Preoperative Measures to Prevent Surgical Site Infections

We regret to report there has been anerror in the April, 2001 issue of Infection Control Today®. In the BestPractices article entitled Preoperative Measures to Prevent Surgical SiteInfections, by Carolyn A. Ramsey, we incorrectly labeled the answer for testquestion #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

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

Hair Removal

Removal of hair at the surgical incision site has been discussed for sometime. Traditionally, the surgeon has always made the decision of how much hairshould be removed and the technique for removal. Many studies show hair removalwith 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. Ina 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 shavecompared to a 0.6% rate among those who had hair removed by depilatory or whohad no hair removed."² To have the best patient outcome,perioperative nurses should be involved with physician education in areas ofpreoperative preparation and infection control.

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

Price lists skin preparation as a major intrusion into the patients' bodyspace. Removal of hair also can be very embarrassing for the patient, givingthem a sense of loss of control and even a loss in sexual identity, especiallywhen pubic hair is removed. Discomfort is felt while the hair removal is takingplace, and serves as a constant reminder of the surgical experience and illnesswhile the hair is growing back.⁴ This discomfort and reminder couldhave an adverse effect on the psychological recovery of patients undergoingsurgery.

In 1979, Tkach, Shannon, and Beastrom conducted a study of patients havinglower abdominal surgery to compare close shaving of the pubic hair with atechnique 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 ofthe follicle and curling up into the skin, causing an ingrown hair.⁵

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

Depilatory Creams

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

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

Preoperative Showers

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

The agent used to cleanse the skin before surgery and the agent used in theoperating room to disinfect the surgical site have also been discussed.Chlorhexidine is frequently used as a preoperative shower. It is well toleratedand 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 definitionsof surgical infection, the study was inconclusive, but Hayek continued torecommend Chlorhexidine be used in preoperative cleansing.¹⁰Chlorhexidine can also be used immediately before the surgical incision, butmany practitioners are choosing a povidone-iodine and alcohol product(Figure2). The one-step application saves time and leaves a film on the skin thatcontinues to reduce the number of bacteria during the surgical procedure.

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

Conclusion

In conclusion, preoperative skin preparation continues to be an area ofvaried procedures. Healthcare providers strive to provide surgical patients witha safe and non-complicated recovery. Prevention of infection is of utmostconcern. Preoperative reduction of skin flora remains the goal and standard ofcare. Skin should be cleansed before surgery. Preoperative showers have beenadopted as a routine in many hospitals. Patients are given a chlorhexidine soapto use the night before surgery and the morning of surgery. If the patient ishospitalized before surgery, the nursing staff assists the patient with a showeror bath as appropriate.

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

Additional cleansing is performed immediately before the surgical incision ismade in the operating room using sterile technique. The nurse checks patientallergies and after the patient is anesthetized and positioned, a sterile prepis carried out. Basic principles include using an antimicrobial agent,preventing unnecessary exposure, beginning the prep at the incision site, andworking outward toward the periphery. Once the sponge is used on the outeredges, it should be discarded and not used at the incision area again. If acombination povidone-iodine/ alcohol agent is used, the same principles areused. When using this product, one application is all that is necessary. A filmof antimicrobial agent remains on the skin during the surgical procedure, whichprolongs the bacterial kill. Practitioners should keep in mind that even themost rigid preoperative preparation cannot reduce the need for strict aseptictechnique, gentle handling of tissues and control of bleeding to help preventpostoperative SSI's.

References

1. Association of Operating Room Nurses (AORN). Recommended Practicesfor Skin Preparation of Patients, In: Standards, Recommended Practices andGuidelines. 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 andHospital 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 SurgicalPatient. Professional Nurse. 1993; 8(10): 670-672.
5. Tkach J R, Shannon A M, and Beastrom R Pseudofolliculitis Due toPreoperative Shaving. A.O.R.N. Journ. 1979; 30(5): 881-884.
6. McIntyre F J, and McCloy R, Shaving Patients Before Operation: ADangerous Myth? Ann R Coll Surg Engl. 1994; 76(1): 3-4.
7. deKoos Paul T, and McComas Bruce Shaving Versus Skin Depilatory Creamfor 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 ofPreoperative Showers on Staphylococcal Skin Colonization: A Comparative Trial ofAntiseptic Skin Cleansers. Annals of Thoracic Surgery. 1988; 45(1):35-38.
9. Byrne D J, Napier A, and Cuschieri A Rationalizing Whole BodyDisinfection. Journal of Hospital Infection. 1990; 15(2): 183-187.
10. Hayek L A Placebo-controlled trial of the Effect of Two PreoperativeBaths or Shower: With Chlorhexidine Detergent on Postoperative wound InfectionRates. Journal of Hospital Infection. 1989; 13(2): 202-204.
11. Byrne D J, Napier A, Phillips G, and Cuschieri A Effects of WholeBody Disinfection on Skin Flora in Patients Undergoing Elective Surgery. Journalof Hospital Infection. 1991; 17(3): 217-222.

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.

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

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