Science Feature - April 2006
By Ken Ortolon
Tradition dies hard. But when tradition kills people or makes them sick, it's got to go.
More than 30 years of scientific evidence has demonstrated that shaving surgical sites before operations actually increases the risk of sometimes deadly infections. Despite this evidence, many hospitals and surgical centers still shave patients, rather than removing hair with clippers or by other methods.
But that may soon change. Several organizations ranging from the Institute for Healthcare Improvement (IHI) to the National Patient Safety Foundation to the Texas Medical Association have taken up the issue. And they hope to ban the razor from the operating room once and for all.
"It's a fairly simple concept if we could just get people to buy into it from the [hospital] administration through central supply and all the way down," said TMA President Robert T. Gunby Jr., MD, who made patient safety a major focus of his presidential term.
Changing the Culture
Shaving the surgical site before an operation once was as routine as taking a patient's blood pressure in a physical examination. But beginning more than 40 years ago, medical experts began questioning whether the microscopic skin abrasions caused by shaving might actually increase the risk of postoperative infections, even in clean wounds.
In 1971, the American Journal of Surgery published research indicating that unseen razor injuries released bacteria into the surgical site. Several other studies conducted during the 1970s reached similar conclusions.
And in 1981, physicians in Alberta, Canada, published the results of a 10-year study of surgical site infections that showed having patients shower with antimicrobial agents before surgery and not shaving the surgical site reduced clean wound infection rates.
But dropping the razor in favor of clippers, depilatories, or no hair removal at all has been a painstakingly slow process.
Dr. Gunby says the tradition of shaving surgical sites is so ingrained in the medical culture that change is difficult.
"The problem is the infection rate is so low, just 1 or 2 percent. Nobody really sees many infections, so it's hard to get people to change. They really don't believe that it's important."
Houston neonatologist Michael Speer, MD, a member of the TMA Board of Trustees and chair of the Texas Patient Safety Alliance, says it's the "tyranny of small numbers." If physicians, nurses, hospital administrators, or others don't see large numbers of infections, they don't perceive that there is a problem.
Even though the rate of surgical site infections is statistically low, they impact hundreds of thousands of patients each year in the United States.
According to a study published in 2004 by the National Surgical Infection Prevention Collaborative, surgical site infections complicate 780,000 operations annually in this country.
And, IHI says surgical site infections account for 14 to 16 percent of all hospital-acquired infections. What's more, patients who develop surgical site infections are twice as likely to die as other surgical patients, IHI says.
IHI considers eliminating preoperative surgical site shaving so important it included it among six proven, lifesaving interventions it's asking hospitals and health care professionals to implement as part of its 100,000 Lives Campaign. The campaign is an 18-month initiative that IHI hopes will save 100,000 lives by June. The six recommended interventions include:
- Deploying rapid response teams at the first sign of patient decline;
- Delivering reliable evidence-based care for acute myocardial infarction to prevent death from heart attacks;
- Preventing adverse drug events through medication reconciliation;
- Preventing central line infections by implementing a series of interdependent, scientifically grounded steps called the "Central Line Bundle";
- Preventing surgical site infections by reliably delivering the correct perioperative care; and
- Preventing ventilator-associated pneumonia by implementing a series of interdependent, scientifically grounded steps called the "Ventilator Bundle."
According to IHI, ideal perioperative care has four key components: appropriate use of antibiotics, appropriate hair removal, perioperative glucose control for major cardiac surgery patients cared for in intensive care units, and perioperative normothermia for colorectal surgery patients.
IHI says Mercy Health Center in Oklahoma City reduced surgical site infections by 78 percent in one year by implementing these strategies.
IHI recommends hospitals and surgical centers simply remove all razors from operating rooms and supply areas as a first step toward adopting appropriate hair-removal techniques. The organization also says hair removal, when necessary, should be performed with clippers right before surgery, that hospitals should establish protocols for when and how to remove hair in affected areas, that patients should be provided with educational materials on appropriate hair-removal techniques to prevent shaving at home, and that shaving heart surgery patients for electrocardiograms conducted shortly before surgery should be avoided.
Last October, TMA, the Texas Hospital Association, the Texas Pharmacy Congress, and the Texas Nurses Association joined the 100,000 Lives Campaign. Since then, the TMA Select Committee on Patient Safety - appointed and chaired by Dr. Gunby - has focused its efforts on three of the six campaign interventions, including reducing surgical site infections by clipping, not shaving, hair on surgical sites. (See "TMA's Three Steps to Improve Outcomes of Texas Patients.")
The select committee is preparing an educational campaign to raise awareness of appropriate hair-removal techniques and why they're important. The campaign will include posters to be placed in physician lounges and operating rooms, as well as educational brochures for physicians and handouts that doctors can give to their patients. A physician-education brochure, "Doctors. Saving Lives" is included in this issue of Texas Medicine .
Dr. Speer says appropriate hair removal is really a systems issue for hospitals and surgical centers. But physicians can be a catalyst for change in the operating rooms in which they work, he says.
"Doctors now are realizing this is something where we can have a positive impact on patient care," he said. "And we need to get our physicians aware of this so they can tell their surgery centers, so they can tell their OR people to have clippers available."
Dr Gunby added, "It just takes one person in every hospital to be a champion for it."
Meanwhile, TMF Health Quality Institute launched a surgical site infection initiative that closely follows the interventions recommended as part of the 100,000 Lives Campaign.
Working under its contract with the U.S. Centers for Medicare & Medicaid Services, TMF has recruited 52 Texas hospitals to participate in a Surgical Care Improvement Project (SCIP) Collaborative, says Adonica Benesh, TMF director of hospital quality improvement. SCIP will be a more structured approach to reducing surgical infections than the 100,000 Lives Campaign, Ms. Benesh says. Participating hospitals will form interdisciplinary teams of physicians and staff included in surgical care. The teams will test changes, such as avoiding shaving the surgical site, that can improve their quality of care, and will report their results to TMF every two months.
The hospitals also will share their results with other hospitals in the collaborative, Ms. Benesh says.
Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
TMA's Three Steps to Improve Outcomes of Texas Patients
TMA has joined the Institute for Healthcare Improvement's 100,000 Lives Campaign to reduce patient deaths and injuries in hospitals, and adopted these three goals to help improve Texas patient outcomes:
- Prevent surgical site infection and related deaths by reliably implementing a set of recommended interventions for all surgical patients,
- Prevent deaths among patients hospitalized for acute myocardial infarction by ensuring the reliable delivery of evidence-based care, and
- Prevent adverse drug events through medication reconciliation.
In addition, TMA has established the Patient Safety Resource Center on the TMA Web site. The center is continuously updated with the latest news, research findings, and links to useful tools for practicing physicians.
You can e-mail your ideas for published patient safety research or clinical tools that should be included to Karen Batory, director, TMA Division of Public Health, Quality, and Medical Education, at karen.batory[at]texmed[dot]org.
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