Peri operative nursing care includes nursing care given before (preoperative), during (intraoperative) and after surgery (post operative) (Crisp J &Taylor C 2005:1660). Peri operative nursing is a fast paced, changing and challenging field. Skin preparation is one of the important peri operative procedures. Evidence based practice provides a helpful framework for health care providers in peri operative settings to use research in practice settings (Beyea S 2004:97). In this essay exploration of research evidence around skin care preparation will be discussed. Based on the findings from the research material, conclusion will be drawn.
Surgical site infections are reported to be the third most frequently occurring nosocomial infection among hospitals patients. It can increase the length of stay up to 7.3 days, and increase the cost by prolonged postoperative stay as well as increase morbidity & mortality ( The impact of Preoperative 2003:1). SSIs can occur both peri and postoperatively, and skin is a potential source of microbial contamination. Therefore, it is important to prepare peri operative skin preparation. Skin preparation is a pre-operative procedure, which is performed to reduce the risk of postoperative wound infection and to prepare patient for surgery by removing soil and transient microorganisms from the skin. Peri operative skin preparation involves two processes- the first is physical cleansing, the physical removal of bacteria and dirt by washing with soap, detergent and water. Second process involves disinfection of the skin by bacterial agent (I. Mackenzie 1988:27). The surgical site should be assessed before skin preparation, and presence of any rashes, warts or other surgical site condition should be documented.
The length of time patient is in hospital preoperatively is directly related to the risk of SSI. Since many of the micro-organisms responsible for Surgical Site Infection (SSI) reside on the patient's own skin, preoperative skin preparation serves as a front-line defence against surgical site infection. One goal of SSI risk reduction is to decrease the bacteria count on the skin prior to any procedure while minimizing the potential for skin damage. The Guidelines for Prevention of Surgical Site Infection (1999) provides recommendations concerning reduction of surgical site infection (SSI) risk and first recommendation for pre operative skin treatment is “Whenever possible, identify and treat all infections remote to the surgical site before elective operation and postpone elective operations on patients with remote site infections until the infection has resolved.” This is because skin infection anywhere on body is associated with increased risk of SSI. This may be due to high rate of potential pathogens on the skin but also, if skin infection is chronic, to impair wound healing capacity (Gardlund B 2007:991). Body hair removal and antimicrobial skin prepping are key elements of the preoperative skin preparation process.

The main aim of preoperative skin preparation is to reduce the risk of postoperative infections. For a long time shaving was used as method to remove hairs from surgical site in hospitals. The Centres for Disease Control (CDC, 1999: J1) and the association of Operating Room Nurses (AORN, 1994:196) published recommendations regarding surgical skin preparation. Both recommend that hair be left at the operative site unless it interferes with the procedure or closure of the wound. It was further recommended by both that if hair removal is necessary; it should be removed as close to the time of surgery as possible and with electric clippers. Several studies have been done in this area which supports the recommendations. One of the study (Tanner J, Woodings D, Moncaster K :2006) was done to study the efficacy of three methods of hair removal which are currently used; shaving with a razor, clipping with clippers and using a cream which dissolves the hair. Three trials involving 3193 people compared shaving with clipping and found that there were statistically significantly more SSIs when people were shaved rather than clipped. Seven trials involving 1213 people compared shaving with removing hair using a depilatory cream and found that there were statistically significantly more SSIs when people were shaved than when a cream was used. This study emphasis the use of clippers rather than shaving with a razor as it results in fewer surgical site infections.

Another study ( Alexander, J.W., Fischer, J.E., Boyajian, M., Palmquist, J., & Morris, M.J:1983) was done on 1013 patients to compare the influence of shaving and clipping on incidence of wound infections. The results showed the efficacy of the use of clipping as compared to shaving. Gail M Meyer (1995) did extensive search into different research studies into hair removal methods used in the health care settings and found these studies points to efficacy of using clipping as compare to shaving.
Another study was done to evaluate the safety and patient acceptance of minimal hair removal during cochlear implantation. Forty-six consecutive patients (17 adults, 29 children; age range 13 months to 84 years) received cochlear implantation with a minimal hair removal technique. Patients were found with few complications but importantly, no wound infections were documented. Use of minimal hair removal did not increase SSI and patients & family response to the minimal shave technique was dramatic, particularly for the paediatric patients rather than complete hair removal (Roberson JB, Katrina R, Kenneth MS, Tonokawa L 2000:625). All these researches further strengthen the Centres for Disease Control and the association of Operating Room Nurses guidelines.

Preoperative showering is also very important preoperative skin preparation procedure and strongly recommended (The Centres for Disease Control 1999: J1). It has been practiced since the late nineteen century and function to remove dirt or to reduce microbial flora from the surgical site (Seal LA & Cheadle D 2003: 58). In 1961, Lowbury stated "Although skin disinfection has been the subject of interest and research over hundred years, there is no generally accepted procedure for use either at the operation site or in the hands of surgeons and nurses” (Lowbury 1961:1).

Careful selection of site preparation and appropriate use of product can impact surgery related mortality and morbidity (Seal LA & Cheadle D 2003: 58).
The traditional method of pre-operative skin preparation is still practiced in few countries. This generally consists of scrubbing the part vigorously for seven to ten minutes with a solution containing an antiseptic detergent, the excess detergent being removed by a dry swab. This is followed by the application of an alcohol based antiseptic (Shirahatti RG 1993:134). Vigorous scrubbing of the skin can release large numbers of organisms, which reside in the deeper layers of the skin. Many discrepancies in the evaluation of individual antiseptics have been due to the differences and deficiencies in the techniques of testing. The CDC strongly recommends “Require patients to shower or bathe with an antiseptic agent on at least the night before the operative day” (CDC 1999:J2). Several studies have been done in past to check the efficacy of the method. Showering is more effective than bathing. There was a study done by Byre to find out the most effective number of showers and found out there was significant decrease in the skin flora after the first and second showers. After that no further significant fall with subsequent showers (Byrne D J, Napier A, and Cuschieri 1990). Two showers are most frequently advised--one the night before surgery and one the morning of the procedure.

The use of an antiseptic solution for pre-operative bathing or showering is widely practiced in the belief that it will help to prevent surgical site infection (Webster J & Osborne S 2007:1). Many agents have been used for this purpose over the years of which some are more familiar e.g. Iodine, Alcohols, Mercury, Quaternary, Hexachlorophene, Iodophors. Chlorhexidine was introduce in 1954 and has a wide range of activity against bacteria. At the present time Chlorhexidine and the iodophors are the most commonly used antiseptics in skin preparation (I. Mackenzie 1988:29-30). In a study conducted in 1988, chlorhexidine gluconate (Hibiclens) was found to be more effective in reducing organisms than povidone-iodine (Betadine) (Kaiser AB, Kernodle DS, Barg NL, Petracek MR 1988: 35-38). Another study was done by Webster and Osborne, they included six trails in which 4% chlorhexidine gluconate had been compared with soap or no washing. Use of chlorhexidine was not found to be associated with a statistically significant reduction of Surgical Site Infection as compare with other wash product (Ahmed K 2006:400). It is unclear whether using chlorhexidine for preoperative bathing or showering prevents surgical site infection (Webster J & Osborne S 2007:1).

Skin preparation is an important procedure to reduce the incidence of infectious complications. Based on research available, skin preparation is a vital in patient outcome and prevention of SSI. Hair removal should be done only if it’s necessary. Clipping is preferred over shaving. CDC guidelines recommend strongly preoperative showering with an antiseptic skin product, there is no definitive evidence supporting this. But still this guideline should be used.

In conclusion, preoperative skin preparation continues to be an area of varied procedures. Prevention of infection is of utmost concern. Peri operative skin preparation has a positive impact on SSI rates and may eliminate some of the additional cost associated with this prevention. However, research into surgical site infection found that removal of hair for the surgical site may be perform for a number of reasons, but is not considered effective as a preventive measure in SSI. Removal of hair with clippers found to be safer and resulted in a lower incidence of surgical site than shaving. There are recommendations for preoperative showering with antiseptic although no definite evidence exists. Chlorhexidine solutions are mostly used in current health care settings but which ever solution is used, education of health care team is important for their appropriate use. Implementation of CDC guidelines in all surgical and medical departments should be a priority, as it can improve patient outcomes and decrease hospital costs associated with preventable infections in surgical sites.

References:

Association of Operating Room Nurses (2002) Recommended practices for skin preparation of patients [online] Avaliable: http://findarticles.com/p/articles/mi_m0FSL/is_1_75/ai_83664586/pg_1

Crisp J & Taylor C (2005) Potter and Perry’s Fundamentals of Nursing, St. Louis, Mosby, Chapter49: The Surgical Client,1660-1713

Gardlund B (2007) Postoperative surgical site infections in cardiac surgery
––an overview of preventive measures APMIS 115: 989–95

Association of Operating Room Nurses. (1994). Recommended practices: Skin preparation of patients. Standards and Recommended Practices (pp. 195-199). Denver, CO: AORN.

Tanner J, Woodings D, Moncaster K Cochrane Database of Systematic Reviews
2006, Issue 3. Art. No.: CD004122 :1-27 http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004122/pdf_fs.html

Recommendation for Surgical Skin Preparation: An Integrative Review of the Literature Volume 2, Document Number 10 • The Online Journal of Knowledge Synthesis for Nursing Volume 2 October 12, 1995 Document Number 10
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Webster J & Osborne S (2007) Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database of
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Lowburry EJL. Skin disinfection. J Clin Pathol 1961; [online]14:85-90 Available; http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=480165&blobtype=pdf
Shirahatti RG, Joshi RM, Vishwanath YK, Shinkre N, Rao S, Sankpal JS, Govindrajulu NK(1993) Effect of pre-operative skin preparation on post-operative wound infection J Post grad Medical [online] 39 (3) : 134-136 Available: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1993;volume=39;issue=3;spage=134;epage=6;aulast=Shirahatti Mackenzie (1988) Preoperative skin preparation and surgical outcome, Journal of Hospital Infection, [online] 27-32
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The Impact of Preoperative Hair Removal on Surgical Site Infection (2003) Best Practice Evidence Based Practice Information Sheets for Health Professionals Volume 7, Issue 2:1-6

Roberson JB, Katrina R, Kenneth MS, Tonokawa L (2000) Cochlear Implantation: Minimal Hair removal technique Otolaryngology- Head and Neck Surgery volume 122 [online]

Ahmed K 2006 Showering and shaving Before surgery, Cochrane databases: [online] 400

Kaiser AB, Kernodle DS, Barg NL, Petracek MR 1988 Influence of preoperative showers on staphylococcal skin colonization: a comparative trial of antiseptic skin cleansers [online] 45(1):35-8

Byrne D J, Napier A, and Cuschieri (1990) A Rationalizing Whole Body Disinfection. Journal of Hospital Infection. [online] 15(2): 183-187