Open | Reducing surgical site infection: Preoperative hair removal

Clipping not shaving the surgical site is the third in a series of intervention guidelines[1] developed by the Health Quality & Safety Commission’s national Surgical Site Infection Improvement (SSII) Programme, led by Auckland and Canterbury district health boards (DHBs).

A surgical site infection (SSI) is an infection that develops as a result of a surgical procedure. SSIs are associated with increased morbidity and mortality, prolonged hospital stays and increased health care costs. The SSII Programme aims to reduce SSIs following hip and knee arthroplasty procedures and will focus on reducing SSIs following selected cardiac procedures over the next year.

Preoperative hair removal by any means is associated with increased SSI rates[2]. According to World Health Organization guidelines[3] hair should not be removed unless it interferes with the surgical procedure. If hair removal is required, the evidence supports the use of clippers, which cut the hair close to the patient’s skin, for all sites.

The use of razors (shaving) prior to surgery has been shown to increase the incidence of SSI when compared to clipping, depilatory use or no hair removal at all. Shaving results in epidermal micro-trauma and bacterial colonisation which is associated with a higher risk of wound infection[4]. Clipping rather than shaving when hair removal is necessary improves the safety and quality of care that patients receive.

The clipping not shaving guidelines recommend that hair removal using electric clippers should occur as close to the time of the surgical procedure as possible. Ideally this should be done outside the operating room to minimise the dispersal of loose hair and the potential for contamination of the sterile field or surgical wound.

Patients can also be engaged in reducing their risk of wound infection through education on appropriate hair removal[5]. Advice to ‘leave the clipping to us’ can be incorporated into preoperative discussion and patient information on preoperative skin preparation (see for example the Open for better care patient information brochure Preventing infection after surgery[6]).

From October 2013 to March 2014, to complement the work being carried out by the SSII programme, the Open for better care campaign has promoted a bundle of interventions, with a particular focus on one each month:

• November 2013: SSI surveillance
• December 2013: Correct use of prophylactic antibiotics
• January/February 2014: Using appropriate skin preparation before surgery
• March 2014: Clipping not shaving the surgical site.

References:

1.  Surgical Site Infection Improvement Programme. 2014. Clipping not Shaving Intervention Guidelines.
2.  Centers for Disease Control (CDC). Guideline for Prevention of Surgical Site Infection. Infect Control Hosp Epidemiol. 1999;20:247-280.
3.  WHO: Patient Safety. WHO Guidelines for Safe Surgery. 2009.
4.  NICE: National Institute for Clinical Excellence. Clinical Guideline: October 2008. Surgical Site Infection- Prevention & Treatment of Surgical Site Infection.
5.  AORN. Perioperative Standards and Recommended Practices. Denver, CO: AORN, 2013; 1:75-90.
6.  HQSC : Open for Better Care, Preventing Infection After Surgery. Patient Information. Available online at: http://open.hqsc.govt.nz/infections/publications-and-resources/publication/1286/.
7.  Ng W, Alexander D, Kerr B, Ho MF, Amato M, Latz K. A hairy tale: successful patient education strategies to reduce pre-hospital hair removal by patients undergoing elective caesarean section. J Hosp Infect. 2013; 83: 64-7.
8.  Safer Healthcare Now, Canada. 2011. Prevent Surgical Site Infections, Get Started Kit. www.saferhealthcarenow.ca.