, contamination and the incidence of SSIs. The literature indicates that new air treatment systems consume more energy and do not necessarily reduce SSIs compared with conventional systems.

Conclusion: Infection prevention measures in ORs can be at odds with sustainability. The use of new air treatment systems and disposable items generally leads to significant greenhouse gas emissions, and does not necessarily reduce the incidence of SSIs. Alternative infection prevention measures with less environmental impact are available. Implementation could be facilitated by embracing environmental impact as an additional dimension of quality of care, which should change current risk-based approaches for the prevention of SSIs.

Keywords: Carbon footprint; Disposable equipment; Equipment reuse; Operating rooms; Surgical site infections; Sustainable development.

Abstract
Surgical site infection is one of the most frequent and serious postoperative complications. Surgical site infections may be precipitated by high bacterial loads introduced into the operating room setting. The most common microorganisms contributing to infections are Staphylococcus, Streptococcus, and Pseudomonas. The potential for scrub uniforms to carry bacteria has been shown in several studies. Recommendations for surgical scrubs worn by operating room personnel and specific laundering techniques remain debated in evidenced-based research. There exists a variance in perception and a lack of consensus among providers regarding the concept of where and how to launder surgical scrubs. The purpose of this literature review is to determine if facility-laundered surgical scrubs are superior in the prevention of surgical site infections for patients undergoing surgery over home-laundering methods, to evaluate the appropriateness and safety of surgical staff laundering scrub uniforms at home, and to provide recommendations for the laundering of reusable surgical scrubs.

Keywords: Facility laundering of hospital garments, home laundering of hospital uniforms, hospital uniform laundering guidelines, laundering of surgical scrub uniforms.