Impact of the Time and Method of Preoperative Hair Removal on Surgical Site Infection in Lower Abdominal Surgery

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1 Med. J. Cairo Univ., Vol. 77, No. 3, December: , Impact of the Time and Method of Preoperative Hair Removal on Surgical Site Infection in Lower Abdominal Surgery WAFAA ISMAIL SHEREIF, D.N.Sc. and AMIRA AHMAD HASSANIN, D.N.Sc. The Department of Adult Care Nursing, Faculty of Nursing, Mansoura University. Abstract Surgical site infections are common and serious postoperative complications. Hair removal may or may not reduce surgical site infection, but certainly may increase infection rates if not done properly. The aim of this study was to identify impact of the time and method of preoperative hair removal on surgical site infection in lower abdominal surgery. This quasi-experimental study was conducted in the surgical department at El-Mansoura University main Hospital on a convenience sample of 152 lower abdominal surgical patients equally divided into 3 groups (G1) hair shaving by razor at the night before surgery, (G2) shaving by razor immediately before surgery inside the operating room and (G3) shaving by clipper immediately before surgery inside the operating room. An assessment tool was used to collect data pre and postoperatively. Data were collected throughout nine months and the results showed that all patients in the 3 groups had prophylactic antibiotics and the majority complied with its intake. After one week, (G1) had significantly higher percentages of wound sepsis (51.0%), systemic symptoms and signs (84.3%) and abnormally high ESR (54.9%) and WBC count (60.8%) and 11.8% of the patients in this group had positive incision culture, compared to none in the other two groups. (G3) patients were lowest in almost all abnormal outcomes, and highest in healing (86.0%). After 2 weeks, G1 patients still had the highest percentages of wound sepsis (37.3%), systemic symptoms and signs (43.1%) and abnormally high ESR (35.3%) and WBC count (56.9%) and 9.8% had positive incision culture, compared with 3.9 in (G2) and none in (G3). The study findings confirm the superiority clipping in preoperative hair removal, compared with shaving and of performing the process immediately before surgery. Thus, clipping just before surgery is recommended. Further study is suggested to compare the incidence of surgical site infections in clipping versus non-removal of hair. Key Words: Clipping Razor shaving Surgical site infection. Introduction WOUND infections are serious and relatively common postoperative complications. Surgical site infections (SSIs) account for about 40% of all Correspondence to: Dr. Wafaa Ismail Shereif, dr-wafaaismail@yahoo.com hospital-associated infections among surgical patients in the United States, despite continued efforts to reduce or eliminate the infection. Nearly 3% of postoperative patients develop an SSI, prolonging hospital stays and raising costs. Patients who develop SSIs are twice as likely to die as other postoperative patients. While, if the SSI develops after discharge, they are five times more likely to be readmitted to the hospital. If one in each 20 patients develops an infection following surgery, the costing the National Health Services in UK would be around one billion pounds each year [1]. According to [2], 22% of healthcare associated infections were resulted from surgical site infections (SSIs). This is one of the most common healthcareassociated infections among surgical and hospitalized patients especially with lower abdominal surgery. They are generally detected five to nine days after surgery and are usually attributed, even by surgeons, to poor surgical technique or failure to maintain sterility. It has been known for decades that all wounds become contaminated, often by bacteria from skin or within the patient. Therefore, reducing the number of bacteria on skin has been a common preoperative practice. According to [3], the skin flora as Staphylococcus aurous, coagulate-negative staphylococci is responsible for most surgical site infections (SSIs). The two major methods for reducing local concentrations of bacteria are administration of an antibiotic and cleansing of the skin. Between 40% and 60% of SSIs can be prevented. That's why the Institute for Healthcare Improvement has included preventing SSIs as one of six initiatives intended to save or extend lives of 100,000 patients [4]. However, [5] compared the practices of 589 surgeons in Canada to the recommendations of evidence-based guidelines and found 107

2 108 Impact of Preoperative Hair Removal on Site Infection that 63% were not in compliance with guideline recommendations for preoperative bathing, hair removal, antimicrobial prophylaxis, or intraoperative skin preparation. Preparation of people for surgery has traditionally included the routine removal of body hair from the intended surgical wound site. Hair is removed as its presence can interfere with exposure of the incision and subsequent wound, with the suturing of the incision and with the application of adhesive tape and wound dressings. Hair is also perceived to be associated with lack of cleanliness and the removal of hair is thought to reduce the risk of surgical site infection [6]. However, there are studies which claim that pre-operative hair removal is deleterious to patients, perhaps by causing surgical site infections (SSIs) and should not be carried out. In a systematic review of eleven RCTs, no statistically significant differences could be revealed between hair removal using either depilatory cream or razors with no hair removal. Three trials showed shaving to be associated with statistically significantly more SSIs compared to with clipping. One trial compared shaving on surgery day with shaving day before surgery and one trial compared clipping on surgery day with clipping day before surgery, and neither trial found a statistically significant difference in the number of SSIs [7]. Similarly, [8] reviewed four clinical trials and concluded that evidence regarding whether preoperative hair removal has any effect was inconclusive. When hair removal was considered necessary, evidence about the best time for removal was inconclusive. There was some evidence that hair removal by clipper is superior to removal by razor. The same conclusion was arrived at by [9]. Although the 1993 guideline from the Dutch Institute for Healthcare Improvement states that preoperative hair removal not serves any purpose in preventing wound infection, [10] found that the majority of surgical short-stay departments apply preoperative hair removal (88%). Less than half of the hospitals use a hair removal protocol. Hair clippers were used for preoperative hair removal in most hospitals (86%) and in (71%) the procedure was carried out within two hours of the planned operation and mostly by nursing staff. Standards and recommended practices from the Association of Preoperative Registered Nurses (AORN) state that preoperative skin preparation of surgical patients should include little hair removal, cleansing of the area around the surgical site and use of an antiseptic agent immediately before the surgical intervention. However, the surgeon is the one who always makes the decision of how much hair should be removed and the removal technique [11]. Operating room nurses have important roles in preparing a site prior to an operation. Therefore, they should be educated about how they can help with prevention of surgical site infection, including infection control practices in the operating room and the appropriate timing of shaving a surgical site. Hair removal may or may not reduce surgical site infection, but certainly may increase infection rates if not done properly. The necessity of removal should be critically assessed for each patient [12]. Aim of the study: The aim of this study was to identify the impact of the time and method of preoperative hair removal on surgical site infection in lower abdominal surgery. Subjects and Methods Study design: A quasi-experimental research design was adopted in this study. Setting: The study was conducted in the surgical department at the main El-Mansoura University main Hospital. Subjects: A convenience sample of 152 surgical patients was recruited from patients who were scheduled to undergo lower abdominal surgery in the study setting. The inclusion criteria were being a male adult (18 years age or older). Exclusion criteria included factors that can increase the risk of postoperative surgical site infection such as diabetes mellitus, morbid obesity, hypertension, renal failure, chronic use of steroids, alcoholism, jaundice and previous radiotherapy or chemotherapy. Recruited eligible patients were consecutively assigned to one of the following three treatment groups: Group I (G1): Hair shaving by razor at the night before surgery according to hospital policy. Group II (G2): Hair shaving by razor immediately before surgery inside the operating room. Group III (G3): Hair shaving by clipper immediately before surgery inside the operating room. Each group included 51 patients. However, the last group had a dropout of one patient due to surgical list.

3 Wafaa I. Shereif & Amira A. Hassanin 109 Data collection tool: An assessment tool was developed by the researchers based on the related literature. It was used to collect data pre and postoperatively. This tool included a part for socio-demographic data such as age, marital status, job status, education and weight. The second part was related to the characteristics of surgery and its duration. The third part was for clinical assessment for wound sepsis, systemic symptoms and signs and wound healing. These were in form of objective criteria as erythema, exudates, pus, as well as systemic symptoms as pain, fever and chills. The patient was considered positive for wound sepsis or systemic symptoms and signs if he/she had any of the criteria assessed. Laboratory investigations included measurement of erythrocytes sedimentation rate (ESR), leucocytic count (WBCs) and bacterial culture from incision. Methods: Permission to conduct the study was obtained from appropriate authorities in El Mansoura University main Hospital. An informed consent was obtained from each patient to participate in the study. A pilot study was conducted on five patients who met predetermined selection criteria to test the feasibility of the study maneuvers and applicability of the tool. Data were collected throughout nine months and patients scheduled for lower abdominal surgery were assessed individually by the researchers preoperatively and assigned to one of the three groups. Data collection was done in three phases: Phase I (preoperative phase): Patients were selected from surgical department by researchers according to inclusion and exclusion criteria. They were individually initially assessed using the data collection tool and then allocated to their respective groups. Phase II: Started from the first week after surgery and the researcher repeated assessed patient for symptoms and signs of wound sepsis, lab result and wound healing this assessed repeated for three groups. Phase III: Started from the end of the second week postoperatively, three groups of patients were assessed for symptoms and signs of wound sepsis, lab result and wound healing and recorded in the same tool. Statistical analysis: Data entry and statistical analysis were done using SPSS 14.0 statistical software package. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables and means and standard deviations for quantitative variables. Qualitative categorical variables were compared using chi-square test. Whenever the expected values in 10% or more of the cells was less than 5 in larger than 2x2 cross-tables, test could not be applied whenever the expected value. Statistical significance was considered at p-value <0.05. Results The three groups were comparable in terms of marital status, job status and body weight (as Table 1 indicates). However, groups I and II had slightly more patients in the youngest age group, while group III had a higher percentage of illiterate patients. These differences were statistically significant, p=0.02 and p=0.03, respectively. The table also shows that no differences of statistical significance among the three groups regarding the duration of surgery. All patients in the three groups had prophylactic antibiotics, and the majority complied with its intake. Table (2) illustrates a comparison of outcomes of patients after one week from surgery among the three study groups. It points to statistically significant differences in almost all outcomes. As evident from the table, Group I patients had the highest percentages of wound sepsis (51.0%), systemic symptoms and signs (84.3%) and abnormally high ESR (54.9%) and WBC count (60.8%). Also, (11.8%) of the patients in this group had positive incision culture compared to none in the other two groups. On the other hand, Group III patients were lowest in almost all abnormal outcomes and highest in healing (86.0%). A comparison of outcomes of patients after two week from surgery among the three study groups is presented in Table (3). Statistically significant differences are noticed in all outcomes. Group I patients still had the highest percentages of wound sepsis (37.3%), systemic symptoms and signs (43.1%) and abnormally high ESR (35.3%) and WBC count (56.9%). About onetenth (9.8%) of the patients in this group had positive incision culture compared with 3.9 in Group II and none in Group III. Meanwhile, Group II and III patients were close in most outcomes, although Group II had more use of antibiotics, more patients with high WBC counts and higher healing (96.1%).

4 110 Impact of Preoperative Hair Removal on Site Infection Table (1): Characteristics of patients in the three study groups. Group I (razornight) II (razorimmediate) III (clipperimmediate) n=50 X 2 Test p value No. % No. % No. % Age (years): < * Marital status: Married Unmarried Job status: Working Not working Education: Illiterate Secondary * University Weight: Normal Underweight Overweight Duration of surgery (hrs): < < Compliance to prophylactic antibiotic (*) Statistically significant at p<0.05. Table (2): Symptoms and signs of wound sepsis, lab results and healing one week after surgery among patients in the three study groups. Group I (razornight) II (razorimmediate) III (clipperimmediate) n=50 No. % No. % No. % X 2 Test p value Wound sepsis * Wound debridement Use of antibiotic Systemic symptoms/signs * Lab results: High ESR * High WBC * +ve incision culture Good healing <0.001* (*) Statistically significant at p<0.05. ( ) Test result not valid.

5 Wafaa I. Shereif & Amira A. Hassanin 111 Table (3): Symptoms and signs of wound sepsis, lab results and healing two weeks after surgery among patients in the three study groups. Group I (razornight) II (razorimmediate) III (clipperimmediate) n=50 No. % No. % No. % X 2 Test p value Wound sepsis <0.001* Wound debridement Use of antibiotic Systemic symptoms/signs <0.001* Lab results: High ESR * High WBC <0.001* +ve incision culture Good healing <0.001* (*) Statistically significant at p<0.05. ( ) Test result not valid. Discussion Skin preparation of the patient begins before arriving to the operating room; its purpose is to reduce the risk of post operative wound infection. Hair removal, as part of this preparation, is still debatable in terms of timing and method and even whether it should be done or not. The present study identifies the impact of the time and method of preoperative hair removal on surgical site infection. Although the design was quasi-experimental rather than randomized clinical trial, the three study groups were comparable in terms of marital status, job status and body weight, with some differences in age and educational level. These factors are important since they could play the role of confounders in the causation of SSIs. According to the present study, the three groups of patients had similar lower abdominal surgeries, with no differences of statistical significance among them regarding the duration of surgery. This was quite important since the type and duration of surgery are known risk factors for the occurrence of SSIs. In congruence with this, it has been demonstrated that longer surgical duration was an independent risk factor for SSI [13]. Furthermore, all the patients in the present study groups were having prophylactic antibiotics, and the majority of them showed compliance to intake of their medications. The role of prophylactic antibiotics could also affect the rate of SSIs and thus its potential role as confounder was removed in the present study since all patients were exposed to it. This is in congruence with the recommenda- tion of [14] that the use of antimicrobial agents for prophylaxis represents the most effective method of reducing the prevalence of wound infection after lower abdominal surgery and should be considered essential to the overall prevention approach. The rate of use in the present study is even higher than that reported in the literature. Thus, in a study of SSIs in Italy, it was found that antimicrobial prophylaxis was administered in only 63.3% of the cases and was continued into the postoperative period in 43% of cases [15]. According to the present study findings, the incidence of SSIs was highest in the group with shaving the night before operation, and exceeded one half of the patients (51.0%). The rate was lowest in the clipping group immediately before the operation (18.0%). This latter rate in the clipping group is in the range reported by [14] who found that SSIs in lower abdomen surgery ranged between 9 to 27%, depending on the duration of surgery. Similar rates were demonstrated by [16] among patients who underwent abdominal operations, where the rates ranged between 11 to 20%. These patients had correct antibiotic dose and hair removal with clippers. The more than double the rate in the overnight shaving group of the present study would point to a deleterious effect of this maneuver. The difference has also increased at the second week follow-up. This is in congruence with [17] who lighted that reducing the risk of infection could be achieved by using clippers instead of razors to shave clients before surgery. Furthermore, [18] found that preoperative shaving by razor was associated with a

6 112 Impact of Preoperative Hair Removal on Site Infection significantly higher surgical site infection (SSI) risk. Thus, [19,20] recommended that when hair removal is considered necessary, shaving should not be performed, but a depilatory or electric clipping, preferably immediately before surgery, should be used. The present study findings further point to superiority of clipping hair in the operating room, compared to shaving overnight, which is shown in significantly lower rates of systemic symptoms and signs. This was also more confirmed by more patients having high ESR and WBC count in the shaving group. Additionally, none of the patients in the clipping group and also in the group of shaving immediately before operation had positive culture from the incision. These findings are in agreement with [2] who mentioned that evidence based practice demonstrates using clippers immediately before surgery, when preoperative hair removal is necessary, results in the fewest surgical site infections. On the same line, [21] showed that early preoperative hair removal was an independent risk factor for SSIs. Similarly, [18] who found that the risk of SSIs is increased if hair removal is performed in advance and not immediately before surgery. Although the present study, in addition to previous similar studies, give evidence of lower risk of SSIs in clipping compared to shaving in preoperative hair removal, still the process of shaving in [22] a study of skin preparation for surgical patient in 3 different hospitals of the General Organization for Teaching Hospitals and Institutes (GOTHI) in Egypt found that removing hair by clipping was only done in 23.7% of the patients, while removing hair by shaving was 44.6%. Conclusion and recommendations: The study findings give evidence of the superiority of the use of clipping in pre-operative hair removal, compared to shaving. Also, performing the process immediately before surgery is associated with lower risk of surgical site infections. Therefore, it is recommended to use clipping whenever hair removal is judged necessary and this should be done just before surgery. Further study is suggested to compare the incidence of surgical site infections in clipping versus non-removal of hair. References 1- TANNER J. & KHAN D.: Surgical site infection, preoperative body washing and hair removal. J. Perioper Pract., 18 (6): 232, , WADDINGTON C.: Changing behavior: Evidence based practice supporting hair removal with clippers. ORL Head Neck Nurs., 26 (4): 8-12, DOHMEN P.M.: Influence of skin flora and preventive measures on surgical site infection during cardiac surgery. Surg. Infect (Larchmt), 7 Suppl 1: S13-7, ODOM-FORREN J.: Preventing Surgical Site Infections. Nursing, 36 (6): 59-36, DAVIS P.J., SPADY D., DE GARA C. and FORGIE S.E.: Practices and attitudes of surgeons toward the prevention of surgical site infections: A provincial survey in Alberta, Canada. Infect. Control Hosp. Epidemiol., 29 (12): , ILKSEN G. and WENZ J.F.: Perioperative Infection Control: An Update for Patient Safety in Orthopedic Surgery, Orthopedic, 29: 329, TANNER J., WOODINGS D. and MONCASTER K.: Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst. Rev., 3: CD004122, NIËL-WEISE B.S., WILLE J.C. and VAN DEN BROEK P.J.: Hair removal policies in clean surgery: Systematic review of randomized, controlled trials. Infect Control Hosp. Epidemiol., 26 (12): 923-8, TANNER J., MONCASTER K. and WOODINGS D.: Preoperative hair removal: A systematic review. J. Perioper Pract., 17 (3): , , VAN BEURDEN A., DE RUIJTER S.H. and SCHMITZ R.F.: Widespread preoperative hair removal in the southwest of The Netherlands despite an evidence-based guideline discouraging this practice. Ned Tijdschr Geneeskd., 151 (46): , RAMSEY C.A.: Preoperative Measures to Prevent Surgical Site Infections, issue of Infection Control Today. In the Best Practices article entitled, 4 Jun., COLLIER M.: Understanding wound inflammation. Nurs Times, 99 (25): 63-64, BOSTON K.M., BARANIUK S., O'HERON S. and MUR- RAY K.O.: Risk factors for spinal surgical site infection, Houston, Texas. Infect. Control Hosp. Epidemiol., 30 (9): 884-9, DANIEL I. and SESSLER M.D.: Non-pharmacologic Prevention of Surgical Wound Infection. Anestheiol. Clin., 24 (2): , CASTELLA A. CHARRIER L., DI LEGAMI V., PAS- TORINO F., FARINA E.C., ARGENTERO P.A. and ZOTTI C.M.: Piemonte Nosocomial Infection Study Group. Surgical site infection surveillance: Analysis of adherence to recommendations for routine infection control practices. Infect. Control Hosp. Epidemiol., 27 (8): , WICK E.C., GIBBS L., INDORF L.A., VARMA M.G. and GARCIA-AGUILAR J.: Implementation of quality measures to reduce surgical site infection incolorectal patients. Dis. Colon. Rectum., 51 (7): , ORTOLON K.: Clip, don't nick. Tex Med., 102 (4): 33-5, ORSI G.B., FERRARO F. and FRANCHI C.: Preoperative hair removal review. Ann. Surg., 17 (5): , 2005.

7 Wafaa I. Shereif & Amira A. Hassanin KJØNNIKSEN I., ANDERSEN B.M., SØNDENAA V.G. and Segadal L.: Preoperative hair removal-a systematic literature review. AORN J., 75 (5): , 940, KUMAR K., THOMAS J. and CHAN C.: Cosmesis in neurosurgery: Is the bald head necessary to avoid postoperative infection? Ann. Acad. Med. Singapore, 31 (2): 150-4, KAYA E., YETIM I., DERVISOGLU A., SUNBUL M. and BEK Y.: Risk factors for and effect of a one-year surveillance program on surgical site infection at a university hospital in Turkey. Surg. Infect. (Larchmt), 7 (6): , EL SAYED I.A., HASHEM S.A., EL SAYED A.S., GADOUA I.M., KAMEL A.E., PERSE O.K., BAGHAG- HO E.A. and TERZAKI S.R.: Patient skin preparation for surgery. J. Egypt Public Health Assoc., 83 (3-4): , 2008.