Perioperative Shavings
Victor A. Moore
Western Governors University

Prepping a patient for a surgical procedure usually involves removing the Hair at the incision site. The surgical care improvement project commonly known as SCIP is a national partnership of organizations focused on improving surgical care by significantly reducing surgical complications. One complication is surgical site infections SCIP has developed recommendations for hair removal. There are several SCIP measures, antibiotic within one hour before incision, received prophylactic antibiotic consistent recommendations, prophylactic antibiotic discontinued within 24 hours, control of postoperative serum glucose and appropriate hair removal. (Patterson, 2011, p. 120) What is appropriate hair removal? Razors can remove hair and has been the traditional method of hair removal, powered surgical clippers can trim hair at surgical site and does not leave cuts and microscopic abrasions where microscopic Flora can colonize in the surgical site causing postoperative infection. The National Quality Forum has endorsed to SCIP infection control measures. According to the Surgical Quality Alliance, which is a collaboration among specialty societies that provide surgical and perioperative care to improve the quality of care for the surgical patients, states that” following the endorsement by the National Quality Forum SCIP measures were incorporated into Medicare's reporting of Hospital Quality data for annual hospital payment. (Corrigan, 2009, p. 79) It was also identified as the National Patient Safety goal under the Joint Commission Hospital accreditation program. As January 1, 2010 the Joint Commission considers shaving with razors an inappropriate hair removal method. There are many different types of surgeries such as craniotomies, total knee replacements, and spinal surgery. A” blanket” policy concerning all surgeries where patients are shaved is inappropriate and needs to be reviewed and policies changed. The Person who determined that this practice of shaving all patients is the Chief Nursing officer Debbie Hankins . The Chief Nursing Officer of Adventist Health is responsible for the implementation of all procedures used In the Nursing Department and the Operating Room specifically. The rational for this decision to shave all patients in this manner is the reduction of surgical site infections. The increased prevalence of surgical site infections were determined to be reduced by shaving patients with clippers. How ever the fact that this reduced surgical site infections does not mean that it is appropriate in every surgical situation .At Adventist Health the decision was made to shave all patients with clippers which was instituted in the normal preoperative routine according to the evidenced based research at the time. As stated before the basis for the practice is SCIP and the decision of Medicare to link payments with quality. A proposal for value-based purchasing from the Centers for Medicare and Medicaid services (CMS) has made this requirement and affects the financial stability of the hospital. (Patterson, p. 120) A review of whether or not shaving of all patients is appropriate. Surgical Quality Alliance states ”that there is very little data from well-designed, properly powered, carefully controlled studies that demonstrates that removing hair through shaving with razors decreases surgical site infections for neurosurgical procedures”. (Corrigan, p. 79) A study commissioned by the Agency for Healthcare Research and Quality ( AHRQ) performed through to Stanford UCSF Evidence-based practice Center observed” no conclusion can reach regarding the effectiveness of Q I strategies at promoting perioperative glucose control, perioperative normothermia, or decreasing operative shavings. We are able to determine any strategies effectively reducing rates of SS I. In the studies that did not have important mythological flaws surgical site infections were not consistently reduced even when process measurements were improved. (Corrigan, p. 79). At Adventist Health in Bakersfield California the policy for skin Preparation is explained in detail why the procedure is done this way proper preparation of skin for surgery renders it free as possible from microorganisms. The policy explains how to gather equipment and how implement the hair remove in 21 steps and special considerations about various ways to remove hair and where to store the hair. A visual picture is included in the policy to show Nurses what areas to shave such as when shaving patients from shoulder and upper arm, the elbows and arms and thighs and back. The reference used for this policy is the 2012 Lippincott Williams &Wilkins Textbook chapter Skin preparation, preoperative.
Tanner J, Moncaster K.,Woodings D., Perioperative Hair Removal: A systematic review: Journal Perioperative Practice.2007 March; 17(3):118-21
Nowinski G. , Don’t Shave unless you have to! American Academy of Orthopedic Surgeons. Nov 2008
Celik S.E., Kara A. Shaving Surgical Site before Spinal Surgery. AORN Journal 2007:32(5)1575-1577
Reichman D., Greenberg J., Reducing Surgical Site Infections: A review. Obstetrics and Gynecology. Nov 2009 2(4) 212-221
Patterson P.SCIP measures to weigh in medicare pay starting in 2013.OR Manger. March 2011 27(3)

The clinical implications of shaving with either clippers or razors is the prevention of surgical site infections. Infections at or near incisions within 30 days of an operative procedure contribute substantially to surgical morbidity and mortality each year. (Celik, 2007, p. 1575) The prevention of surgical site infections encompasses a variety preventative measures aimed at neutralizing the threat of bacterial, viral and fungal contamination from staff, the operating room environment, and the patients endogenous skin flora. Numerous studies have examined the practice of preoperative hair removal and its relationship to operative site infections. (Tanner J, 2007, p. 118) Hair has often been perceived to be associated with lack of cleanliness and its removal linked to infection prophylaxis, routine preoperative shavings was not shown to decrease surgical site infections in laparotomy's, However studies have shown the shavings skin as compared to clippers results in in statistically increased in the rates of SSI in other types of surgery. (Tanner J, p. 118)Shaving results in microscopic cuts and abrasions, thus disrupting this barrier defense against microorganisms. Clippers when used correctly should not cut into the patients skin. The Centers for Disease Control's recommends that hair not be removed unless it interferes with the operation and if it is to be removed, it should be done immediately before the operation with electric clippers. (Mangram, p. 247) Patients who insist on hair removal prior to surgery should be told clip rather than shave with razors, but the decision to do so the morning of the surgery of the day prior can be left up to patient preference. Using the depilatories creams remove that hair at the surgical site using chemical rather than mechanical action may be more effective in lowering infection rates. Although depilatories creams are easy to apply and avoid mechanical trauma to the skin, they are costly and may generate a sensitivity reaction at surgical site. Shaving with clippers versus shaving with razors the cost of one set of clippers is cheaper and can be used several times after disinfection and is more cost-effective than razors which have to be disposed of after one use. Following the Centers for Disease Control guidelines that hair not be removed unless it interferes with the operation is the best cost-effective course of action. The involvement of key stakeholders in this decision to change policy includes the Nursing Department manager and the manager of the Surgery Department. Stakeholders should have different levels of involvement at various stages of implementation they can be informed, consulted, collaborated with or be active participants. Stakeholders should be provided as much information as possible including baseline data the objectives and should be involved in anticipating solutions. A meeting of Department managers where detailed explanation of the proposed change in policy will be presented to the leadership of the hospital, evidence-based information and results from controlled studies will be also presented to the executive leadership. A proposal to have a surveillance program to track surgical site infections would be appropriate. This can be determined through Monitoring whether not change in policy is warranted. The difficulty in translating information about shaving patients in the practice would involve changing the attitude of the staff and increase education about what actually causes surgical site infections. Also bridging the gap from research clinical practice can be accomplished by multiple means .One of the most common ways is incorporating the evidence into the organizations policies and procedures. Several operational issues can hinder synthesizing research and practice. First there are numerous articles and randomized controlled studies about shavings of patient's. Evaluating literature for scientific method can be a very large task. There is some difficulty in distinguishing what exactly the research that is says. For example one research study the Tanner article states there no statistical difference in the surgical site infections between shaving with a razor and shaving with clippers. It is difficult to distinguish the best course of action. SCIP guidelines state to remove hair appropriately. (Tanner J, p. 118)The hospitals policies concerning hair removal is to remove hair using clipper for every surgical procedures Conflicting research concerning methods of shaving with clippers or razors need to be clarified before implementing the change of not shaving patients for certain surgeries such as neurosurgery or laparotomies .If a decision is made to change policy implementing this change is very complicated, the staff may not be aware of the reasons for the change in procedure and why is necessary they may feel that there are more important issues to be dealt with. Other barriers include the staff may not agree with the proposed change of there is a better way to achieve the outcome. The staff may disagree with the way the change is being implemented. Since improvement depends upon the actions of people, ultimately it comes down to winning the hearts and minds, to be successful there must effective communication. There are strategies that can be used to overcome barriers such as developing ways to communicate the reasons why change is necessary. Having a shared vision about what the change will accomplish, listen to the staff and accept suggestions. Identify change champions innovators who will be prepared to introduce to change. Have a plan for implementation and be prepared to adapt to changes as needed if additional research develops in the future. Traditionally patients undergoing surgery have had their hair removed from the incision as to reduce contamination at the surgical site . Hair has removed by several different methods include shaving, clipping and use of creams to dissolve hair. Existing research studies have too many methodological flaws to allow clinicians to draw conclusions from the basis of this evidence. It is not clear whether preoperative shaving is vector for surgical site infections in every case of surgery. However if hair has to removed to facilitate surgery or the application of adhesive dressings clipping is the preferred method to reduce Surgical site infections. These findings about shaving versus clipping suggests a review needs to be done and change in policy. It would take a long time for additional research to be conducted by the hospital and discussion of changing policies and what is best practice concerning removal hair. The basis of this change should be scientific evidence, randomized studies and primary research that reveal definitive proof that surgical site infections are caused by shaving . In fact some research suggests that removing hair doesn’t necessarily prevent surgical site infections. Further studies are needed and with collaboration leaders of surgical department a change policy can be done to ensure the highest quality of care .Between 2000 and 2004,789 patients having spinal surgery performed by the same surgeon at a hospital in Istanbul, Turkey were randomly assigned to one or two groups : those whose surgical sites were shaved preoperatively(ie, the shaved group) and those whose surgical site were not shaved(ie, the non-shaved group. Surgical procedures included lumbar disc surgery, surgery for lateral recess syndrome, and complex spinal procedures such as spinal stenosis, excision of tumor and placement of instrumentation. There were 371 patients in shaved group and 418 patients in the non-shaved group. The groups were not of equal size because of incomplete follow up on 47 patients. (Celik, p. 1575) The postoperative infection rate was higher in shaved group four patients developed postop infections and one patient developed in the non-shaved group. The results of this study reveals that not shaving the surgical incision site did not impede the performance of the surgical procedure and that shaving the incision site immediately before surgery may increase the rate of postoperative infections. Additional studies and research needs to be conducted concerning different types of surgery so that shaving every patient for surgery is not the standard.

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References
Celik, S. (November,2007). Shavings Surgical Site before Spinal Surgery. Association of Perioperative Registered Nurses, 5(32), 1577.
Celik, S. (November,2007). Shavings Surgical Site before Spinal Surgery. Association of Perioperative Registered Nurses, 5(32), 1577.
Corrigan, J. (July,2009). Request to reverse endorsement of SCIP hair removal measures. Surgical Quality Alliance, 82.
Corrigan, J. (July,2009). Request to reverse endorsement of SCIP hair removal measures. Surgical Quality Alliance, 82.
Corrigan, J. (July,2009). Request to reverse endorsement of SCIP hair removal measures. Surgical Quality Alliance, 82.
Mangram, A.J. Guidelines for Preventionof Surgical Site Infections. Infection Control and Hospital Epidemiology, 4(24), 278.
Patterson, P. (March,2011). SCIP measures to weigh in Medicare pay starting in 2013. OR Manger, 3(27), 124.
Patterson, P. (March,2011). SCIP measures to weigh in Medicare pay starting in 2013. OR Manger, 3(27), 124.
TannerJ. (2007). Perioperative Hair Removal: a systemactic review. Journal of Perioperative Practice, 17(3), 121.