Evidence-based practice (EBP) entails the application of research findings showing the merits of a new intervention or process. To accomplish this, studies have to be collected and appraised before a decision to adopt the new practice is made. The PICOT method facilitates the process of EBP by providing a problem-solving approach that starts with a question, delimits the target population, defines the intervention’s place in time, and enables comparison between conventional and alternative practices. The following implementation plan is based on the results of a PICOT question comparing preoperative clipping with shaving when hair needs to be removed for surgery.
Description of the Problem
Surgical site infection (SSI) is defined as “an infection related to a surgical procedure that affects the surgical wound or deeper tissues handled during any given procedure” (Weaving, Cox & Milton, 2008, p.199). This typically occurs within 30 days of surgery and can be superficial, with only the skin involved, or more serious as to involve deeper tissues and underlying organs. SSIs compose 15% of hospital acquired infections and are the most common infections noted among surgical patients (Reichman & Greenberg, 2009). Infections of the surgical site significantly contribute to patient morbidity and mortality. Moreover, SSIs lengthen hospital stay and increase healthcare costs. Thus, prevention should be a major component of care.
Common operating room practices involve the removal of body hair through shaving as an adjunct to skin preparation. The often-stated rationale for this practice is that it reduces the likelihood of surgical site infections (Norwinski, 2013). Bacteria belonging to the skin’s normal flora are also present on hair and it is thought that removal reduces bacterial colonies. A high bacterial count is associated with higher chances of infection especially when other contributing factors are present (Reichman & Greenberg, 2009). Shaving is the best way to completely remove body hair. Another reason cited by surgeons is that shaving facilitates access to the operative site as for instance during a craniotomy.
However, there are studies showing that preoperative shaving actually does not decrease the infection rates (Sebastian, 2012). There are also research findings proposing that, on the contrary, shaving contributes to a higher risk of infection (Reichman & Greenberg, 2009). Further, there have been investigations on the greater effectiveness of other methods of preoperative hair removal such as clipping. In light of these findings and the need for greater accountability in the provision of healthcare, it is time to take a closer look at the practice of preoperative hair removal and shaving to ascertain what the literature is collectively suggesting about its effectiveness and whether there are alternatives that result in better patient outcomes.
The Proposed Solution
In the preoperative period, hair removal will be performed by nurses on the day of surgery using an electric hair clipper instead of a razor (Gould, 2012). If the case is an emergency, clipping will be done by OR nurses immediately prior to the start of the procedure. The usual solutions and methods of skin preparation will be carried out. Compared to shaving, clipping leaves a few millimeters of body hair intact. It does not cause minute abrasions or cuts because blades do not come into direct contact with the skin as razors do (Reichman & Greenberg, 2009). Microscopic skin injuries related to shaving are routes of entry for pathogens.
In addition, preoperative patient education will include instructions not to shave parts of the body that will be operated on. The basis for the change in practice will be thoroughly explained to increase compliance as male patients sometimes shave their chest hair and obstetric patients shave their pubic hair prior to hospital admission. It should be emphasized that shaving can increase the risk for infection. Patient questions should be elicited and adequately answered.
However, SSI is a complex clinical issue and hair removal through clipping should be placed in the context of a more comprehensive plan addressing the various factors contributing to unacceptable rates. Such factors include the physical structure of the operating suite, supplies used, and medical devices employed. Staff preparation, skin preparation, patient draping, instrumentation, and aseptic techniques are practices that also impact the rate of SSI (Weaving, Cox & Milton, 2008). Further, greater efficiency leading to shorter operative times, timely administration of antibiotics as prophylaxis, and the appropriate management of patient risk factors should be part of the comprehensive plan.
Rationale of the Proposed Solution
The U.S. healthcare system recently shifted to value-based purchasing. Reimbursements from the Centers for Medicare and Medicaid Services (CMS) are now based on a hospital’s ability to meet benchmarks and standards related to quality of care and patient satisfaction. These are indicated in guidelines pertaining to Conditions for Participation and Conditions for Coverage (The CMS, 2012). Falling short of these measures translate to reductions in total reimbursement or non-reimbursement that equate to financial loss.
Among the benchmarks used is the rate of hospital-acquired infections (HAIs) including surgical site infections specifically following coronary artery bypass graft, bariatric surgery, and orthopedic surgery (The CMS, 2012). It is expected that private health plan providers will also develop similar reimbursement schemes in the future. Value-based purchasing is consistent with the principles of the Accountable Care Act of 2010 promoting greater accountability.
Moreover, healthcare is a competitive industry. Consumers choose facilities and providers on certain criteria which include quality indicators. Accrediting institutions, most notably the Joint Commission, help consumers make decisions by certifying that facilities have met accreditation criteria associated with better services and patient outcomes. Media entities such as US News and CNN as well as consumer groups also periodically rank hospitals across the nation on the basis of performance. Being placed in the list of top hospitals complements marketing initiatives aimed at maintaining and expanding the organization’s consumer base. With various surgeries making up the hospital’s service lines, there is a need to improve hospital performance in terms of SSI prevention.
Evidence from Literature
A systematic review, especially if it includes high-quality randomized controlled trials, provides the highest level of evidence based on the evidence hierarchy (Polit & Beck, 2012). Tanner, Norrie & Melen (2011) and Hemingway et al. (2011) conducted separate systematic reviews which revealed that compared to shaving, clipping resulted in a lower rate of surgical site infection. Another systematic review by Sebastian (2012) validates this finding as well as adds that shaving may in fact increase SSI rates. Individual studies by Adisa, Lawal & Adejuyigbe (2011), Dizer et al. (2009), and Jose & Dignon (2013) are experimental research echoing the above conclusions.
However, the above systematic reviews point to poor quality and insufficient sample sizes as major limitations of the studies included. Researchers are still to respond to recommendations for more rigorous trials with larger samples that will enable a systematic review update with more definitive conclusions. Based on available evidence, the use of clipping in lieu of shaving when patient hair needs to be removed preoperatively have been incorporated in national guidelines developed by the U.S. Centers for Disease Control and Prevention (CDC) and the Surgical Care Improvement Project in the U.K. (Norwinski, 2013).
Obtaining Approval and Support
Modifying the current preoperative hair removal practice entails a change process. Kurt Lewins’ change theory states that there must be acceptance of the need for change, effective change management during implementation, and reinforcement of the change to achieve success (Spector, 2010). The support of management and stakeholder buy-in are indispensable components of the process. Major stakeholders are OR nurses, surgeons, and surgical patients. Thus, approval by the medical director and chief nurse needs to be secured. Submitting a proposal will initiate this process. Leadership must communicate their commitment to the practice change verbally or through writing and by role modeling to inspire OR personnel to follow (Frankel, 2008).
Resistance is an expected stakeholder reaction to change. It stems from a reluctance to go beyond one’s comfort zone to learn and apply something new. Using a participatory approach to implementing the change should overcome initial staff resistance (Borkowski, 2009). This will be realized by conducting a one-month pilot study wherein the change is adopted by a limited number of OR nurses and surgeons on a limited number of cases. The experience will be documented and assessed to further enhance actual implementation.
The staff will be involved in determining the brand of clipping equipment to use, how to fit the added costs into the budget, gathering data, how to communicate the change to patients, and evaluating the outcomes of both pilot and implementation. By promoting ownership of the practice change through participation, stakeholders are more likely to give their solid support (Borkowski, 2009). A pilot study is also an opportunity to obtain feedback from patients.
Implementation Logistics
Following the pilot study, the planned shift to using hair clippers for preoperative hair removal will be reevaluated and finalized for full implementation. This will be a nurse-led initiative since preoperative hair removal is a responsibility of OR nurses. However, hair removal affects surgeons who may assert, on behalf of patients, what they believe would be the benefits of shaving. They may also see incomplete removal of body hair as a hindrance to their performance of surgical procedures. Therefore, their involvement and buy-in would be elicited. The formation of a multidisciplinary committee for the reduction of SSIs within a culture of sustained quality improvement can take on the change as one of its projects.
Resources Required for Implementation
Staff education is a major component of implementing the use of hair clippers. A good understanding of the rationale and evidence base underlying the practice promotes the necessary behavioral change (Borkowski, 2009). A learning needs assessment will determine gaps in knowledge and skills that will be addressed through in-service education sessions using lectures with PowerPoint presentations as teaching strategies. Demonstrations on the use of hair clippers will also be held. Creating pamphlets and posters will be useful for patient education. There are also costs associated with developing and implementing education and training as well as administrative expenses.
Conclusion
Evidence-based practice requires openness to change and a commitment to safe and quality patient care. Using the PICOT question promotes the use of EBP. Available literature supports the effectiveness of preoperative clipping instead of shaving hair in reducing the incidence of surgical site infections. Current regulatory and market pressures also drive better performance by reducing SSI rates. Planning and implementing practice changes to achieve this goal is a multidisciplinary responsibility where nursing leadership is vital. This can only be successful within an organizational culture of commitment to quality and if participatory change management is utilized. Planning must incorporate logistics and cost data to ensure the availability of needed resources.
References
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Tanner, J., Norrie, P., & Melen, K. (2011). Preoperative hair removal to reduce surgical site infection. Cochrane Database of Systematic Reviews, 11(3), 22-25.
The Centers for Medicare and Medicaid (2012). Retrieved from https://www.premierinc.com/safety/topics/guidelines/cms-guidelines-4-infection.jsp
Weaving, P., Cox, F., & Milton, S. (2008). Infection prevention and control in the operating theatre: reducing the risk of surgical site infections (SSI). Journal of Perioperative Practice, 18(5), 199-204.
