Routine shaving of a site where surgery is to be conducted has been in practice for a long time. Initially, hair was often removed to prevent infection by bacteria present on the skin and the hair and preventing hair from entering into the incision. However, recent research findings indicate that shaving hair may be counterproductive. This paper seeks to utilize existing literature to establish the practice of shaving before surgery in regard to the process itself; the basis of its undertaking; the rationale for making the decision for the process; why the process is done in a certain way and why the process should be modified or changed.
Procedure / Basis of the Practice
Shaving is the oldest and one of the most commonly performed methods of hair removal prior to surgery. The practice has been around since the 18th century though its origin is not clearly stated. The current shaving procedure undertaken was established and approved by the WHO. It’s not clear who determined the policy for pre-operative shaving in the nursing area. However, the policy may be superseded in cases such as oozing or broken skin and thus a decision will be made on whether shaving is appropriate in the particular case in question other techniques of hair removal include the use of a depilatory cream or clipping. Shaving is preferred to other techniques because it’s cost-effective and easy to carry out. The following procedure is often followed when hair is to be removed for surgery by shaving: The area to be shaved is washed using a mild soap to prevent any incidences of infection should the razor prick the patient accidentally. After washing, the site is rinsed thoroughly using warm water; the area to be shaved is then covered with a layer of shaving gel or cream; A new sterile razor is then used to shave to prevent incidences of infection; shaving is conducted in the direction of the hair growth; to prevent clogging, the razor is rinsed with running water after every stroke; after shaving, the shaving cream or gel is washed off using warm water and a washcloth (Anderson, Gardner, & Millard, 2006). Despite all the precautions that are taken to prevent infection resulting from shaving, there is evidence that hair removal by shaving increases the chances of surgical site infection. Thus pre-operative shaving needs to be reviewed.
Rationale
Hair removal from a surgical site is primarily carried out to facilitate the surgical process. It’s done to enable the surgeon to clearly visualize what he/she is doing. It’s also carried out to prevent hair from getting into the incision and possibly causing an infection. In the early years of the 20th century, the field of surgical sepsis and antisepsis identified hair as a major carrier of pathogens and therefore it was to be removed (Kaya, Yetim, Dervisoglu, Sunbul, & Bek, 2006 ). Increasing evidence suggests that hair removal is not necessary. However, surgeons continue to do it today. There are various methods of hair removal before surgery but the choice depends mostly on the established hospital practices and the level of care. Most hospitals remove hair by shaving due to the fact that the procedure is simple, fast and convenient. Shaving may also be conducted due to the contraindications associated with other techniques. For instance, depilatory cream may lead to a reaction that results in the cancellation of the surgery. The decision to remove hair by shaving may be arrived at depending on the following; the site where the operation is to be conducted, safety requirements, for instance, some areas such as the armpit are likely to be pricked if the hair is removed using a razor.
Explanation
As indicated earlier, there is a tentative procedure that is often followed while shaving a surgical site. Briefly, the area is washed using a mild soap to prevent any incidences of infection should the razor prick the patient accidentally. Its then rinsed thoroughly using warm water; the area to be shaved is then covered with a layer of shaving gel or cream; A new sterile razor is then used to shave; shaving is conducted in the direction of the hair growth; to prevent clogging, the razor is rinsed with running water after every stroke; after shaving, the shaving cream or gel is washed off using warm water and a wash cloth (Phillips, 2004). The procedure is conducted this way to ensure that surgical site infections (SSIs) are prevented as much as possible. Bacteria such as Staphylococcus aureus are often present on the skin thus washing of the skin with mild soap is intended to remove the bacteria from the patient’s skin prior to shaving (Kaya, Yetim, Dervisoglu, Sunbul, & Bek, 2006 ). The shaving gel or cream is applied to ensure that the skin structure is least interfered with. Breaking of the skin during shaving also provides a pathway for the entrance of disease causing bacteria and other unusual species such as Moraxella osloensis and Serratia marcescens. A new sterile razor is used to prevent the transfer of infection causing microorganisms (Kjonniksen, Marit, & Sondenaa, 2002).
Clinical implications
Hair removal at the surgical site was primarily intended to reduce postoperative infections. However, recent research indicates that shaving may actually be accounting for most of the postoperative infections. Shaving has been identified to result into increased incidences of SSIs in comparison with other techniques of hair removal. To counter this, shaving should be conducted as close as possible to the surgical procedure or should not be done all together.
Procedural changes
Comparative studies carried out recently have associated hair removal with increased incidences of infection. Thus it’s even recommended that hair should not be removed unless it will interfere with the surgical process (Kaya, Yetim, Dervisoglu, Sunbul, & Bek, 2006 ). Some neurosurgeries have been carried out with hair in place and this has not increased the incidences of SSIs. Hair removal by shaving is the least recommended method. This is due to the fact that shaving is likely to result in “small cuts or abrasions that are associated with increased surgical site infections compared to other techniques such as depilatory cream or clipping” (Pfiedler ENTERPRISES , 2009, p. 10 ). In response to these findings, it’s now recommended that whenever possible, the hair should be left in place or braided away from the surgical site. If hair removal must be done then it should be done not more than 2 hours before the surgery. In this case the hair that will significantly interfere with the surgical process should be removed. Hair removal should be done using an electric or battery operated electric clipper (Phillips, 2004). Research findings from several comparative studies have shown that clipping of hair results in fewer incidences of SSIs. The clipping should be done outside the operating room to minimize contamination of the sterile room. Depilatory cream may also be used for hair removal but it should be done after appropriate skin tests have been carried out. Furthermore, the depilatory creams are more expensive compared to clipping or shaving.
Stakeholders
The determination of appropriate techniques for hair removal is determined in conjunction with the recommendations of organizations such as the Association of perioperative Registered nurses (AORN), Centers for Disease Control and Prevention (CDC) and the world health organization (WHO) (Pfiedler ENTERPRISES , 2009). The CDC has particularly played a major role in comparing up to 120 research studies and giving appropriate recommendations regarding hair removal prior to surgery. However, the decision as to whether hair should be removed or not and the technique to be used in the removal is reached by the surgical team, specifically the surgeon and the registered operating room nurse. The CDC states that “if hair is to be removed, remove it immediately before the operation, preferably with clippers” (Kaya, Yetim, Dervisoglu, Sunbul, & Bek, 2006, p. 5 ). The results of studies that associate pre-operative shaving with increased SSIs should be available to the key stakeholders to provide evidence and form a basis for the adoption of the proposed changes.
Translation of research
Research has mainly concentrated on the broader issue of surgical site infections (SSIs). These infections pose the greatest challenge in the field of surgery. SSIs are the most common nosocomial infections and sometimes results into the death of patients (Anderson, Gardner, & Millard, 2006). Hair removal prior to surgery, particularly by shaving has been identified as one of the major causes of the SSIs. The findings are supported by well-designed “experimental, clinical or epidemiological studies” (Kaya, Yetim, Dervisoglu, Sunbul, & Bek, 2006, p. 9). Scientific searches have conducted by the CDC and other independent groups such as the Norwegian Centre for Health Technology. Searches have been carried out on the following electronic databases: the “Cochrane Trial Register, Embase, Medlineand the CINAHL” (Kjonniksen, Marit, & Sondenaa, 2002, p. 6). Articles that report on the findings from both random and observational studies have been included for review. Hundreds of articles have been identified for review by the different agencies undertaking the comparative studies. Systematic review have been carried out basing on the following groups: Comparison of shaving to no hair removal; comparison of shaving to hair removal by clipping; comparison of shaving to depilation and the timing of perioperative hair removal using the different modes (Pfiedler ENTERPRISES , 2009).
A researcher who compared shaving to no hair removal identified that 12% of shaved patient’s presented with SSIs compared to the 7.8% of those who were not shaved (Kjonniksen, Marit, & Sondenaa, 2002). This finding is however not significantly different. In other studies patient were given different treatments thus making it difficult to draw any comparisons.
The findings of studies that compared shaving to clipping showed that clipping generally resulted in reduced rates of infection compared to shaving (Anderson, Gardner, & Millard, 2006). These findings are often not interpreted and readily applied into practice due to the following reasons. First, most of the findings are not easily made available to operating room staff members that are required to effect the changes. Secondly, the chains of command of in the hospital administration main act as a stumbling block by making it difficult for the staff on the ground from indulging in research or effecting proposed changes. Thirdly, studies conducted to compare different methods of hair removal give findings that are not of any statistical significance and thus cannot form a basis to effect a change in hair removal procedure.
Barriers
Most agencies such as the CDC have proposed that hair should not be removed unless it will interfere with the surgery. And if it has to be removed then it should be removed preferably by clipping. However, it’s common to see hair being removed even when its will not directly interfere with the surgery. The practice is deeply entrenched in the surgery practice that it is difficult to see it changed. Previously it was thought that the presence of hair may increase instances SSIs but current findings show that hair removal actually increases the risk of SSIs. The current operating room staffs have been taught that hair increases the chances of SSIs, thus it will take a great deal of effort to convince them otherwise. Another possible barrier is that clippers may not be readily available or as cheap as razor blades.
Strategies
The following should be done to ensure that operating room staff interpret and implement the proposed change in preoperative hair removal. A program should be established by different stakeholders such as the CDC and the WHO to spearhead the adoption the change in pre-operative hair removal by the operating room staff. The program should include educating the operating room staff about the recent research findings that show shaving increases the chances of SSIs. The program may include subsidies of prices of clippers to make them easily accessible to those who may find the cost to be prohibitive.
Applications of findings
Based on the findings of the review that proposes a change surgical hair removal, the management of hospitals and operating room staffs around the world should be informed of the findings (Pfiedler ENTERPRISES , 2009). Operating room staff of different hospitals may conduct comparative studies to authenticate the findings and form a strong basis on which real change is adopted
References
Anderson, E., Gardner, D., & Millard, M. (2006). Clipping, Prepping and Drapping for Surgical Procedures. Manging Infection Control , 70:7475-9.
Kaya, E., Yetim, I., Dervisoglu, A., Sunbul, M., & Bek, Y. (2006 ). Risk Factors for and Effect of a One-Year Surveillance Program on Surgical Site Infection at a University Hospital in Turkey. Surgical infections , 7(6):519-528.
Kjonniksen, I., Marit, B., & Sondenaa, V. (2002). Preoperative hair removal: A systematic literature review. AORN Journal , 9:245-266.
Pfiedler ENTERPRISES. (2009). Preoperative hair removal: Impact on Surgical site infections. Aurora : Pfiedler Enterprises.
Phillips, B. (2004). Operating room Technique. St. Louis: Mosby.