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Clippers vs. razors: Simple step to reduce SSIs
Education, staff champions make transition smooth
When an outpatient surgery program has a low surgical site infection rate, it is hard to attribute the low rate to any one activity, but experts interviewed by Same-Day Surgery agree that following Centers for Disease Control and Prevention's (CDC) guidelines for hair removal prior to surgery is a simple step to take as part of an overall program.
"The use of clippers vs. razors in the operating room is not an exciting issue, but it is important as outpatient surgery programs look at reducing surgical site infections," admits Mardi Bentzen, marketing manager for 3M Health Care in St. Paul, MN.
Guidelines from the CDC1 and Association of periOperative Registered Nurses (AORN) ("Recommended Practices for Skin Preparation of Patients" in 2007 Standards, Recommended Practices, and Guidelines) state that hair removal is not even necessary unless the hair will interfere with the incision, draping, or postoperative dressing, Bentzen points out. "If hair must be removed, the CDC recommends the use of clippers instead of razors,1" she adds. [Click here for a copy of the CDC guideline for hair removal.]
Surgeons who don't like the use of clippers say they don't like the stubble left as opposed to the "cleaner" area left by a razor, says Bentzen. "The stubble means that the skin has not been damaged and the number of portals for bacteria to enter has been minimized," she says. "Most often, the choice of hair removal technique is more habit than anything else."
Progress is being made as more surgery programs promote the use of clippers, says Bentzen. "Clippers have been in use since the late 1990s but have just now reached the point where clippers are used in about 60% of the cases performed by my clients as opposed to the use of razors in the other 40% of cases," she says. Because all programs are different, the method of introducing the use of clippers varies, she points out.
Reducing the use of razors was easy in Tria Orthopaedic Center in Bloomington, MN, says Dianne Rawson, RN, MA, director of the center. "We made the decision before we opened in 2005 that we would have no razors in the center," she says. "In fact, a mistake was made and razors were ordered prior to our opening. I returned them to the vendor."
Physicians were prepared for the elimination of razors through presentations made at medical staff and board meetings in which Rawson presented the CDC guidelines along with the supporting references. "There was no resistance to the change among the nurses, and we did have several physicians who had used clippers for hair removal in other facilities, so they were also receptive," she explains.
While education was important at Tria, it is even more important in a facility that has traditionally used razors then switches to clippers, points out Bentzen. "It takes a lot of teamwork to change habits that have been formed over a long time, and it helps to have a physician champion or champions to push support of the change," she says.
At Concord (NH) Hospital, the chief of surgery is supportive of the efforts to reduce the use of razors, says Susan Haines, RN, BSN, CNOR, operating room educator. "We present educational sessions at all of the OR committee meetings with updated information on all issues related to surgical site infections," Haines says. The nursing staff also receive the same information at monthly staff meetings and special inservices to reinforce the message that clippers decrease the risk of infection, she adds. "We still have razors for surgeons who are not ready to switch, but clippers are in all of our pre-op areas and operating rooms," says Haines. "We are seeing more use of clippers."
Surgeons' choice of clippers vs. razors usually is related to type of procedure, she says. "Our orthopedic surgeons are more likely to use clippers, while our urologists are more likely to use razors because of the amount of hair on the area of the body on which their procedures are performed," Haines explains.
Assess skin carefully prior to hair removal
Other factors that determine use of clippers vs. razors include gender, age, and race, says Bentzen. Men have more body hair than women, Asians have less body hair than Caucasians, and older people have more fragile skin that can be damaged by razors, she explains. "You also have to be careful with younger people who have undergone chemotherapy or other treatments that can make the skin more fragile," she adds.
To make sure the proper hair removal approach is used, physicians and nurses need to assess the patient's skin carefully prior to the hair removal, suggests Bentzen. "Note any fragile skin, excessive hair, scars, or skin tags in the area, and document the steps you take to minimize damage," she says. If possible, the surgeon also should opt for no hair removal if it is not necessary or if it might present a higher risk for infection, she adds.
As Rawson's center continues to educate surgeons and as the center continues to post very low infection rates, surgeons not only accept the use of clippers, but some even opt not to remove hair, based upon the patient and the procedure, Rawson points out. "If the hair won't interfere with the incision and if we can properly drape the area, surgeons are comfortable with no hair removal," she says.
One other aspect of hair removal that reduces the chance of infection is timing, says Bentzen. "If you are removing hair, do it as close to procedure time as possible," she says. This isn't a problem for most outpatient programs because patients arrive just prior to their procedure, but staff should pay attention to timing in the event a procedure is going to be delayed, Bentzen suggests. "Hair should be removed in the pre-op area just before the patient goes into the operating room," she says.
While Rawson says the Tria surgical site infection rate is very low, she says that it is hard to attribute her center's success to only one activity. "A program to address surgical site infections must be multifaceted, but addressing issues related to hair removal is easy and should be the first step in any program," Rawson says.