Preoperative Skin Procedure in Nursing

Introduction:
As a nurse in a leadership role on a surgical floor, you and some of your colleagues have
begun to question some of the routine perioperative procedures that are conducted. You
wonder whether the procedures have a basis in research. In order to improve quality of
care, you decide to undertake an evidence-based project to determine the basis for the
procedures, any suggested changes, and possible barriers to implementation of a revised
clinical practice guideline.
Task:
A. Select a perioperative procedure (e.g., routine shaving of the surgical site) that you
would commonly find on a surgical floor.

  1. Describe the process or procedure you have chosen and why you think it needs
    change.
  2. Based on your initial investigation of the situation, do the following:
    Note: You will need to ask hospital personnel.
    a. Explain who determined the basis for the practice.
    b. Explain the rationale for making the decision for the procedure.
    c. Explain why the practice is performed this way.
  3. Conduct a review of the literature concerning the procedure you have chosen.
    a. Provide an APA-formatted reference list documenting at least five sources used in
    your review.
    Note: You do not need to write a review of the literature.
    Note: Credible sources may include professional journals, research reports,
    professional Web sites, governmental reports, current texts less than five years
    old, and presentations from professional meetings.
  4. Explain (suggested length of 1/2–1 page) what the clinical implications of this
    practice might be, based on your review of the literature.
  5. Discuss (suggested length of 1/2–1 page) whether the procedure could be done
    better, more efficiently, or more cost-effectively.
  6. Discuss (suggested length of 1/2–1 page) how you would involve key stakeholders in
    the decision to change this procedure or comply with a proposed change.
    B. Write an essay (suggested length of 1–2 pages) in which you:
  7. Discuss the difficulties in translating what you have identified in the research into
    practice.
    Note: You should distinguish between difficulties you would have interpreting what
    the research says and synthesizing it into a practice guideline or procedure, rather
    than just the outside barriers to change.
  8. Discuss the possible barriers you could encounter in attempting to institute a change
    in procedure, based on your evidence-based study.
  9. Identify at least two strategies that you and your team could use to overcome these
    barriers to change.
  10. Explain how you can apply your findings to guide the implementation of
    improvements to the procedure.

Part A

Preoperative Skin Procedure in Nursing

1. Preoperative Procedure and Why There is Need for Change

The current practice of pre-operative hair removal from a surgical site involves, noticeable, the use of razors. Though the Association of Operating Room Nurses (AORN) provides proper guidelines for skin pre-operative procedure of the surgical site, various setbacks are still identifiable in most clinical settings. The use of razors in pre-operative hair removal predisposes patients to a wide array of infections, which originate mainly from their skin surfaces.  The practices recommended by the AORN are attainable and are supposed to point to an optimal point of practice (AORN).

In the current policy/procedure, clinical staffs are required to make the surgical room clean prior to performing an operation; close examination of the surgical site is conducted to identify the extent of damage, and the need for shaving; razors are then used to carry out the operation. Among other elaborate specifics of the policy, the above mentioned details stand out as needing in change. Surgical site reports from various hospitals indicate that approximately forty percent infections occur in every sample of patients (Borgey, 2012). The suggested practices for the skin preoperative procedures by the Association of Operating Room Nurses as later discussed in this paper should be followed, so as to minimize occurrences of infections among patients undergoing surgical procedures.

There is a need to change the policy of pre-operative hair removal in order to prevent various infections arising from this practice. Prevention of surgical site infections is the basic objective for the preoperative team. There is need to change the policy because there are different factors which predispose patients to surgical site infections (SSI). It is estimated that 27 million patients undergo various forms of surgical procedures annually (Milstone et. al 2009). Approximately, 500,000 patients have been suffering from surgical site infections in hospitals. It is examined that annually 10,000 deaths are due to the surgical site infections (SSI) (Tanner, Norrie & Cochrane, 2008). It is required to control the surgical site infections for the sake of development.

2a. Determiner of the Practice

In 2009, the director of the hospital Memorial Hermann Southeast Hospital has made the policies and suggestions for skin preoperative procedure. The current director of the hospital has revised these policies and conversed to the managers. The concerned policy team of the department will change the policy after assessment or reviewing (Memorial Hermann Southeast Hospital, 2009).  

2b. Rationale for Decision Making of Procedure

Policies exist that guide this particular organization on matters concerning preoperational surgical procedure. These have been put in place to help in reducing occurrence of infections during or after the operation. Actions or procedures should be duly communicated to the surgeons and recommended alternatives sought. These are comprehensive suggestions put forward by AORN, but still there is need for further establishment for these policies. There is need for different types of solutions, privacy of the patient and preoperational charts for understanding the policy and method.

Researchers have demonstrated that pre-surgical shaving by use of blades, especially under non-hygienic conditions, increases chances of surgical site infections, as opposed to when clippers are used. However, at the time this procedure was being devised, it seemed to be the best alternative for the organization. Blades were cheaper as compared to clippers, or any other feasible alternative, and no research existed to show that the use of razors would pose challenges to patients. Sanitization of the surgical room, coupled with cleansing of the surgical team was an almost satisfactory step that was thought to combat any possible side chances of infections. In addition, shaven surgical sites made it easier for surgery to be performed, without interferences brought by existing hair.

2c. Justification of the Current Procedure

Pre-operational hair removal is considered an essential step in many surgical procedures, a as it helps shave off the hairs that might cause interferences during the procedure. Usually, the practitioners examine closely the surgical site and then shave off the hair around that particular spot. Apart from the above mentioned justification, this practice is also aimed at reducing chances of infections that might originate from the surface of the skin. The policy requires that the procedure be carried out of the operation room, which is a precautionary measure to avoid post-operational infections.

Additionally, the use of razors in hair removal is still adopted since is relatively cheaper as compared to its alternatives like the clippers. The procedure for skin protection takes place according to the surgeon’s instructions for the treatment of hair removal. In most the cases the area of surgical operation is treated with the antiseptics, through the depilatory procedure, or by use of clippers (though not always, but in advanced cases). The use of clippers in shaving is preferred to razors since it eliminates chances of occurrence of scratches that may interfere with skin obstructions. This goes a long way in reducing the passage of microorganisms from the skin surface into the surgical wound. The preparations are being take place in the holding area proceeding to the surgery.  At the beginning of the preparation, an alcohol-based product is used, though a catalog of frequently used solutions and preparation agents is not documented in the policy guide.

References

Borgey, F. et al.  (2012). Pre-operative skin preparation practices: results of the 2007 French national assessment. The Journal Of Hospital Infection, 81(1), 58-65.

Memorial Hermann Southeast Hospital (2009). Preoperative Skin Prepping, Policy and Procedure Manual.

Milstone, AAORN M, et. al (2009). Chlorhexidine: Expanding the Armamentarium for Infection Control and Prevention, (2), 274-281. Retrieved on February 15, 2013 from http://cid.oxford journals.org/content/46/2/274..

Preoperative Hair removal: Impacts On Surgical Site Infections (2009) (A Nursing Continuing Education Self-Study Activity) retrieved on February 26, 2013 from www.pfiedler.com/1091/1091.pdf

Recommended Standards of Practice for Skin Prep of the Surgical Patient, (2008). Association of Surgical Technologists Retrieved on February 15, 2013 from http://www.ast.org/pdf/Standards_of_Practice/RSOP_Skin_Prep.pdf

Tanner, J., Norrie, P. & Cochrane, M. K. (2008). Pre-operative hair removal to reduce surgical site infection. Australian Nursing Journal, 15(7), 27-29.

4. Clinical Implications of the New Process

Clinical implications of preoperative hair removal by use of razors are, as aforementioned, obviously dangerous, since they predispose the site to infections. Research shows that the use of clippers is less risky, though most infections originate from the patient’s own micro flora (Tanner, Moncaster & Woodings, 2007). A proper guideline procedure must thus be created to avoid any chances of bacterial entry into the surgical operation site. Simple scratches made by razors can pose serious dangers to the patient, thus this practice should be completely avoided. Due to increased rates of infections in the process of preparing for surgery, most patients are affected, as it adds to more suffering. Infected sites take long to heal, which may lengthen a patient’s visit to the hospital than is necessary.

In addition, the length of time spent in the preoperative stage is unfavorable to most patients who would want to get through with the procedure and retire to their normal businesses. Moreover, the hospital fraternity also suffers loss as a result of a prolonged stay by a particular patient, since resources will be squeezed. The hospital ends up spending much on a single patient, than would have been practically feasible.  Tanner et al. (2007) conducted a study in which they found out that carrying out preoperative hair removal is safer than leaving the hair unshaved, as the latter would result into more infections. In order to safely carry out this procedure, the researchers suggest that clippers and depilatory creams should be used, since these reduce chances of bacterial entry. Their statistics concur with other facts presented in literature that use of blades/razors is worse.

Celik and Kara (2007) have conducted a study on whether shaving before a spinal surgery would result in postoperative infections. The study revealed that shaving prior to carrying spinal surgery would increase the postoperative infections. In their research, out of 789 patients who underwent the spinal surgery procedure, 371 patients were shaved prior to the surgery while 418 patients were not. Four patients were affected by the infections in shaved category and one patient was affected by the infection in non-shaved category. These results reveal that shaving prior to the spinal surgery would lead to increase the postoperative infections.

Patient’s privacy should be maintained in the area where the pre-operative preparation is being performed. During this procedure, patient support would be required in the context of privacy. Educational communication should also be utilized for the credible treatment of hair removal.

5.  Improvement of the New Process

The old procedure of preoperative hair removal, as has been discussed, is inefficient and dangerous, owing to the risks of infection patients are exposed to.  Hospital Infection Control Practices Advisory Committee (HICPAC) has outlined an alternative procedure, which in view of all past experiences, would be able to eliminate problems associated with preoperative hair removal during surgical procedures. In their new guidelines, it is stated that in the preopearive procedure, hair removal should be avoided; unless it is proven that it would interfere with the surgical procedure. Alternatively, if the hair has to be removed thus, the use of electric clippers, instead of ordinary razors and clippers should be employed.

Conventionally, the above outlined procedure could be used by the surgical team to regulate any eminent infections.  Clear and strict guidelines have been set, which must be observed by every team member in the surgical room. Pre-operative cleansing of surgical team as well as the patient would increase the overall efficiency of the procedure. In extension, strict observance of the recommended procedure would lead to fewer risks, to both the staff and the patient. For instance, maintenance of privacy and prevention of post-operative infections would reduce the number of ligation cases launched by the patient, which would the nursing staff from a lot of troubles. As a result, the reputation of the staff, physicians and the institution would be upheld.

6. Stakeholders Involved In the New Process

Stakeholders could play an important role in implementation of the new preoperative procedure. For instance, they would be helpful in the implementation of the new procedure as they have a strong regulatory authority. Stakeholders from the medical and public health could be helpful in order to prevent the infections, especially at the national level. Medical agencies, human rights commissions, government representatives, health-related ministries, international organizations, research institutions, and other non-governmental institutions are some of the influential stakeholders whose opinions and contributions would be worthwhile in the process of implementing the new procedure (Milstone et al, 2009). These official groups have a strong impact on advocacy issues, and their joint efforts would culminate in a hybrid outcome, as far as set targets are concerned. Joint efforts would be helpful in order to achieve the targeted level.

Stakeholders can be involved in the process by holding talks with them concerning new strategic targets of the operations. Members of the public, for instance, could be made to participate in a survey, especially those that can provide expert advice on the matter at hand. Others, including research institutions, can be used as the key point-men in implementing the new change, since they could be act as public watchdogs, monitoring an evaluating a nation’s progress in preventing infections. Thus, stakeholders should be incorporated into both current and future activities in order to combat the problems of infections arising from poor preoperative surgical procedures.

Part B

B1. Difficulties in Translating Research into Practice

Carrying out of research into the new preoperative procedure that would be critical in eliminating infections is one thing; translating it into practice is quite another task that has a fairly different entity and challenges. For instance, incorporating the new procedure, by engaging the clinical staff in doing research is quite a challenge, especially during the normal working hours. Usually, health concerns come in form of emergencies, and less time exists that would allow the staff to engage in a research expedition. Secondly, not every clinical institution is endowed with the necessary reading and reference materials that would serve to inform them about the new process (Pyrek, 2002). Consequently, the medical staff, especially the old ones, would continue with the old practice, due to inaccessibility of research materials, e.g. the library. Evaluation of infections is one of the major difficulties experienced while translating research into practice.

In addition, most medical staff would find the new procedure involving and difficult to keep up with. Practical barriers would come in form of limited time, and inadequate materials to confer with the laid-down procedure, for instance, sanitization of the surgical team before every operation, regardless of the severity. Some cases which require surgery may be mild, and the clinical staff may consider it unnecessary to undergo the entire procedures which have been recommended. In combination, these barriers would slow down the implementation process of the new procedure, as envisaged in research.

B2. Barriers to Instituting This Change

Possible barriers to this change would include cost, resistance, and lack of preparedness on the side of the clinical staff. High initial hospital costs would be required for conversion of razors to electric clippers. In a study the cost of clippers and razors was compared and a large parity was identified between the two (Griffin, 2005). Thus, implementing this change would require a costly input, which the state might not be able to sanction immediately.

Secondly, resistance from existing medical staff members is an expected reaction. As is common with all human kind, inception of a new change is difficult, and people vary in the propensity to adopt new innovations. Most clinical staff would resist this because of the extra research and dedication needed, as well as extra procedures that need to be undertaken in the process. Another reason for resistance of staff members is the recurrent nature of razors. Additionally, lack of staff training on the importance of following the right procedure would be a possible cause of resistance (Ortolon, 2006).

B3. Two Strategies to Overcome Barriers

Successful implementation of the researched procedure would require an invention of appropriate strategies to overcome barriers arising. The state, in implementing this change for instance, should devise a plan that would strategically replace the old procedure in different phases, so that costs are spread across a wide period of fiscal plan. Funds can also be sourced from key stakeholders, especially the non-governmental organizations, and other interested multinational agencies. 

In addition, the advocator for change should come up with enticing strategies to beguile the rest of the staff to accept the innovation, and teach them on the possible dangers caused by the old procedure to the patient and them as well. There is also need to educate the rest of the staff on the importance of following guidelines of a safe surgical procedure. In order to carry out an efficient preoperative procedure, there is a need to acknowledge the importance of trained staff especially in the usage of clippers in a best manner. Mostly the merchants provide the instructions regarding their products. The complete struggle is required for the elimination of usage of razors in hospitals and there is need to educate the staff members regarding the usage of razors.

B4. Application of Findings

The recommended new policy steps will include replacement of traditional razors with clippers, aimed at reducing occurrence of surgical site infections. Elaborately, the surgical operation site, as well as the medical practitioners, should be spotlessly hygienic. The surgical area/spot should be thoroughly studied prior to the operation, and sanitized. If skin removal would be necessary, proper procedural steps must be followed, as outlined in the new policy, that is, by use of electric clippers and sanitation by use of alcohol-based solutions. Generally, preoperational shaving should be avoided as research has extensively shown that it leads to increased chances of infections.

In addition, the clinical staff would have to possess full knowledge and techniques of the new procedure, to ensure that both preoperational and actual surgical procedures are carried out in a proper manner that would not predispose the patient to any infections. These procedures, which would follow AORN’s guidelines, must be documented in a written format, where practitioners would easily access, and make reference to them. In line with advancement in technology, surgical hair removal through this procedure would be pragmatic, and if followed consistently by the medical staff, would lead to a remarkable decrease in cases of infections. Moreover, adoption of different strategies and AORN suggestions would be helpful in reducing the surgical site infections. A $7.5 million project is currently planned for the restoration of pre-operative areas. Preparation lists and skin preparation charts will be provided to assist the staff in implementing the new procedure. The policy will serve as a guideline to advance performance activities of the clinical staff, and ensure more satisfaction of patients.

References

Celik SE, Kara A. (2007) Does shaving the incision site increases the infection rate after spinal surgery? Spine; 32(15): 1575-1577.

Griffin, Frances A., RRT, MBA (2005). Preventing Surgical Site Infection, Nursing Management, 36(11):20-26.

Memorial Hermann Southeast Hospital (2009). Preoperative Skin Prepping, Policy and Procedure Manual

Milstone, AAORN M, et. al (2009). Chlorhexidine: Expanding the Armamentarium for Infection Control and Prevention, (2) pgs. 274-281.

Ortolon Ken, (2006). Physicians target hair removal to cut surgical infections,

Preoperative Hair removal: Impacts On Surgical Site Infections (2009) (A Nursing Continuing Education Self-Study Activity)

Pyrek, Kelly M. (2002). Pre-op Prep Should Safeguard Skin Integrity. Infection Control Today,

Recommended Practices for Skin Preparation of Patients, (2002). Association of Operating Room Nurses,

Recommended Standards of Practice for Skin Prep of the Surgical Patient, (2008). Association of Surgical Technologists

Tanner. J., Moncaster K. & Woodings, D. (2007) Preoperative hair removal: a systematic review. J  Perioper Pract; 17:118-21, 124-32.

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