Patient Skin Preparation for Surgery

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1 Patient Skin Prearation for Surgery Iman A.El Sayed, * Samar A. Hashem, * Abdallah S. El Sayed, * Iman M. Gadoua*, Ahlam E. Kamel, * Olivia K. Perse, ** Ehssan A. Baghagho, * Soraya R. Terzaki, * * General Organization of Teaching Hositals & Institutes. ** Centre Hositaliére Princess Grace Det, Monaco- France. ABSTRACT Skin rearation of the atient begins before arriving to the oerating room; its urose is to reduce the risk of ost oerative wound infection. The objective of this study was to assess the skin rearation for surgical rocedures in 3 different hositals of the General Organization for Teaching Hositals & Institutes (GOTHI) and to determine their conformity to the existing rotocol and make comarisons between them in their erformance. A rosective study using the audit was done for 1 month, nearly for the same eriod in each of the 3 hositals (A,B,C) to observe the skin rearation ractices considering showering, hair removal and the 5 stes of atient skin rearation on table in the oerating room. The global results revealed that the comliance rate in the three hositals together as regards erforming the 5 stes of skin rearation in the oerating room was 36.2%. It was 50.6% in hosital A, 43.3% in hosital B and 18.7% in hosital C. As regards showering before surgery, it was 55%, removing hair aroriately (cliing) was 23.7% and removing hair by means was 44.6%. Key words: Surgical site infection, surgical skin rearation, showering, hair removal INTRODUCTION The skin rearation of the atient begins before arriving to the oerating room (OR); its urose is to reduce the bacterial Corresonding Author: Dr. Ehssan A. Baghagho, General Organization of Teaching Hositals & Institutes, ehssanbaghagho@yahoo.com

2 load of normal flora on the skin which is a major risk for ost oerative surgical site infection. (1) In other words, the aim is to reduce the rate of ost oerative surgical site infection by removing soil and reducing transient microorganisms count to sub-athogenic levels in a short eriod of time and with least amount of tissue irritation and inhibiting raid rebound growth of microorganisms. (2) It has been shown that there is a high significant correlation between densities of bacteria at the time of surgery and the subsequent wound sesis. (3) Surgical Site Infections (SSIs) are the second most frequent nosocomial infection in most hositals, and are imortant causes of morbidity, mortality and excess hosital costs. (4,5) In our studies in GOTHI health facilities to detect nosocomial infections, the first most imortant tye of infection was always the surgical site infection. Many studies revealed the imortance of reoerative shower using a bacteriostatic soa. It is suggested to clean the skin from surface soil, debris and transient microbes. (1) It was found that the skin flora were greatly reduced in the atients who had a shower with chlorhexidine comared to those showered with lacebo. (6) CDC recommendation for revention of SSI requires atients to shower with an antisetic agent at least the night before the oerative day. (7) Regarding hair removal, all recommendations including CDC state that hair should not be removed at the oeration site unless it will interfere with surgery; and if hair needs to be removed, cliers are the best way to do this. (1) The timing of hair removal is another factor that affects occurrence of surgical site infection; shaving of the surgical site the night before an oeration is associated with a significant higher SSI rate. 296

3 Cliing hair immediately before an oeration has been associated with a lower rate of SSI than cliing the night before an oeration (SSI rates immediately before = 1.8% vs 4.0% night before). (8,9) In the oerating room, on table, the site of surgery should be cleaned with a soa before antisetic alication, so before the skin disinfection is initiated, the skin should be clean. (10) Alying an antisetic soa beginning from the area of the roosed skin designed for oeration. and concentrating on the site of incision, the reared area should be large enough to give a lace for extending the incision or creating a new incisions or a drain sites, if necessary ( recommendation category II ). (7,11) In GOTHI hositals a rotocol of work was exlained and distributed to be alied. A follow u rocedure was checked and confirmed. The objectives of the study were to: 1- Assess the comliance of skin rearation rocedures to the existing rotocol in three hositals. 2- Comare the comliance and erformance between the three GOTHI hositals MATERIAL AND METHODS Poulation and data collection: A rosective study was done using audit as a tool for 1 month in each hosital: A, B and C searately, using checklists reared locally by the infection control ersonnel. The oulation included all the atients that will be subjected to surgical rocedures in the main oerating theatres of the 3 hositals during the audit eriod. It included scheduled 297

4 general and secial surgery. The emergencies and normal labors were excluded. The data collected included, in addition to the identification data of the atient, the tye of surgery, showering details (where, when, by what), hair removal timing and tye, if done, and the 5 stes of skin rearation according to GOTHI rotocol:- 1- Cleaning with an antisetic soa beginning from the area of the roosed incision. 2- Rinsing with sterile water or sterile saline. 3- Drying with sterile gauze. 4- Alication of antisetic solutions (the same antisetic used in cleaning). 5- Waiting for the antisetic to dry. The following equation was used to calculate the rate of comliance to the rocedure done on oerating table: Number of correct rocedures Number of rocedures observed 100 Correct rocedures are those rocedures that fulfill doing the 5 stes of atient skin rearation in the oerating room. RESULTS The total observed cases included in the study were 473 atients distributed as follows: 150 in hosital A, 141 in hosital B and 182 in hosital C. Table (1) illustrates the differences between the 3 hositals regarding the showering ractice. Overall, 55% out of the 473 atients had showered, 24% of them had showered in the 298

5 hosital before surgery, and 15% had showered in the morning, which is the best timing. Most atients used bar soa. In comaring the showering between hositals, table (1) shows that 71.6% had showered in hosital B. Most of the atients in the 3 hositals had the shower at home (72%, 67%, 90% resectively). Having the shower the night before was redominant and the soa was the most common to use. Table (1): The Distribution of Studied Cases Regarding the Showering Practice Showering ractices Hosital A N=150 Hosital B N=141 Hosital C N=182 Total N=473 No. % No. % No. % No. % Have shower * B # A, C At home At hosital Night before In the morning Liquid soa Bar * C # A, B A, B # C A # B, C Table (2) illustrates the differences between the 3 hositals as regards data about hair removal ractice. Overall 211 atients had their hair removed at the site of the surgery (44.6%), 151 had their hair removed on the morning of the oeration (71.6%) 299

6 and 90 atients (42.7%) had their hair removed by razor. In comaring the hair removal ractice between the hositals, table (2) shows that in hosital B 69.5% of atients had their hair removed before the surgical intervention comared to 28.7% in hosital A and 38.5% in hosital C. Removing hair on the morning of the surgery occurred in 83.7%, 74.5% & 60% in hosital A,B & C resectively. Using Razor for hair removal was the redominant method in both A and C hosital (62.8% and 74.3% resectively) while using deilation (cream) was more revalent in hosital B (66.3%). Table (2): Distribution of Studied Cases Regarding Hair Removal Practice Hair removal ractices Night before Hosital A N=150 Hosital B N=141 Hosital C N=182 Total N=473 No. % No. % No. % No. % Hair removal * B # A, C In the morning Method used By razor Cliing Deilation * C # A, B * B # A, C Table (3) illustrates the differences between the 3 hositals regarding skin rearation ractice in the oerating room. The total comliance rate was 36.2%. It also shows that there is a significant difference between hosital C and both hositals A & 300

7 B regarding the skin rearation ractice at the oeration room. Figure (1) demonstrates that ste 1 then ste 2 followed by ste 5 are those with major defects (95%, 77.8% and 70.2% resectively). Table (3): Distribution of Studied Cases Regarding the Skin Prearation Practice at the Oerating Room Skin rearation ractice Hosital A N=150 Hosital B N=141 Hosital C N=182 Total N= 473 No. % No. % No. % No. % Skin rearation * C # A, B Incorrect skin rearation stes ste Ste Ste Ste Ste Total (%) Ste 1 Ste 2 Ste 3 Ste 4 Ste 5 Figure (1): Distribution of the Studied Cases According to the Incorrect Skin Prearation Stes. 301

8 DISCUSSION It is a known fact that any surface or object to be disinfected should be cleaned first. It was stated by CDC's 1999 guidelines and others that the incision should be clean before surgical skin rearation. In the standard recommended ractices, and guidelines of the Association of Oerating Room Nurses (AORN) and the French recommendations ublished in the "conference de consensus" in March 2004, the surgical site and surrounding areas should be clean before disinfection. (12) Considering our results about the showering ractice, there are differences in the overall ractice between Hosital B and hositals A & C which could be exlained by the fact that hosital B is an obstetrical hosital where females ay more attention to have shower before giving birth. Regarding the site of showering, the resent results may reflect one of the roblems in our general Egytian hositals as many of the facilities lack hot water. Issues to be considered are the number of shower units available for each deartment, the number of functioning units and the units with hot water suly. Regarding the timing of having shower, the results reflect the revious oint. The significant difference between hosital C and hositals A & B which could be exlained by the higher attention aid to imlement the surgical atient rearation rotocol by both hositals comared to hosital C. Regarding the hair removal ractice, the results are in accordance with the CDC recommendations secifying that no removal of hair is done unless the hair at or around the incision site will interfere with the oeration category IA; and if hair is removed, it should be removed immediately before the oeration, 302

9 referably with electric cliers category IA. (7) The whole ractice needs reorientation and training of the concerned health workers. Considering the atient's skin rearation in the oerating room, in our study, the non-comliance rate to the rotocol in hosital A was almost 50% reaching around 80% noncomliance in hosital C which needs swift intervention to raise the awareness about rotocol followed by regularly conduct assessment and evaluation for imlementation of the rotocol. By reviewing the 5 stes of the skin rearation the stes 1,2 & 5 are the least done. Ste 1: alication of the antisetic soa; cleansing. This was not done in 100% of cases in both hositals A & C and 81.3% in B. This could be exlained by the fact that old methods of surgical skin rearation begin by alying the antisetic to the atients without the rerequisite of cleansing first. Ste 2: Rinsing with sterile water or saline, which is accordance to the rotocol for revention of surgical site infection, stating: thoroughly washing and cleaning at and around the incision site to remove gross contamination before erforming antisetic skin rearation category 1B. (7) This was not done in 100%, 63.8% and 48.6% of cases in hositals C, B & A resectively. The deendence of this ste on ste 1 may exlain the low comliance to it. Ste 5: let to dry. Non-comliance to this ste was resent in 77.7%, 64.9% and 61.3% of cases in hositals C, A & B resectively. The exlanation of the antisetic characters and the imortance of the contact time to the concerned health workers may imrove this defect dramatically. 303

10 CONCLUSION AND RECOMMENDATIONS In site of the existence of a standard rotocol reared centrally and distributed after meticulous exlanation, the comliance to the rotocol is still far from being accetable. The surgeons as well as the oerating room nurses should be our targets in the near future lan. Extra efforts and regular follow u for the imlementation with frequent evaluation are needed as it is usually hard to change the old rotocol. For the three hositals it is recommended to suly them with the adequate devices and instruments which would be more beneficial than carrying out on-the-job training. REFERENCES 1. Gericola S. The surgical skin rearation. Plastic Surgical Nursing. 2001; 21(4) : Anonymous. Recommended ractices for skin rearation of atients. AORN Journal. 2002; 75 (1): Byrne D, Phillis G, Naier A, cuschieri A. The effect of whole body disinfection on interreting wound contamination. J. Hosital Infection. 1991; 18: Altemeier WA. Sesis in surgery, Presidential address. Arch Surg. 1982; 117 (2) : Brachman PS, Dan BB, Haley RW, Hooton TM, Gamer JS, Allen JR. Nosocomial surgical infections: incidence and cost. Surg Clin North Am. 1980; 60: Lynch W, Daveg P, Malek M. Cost effectiveness Analysis of the use of chlorhexidine detergent in reoerative whole body disinfection in wound infection rohylaxis. Hosital Infection. 1992; 17: CDC Recommendations Infection Control and Hosital Eidemiology. 1999:

11 8. Alexander J, Fischer J, Boyajian M, Palmquist J, Morris M. The effect of hair removal methods on wound infection. Arch Surg. 1983; 188(3) : Masterson T, Rodeheauer G, Morgan R, Edlich R. Bacteriologic evaluation of electric cliers for surgical hair removal.am J Surg. 1984; 148 (3): Association of Oerating Room Nurses. Recommended ractices for skin rearation of atients. AORNJ. 1996; 64(5): Shirahatti R, Joshi R, Vishwanath Y, Shinkie N, Rao S, Sank al J et al. Effect of reoerative skin rearation on ost oerative wound infection. J Post Grad Med. 1993; 39 (3): Bennett S, Nc neil M, Bland L, Arduino M, Villarino M, Perrotla D. Post oerative infections traced to contamination of an intravenous anesthetic, roofol. N Engl J Med. 1995; 333:

Bibliography. Surgical. Clippers

Bibliography. Surgical. Clippers Bibliography Surgical Clippers Key concepts The problem of postoperative infection can contribute to patient morbidity and mortality, increased length of hospital stay, and higher treatment costs. Preoperative