Preoperative Measures to Prevent Surgical Site Infections

April 1, 2001

We regret to report there has been an
error in the April, 2001 issue of Infection Control Today®. In the Best
Practices article entitled Preoperative Measures to Prevent Surgical Site
Infections, by Carolyn A. Ramsey, we incorrectly labeled the answer for test
question #8 as being true. The answer is actually false. We regret the error.

Preoperative Measures to Prevent Surgical Site Infections

By Carolyn A. Ramsey, RN, MSN, CNOR


Figure 1. Use of battery operated clippers. Performed in the preoperative
holding area.

The fight against post-operative wound infections has long been undertaken by
practitioners. We appreciate that surgical site infections (SSIs) are frequently
caused by bacteria commonly found on the skin. Therefore, reducing the number of
bacteria on the skin has been a common preoperative practice. Standards and
recommended practices from the Association of periOperative Registered Nurses (AORN)
state preoperative skin preparation of surgical patients should include little
or no hair removal, cleansing of the area around the surgical site, and use of
an antiseptic agent immediately before the surgical incision.1

Hair Removal

Removal of hair at the surgical incision site has been discussed for some
time. Traditionally, the surgeon has always made the decision of how much hair
should be removed and the technique for removal. Many studies show hair removal
with a razor or clippers can cause skin abrasion, or even nicks in the skin,
which can lead to the development of pseudofolliculitis and subsequent SSIs. In
a study discussed in the Guideline for Prevention of Surgical Site Infection,
1999, "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."2 To have the best patient outcome,
perioperative nurses should be involved with physician education in areas of
preoperative preparation and infection control.

Plastic surgeons have requested hair be left in place on patients having
scalp lacerations as early as 20 years ago. Neurosurgeons have notoriously
shaved the entire head for all types of cranial surgery. An editorial in The
Lancet
described a non-controlled study that showed no increase in infection
rate when scalp hair was left in place. The patients shampooed with
chlorhexidine the night before surgery. In the OR the scalp was scrubbed for
eight minutes and irrigated with alcohol. The hair was parted at the proposed
incision site and tied back.3 Leaving hair intact greatly reduces the
patients' anxiety, especially when it can be readily seen, as on the head.

Price lists skin preparation as a major intrusion into the patients' body
space. Removal of hair also can be very embarrassing for the patient, giving
them a sense of loss of control and even a loss in sexual identity, especially
when pubic hair is removed. Discomfort is felt while the hair removal is taking
place, and serves as a constant reminder of the surgical experience and illness
while the hair is growing back.4 This discomfort and reminder could
have an adverse effect on the psychological recovery of patients undergoing
surgery.

In 1979, Tkach, Shannon, and Beastrom conducted a study of patients having
lower abdominal surgery to compare close shaving of the pubic hair with a
technique developed to leave approximately 1 mm of stubble. By leaving stubble,
it was felt that the patient would be less likely to develop pseudofolliculitis.
Course, kinky hair is especially susceptible to re-growing out of the side of
the follicle and curling up into the skin, causing an ingrown hair.5

The best practice is to refrain from hair removal unless it interferes with
the surgical procedure or wound closure.6 If hair is removed, it
should be done so using clippers or a depilatory cream (Figure 1). Razors
have no place in the preoperative setting. It has been reported that surgical
residents or surgeons have used a razor to remove hair in an emergency situation
to save time. In this situation, it would be better to leave hair intact.

Depilatory Creams


Figure 2. Use of a Povidone-Iodine scrub in the operating room.

Depilatory creams are usually used the night before surgery. Most patients
having elective surgery are not hospitalized the night before surgery;
therefore, careful instructions must be given to patients who are expected to
use the depilatory cream before coming to the hospital or outpatient surgery
center. A skin sensitivity test must be performed to assure no allergies are
present. Depending on the surgical site, the process can be time consuming and
tedious, but may save the patient embarrassment if carried out before he or she
reports for surgery. The nursing staff must be reminded to leave any hair that
might not have responded to the depilation, or remove using clippers, just
before surgery in an area outside of the operating room.

In 1983, 253 patients took part in a study by de Koos and McComas. Half of
the subjects had skin prepared for surgery using a wet shave 30 minutes before
surgery. The other half used a depilatory cream the night before surgery. The
results of this study showed no statistical difference in the infection rate
between the two methods of hair removal. All of the subjects also were given a
preoperative shower of povidone-iodine soap the night before surgery and on the
day of surgery,7 which may account for the discrepancy in the
findings, compared to similar studies.

Preoperative Showers

Preoperative showers have also been used to reduce skin colonization of
staphylococci, a frequent organism found in post-operative wound infections. In
a study conducted in 1988, chlorhexidine gluconate (Hibiclens) was found to be
more effective in reducing organisms than povidone-iodine (Betadine).8
Other studies also showed Hibiclens to be the preferred agent of choice for
preoperative showers. One study compared the results of preoperative baths and
showers. Showers were found to reduce more skin bacteria than baths. The most
effective number of showers was also studied. Bryne revealed a study that
included eight showers. When showers were compared to hand disinfection, flora
decreased up to the fifth time the hands were washed.9 Two showers
were most frequently advised--one the night before surgery and one the morning
of the procedure.

The agent used to cleanse the skin before surgery and the agent used in the
operating room to disinfect the surgical site have also been discussed.
Chlorhexidine is frequently used as a preoperative shower. It is well tolerated
and does not leave discoloration as a povidone-iodine preparation does. Hayek
(1989) described a study that compared 4% Chlorhexidine and an unnamed bar soap.
Considering methods of showering that could not be controlled, and definitions
of surgical infection, the study was inconclusive, but Hayek continued to
recommend Chlorhexidine be used in preoperative cleansing.10
Chlorhexidine can also be used immediately before the surgical incision, but
many practitioners are choosing a povidone-iodine and alcohol product(Figure
2
). The one-step application saves time and leaves a film on the skin that
continues to reduce the number of bacteria during the surgical procedure.

Recently, lay magazines and news reports have discussed the everyday use of
antimicrobial soaps and lotions. Described as a concern by Byrne
"suppression of the normal flora ... has led to colonization by Proteus
species."11 We should perhaps limit antimicrobial soaps except
in cleansing minor cuts and abrasions. Normal flora has a role in protecting the
body against potential harmful pathogens.

Conclusion

In conclusion, preoperative skin preparation continues to be an area of
varied procedures. Healthcare providers strive to provide surgical patients with
a safe and non-complicated recovery. Prevention of infection is of utmost
concern. Preoperative reduction of skin flora remains the goal and standard of
care. Skin should be cleansed before surgery. Preoperative showers have been
adopted as a routine in many hospitals. Patients are given a chlorhexidine soap
to use the night before surgery and the morning of surgery. If the patient is
hospitalized before surgery, the nursing staff assists the patient with a shower
or bath as appropriate.

Hair should ideally be left in place. If hair interferes with the surgical
procedure it can be removed using scissors or clippers, and should be carried
out in an area outside the operating room. A patient's privacy must be of utmost
concern and a professional atmosphere and uncluttered space should be provided.
Many preoperative areas consist of a large room with only curtains separating
patients, providing little in the way of privacy. If this is the case, staff
should keep this in mind and speak quietly at all times. If possible, a separate
room should be used for hair removal.

Additional cleansing is performed immediately before the surgical incision is
made in the operating room using sterile technique. The nurse checks patient
allergies and after the patient is anesthetized and positioned, a sterile prep
is carried out. Basic principles include using an antimicrobial agent,
preventing unnecessary exposure, beginning the prep at the incision site, and
working outward toward the periphery. Once the sponge is used on the outer
edges, it should be discarded and not used at the incision area again. If a
combination povidone-iodine/ alcohol agent is used, the same principles are
used. When using this product, one application is all that is necessary. A film
of antimicrobial agent remains on the skin during the surgical procedure, which
prolongs the bacterial kill. Practitioners should keep in mind that even the
most rigid preoperative preparation cannot reduce the need for strict aseptic
technique, gentle handling of tissues and control of bleeding to help prevent
postoperative SSI's.

References

1. Association of Operating Room Nurses (AORN). Recommended Practices
for Skin Preparation of Patients, In: Standards, Recommended Practices and
Guidelines
. Denver: AORN; 2000:329-333.

2. Mangram, A J, Horan, T C, Pearson M L, Silver, L C, and Jarvis, W R.
Guideline for Prevention of Surgical Site Infection. Infection control and
Hospital Epidemiology
. 1999; 20(4):257-258.

3. Editorial, Shaving the Head: Reason or Ritual? Lancet. 1992;
340(8829): 1198-1199.

4. Price B, Dignity That Must Be Respected. Body Image and the Surgical
Patient. Professional Nurse. 1993; 8(10): 670-672.

5. Tkach J R, Shannon A M, and Beastrom R Pseudofolliculitis Due to
Preoperative Shaving. A.O.R.N. Journ. 1979; 30(5): 881-884.

6. McIntyre F J, and McCloy R, Shaving Patients Before Operation: A
Dangerous Myth? Ann R Coll Surg Engl. 1994; 76(1): 3-4.

7. deKoos Paul T, and McComas Bruce Shaving Versus Skin Depilatory Cream
for Preoperative Skin Preparation. American Journal of Surgery. 1983;
145(3): 377-378.

8. Kaiser A B, Kernodle D S, Barg N L, and Petracek M R Influence of
Preoperative Showers on Staphylococcal Skin Colonization: A Comparative Trial of
Antiseptic Skin Cleansers. Annals of Thoracic Surgery. 1988; 45(1):
35-38.

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

10. Hayek L A Placebo-controlled trial of the Effect of Two Preoperative
Baths or Shower: With Chlorhexidine Detergent on Postoperative wound Infection
Rates. Journal of Hospital Infection. 1989; 13(2): 202-204.

11. Byrne D J, Napier A, Phillips G, and Cuschieri A Effects of Whole
Body Disinfection on Skin Flora in Patients Undergoing Elective Surgery. Journal
of Hospital Infection
. 1991; 17(3): 217-222.

Objectives

To describe the AORN preoperative skin preparation recommendations. To
describe the importance of hair and removal. To identify the importance of
preoperative showers.

True or false questions

1. AORN recommends total hair removal during preoperative skin
preparation.
2. Hair removal increases patient anxiety.
3. If hair is removed, it should be done with a razor.
4. Preoperative showers are used to reduce staphylococci.
5. Baths reduce more skin bacteria than showers.
6. Normal flora protects the body from harmful pathogens.
7. A patient's privacy should not be the top concern when handling
preoperative hair removal.
8. A nurse should check for allergies after the patient is anesthetized.
9. Nurses should begin prepping at the incision and work outward.
10. Two applications of povidone-iodine solution should be used to prep
the incision site.


Answers

1. F.
2. T.
3. F.
4. T.
5. F.
6. T.
7. F.
8. T.
9. T.
10. F.

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