Preventing surgical site infection is a health intervention

Proposal for the implementation of surgical clippers/shavers versus razors to comply with best practices and the reduction of surgical site infections

 

1.0  Executive Summary

 

2.0  Background of Evaluation

The preparation for surgery has traditionally included the routine removal of body hair from the intended surgical wound site. Customary hair removal in the preoperative phase is a practice thought to offset the increased risk for post-surgical infections especially that hair removal was discovered to be a significant risk contributor toward developing infections. The act of shaving causes skin abrasions or microscopic nicks which can provide a favorable avenue for bacterial colonization, allowing skin-dwelling microorganisms to collect and multiply. Aside from this it was noted that the hair would interfere with proper wound closure and healing. There are three choices for removing hair: razors, clippers or shavers and chemical depilation. It was believed that razor shaving increases the risk of infection through the creation of microabrasions in the skin while clipping hair using electric shavers or trimmers does not damage the skin thereby lower infection rates. Preoperative shaving of the surgical site which is done the night before the operation is associated with significantly higher risks of surgical site infections (2007; 2005).

 

Preventing surgical site infection is a health care intervention which is based on scientific evidence. Surgical site infection is one of the most common types of adverse events occurring in hospitalized patients. As such, infections are identified to increase preoperative mortality, re-admission rate, length of stay and incurred cost for patients. The care components of surgical site infection include the day of surgery admission, the appropriate use of prophylactic antibiotics, appropriate hair removal and compliant with local surgical wound dressing protocol. Such ‘bundle’ is a group of evidence-based intervention for patients who will and is currently undergoing surgery. It was believed that when these care components are implemented together, substantial improvement will be achieved. The prevention is perceived to improve patient care and prevent avoidable deaths during the preoperative period that is why the intervention is strongly advocated. The preoperative period refers to the time period encompassing a patient’s surgical procedure including ward admission, anesthesia, surgery and recovery. Generally, the term preoperative refers to the three phases of surgery namely preoperative, intraoperative and postoperative. Surgical site infection, on the other hand, refers to the infection at the site of an operation caused by the operation.

 

As debatable as it is, the question remains to be about the best method to be used given that appropriate removal of hair does help prevent surgical site infections. Surgical site infections remain a major source of postoperative morbidity in patients undergoing surgery with complications that compromises patient outcomes while also increasing the cost of healthcare delivery (2008). Thereby, the requirement is to prevent nosocomial infection after surgery through appropriate patient skin preparation. Anderson and Millard (2006) believed that the results of research have been so overwhelming in favor of clipping that several healthcare organizations recommend a procedural change from shaving to clipping. As stated by the Association of preoperative Registered Nurses (AORN), when hair removal is necessary, an electric or battery powered clipper with a disposable or reusable head that can be disinfected between patients should be used, if possible. In accordance, the Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Surgical Site Infection affirmed that: if hair is removed, remove immediately before the operation, preferably with electric clippers (as cited in  2006).

 

3.0  Evaluation Design

 

4.0  Justification for Evaluation

It is of my best belief that evaluation could lead to significant improvements in the health care sector. However, evaluation has been a practice which lacks recognition in literature and research. Evaluating the implementation of surgical clippers/shavers as opposed to utilization of razors during the preoperative phase could lead to the development of a systematic understanding of reducing and preventing surgical site infection. Given that, there are no concrete and updated guidelines about the best practices in implementing surgical devices, the findings of this evaluation will be important. As such, the results of the evaluation will be a significant development of evidence-based benchmark practices. This evaluation will be significant for practitioners and service managers as well as policy makers and purchasers of the health service. Such evaluation will be also an important area of study for the academia towards the establishment of benchmark practices when it comes to proper hair removal using the most appropriate medium.  

 

5.0  Review of Literatures

 

The evidences of the implementation of surgical clippers/shavers instead of razors have its root since the 1980s. Several studies were conducted during that time. One is that of (1982) which reported that preoperative clipping immediately before operation is a safe and well-tolerated procedure. The researchers conducted the study through 200 patients while adhering to strict hospital protocols. They have discovered that unsatisfactory skin preparation was noted in 7% while that of clipped with 4%. Subcutaneous wound infections also occurred in 2% of the shaved patients and 1% in the clipped group. The problem, however, in this research is evidently on the generalisability of the findings. The researchers used a relatively small sample and that their findings are almost close to perfect. The research is also conducted during skin hair removal and does not provide a significant amount of time for subsequent occurrences.

 

 (1983) clearly said that preoperative shaving is deleterious and that the practice should be abandoned. The influence of preoperative shaving versus clipping was conducted with the contributions of 1, 013 patients whom will undergo elective operation the following day at a single hospital. The AM clipper method was used and was associated with significantly fewer infections than were the other methods as evidenced by scrutiny at discharge and after 30 days. The authors also noted that in every 1, 000 patients treated a saving of 0, 000 could be realized. Admittedly, however, the greatest benefit was in the group with clean wounds. This study has a clear implication for the responsibilities and competence of nurses with respect to preoperative preparation. A separated study after at least 13 years established this point.  (1996) conducted a case report with emphasis on the role of nurses, relating that preoperative hair removal is extremely dangerous when practitioners at all levels are not educated and that although they are informed, nursing negligence is punishable. The report figured that the findings reinforce the importance of strict adherence to hospital protocols to protect patient’s safety. 

 

A randomized prospective study conducted by  (1985) assessed the necessity of shaving before operation. They have included 716 cases which were divided into two groups. The first group is treated with traditional method of preoperative skin preparation, employing routine shaving and using centralize and chlorhexidine in alcohol for cleansing, while the second group was treated with an alternative method – without preoperative shaving. They have discovered that routine shaving has no advantage in reducing wound infection rate as evident by the 5.08% rate for the traditional method group and 5.56% for the alternate method group. Even so, the study is clearly one-sided as it only examined the before aspect of the operation. The question lies in the fact that the necessity of hair removal also applies in the condition after the operation. In lieu with this, another study offers a different perspective.  (1984), although their research is conducted a year before that of  , discovered that aside from having no distinct advantages, shaving is costly for both the patient and the care providers.    

 

A randomized controlled trial conducted by  (2005) found out that if hair removal is required, clippers cause fewer abrasions than razor blades based on interviews with 157 patients. These patients were interviewed twice, after shaving using a razor or a clipper and then two weeks after the surgery in aspects of pain, itchiness, redness and sustained cuts as well as opinions on shaving methods. However, the methods used by the researchers have inherent subjectivity since it focuses on self-assessment of the patients hence may not be reliable. The second interview was done through telephone. Nonetheless, the patients reported that 10% of both groups reported that they had experienced redness of the skin. In line with this study,  and  (2007) conducted a systematic review stating that there is insufficient evidence that using razor can increase the risks of nosocomial infections. However, if the need for removing hair arises, clippers must be prioritized over razor shaving because of the proven lesser infection rates of using clippers and trimmers.  (2003) supported such view, disclosing that clipping is a better hair removal method to prevent surgical site infection.   

 

A clinical review by  (2007) recommended that if hair removal must be practiced, then it would be conceivable to note that shaving the night before the surgery or at any time other than immediately prior to operation is considered inappropriate. Preferably, the use of electronic clippers shall be applied and razors should be removed from surgical preparation kits. While also, the hospitals must increase the level of physician and clinical staff awareness regarding the infection rates associated with preoperative shaving and that the patients must be also made aware of the consequences of shaving as part of the preoperative preparation. Aside from these recommendations,  (2005) also suggested that hair must not be removed unless necessary and unless the physician orders that it be removed. The decisions of whether to remove hair or not must depend on the basis of the amount of hair, the location of the incision and the type of surgical procedure to be performed.      

 

6.0  Relevant Stakeholders

Basically, the evaluation will include the surgery ward and operating suite as well as the surgeons, anesthetists, nursing staff from ward and operating suite, infection control professional and nursing clinical coordinator and the patients as well as the academia and the health and social care community. Specific considerations in choosing and determining the levels of engagement highlight three important aspects as health service improvement, accountability and confidence. Important is to held stakeholder consultation process after the stakeholders are identified and analyzed. Next is to disclose the information to them then negotiate.  Stakeholder engagement could take many forms and shape many consequences and influences but proactive engagement must be practiced at all times. As such, stakeholders will be engage as early as possible to cultivate ownership of the process. Stakeholders are a significant source of expertise which contributes to the design, implementation and outcomes of the evaluation.    

 

7.0  Criteria for Evaluation

There are five general criteria for this evaluation: safety, process effectiveness, economic impact/cost, clinician acceptability and patient satisfaction. Primarily, safety is a judgment of the acceptability of the health risk associated with using surgical clippers/shavers and razors. Though this aspect is more of a function of the clinician, infection control officer or the surgeon itself, safety is much important for the surgery patients. Efficacy of the process of hair removal using the most appropriate device is central on the risk reduction for patients, leading to improvement of signs, symptoms, diagnosis, treatment and prognosis. Consequently, there are direct, indirect and operational costs, and which could be determine using cost-related analyses. In the evaluation, acceptance of healthcare professionals is a must due to the negative influences imposed by levels of control over patient care. As such, clinician might avoid implementing a practice therefore precluding the benefits of complying with best practices. Specific aspects of patient satisfaction must be also considered such as convenience, comfort and willingness.      

 

8.0  Resource Implications/Requirements

It is hope that the evaluation will push through simply because I believe that the evaluation and implementation will benefit the healthcare community. There are direct costs of the evaluation including capital costs, building-related expenditure and other service-related expenditure. As well, there are also inherent administrative costs to the evaluation.  Nevertheless, the costs have differing relationships with the level of activity with respect to evaluation. For instance, the capital cost is fixed while other may vary depending on the changes of the level of activities. Overall, the evaluation is feasible considering the unit of activity. For every unit of activity, accomplishing an estimate of cost allocation would be plausible. In the meantime, the actual cost of evaluation cannot b determined because it is yet to decide whether to use top-down or bottom up approach to cost valuation of evaluation and implementation.

 

9.0  Data Sources and Collection

This evaluation will make use of the randomized controlled experimental model through random allocation. The rationale behind random allocation is to make the reduction of potential biases between two groups of people with different interventions easy. For this evaluation, the summative approach was chosen. The aim is to provide a summing up assessment of the things being evaluated, in this case, the implementation of surgical clippers/shavers against the use of razors. This evaluation also intends to inform decision makers of the necessary next step through a final report which will shape how the intervention develops ( 2002).  

 

Primary and secondary data sources will be both incorporated in this evaluation. Survey and interview will be conducted spontaneously because in-person interviews are the most effective method in obtaining answers to complex questions and that people are more likely to complete a survey when they are interviewed in person and when sufficient background information is provided. A semi-structured questionnaire will be used for this evaluation. Accordingly, semi-structured interviews provide the opportunity to ‘probe’ answers, which can be done in instances where there is a need or want for the interviewees to explain further or build on their responses. As initially planned, 500 patients, 250 of which are incised through razors and 250 through clippers/shavers, and relevant stakeholders will be surveyed and interviewed including surgeons, anesthetists, infection control professionals and nursing coordinators.

 

Archival data, hospital administrative data, patient records, medical reports, issue and working papers will be used as secondary sources of information. Journal and research papers to be retrieved both online and from local libraries also represents good source of secondary data and are probably the most reliable sources of information. This is because these resources tend to detail the results of other researchers’ findings compared to books. The biggest problem however will be finding specific papers on my subject area. Based on initial search, online libraries dedicated to medical category include eMedicine, PubMed and BMJ. Official statistics will be also incorporated in the evaluation in addition to books, the Internet, magazine and newspaper articles.   

 

Further, exact and sophisticated observation will be also employed during the evaluation process. Non-participant observation will be conducted and the observer will make use of audio and visual devices for recording observations. Observation guide will be prepared to aid observers during the process. A resource person with clinical expertise will be contacted to assist in observation. Observation encounters will start from preoperative to post-operative periods. What will be observed is the process of hair removal including the timing of removal and after effects of the process. Prior to observation, written consent and interview forms will be accomplished.     

 

10.0         Data Analysis and Interpretation

Multi-data analysis methods will be utilized for this evaluation. First is the qualitative analysis. Thematic analysis will be used for both secondary research and interview. Analyzing by theme, this type of analysis is highly inductive as the themes emerge from data and are not imposed by the researcher or evaluator. Background reading can form part of the analysis process. Thematic analysis is always accompanied by comparative analysis. For the qualitative analysis of the responses, content analysis will be used, a process which is more mechanical where analysis takes places after data has been collected. In this evaluation, there are two approaches to content analysis as the questionnaire will include open-ended questions. The first is through preparing a list of categories and the second is letting the categories emerge from the data, enabling the researcher and/or evaluator to quantify the responses (1998,). Further, the evaluation will make use of contrasts of photographs for further assessment of effectiveness.

 

The second analysis will be carried out through quantitative analysis to know the prevalence rate and incidence rate of the occurrence of surgical site infections.  Prevalence refers to the number of existing cases identified or arising in a population at a particular time while prevalence rate is the proportion of cases in a population at a particular time. Incidence rate, on the other hand, is defined as the proportion of new cases which arise over a period of time.   

 

Decision analysis method will be the third method. Decision analytic methods are primarily used in health care research towards the development of sound clinical interventions, policies or programs. Decision analysis is used to identify, clearly represent and formally asses the important aspects of a decision situation for the purpose of prescribing the recommended course of action. This can be done through applying the maximum expected utility to a well-formed representation of the decision. Influence diagrams and decision trees are the two most commonly used graphical representation of decision analysis. Influence diagrams (or decision network) and decision trees presents possible consequences, which include chance event outcomes, resource costs and utility.  (1996) asserts that both tools are useful in representing alternatives available to the decision makers as well as the uncertainty they are facing.   

 

11.0         Communication of Results

The evaluator’s responsibilities also include the communication of evaluation findings. There are two ways by which results will be communicated. First is through written reports. The final report will be divided into three subreports including the program antecedents, program implementation and program results. In addition, summary tables and technical appendix documents will be provided. Prior to final reporting, prerelease reviews of drafts and feedback workshops will be conducted. The final written report will be published in medical journals accessible to users and electronically via putting the findings on a database or dissemination network accessible to both users and other stakeholders. There will be also informal discussions of the findings with relevant stakeholders.

 

12.0         Recommendation

 

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