Routine_Shaving_at_the_Surgical_Site

EBT1 Task Three, page 1 Jessica Johnson Student ID: 000252422 BS in Nursing, 02/01/2012 Mentor: Linda Byrd EBT1 Task Three! A1. Procedure ! Routine preoperative shaving of the surgical site has proven to be a source of surgical site infections (SSI). Using a razor prior to surgery can abrade the skin and allow bacteria to permeate the surgical site. Preoperative shaving of the surgical site the night before an operation is associated with a significantly higher SSI risk than either the use of depilatory agents or no hair removal (Healthcare Infection Control Practices Advisory Committee [HICPAC], 1999). Routine hair removal remains popular with some doctors today, especially in developing countries. A2. Initial Investigation ! The practice of shaving the surgical site began in the early twentieth century when humans first began experimenting with surgical arts. Hair around the surgical site was thought to interfere with wound closure. Later, when antiseptic techniques were introduced, hair was thought to be a source of bacterial colonization and subsequent infection. It is still common today for physicians at LDS Hospital to request preoperative shaving when patients have excessive hair at the surgical site because hair prevents the surgical drapes, necessary to maintain a sterile field, from adhering to the patient. Many physicians were concerned that hair sabotaged the sterility of operations, and subsequently had it removed prior to the procedure. EBT1 Task Three, page 2 ! The process of eliminating the shaving ritual from preoperative procedures was initiated by the CDC. HICPAC released the Guideline for Prevention of Surgical Site Prevention in 1999 which reviewed Preoperative SSI risk in association with routine hair removal, and suggested that whenever possible, no hair should be removed prior to surgery. If hair will interfere with the procedure, the CDC recommends using electronic clippers (2010). ! Within LDS Hospital, quality improvement, patient safety, infection control, as well as nursing and medical directors were responsible for the change of practice. The process was put in place there due to the lower risk of SSI in surgical patients who had not been routinely shaved. LDS Hospital physicians were able to adopt the change and decrease their infection rates. A3. Sources for Literature Review Adisa, A., Lawal, O., & Adejuyigbe O. (2011). Journal of Infection in Developing ! Countries, 5(10), 717-722. AORN. (2008). Recommended practices for preoperative patient skin antisepsis. ! ! Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc, 537-555. Broekman, M., van Beijnum, J., Peul, W., & Regli, L. (2011). Nuerosurgery and shaving: ! whatʼs the evidence' A review. Journal of Neurosurgery, 115(4), 670-678. Celik, S. & Kara, A. (2007). Does shaving the incision site increase the infection rate ! after spinal surgery' Spine, 32(15), 1575-1577. EBT1 Task Three, page 3 Jose, B. & Dignon A. (2013). Is there a relationship between preoperative shaving (hair ! ! removal) and surgical site infection' Journal of Perioperative Practices, 23(1), 22-26. Kneedler, J., Pfister, J., Austin, P., & Moss, R. (2011). Preoperative hair removal: impact ! ! on surgical site infection. Continuing education activity by Pfiedler Enterprises. Accessed May 29, 2013 from http://www.pfiedler.com/1091/1091.pdf Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). ! ! Guideline for prevention of surgical site infection. Infection Control Hospital Epidemiology, 20(4), 205-178. Waddington, C. (2008). Changing behavior: evidence based practice supporting hair ! removal with clippers. ORL Head Neck Nurs, 26(4), 8-12. A4. Clinical Implications ! The clinical implications of not removing hair prior to surgery are great. In the United States, of the estimated 27 million patients who undergo surgical procedures annually, approximately 500,000 will suffer an SSI; additionally, 10,000 deaths are associated with SSIs on an annual basis (Kneedler, Pfister, Austin, and Moss, 2011). By implementing projects to reduce SSIs, hospitals could recognize a savings of $3,152 and a reduction in extended length of stay by seven days for each patient who avoids an infection (Kneedler et al, 2011). ! SSIs are reduced when the surgical site is not shaved, resulting in cost-savings for both the patient and the hospital. Each of the articles reviewed supported findings that suggested SSIs are increased when the skin is compromised by shaving. Recommendations included using depilatory cream, which chemically dissolves hair, but EBT1 Task Three, page 4 preferably electric clippers immediately prior to the operation if hair removal is absolutely necessary (Waddington, 2008). ! Many patients dread hair removal prior to procedures, including laboring mothers and neurosurgical patients. They often report feeling exposed and embarrassed, and are forced to deal with the irritation and itching as the hair regrows. This is supported in the study by Broekman et al in 2011. Patient comfort is increased when the practice of routine preoperative hair removal is abandoned. ! Staff education must be considered when establishing new evidence-based practice. Nursing staff, physicians, and patients must be taught about the new policy in a way that facilitates open dialogue and idea exchange. Some staff may resist the new policy, so utilizing staff for implementing the new guidelines is important as it increases compliance. Patients must be taught to not shave the area prior to arriving at the hospital due to the increased risk of SSI. Preop nurses can include this information in the days leading up to surgery. A5. Procedure Effectiveness ! Eliminating ritual hair removal prior to surgery is safer for patients. Infection rates are decreased, hospital stays are shorter, and costs are lowered. SSI rates were 5.6% in patients who had hair removed by razor shave compared to a 0.6% rate among those who had hair removed by depilatory or who had no hair removed (HICPAC, 1999). This makes elimination of hair removal procedures better, more efficient, and more costeffective. By implementing projects to reduce SSIs, hospitals could recognize a savings of $3,152 and a reduction in extended length of stay by seven days for each patient who avoids an infection (Kneedler et al, 2011). EBT1 Task Three, page 5 ! Practitioners should follow the national and local guidelines according to patient needs, rather than carrying out hair removal as a ritual (Jose and Dignon, 2013). Based on the research presented, continuing to shave patients preoperatively increases SSI, increases length of stay, and decreases hospital revenue. A6. Stakeholders ! Staff compliance with the proposed change is vital. After hospital administrators approve the evidence-based recommendation, education must be provided to staff from the top down. Administrators need to work with infection control, risk management, supply management, and perioperative departments to eliminate the use of razors for hair removal (Kneedler et al, 2011). Unit managers must be informed and educated regarding the rationale, and implementation guidelines and deadlines must be established. Unit educators must then be forwarded evidence supporting the change, and develop in-services or computer based trainings that staff be required to attend. Alternatives to hair removal should be provided, such as braiding hair on the scalp or using a nonflammable gel to keep hair away from the surgical site (Kneedler et al, 2011). ! It is critical that floor nurses embrace the new policy. Nurses and all members of the surgical team serve as the patientʼs advocate; in this role, they must internalize the belief that engaging in any practice that may cause harm to a patient or increase the risk for a surgical site infection could be considered a breech of professional standards of care (Kneedler et al, 2011). ! Hospital administrators need to ensure removal of all razors from the entire facility and advise the purchasing department to longer stock razors. They should also EBT1 Task Three, page 6 institute the placement of electric clippers throughout areas of the hospital where hair removal is likely to occur (Kneedler et al, 2011). ! Bedside staff should educate patients not to self-shave prior to arriving at the hospital. Campaigns involving posters and brochures can help remind patients about the new policy, as well as enable them to speak up if staff try to shave them preoperatively. B. Essay ! It may prove difficult to translate the studies into clinical practice to promote positive outcomes. Shaving the operative site has been in practice since surgeries were first performed. Some surgeons believe it eliminates bacteria that cling to the hair and can contaminate the surgical site (OʼConnor, 2012). Changing physician practice that is associated with proven medical theory may be difficult. Physicians may be resistant to changing traditional methods of preventing infection when it involves leaving resident flora in place, flora that has been implicated in SSI in other studies. ! Other barriers include politics and negative organizational cultures that may exist, which devalue the importance of change. Older healthcare workers may find it difficult to accept new evidence-based practice because they were educated at a time when tradition of the healthcare system was valued more, and evidence-based practice was still in itʼs infancy (nurse.com, 2012). Providing adequate education and access to information may change the environment enough to allow organizational support for new policy. ! Clinicians may be resistant to leaving hair intact for various reasons, including habit and lack of policy support. The best way to combat this is to provide education and EBT1 Task Three, page 7 enlist the support from a multidisciplinary team including surgeons, administration, and perioperative nursing staff. Demonstrating the safety, improved efficiency, and impact on quality patient care and clinical outcomes will help staff transition to a no-shaving policy. Administrators should confirm that alternative methods of hair removal, such as clippers, are stocked and readily available. ! Education and communication are key strategies to implementing change within a healthcare organization. A multidisciplinary team consisting of trusted providers from various departments can be effective instruments in reforming practice. Providing staff education will lend support to the new policy. Strategically-placed posters with catch phrases such as “no-shave zone” above scrub sinks can reinforce policy and entitle policy supporters. Brochures for patients can discourage self-removal of hair, and empower them to speak up. ! Based on the evidence provided in the research cited, shaving hair from the operative site has been shown to increase the risk of SSI. SSIs are responsible for approximately one third of all nosocomial infections (Mangram et al, 1999). By decreasing wound infections, patient discomfort, morbidity and cost of care will decrease significantly (Adisa, Lawal, & Adejuyigbe, 2011). Educating staff on research finidngs regarding preoperative hair removal as well as the risks associated with shaving will ensure success with the new policy and procedure (Kneedler et al, 2011). EBT1 Task Three, page 8 References Adisa, A., Lawal, O., & Adejuyigbe O. (2011). Journal of Infection in Developing ! Countries, 5(10), 717-722. AORN. (2008). Recommended practices for preoperative patient skin antisepsis. ! ! Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc, 537-555. Broekman, M., van Beijnum, J., Peul, W., & Regli, L. (2011). Nuerosurgery and shaving: ! whatʼs the evidence' A review. Journal of Neurosurgery, 115(4), 670-678. Celik, S. & Kara, A. (2007). Does shaving the incision site increase the infection rate ! after spinal surgery' Spine, 32(15), 1575-1577. Centers for Disease Control and Prevention. (2010). FAQs about SSIs. Accessed May ! 30, 2013 from http://www.cdc.gov/hai/ssi/faq_ssi.html Jose, B. & Dignon A. (2013). Is there a relationship between preoperative shaving (hair ! ! removal) and surgical site infection' Journal of Perioperative Practices, 23(1), 22-26. Kneedler, J., Pfister, J., Austin, P., & Moss, R. (2011). Preoperative hair removal: impact ! ! on surgical site infection. Continuing education activity by Pfiedler Enterprises. Accessed May 29, 2013 from http://www.pfiedler.com/1091/1091.pdf Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). ! ! Guideline for prevention of surgical site infection. Infection Control Hospital Epidemiology, 20(4), 205-178. EBT1 Task Three, page 9 Nurses struggle to implement evidence-based practice. (2012, September 3). ! ! Nurse.com News, accessed May 30, 2013 from http://news.nurse.com/article/ 20120903/NATIONAL01/309030023 OʼConnor, A. (2012, June 4). Really' Always shave the patient before surgery. New ! ! York Times. Accessed June 3, 2013 from http://well.blogs.nytimes.com/ 2012/06/04/really-always-shave-the-patient-before-surgery/ Waddington, C. (2008). Changing behavior: evidence based practice supporting hair ! ! ! ! removal with clippers. ORL Head Neck Nurs, 26(4), 8-12.