Clipping versus Shaving: Who Wins in the End? Infection Risk and Hair Removal Guidelines

Dave Droll, RT(R)(T)(CV), RCIS and Robert F. Schaper Heart Center
Dave Droll, RT(R)(T)(CV), RCIS and Robert F. Schaper Heart Center
Cardiac catheterization remains the standard for diagnosis and treatment of various cardiovascular conditions. Although cardiac catheterization in a laboratory environment is a sterile process, any surgical procedure carries some risk of infection.1,2 The median infection rate associated with cardiac catheterization was 0.35% in an early analysis of 107,203 procedures conducted in 385 laboratories.3 This study revealed that many factors affect catheterization-associated infection risk. For example, using a brachial approach, compared to a femoral approach, elevates infection risk ten-fold (0.62% versus 0.06%).1,2,4 Decisions about the site of vascular access are multifactorial and are generally made based on anatomy and planned procedure, rather than infection risk.4 In contrast, site preparation and care practices have a substantial impact on infection risk and can be improved without affecting surgical procedure choice and practice.2 The Centers for Disease Control and Prevention (CDC) has published infection control guidelines that address several aspects of site preparation and care, along with recommended hygiene practices for healthcare practitioners. The incidence and prevention of catheter-related bloodstream infections (CRBSIs) is thoroughly addressed in the Guidelines for the Prevention of Intravascular Catheter-Related Infections.5 The transmission of pathogens is discussed in detail in the Guidelines for Hand Hygiene in Health-Care Settings.6 Of particular relevance to cardiac catheterization is the 1999 publication, Guideline for Prevention of Surgical Site Infection.2 Despite the wide availability of these guidelines and their promotion by healthcare societies, the adoption of certain proven infection control measures has been slow. Specifically, pre-operative hair removal practices recommended in the CDC’s surgical site infection (SSI) guidelines have not been uniformly adopted in the catheterization laboratory environment. The objectives of this review are to describe the negative impact of nosocomial infections on patient outcomes, the relationship of hair removal procedures to infection rates, and how the adoption of the CDC’s recommendations may reduce infection risk among cardiac catheterization laboratory patients. Infection-Related, Morbidity, Mortality and Costs The incidence of nosocomial infections is tracked by the National Nosocomial Infection Surveillance System (NNIS) of the CDC.7 According to NNIS data, bloodstream infections and SSIs are among the most commonly occurring infections.8,9 Overall, approximately 2 million patients in the United States develop a nosocomial infection each year, and at least 90,000 die as a result of the infection.5“7,10 Septicemia alone accounts for 15% of nosocomial infections and 1% of all deaths.2,9,11 Among all surgical patients, 38% acquire SSIs, and 77% of deaths among these patients are due to infection.2 Along with the health consequences of infection, costs are increased when patients must remain in the hospital to receive additional care. Patients who develop nosocomial infections remain in the hospital an average of 18.2 additional days and the resulting excess costs average over $3,300 per patient.12 Hair Removal Practices and Infection Risk Traditionally, surgical sites, including percutaneous access sites for catheters, have been shaved with disposable razors due to the belief that hair would interfere with proper wound closure and healing.13,14 For decades, however, studies have been published demonstrating that shaving damages the skin and increases the risk of infection.15-21 The source pathogens for most nosocomial infections are skin-dwelling microorganisms.2,5 Razor shaving increases the risk of infection by creating microabrasions in the skin that allow skin-dwelling microorganisms to collect and multiply (Figure 1).2 These organisms may then migrate into the incision site and may also collect on catheters or sheaths that must remain in place for a period of time following the procedure. The longer a catheter or sheath is in place, the higher the risk for catheter-associated infection.22,23 In contrast to shaving, clipping hair using a rechargeable electric trimmer with a disposable head does not damage the skin and is associated with lower infection rates (Figure 2).2,15,19 In a prospective study that compared infection rates among 1,980 surgical patients whose hair was either shaved or clipped pre-operatively, patients who were clipped had a statistically significantly lower infection rate than patients who were shaved (p = 0.024) (Figure 3).19 These results support an earlier study of the effects of shaving versus clipping on infection rates among 1,013 patients undergoing elective surgery. Clipping decreased infection rates both at discharge and at 30-day follow-up. Cost savings of $270,000 per 1,000 patients were estimated (in 1983 dollars) if clipping replaced shaving.15 A study comparing the clinical and cost outcomes of shaving and clipping found a moderate initial increase in hospital cost when converting from razors to clippers, but concluded that substantial long-term cost savings could be expected due to the decreased incidence of postoperative wound infections. This study further recommended discontinuation of razor shaving because of its associated risk of infection.24 Depilatories also have been evaluated, although recent data demonstrating a beneficial effect on infection rates are not available.2,14 The primary advantage to using depilatories is for hair removal in areas that are difficult to shave. However, depilatories are associated with hypersensitivity reactions.2,17,25 Recommendations Some studies have recommended that hair not be removed unless necessary.20,21 The CDC’s guidelines for SSIs mention these studies, but make no specific recommendation to leave hair intact.2 In contrast, the AORN’s 2005 Standards, Recommended Practices, and Guidelines specifically state that hair should be left at the surgical site unless the physician orders that it be removed.26 Clinical studies evaluating the advantages and disadvantages of hair removal at specific sites on the body associated with cardiac catheterization procedures, such as the groin, are not yet represented in the medical literature. Decisions for determining whether hair should be removed are based on the amount of hair, the location of the incision and the type of surgical procedure to be performed. In addition, if removal is necessary, hair should be removed as close to the time of surgery as possible and in an area away from the sterile field (in the pre-catheterization holding area, for example) to prevent loose hair clippings from dispersing onto sterile surfaces and causing contamination.26 A rechargeable electric clipper with a disposable head or one that can be removed and disinfected should be used.26,27 This type of clipper allows the catheterization laboratory staff freedom of movement around the patient without being encumbered by a cord. The procedure in our catheterization laboratory is to prepare the patient’s groin site in the Pre/Post Cath area. We utilize strips of tape gently applied repeatedly to both groin areas to remove the excess hair. If a warm air blower is used for patient comfort, it is important to use the appropriate tubes and to ensure that loose hair has been removed in the area where the air will be blown. This creates a whole new set of contamination issues. For acutely ill emergency department patients who are taken directly to the catheterization laboratory, we prepare the patient on the cath table and, time-permitting, use tape to remove excess hair. Our catheterization staff members utilize the 3M Surgical Clipper with Pivoting Head, model number 9661 (Figure 4), as it provides a cost-effective means to meet the CDC and AORN guidelines and recommendations. Note: Next month’s issue will feature an article on betadine versus 2% chlorhexidine gluconate.
1. Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology. Task Force on Clinical Expert Consensus Documents. American College of Cardiology/Society for Cardiac Angiography and Interventions clinical expert consensus document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2001;37:2170-2214.

2. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20: 250-278.

3. Leaman DM, Zelis RF. What is the appropriate dress code for the cardiac catheterization laboratory? Cathet Cardiovasc Diagn 1983;9:33-38.

4. Olade R. Cardiac catheterization (left heart). Available at: http://www.emedicine.com/med/topic2958.htm. Accessed on June 24, 2005.

5. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002;51(RR-10). Available at: http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr5110a1.htm. Accessed on December 30, 2004.

6. Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/ APIC/ IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23(Suppl 12): S3-S40.

7. Gaynes R, Richards C, Edwards J, et al. The National Nosocomial Infections Surveillance (NNIS) System Hospitals. Feeding back surveillance data to prevent hospital-acquired infections. Emerging Infect Dis 2001;7:295-298.

8. Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 1993;6:428-442.

9. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21: 510-515.

10. Kohn L, Corrigan J, Donaldson M. To err is human: Building a safer health system. Washington, D.C.: Institute of Medicine, National Academy Press, 1999.

11. Hugonnet S, Sax H, Eggimann P, et al. Nosocomial bloodstream infection and clinical sepsis. Emerg Infect Dis 2004;10:76-81.

12. Chen YY, Chou YC, Chou P. Impact of nosocomial infection on cost of illness and length of stay in intensive care units. Infect Control Hosp Epidemiol 2005;26: 281-287.

13. Small SP. Preoperative hair removal: A case report with implications for nursing. J Clin Nurs 1996;5:79-84.

14. Meyer GM. Recommendation for surgical skin preparation: An integrative review of the literature. Online J Knowl Synth Nurs 1995;2:1-7.

15. Alexander JW, Fischer JE, Boyajian M, et al. The influence of hair-removal methods on wound infections. Arch Surg 1983;118:347-352.

16. Mishriki SF, Law DJ, Jeffery PJ. Factors affecting the incidence of postoperative wound infection. J Hosp Infect 1990; 16:223-230.

17. Hamilton HW, Hamilton KR, Lone FJ. Preoperative hair removal. Can J Surg 1977;20:269-271, 274-275.

18. Sellick JA Jr, Stelmach M, Mylotte JM. Surveillance of surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1991;12: 591-596.

19. Ko W, Lazenby WD, Zelano JA, et al. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 1992;53: 301-305.

20. Moro ML, Carrieri MP, Tozzi AE, et al. Risk factors for surgical wound infections in clean surgery: A multicenter study. Italian PRINOS Study Group. Ann Ital Chir 1996;67:13-19.

21. Winston KR. Hair and neurosurgery. Neurosurgery 1992;31:320-329.

22. Pawar M, Mehta Y, Kapoor P, et al. Central venous catheter-related blood stream infections: Incidence, risk factors, outcome, and associated pathogens. J Cardiothorac Vasc Anesth 2004;18: 304-308.

23. Munoz P, Blanco JR, Rodriguez-Creixems M, et al. Bloodstream infections after invasive nonsurgical cardiologic procedures. Arch Intern Med 2001;161: 2110-2115.

24. De Geest S, Kesteloot K, Adriaenssen G, et al.Clinical and cost comparison of three postoperative skin preparation protocols in CABG patients. Prog Cardiovasc Nurs 1996;11:4-16.

25. Olson MM, MacCallum J, McQuarrie DG. Preoperative hair removal with clippers does not increase infection rate in clean surgical wounds. Surg Gynecol Obstet 1986;162:181-182.

26. Recommended practices for product selection in perioperative settings. In: Standards, Recommended Practices, and Guidelines. Denver, Colorado: Association of periOperative Registered Nurses (AORN). 2005:433-436.

27. Masterson TM, Rodeheaver GT, Morgan RF, Edlich RF. Bacteriologic evaluation of electric clippers for surgical hair removal. Am J Surg 1984;148:301-302.