EBT1
TASK 3 Research Integration and Outcome Evaluation
Victoria
Hart
Western
Governors University
A1. Procedure
The preoperative procedure of shaving
the operative site with a razor has been proven to be a source of surgery site
infections. Studies have shown shaving creates micro abrasions that permit
bacteria to penetrate the area and infect the wound. The CDC guidelines
recommend not removing the hair unless it will interfere with the procedure, if
the hair must be removed clipping immediately prior to the surgery is
recommended (Segal, C., 2006).
A2a.
Basis for Practice
The basis for
changing the method of removing hair at the operative site was due to the results
of much research on surgical site infections (SSI) as well as the
recommendations from the Center for Disease Control and Prevention (CDC) and The
Joint Commission on Hospital Accreditation (TJC). The Hospital Infection
Control Practices Advisory Committee published Guideline for Prevention of
Surgical Site Infection in 1999. TJC included reducing the risk of healthcare
associated infections as one of the national safety goals in 2008 (Waddington,
C., 2008).
At the hospital the
Infection Control, Performance Improvement, and Patient Safety committees made
the recommendation for the change from shaving the patient with razors to only
removing hair with clippers and only if necessary. The service line directors
of nursing and surgical surgery were responsible for implementing this change
after the approval of the hospital administration.
A2b.
Rationale
Antisepsis was introduced in 1860
and resulted in the transformation of surgery. The CDC National Nosocomial
Infections Surveillance (NNIS) began tracking nosocomial infections the 1970s.
Based on this data more trends were identified. SSIs are responsible for
approximately one third of all nosocomial infections (Mangram, Horan, Pearson,
Silver, & Jarvis, 1999).
Several
characteristics were identified as causative factors that increase the risk of
SSIs. Preoperative shaving was identified as one of those causes. Unlike
factors that cannot be modified such as the patient’s age changing the way a
patient is prepared for surgery can be altered.
A2c.
Explanation
Originally in the early nineteenth
century surgeons removed hair to prevent it from falling into the wound or to allow
them to visualize the operative area clearly. Later around 1850’s surgeons
removed the hair because they believed it caused infection from the bacteria
that inhabited the hair. In 1927, Dr. Walter Hughson recognized the risk of
shaving with a razor with his description of the condition of the operative
site being worse than if the hair remained present (Altman, 1983). The result
of a Nigerian study of third world country surgical practices conducted by
Adisa, Lawal, & Adejuyigbe in 2010 concluded that depilatory cream is safer
than razors. It was concluded by multiple studies depilatory cream can cause
skin irritation; therefore the 1999 CDC guideline excluded this method of hair
removal. The current recommendation in the United States is for no hair removal
or clipping immediately prior to surgery.
A3a.
Reference List
Adisa, A., Lawal, O., & Adejuyigbe, O. (2011).
Evaluation of two methods of preoperative hair removal and their relationship
to postoperative wound infection. Journal Of Infection In Developing
Countries, 5(10), 717-722.
Altman, L. K. (1983, June 21). The doctor's world;
shaving area of operation now seems dangerous. The New York Times.
Retrieved from
http://www.nytimes.com/1983/06/21/science/the-doctor-s-world-shaving-area-of-operation-now-seems-dangerous.html
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.
Segal, C. (2006). OR special. Infection control:
start with skin. Nursing Management, 37(4), 46-52.
Waddington, C. (2008). Changing behavior: evidence
based practice supporting hair removal with clippers. ORL Head Neck Nurs,
26(4), 8-12.
A4.
Clinical Implications
Clinical
implications of shaving verses clipping may greatly reduce the rate of SSI
resulting in improved patient safety, shorter hospital stays and lower costs
for care. In each of the studies and literature reviewed the results were
significant in the difference between rates of infection with the patients
shaved with at razor as opposed to those clipped.
The comfort of
the patient with this practice is improved as the risk of micro abrasions are
decreased with clippers. The anxiety of the patient is substantially less in cases
that require hair removal in vulnerable areas such as the groin with clippers.
The cost to the
health care industry will be reduced as the cost of disposable razors is
eliminated. The cost of treating infections is reduced as a result of fewer
infections.
Areas of the hospital
impacted by this change are significant. The purchasing department must
research the cost of clippers; order the correct equipment whether it is
reusable or disposable as many patients require preoperative shaving and
removal of any kits containing razors. The nursing staff must be educated to
the new practice. This includes the operating staff and the surgical care unit
staff. Physicians must accept the evidence based recommendation that not all
patients have hair removal. Pre-operative printed educational literature for
patients must be changed to reflect the new process.
A5.
Procedural Changes
By removing the
practice of shaving surgical sites with razors infection rates will be
decreased. “The infectious rate was significantly higher in the manually shaven
than in the electrically clipped patients with an odds ratio of 3.25%” (Ko,
Lazenby, Zelano, Isom & Krieger, 1992). By decreasing wound infections,
patient discomfort, morbidity and cost of care will decrease significantly (Adisa,
Lawal, & Adejuyigbe, 2011). The CDC has recommended hair not be removed
unless absolutely necessary (Segal, 2006).
A cited study in
the Hospital Infection Control Practice Advisory Committee states SSI rates for
hair removal by razor was 5.6% as opposed to 0.6% rate for patients that had
hair removed with a depilatory cream or not removed. The timing of hair removal
is an important factor in SSI, shaving done greater than 34 hours before
surgery increased the rate more than 20%. Additional studies show hair removal
by any method increases infection rates. (Mangram, Horan, Pearson, Silver, &
Jarvis, 1999)
Based on the
research presented, by eliminating preoperative hair removal except when it
would interfere with the surgical procedure, we can significantly reduce SSI.
This will provide a greater safety to the patient, a cost savings to the
organization and increased revenue to the hospital.
A6.
Stakeholders
Once
administration has approved the evidence based practice recommended change,
department managers must be informed and educated to the rationale of changing
the procedure. Beginning with the purchasing department, the necessary equipment
must be obtained. They must understand the desired practice change to identify
the proper equipment and help establish a time line and what education may be
necessary. The education department will provide educational in-services to
explain the change to the nursing staff. They will need all of the evidence to
create the necessary education to the staff. The staff must understand and
accept the change. The front line staff is the one educating and helping
patients understand their surgical care. The medical staff director will
provide education and buy-in from the physicians and surgeons. Infection
Control nurses can be influential in providing up to date statistics of our
SSIs with easy to read graphs and posters in strategically located places. By
showing the trend of lower SSIs acceptance of the change will be increased.
B1.
Translation of Research
Shaving the
operative site has been a practice in hospitals as far back as the nineteenth
century. It has been noted by many great practitioners that bacteria inhabit
the hair and has a role in causing infection. This particular practice is
clearly understood and the theory has been proven in many medical studies. What
may be difficult is explaining to others why the practice of not removing the
hair is the best method of infection prevention. A PowerPoint presentation with
statistics, photos, and references will be the best method of translating the
research to others. Creating a multidisciplinary team to disseminate the
information to other departments will assist synthesizing the conclusions and
recommendations into our organizational procedure. By creating a team to
institute this change the understanding at difference levels and in various
departments will be more effective.
B2.
Barriers
Possible barriers
to instituting this change based on the evidence-based study are physician
refusal to accept the change in practice. Shaving the hair from a surgical site
has been done for centuries, beginning with a straight razor. Physicians that
have a routine may be resistant to change believing it may hinder their outcome
or impair their ability to perform the operation. Nursing staff may be hesitant
to accept the change due to lack of understanding the research and evidence
fearing they may impair their patient’s outcome. Operating room staff may be
concerned with delays due to the surgical site possibly needing to be clipped.
In any situation
involving change people can be resistive; in the operating room confidence in
the accuracy of the research is paramount to accepting new procedures.
B3.
Strategies.
Communication,
understanding and education are the key strategies to help institute a change. A
gradual transition by providing old and new methods of hair removal and
recommendations to avoid hair removal if at all possible will make the change
easier to implement. Department champions are able to gain acceptance within
departments as they are trusted peers.
B4.
Application of Findings
SSIs are responsible for approximately one third of all
nosocomial infections (Mangram, Horan, Pearson, Silver, & Jarvis, 1999).
The CDC guidelines recommend not removing the hair unless it will interfere
with the procedure, if the hair must be removed clipping immediately prior to
the surgery is recommended (Segal, C., 2006). TJC included reducing the risk of
healthcare associated infections as one of the national safety goals in 2008
(Waddington, C., 2008). By decreasing wound infections, patient discomfort,
morbidity and cost of care will decrease significantly (Adisa, Lawal, &
Adejuyigbe, 2011). Based on the evidence presented over the last couple of
decades it has been shown the age old practice of shaving hair from the
operative site has a direct impact on SSIs. Current practice recommendation
guidelines written 1999 from Hospital infection Control Practices Advisory
Committee have been implemented by the accreditation committee TJC. “The Center
for Medicare and Medicaid Services (CMS) MS will continue to work
collaboratively through consensus processes, such as those of the Hospital
Quality Alliance(HQA), National Quality Forum (NQF), and the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO), to coordinate measures and
implementation of the Value Based Purchasing (VBP) program” (CMS Hospital Pa
y-for-Performance Workgroup , 2007).
References
Adisa, A., Lawal, O., & Adejuyigbe, O. (2011).
Evaluation of two methods of preoperative hair removal and their relationship to
postoperative wound infection. Journal Of Infection In Developing Countries,
5(10), 717-722.
CMS Hospital Pa y-for-Performance Workgroup U.S.
Department of Health and Human Services, Center for Medicare and Medicaid
Services. (2007). Medicare hospital value-based purchasing plan development (1st
Public Listening Session). Retrieved from website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads/hospital_VBP_plan_issues_paper.pdf
Freshwater, D. (2003). Understanding and
implementing clinical nursing research. Blackwell Publishing, Ltd.,
Retrieved from http://www.icn.ch/images/stories/documents/networks/Research/48751_4th_proof.pdf
Ko, W., Lazenby, W., Zelano, J., Isom, O., &
Krieger, K. (1992). Effects of shaving methods and intraoperative irrigation on
suppurative mediastinitis after bypass operations. The Annals Of Thoracic
Surgery, 53(2), 301-305.
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.
Segal, C. (2006). OR special. Infection control:
start with skin. Nursing Management, 37(4), 46-52.
Tanner, J., & Khan, D. (2008). Surgical site
infection, preoperative body washing and hair removal. Journal Of
Perioperative Practice, 18(6), 232.
