Operating Room Attire Policy and Healthcare Cost: Favoring Evidence over Action for Prevention of Surgical Site Infections Adham Elmously, MD, Katherine D Gray, MD, Fabrizio Michelassi, MD, FACS, Cheguevara Afaneh, MD, FACS, Michael D Kluger, MD, FACS, Arash Salemi, MD, FACS, Anthony C Watkins, MD, Alfons Pomp, MD, FACS BACKGROUND: The Association of Perioperative Registered Nurses (AORN) released new guidelines for operating room attire in 2015 in an attempt to reduce surgical site infections (SSIs). These guidelines have been adopted by the Centers for Medicare and Medicaid Services. We aimed to assess the relationships among operating room attire, SSIs, and healthcare costs. STUDY DESIGN: In March 2016, our center introduced the AORN attire policy. National Health Safety Network data from our hospital were collected on general surgery, cardiac, neurosurgery, or- thopaedic, and gynecology procedures from January 2014 to November 2017. The SSI rates and microbiological culture data for 30,493 procedures before and after policy implementa- tion were compared using propensity score matching. The associated costs of the AORN pol- icy were analyzed. RESULTS: After 1:1 propensity score matching, 12,585 matched pairs spanning the policy change were included (25,170 patients total); before policy change (BC group) and after policy change (AC group). The rate of SSIs did not differ between groups (1.0% AC group vs 1.1% BC group; p ¼ 0.7). There was no difference in the incidence of Staphylococcal species cultured from wounds (19.3% AC group vs 16.8% BC group; p ¼ 0.6). Multivariable analyses demonstrated that wound classification and emergent procedures were the strongest indepen- dent predictors of SSIs. The cost of attire for 1 person entering the operating room increased from $0.07 to $0.12 before policy change to $1.11 to $1.38 after policy change. Use of the mandated operating room long-sleeved jackets alone in our institution was associated with an added cost of $1,128,078 annually, which translates to an estimated $540 million per year for all US hospitals combined. CONCLUSIONS: Implementation of the AORN guidelines has not decreased SSIs and has increased healthcare costs. (J Am Coll Surg 2018;-:1e9. Ó 2018 by the American College of Surgeons. Pub- lished by Elsevier Inc. All rights reserved.) Hospital-acquired infections (HAIs) are responsible for a considerable proportion of adverse events associated with healthcare, and are associated with high rates of morbidity and mortality as well as increased costs. 1-6 Of the 440,000 HAIs that occur annually among US inpatients, their added annual costs are estimated at $9.8 billion. 7 Surgical site infections (SSIs) account for approximately one-third of all HAIs and constitute the largest portion of HAI- related costs annually (>30%). 6 Surgical site infections are also associated with increased hospital length of stay, increased risk of readmission, and increased mortality. 3,8 Because SSIs are associated with poor healthcare outcomes and represent a large proportion of HAIs, a num- ber of quality improvement and policy efforts, including Disclosure Information: Nothing to disclose. Disclosures outside the scope of this work: Dr Pomp receives honoraria from WL Gore & Associates, Medtronic, and Ethicon. Dr Salemi receives honoraria from Medtronic and Edwards Lifesciences. Dr Afaneh receives honoraria from WL Gore & Associates and Intuitive Surgical. Presented at the Surgical Forum of the American College of Surgeons 104th Annual Clinical Congress, Scientific Forum, Boston, MA, October 2018. Received May 29, 2018; Revised June 22, 2018; Accepted June 22, 2018. From the New York Presbyterian Hospital, Weill Cornell Medicine (Elmously, Gray, Michelassi, Afaneh, Salemi, Watkins, Pomp) and New York Presbyterian Hospital, Columbia Medical Center (Kluger), New York, NY. Correspondence address: Alfons Pomp, MD, FACS, New York Presbyte- rian Hospital, Weill Cornell Medicine, 525 East 68 th St, Box 294, New York, NY 10065. email: alp2014@med.cornell.edu 1 ª 2018 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jamcollsurg.2018.06.010 ISSN 1072-7515/18