Nowadays, an indicator which can measure the quality of a hospital is the nosocomial infection rate. Nosocomial infection is an infection caught while staying in the hospital. These infections can be caused by bacteria, viruses, parasites, fungi or other agents. Known bacteria caught in the hospital are: Staphylococcic, Pseudomonades, Escherichia coli, and Enterococci. The Centre for Disease Control (CDC) has made the definition of nosocomial infection:
There are two special situations in which an infection is considered nosocomial: (a) infection that is acquired in the hospital but does not become evidence until after hospital discharge and (b) infection in a neonate that results from passage through the birth canal.
There are two special situations in which an infection is not considered nosocomial: (a) infection that is associated with a complication or extension of infection already present on admission, unless a change in pathogen or symptoms strongly suggests the acquisition of a new infection, and (b) in an infant, an infection that is known or proved to have been acquired transplacentally (e.g., toxoplasmosis, rubella, cytomegalovirus, or syphilis) and becomes evident at or before 48 hours after birth.
There are two conditions that are not infections: 1) colonization, which is the presence of microorganisms (on skin, mucous membranes, in open wounds, or in excretions or secretions) that are not causing adverse clinical signs or symptoms, and 2) inflammation, which is a condition that results from tissue response to injury or stimulation by noninfectious agents, such as chemicals.
(CDC Definitions of Nosocomial Infections, 1996).
It is estimated that nosocomial infections are increasing year by year. For example, nosocomial infection was the eighth leading cause of death in the United States and there is a five per cent attack rate among patients in the hospital (Spector, 2007). Suwarni (1999 cited in Utama, 2001) reported that in Indonesia, the incidence rates of nosocomial infection were from 0.0% to 12.06%; with the total average being 4.26%. The average Length of Stay (LOS) was 4.3 – 11.2 days; with the total average around 6.7 days.
The risks of nosocomial infection can be got almost in all parts of hospitals. The main causes of cross infection are host, environment, agent and human resources, including nurses. In Indonesia, the highest incidence rates of nosocomial infection were in the surgery ward, at 70% of total nosocomial infection rate (Iwan, 2007), particularly in post surgery patients. Brunner and Suddarth (2000) stated that at present, surgery is a common procedure in hospital and other health care centres.
It is well-known that before surgery there are many nursing intervention plans, these include behavioural objectives, overviews, surgical risk factors, and establishing trust with patients and family, patient assessment, pertinent laboratory evaluations and informed consent. Skin preparation is a common nursing intervention for patients’ physical preparation. A study by Seal, et al (2004) found that preoperative patient skin preparations have a positive impact on infection rates. Thus, patient skin preparation must be planned to prevent nosocomial infection after surgery.
Usually, skin preparation for the patient is started the night before surgery and can be done in the form of scrubbing with a special soap (such as Hibiclens), or hair removal from the surgical area. Hair removal techniques involve a variety of methods to temporarily or permanently remove unwanted body hair (Health Point, 2008). The purpose of hair removal is to avoid or reduce the risk for post surgery infection. Sometimes, nurses let their patients remove the hair by themselves for comfort reasons. The area for hair removal depends on the surgery type and the surgery area. Hair removal on the arm is usually done in order to administer intra venous catheter.
However, hair removal procedure must be done carefully because during the process of shaving, the skin may experience microscopic cuts and abrasions. The micro-organisms can enter and colonise these cuts and contaminate the surgical wound causing postoperative wound infections (Briggs, 1997 cited in Tanner et al, 2007). As a result, the wound healing process after surgery can be affected.
Nowadays, there has been the data that shaving the surgical site is unnecessary and even unsafe. But, changing practice has been difficult. In reality, many nurses still believe that hair removal is a routine nursing intervention. For instance, in Indonesia hair removal by shaving is a common procedure for patient skin preparation. Shaving is a technique which uses a razor blade to cut the hair on the surface of a patient skin. Even though, the guideline from the CDC recommends that hair should not be removed preoperatively unless the hair at or around the incision site will interfere with the surgical procedure. If hair is removed, it is recommended that hair is removed at once before surgery and if possible with clippers (Mangram, 1999 cited in Tanner et al, 2007). Additionally, the Norwegian Centre for Health Technology Assessment guidelines recommend to use clippers or cream as close to the surgery as possible (SMM, 2000 cited in Tanner et al, 2007). Moreover, the Hospital Infection Society Working Party guidelines recommend using cream the day before surgery (HIS, 2003 cited in Tanner et al, 2007).
This review will discuss evidence based practice on preoperative hair removal to reduce surgical site infection. The PICO (Patient or Population or Problem, Intervention or exposure, Comparison and Outcome) question in this review is: a patient was planned for laparotomy surgery and a nurse has removed the hair on his stomach using a razor blade. The other nursing interventions are hair removal with clippers, depilatory cream or without hair removal. Which is the most effective type of hair removal that can reduce the post operative infection?
The resources used were books, the internet, journals and electronic databases. The databases used were EBSCOhost, the Joanna Briggs Institute, CINAHL, AORN and MEDLINE. The keywords are preoperative, nursing, hair removal and infection. In addition, the bibliographies of all articles acknowledged through the search strategy were searched for further studies.
Based on the CDC definition, nosocomial infection can occur after more than 48 hours after admission, but it will vary among patients because of the type of micro-organism pathogenic or patients’ condition, especially for children and older people who have different immunity to adults. Therefore, the search methods were restricted to surgery on adult patients.
Levels of Evidence
The quality of the evidence presented in this report was assessed and classified according to the National Health and Medical Research Council’s (NHMRC) Guidelines (1999, cited in Fowler 2001; COPD-X guidelines 2008).
Basis of Evidence:
Evidence obtained from a systematic review of all relevant randomised controlled trials
Evidence obtained from at least one properly designed randomised controlled trial
III – 1
Evidence obtained from well-designed pseudorandomised controlled trials (alternate allocation or some other method)
III – 2
Evidence obtained from comparative studies (including systematic reviews of such studies) with concurrent controls and allocation not randomised, cohort studies, case-control studies, or interrupted time series with a control group
III – 3
Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel group
Evidence obtained from case series, either post-test or pretest/ post-test
Findings and Discussion
Clippers use fine teeth to cut hair close to the patient’s skin, leaving short stubble of usually around one millimeter in length. The heads of clippers can be disposed of or disinfected between patients to minimise the risks of cross infection. A randomized control trial by Taylor and Tanner (2005) has found that if hair removal is needed, clippers cause fewer abrasions than razor blades (razor blades were p=0.41 and clippers were p^O.l 1). This result was based on interviews with 157 patients who contributed on this study. The patients were interviewed two times; after shaving using a razor blade or a clipper, then two weeks after surgery in terms of pain, itchiness, red skin appearance, sustained cuts and opinions on shaving methods for further surgery.
However, as this study was based on interviews with patients, the data was more subjective and may not be reliable. Moreover, the second interview was by telephone two weeks after surgery. So, the second data was based on self assessment by patients. Additionally, both razor blade and clipper groups have reported that they had experienced redness after surgery (10% for both groups). Redness could be an initial sign of inflammation (Latin: rubor), because blood is concentrated in the infected area to fight the micro-organisms. The other signs of inflammation are heat (Latin: calor), swelling (Latin: tumor), lose of functions (Latin: functio laesa) and pain (Latin: dolor) (Britannica, 2008).
Besides that, CDC has defined that nosocomial infection can occur after 48 hours or more after admission. However, the patient condition and the type of pathogen micro-organisms can be varies, thus, infection can be evident for more than two weeks. In this research, the second interview was two weeks after surgery and nosocomial infection, based on the CDC’s definition, may have been present sometime after that.
In line with Taylor and Tanner, a systematic review by Tanner, Moncaster and Woodings (2007) said that there is not enough evidence that razor blade can increase the risks of nosocomial infection. Nevertheless, if hair removal is needed, clippers are better than razor blades, because clipping results in fewer nosocomial infections than shaving with a razor. These findings are also supported by Adams in 2003. Adams found that clipping is a better hair removal method to prevent surgical site infection.
Many studies have been carried out to look for the effectiveness of using depilatory cream in comparison to razor blades to reduce the risk of nosocomial infections. A study by Powis et al (1976) established that depilatory cream proved to be more efficient, safer and cheaper than shaving with a razor blade. Itching and discomfort are common experiences which were reported by patients during hair regrowth after the use of a blade razor, but such complaints were not reported by patients who used depilatory cream. Other research by Adams (2003) has found that a lower percentage of patients who had depilation developed surgical site infection. Adams recommends that in patients undergoing clean abdominal surgery, depilation is preferred to hair removal with a razor blade to prevent surgical site infection. Additionally, Inge et al (2002) found that there were two observational studies showed that depilation was better than shaving in preventing nosocomial infection.
Even though, these findings were not statistically significant. Most studies on razor blades versus depilatory cream have done based on observational study only. Thus, Powis et al (1976) recommended depilatory cream only for areas which are difficult to shave. But then, Hemingway et al (2007) found that there were statistically significant finding shows that people are more likely to develop nosocomial infection when they are shaved with a razor rather than having hair removed using a depilatory cream. Yet, the trials were of variable quality or did not report clearly. There are no trials which have compared clippers with depilatory cream.
Powis et al (1976) established that depilatory cream is cheaper than saving with a razor blade. However, before using depilatory cream, the doctors have to take a patch test to their patients. This test is necessary to identify that the patient has an allergic on depilatory cream or not. It means that the patients need to pay more expensive for this test. The costs for a patch test and depilatory cream will be more expensive than using a clipper. For Indonesian, it will be harder to do because most patients have to pay all hospital costs by themselves. Thus, depilatory cream, based on research by Powis et al in 1976, may be safer, but it is not cheaper than a razor blade.
Many Indonesian nurses believe that shaving is a common or routine preoperative intervention (George, 2002). Conversely, a study by Adams in 2003 found that there was no relationship between hair removal and infection rates. Adams established that “where possible surgery without hair removal is preferable to preoperative hair removal with a razor blade to prevent surgical site infection”. Adams also suggested that no hair removal may result more advantages than hair removal. More over, Bekar et al (2001) found that unshaven hair carried no more risks for infection. But, this study was only in patients who had cranial neurosurgery and patients without shaving were operated on only by one senior surgeon.
However, the findings above need more trials to be proved because of a systematic review by Inge et al (2002) said that “the disadvantages of shaving compared to no hair removal have been demonstrated only in observational studies and as tendencies in one of two randomized studies. Data give some support to the claim that not shaving patients undergoing surgical procedures is preferable to preoperative shaving”.
Between depilatory cream and unshaven hair, it was also no statistically different. It may be because the researchers used underpowered sample size (Hemingway et al, 2007). There were no studies which compared clippers and no hair removal.
Due to this, it was not strongly documented that shaving hair resulted in disadvantages than unshaven hair.
Regarding to the debate on hair removal and no hair removal, it was not strongly proved that hair removal resulted in a higher frequency of nosocomial infection than no hair removal. There were insufficient evidences to declare whether hair removal increases or reduces nosocomial infection. Due to this, hair removal will be planned depending on the needs, patient’s condition, operation area and comfort. Sometimes hair removal may be needed to administer some equipment in the operating room, such as to give an intra-venous catheter or to put plaster easily after surgery.
If it is necessary to remove hair, clipping (category I) or using depilatory cream (category II) causes fewer nosocomial infections than shaving with blade razors and it is recommended that it be carried out on the day of surgery. It is better to take away all razor blades in surgery ward or in operating room because it is more risk to get infection than other hair removal techniques (category II). However, it is more difficult to use depilatory cream in Indonesia because the patients have to pay more for patch test. On the other hand, clippers can be cleaned using a specific brush and reused for many times. Thus, clippers are more effective to reduce nosocomial infection and more efficient because the patients do not need to pay more.
It is also recommended that further research can find the comparison effects between no hair removal, clippers and depilatory cream in term of nosocomial infection and patient comfortable.
All in all, it is no differences between patients who have had hair removal and those who have no hair removal. If hair removal is needed for several reasons, depilatory cream and clippers are better than saving with razor blades. There are several recommendations that razor blades should be taken away from surgical ward or operating room. Even though, it needs more studies that patients who have had hair removal using razor blades get more risks for nosocomial infection than depilatory cream or clippers. Because of hair removal using depilatory cream needs a patch test to ensure the patient’s allergy, thus, for Indonesian; clippers may be more efficient than depilatory cream.
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