Hair removal is the focus of some concern and controversy. Studies have compared how clippers and razors impact infection prevention, while clinical guidelines have raised questions as to whether we should remove hair at all. We surveyed 121 readers on their hair removal practices.

When — and why — do you clip?
Pre-op hair removal is a common routine at 69% of the facilities we surveyed (see "The Long and Short of Hair Removal" on page 38).

General and abdominal surgeries on male patients, such as open or laparoscopic hernia repairs and gall bladder procedures, often see hair removed from the surgical sites. So do the knees, shoulders and other joints scoped and probed during orthopedic and sports medicine procedures. While hair removal tends to be performed primarily on men, women undergoing gynecological or urological procedures may be clipped to clear the site.

On the other hand, about 28% of survey respondents said they rarely remove patients' hair given the specialties they predominantly handle. Aside from male abdominal tucks, it's not a common occurrence in cosmetic surgery. "Only if the hair is physically in the way — almost never," says plastic surgeon Richard Karpinski, MD, the owner of Karpinski Ambulatory Surgery in New York, N.Y.

Female abdominal surgery doesn't often require hair removal, nor do pediatric, ENT, pain management or natural orifice cases. "Normally, in the few instances that we require shaving, we request that patients do their own shave prep at home," says Sheila Freeman, RN, BSN, director of nursing at the ArkLaMiss Surgery Center in Monroe, La., which specializes in pain management.

The decision on whether to remove hair is driven largely by the physician's preference, say survey respondents. With about 74% reporting that they clip at the surgeon's command, it was the leading factor behind the practice. About 59% also said that a specific case's demands — such as the type of surgery to be undertaken, the location of its incision in relation to a patient's hair and a patient's hirsuteness — determine the need for hair removal. These directed and practical considerations outweighed compliance with professional organizations' guidelines, recommendations and standards, which only 29% cited as a reason for hair removal.

No nicks on the skin
About 14% of survey respondents still use razors to remove hair, even though the Institute for Healthcare Improvement has called for the elimination of all razors from surgical facilities. The IHI's stand is influenced by clinical studies that have shown that razors, even when wielded carefully, can cause microscopic abrasions in the skin, which can provide portals of entry for resident bacteria and increase the risk of post-op surgical site infections.

These studies have put pre-op preparations into perspective, says Lisa Downs, RN, risk manager at the Madison Surgery Center in Madison, Ala. "We've come leaps and bounds from where we were even 15 years ago," she says. "We used to dry shave, which we now know nicked the skin. Now people are more conscious about it. It's actually become an infection prevention priority. We're doing clippers instead of razors. Doing a close shave isn't as important as doing it without nicking the skin."

For that reason, it's important to educate your staff, your surgeons and also your patients on the reasons to avoid razors. Especially your patients. While about 44% of survey respondents say they haven't had a problem with patients shaving their surgical sites themselves, some patients still believe this traditional practice is necessary and expected. About 18% of respondents actually include warnings to leave hair removal to the clinical staff in their pre-surgical instructions.

"Some patients think they are helping us by removing their own hair with razors, and we document this as they often nick themselves," says Kathy Mercuri, RN, BSN, CNOR, a nurse manager at Lake Health in Concord, Ohio. While her facility instructs patients not to shave the site, that instruction sometimes apparently goes unread, she says.

Do razors still have a place?
While razors have largely fallen out of practice for skin prep on infection control concerns and clinical guidelines, some survey respondents point out reasons for their persistence in pre-op.

• Infrequent use. If only a small percentage of your cases require hair removal, clippers may not be high on your instrument budget. "We use inexpensive safety razors and mainly shave the groin area for abominoplasties to improve the ease of suturing the skin," says Steven J. Smith, MD, the medical director at Parkwest Plastic Surgery in Knoxville, Tenn.
• To maintain sterility. When a case is prepped and ready to go, a sterile blade can be a time-saver. "Our staff uses clippers for all hair removal," says the clinical director of a Washington state orthopedic surgery center. "But if a surgeon makes a decision that additional hair needs removal within the sterile field, a sterile razor is provided to the surgeon."
• Sensitive areas. Loose skin isn't conducive to clippers, say OR observers. "Our specialty is urology," says Carole Shirk, RN, clinical director of the Berks Urologic Surgery Center in Wyomissing, Pa. "We do hair removal on a small percent of patients, but since it is in the genital area, the use of clippers is difficult. For some patients, we must use a razor in the genital area." Andy Beck, RN, BSN, director of surgery for Providence Surgery Center in Missoula, Mont., agrees. "Urology procedures seem to be the most difficult for surgeons to remove the hair with electric clippers. They say that you can't get a good job done with electric clippers, and that they'll still nick the skin."

Picking up the pieces
Most respondents (about 63%) said their hair removal practices always took place in pre-op, with the other 37% clipping or shaving in the OR immediately before surgery. Doing the job in the OR requires careful collection of the scraps to ensure a clean surgical site. "It's removed by a surgeon after the patient is under general anesthesia, then we remove excess hair with a sticky glove or tape," says Irene Harder, RN, BScN, clinical manager of the OR and PACU at Grand River Hospital in Kitchener, Ontario, Canada.

Some facilities have found practical reasons for hair removal. In addition to its direct infection prevention angle, there's also an indirect advantage, says Patrice M. Osgood, RN, BSN, CNOR, OR manager at the Lahey Clinic in Burlington, Mass. "We currently use [a chlorhexidine gluconate-alcohol skin prep], which has a 3-minute dry time on hairless skin. If the skin was not clipped, the drying time would be prohibitive."

Another facility integrates it into its surgical safety verifications. "Some of our surgeons remove the incision site hair while marking their patients," says an anesthesiologist for an Illinois health system. "This serves 3 purposes: The site is minimally disturbed, the surgeon's preference is ensured and the surgical site is confirmed with the patient."

Anne Kachelhoffer, RN, the administrator of Pace Surgery Center in Pace, Fla., says infection prevention efforts might benefit more from a focus on pre-op scrubs and post-op care. "Hair removal practices do not prevent infections," she says. "Personal hygiene does. The benefit of educating patients on this issue far outweighs the energy, time and money spent on hair removal. We implemented this as an improvement project for SSI rates with great results."