What the Evidence Shows

The COVID-19 pandemic created an unprecedented natural experiment in operating room practices. When supply chains collapsed, hospitals worldwide abandoned "standard" protocols that had never been properly tested.

Researchers at a major US institution examined what actually happens when you remove disposable head covers, reduce face mask changes, and eliminate shoe covers (Malhotra et al., 2022).

The data is striking. Comparing two years before COVID-19 with the first pandemic year, they found surgical site infection rates dropped from 5.1% to 2.6%. This wasn't a statistical fluke. The reduction held up under propensity score matching and multivariate analysis.

This improvement occurred despite a 14% increase in surgical volume and a threefold increase in contaminated or dirty cases (from 2.2% to 7.4%).

The Uncomfortable Truth About Disposable PPE

These findings expose an uncomfortable reality: many of our "evidence-based" practices in the operating room were never actually tested with proper controls.

The study revealed that disposable face mask usage dropped by 4.3-fold during the pandemic — from 3.5 million masks per year to just 0.8 million. Yet infection rates improved, not worsened.

We've been operating under assumptions that frequent changes of disposable items somehow enhance safety. The data suggests the opposite may be true. Constant changing and disposal of protective equipment may introduce more contamination opportunities than it prevents.

The researchers also noted that hospital-wide hand hygiene compliance improved from 71% to 85% during this period — reinforcing that proper hand hygiene remains the cornerstone of infection prevention, not excessive PPE changes.

Why This Matters for Theatre Teams

This research provides the real-world evidence that NHS trusts and private hospitals need to make informed decisions about surgical site infection prevention.

We've known for years that cloth surgical caps outperform disposable bouffants in controlled laboratory settings. But this study provides something even more valuable: evidence from thousands of real surgeries performed under challenging conditions.

The implications extend beyond safety. The researchers note that discontinuing unnecessary disposable items has "massive cost and environmental implications." For stretched NHS budgets and sustainability targets, this matters enormously.

Theatre teams can now point to concrete evidence that switching to reusable headwear isn't a compromise on safety — it's potentially an improvement. The data supports what many experienced clinicians have long suspected: that good hygiene practices matter more than the specific type of head covering.

Sources

• Malhotra, G., Tran, T., Stewart, C., Battey, H., Tegtmeier, B., McNeese, K., Flood, A., Melstrom, L., & Fong, Y. (2022). Pandemic Operating Room Supply Shortage and Surgical Site Infection: Considerations as We Emerge from the Coronavirus Disease 2019 Pandemic. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000000087

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