Tuesday, May 29, 2012

A “rule” without foundation

The practice of medicine often involves “rules” that are not based on fact or evidence. Many of them are justified in a manner similar to that which we use with our children—“because.” The rationale for some rules is “that’s the way we’ve always done it.”

How about a rule prohibiting the clipping of hair in the operating room? My hospital has decided that if hair is to be clipped, it must be done before the patient arrives in the OR. One reason for this is said to be prevention of infection by loose hair.

Wait a second. It is generally agreed that the fewest wound infections result when patients are not shaved or clipped at all. If that is so (and the evidence is convincing), then why would hair cause a problem if loose? I am not aware of any data that supports the claim that clipping hair in the OR causes wound infections.

After asking about the source for this rule, I find it originates in standards promulgated by the Association of periOperative Registered Nurses (AORN). On page 367, the AORN 2011 Perioperative Standards and Recommended Practices states “Hair removal should be performed the day of the surgery, in a location outside the operating or procedure room.” The justification is said to be “Clipping the hair outside of the operating room minimizes the dispersal of loose hair and the potential for contamination of the surgical field and surgical wound.” No reference is cited.

Other sources such as the Association of Surgical Technologists’ Standards (I.3.B.) say the “shave prep should be performed in the preoperative holding area where the privacy of the patient can be maintained.” I don’t know about your OR holding area, but every holding area I’ve ever seen is far less private than the operating room itself.

The AST apparently hasn’t received the memo that “shave” is not the correct term and has not been for many years. So it’s not infection that’s the problem; it’s privacy?

In addition to not being evidence-based, the recommendation would be difficult to follow because clipping in an area outside of the OR itself will delay the case. If clipping is necessary for the purpose of applying tape after the operation, I prefer to do it myself because 1) I know it will be done without inflicting injury and 2) it will encompass only the area that I want clipped.

I performed a thorough literature search and found nothing to justify this rule regarding infection or privacy.

The problem with rules like these is that, as is the case with the 55 MPH speed limit, rules without reason are often not followed. This breeds mistrust of authority leading to failure to abide by reasonable rules too. General anarchy follows and civilization as we know it will be destroyed.

Do you know of any other "made up" rules like this?


Robert said...

Here's one "made up" rule that irks me:
Having to quote a reference for every statement or rule or it's considered baseless. God forbid you should have to think to come up with a conclusion of your own.

The argument that you make against the recommendation is weak and it seems like you played the evidence based medicine card just cause you had nothing better.

Isn't it easier to clean up after you've clipped hair if its done outside rather than in the OR?

Could it be that it was a policy that was put in based on some case where someone supposedly got infected because of loose hair?

Skeptical Scalpel said...

Robert, Thanks for commenting. I agree that one can go overboard insisting on seeing evidence for everything. We certainly do a lot of things in medicine that are not evidence-based and yet are beneficial for patients.

But this hair-clipping rule came out of nowhere. Hair does not cause wound infections. The evidence is clear that not clipping or shaving hair leads to fewer wound infections. The only reason to remove hair is to facilitate the application and removal of a dressing when needed. It does not matter where this is done.

Even if one patient developed a wound infection because of a hair (impossible to prove), does that justify a rule mandating that everyone has to be clipped in a different place?

We have too many "rules" as it is. The AST standards for skin preparation are 11 pages long not counting the (few) references.

WakingUpCosts said...

1. No warm-up jackets in OR
2. No forced air warming until patient draped.
3. No briefcases in OR.
4. No one may enter room without circulator's permission.
5. No room warming as may cause condensation on surgical instruments.

Skeptical Scalpel said...

WakingUpCosts, those are some real beauties. I could write several blogs, but my early favorite is condensation on the instruments. If they are sterile, how does condensation, if it even occurs, cause a problem? What do you do when you are operating on children? Do you still keep the room cold?

RobertL39 said...

1) Nurses cannot assist the anesthesiologist in placing a regional block by administering the local anesthetic at his/her request. HAS to be an MD.
2) Remove masks every time you leave the OR. And no letting them hang down with just the lower tie done.
3) Circulating nurse and anesthesia have to talk about and agree on the time the case started, anesthesia started, case finished, out of room, etc. How many man-days are wasted doing this every day?
4) Instead of being issued an ID badge, equipment reps in the OR have to get their picture taken and a new, temporary badge made every time they visit.

Skeptical Scalpel said...

RobertL39, I appreciate the comments. I like the one about the masks.

We have one, which nobody follows, that says masks must be worn by anyone in the scrub sink area even if that person is not scrubbing but just walking by. Rationale? Who knows?

Neal Lippman said...

The fact is that a vast amount of what we do in medicine He is based on convention and and anecdote and not in fact or evidence. Anyone who has practiced medicine for any length of time could produce numerous examples. It's all magical thinking.

Now that we have "evidence based medicine," everything seems to be based on "clinical guidelines." Even leaving aside the fact that none of my patients seem to have read the guidelines and therefore they have not instructed their bodies to fall into the specific pigeon holes covered by each guideline, and leaving aside the fact that blind obedience to guidelines leaves little room for medical judgement, and noting that the guild lines have NOT been demonstrated to improve outcomes:

The guidelines are conventionally characterized by the "level of evidence" leading to each guideline. While level of evidence "A", multiple randomized trials, probably indicates a guideline that is worth following, or at least considering for an individual patient, far too many of the guidelines are level of evidence "C" - expert consensus. So, basically, the 8 or 10 guys who got into a room to make the decisions, and got there because they were recognized as "experts in the field" or were politically connected or were friends with someone who was making the committee selections, write down what they think is a good idea without any evidence other than their "experience," which means what they have a always done, and - boom - it's a guideline with the force of a medical society behind it.

w hyman said...

Well then, in the absense of level A, lets just leave everyone to do whatever they want. Freedom to practice! Who cares what 8 or 10 guys think? (Wait..could there have been any women?) Just because something seems like a good idea, doesn't make it so anyway.

Skeptical Scalpel said...

Thanks for the comments, gentlemen. Let's meet in the middle. I think that many guidelines that are based on expert opinion are better than all of us doing things according to our own isolated experiences.

But don't forget that guidelines are not meant to be rigidly applied to every patient. They are guidelines, not laws.

Josh said...

I had the exact same reaction when the VA here a year ago started banning scrub caps, insisting that everyone wear scrub bonnets instead. Why? "Prevents infection." "Patient safety."

This is madness! 'Evidence-based' practice is not without it's faults, but the overall point is to eliminate superstition and baseless bias from what we do. This is no different for bleeding somebody who has influenza.

Ditto for you comments on how this stuff also weakens authority and leadership.

Skeptical Scalpel said...

Josh, good comment. We have the same issue with the caps. The state came in and outlawed the traditional caps. Now everyone, regardless of amount of hair, must wear a bouffant hair net. We look like a bunch of bozos. Of course, there is no evidence that any sort of cap prevents infection or that one style is better than another. And now cloth caps are creeping back in. Who knows when they were last laundered, if ever?

Robert C said...

The hospital I work at has no 13th floor...it goes from 12th to 14th! In this setting, I am expected to convince my patients that I have good evidence for many recommendations!

Skeptical Scalpel said...

Robert C, great point. Superstitions are powerful, just like some of our rules.

Jayne HIStalk MD said...

I think many of the "rules" defining the sterile field are bogus. OK, if I accidentally touch myself above the nipple line, I'm contaminated. Below the nipple line, I'm OK. My nipple line is a lot lower than that of a 6' 6" orthopod. It's a power trip for scrub nurses. Back in the day of real towels and towel clips, I once came out of an OR looking like a medieval warrior with layers of armor (towels) clipped all over me as well as sleeves and other paraphernalia. Bottom line - scrub nurse didn't like me.

Gwynedd said...

Thank goodness we don't have a rule mandating hair removal the day before surgery, since for a reasonable number of our cranial cases, we plan the incision after the image-guidance frame has been hooked up to the patient's head in the OR, and then clip a small area of hair around it. Or at least my colleagues do. I actually don't usually remove hair, because of the lack of evidence for its benefit in terms of infection control. (Unless I'm doing a VP shunt, and I will be quite honest that I have no evidence to suggest one needs to in shunts; it's pure tradition and superstition given that they have a relatively high infection rate with a significant consequence to the infection.)

I completely agree that rules without reason are often not followed and it becomes harder to justify enforcing those with reason behind them. One that currently frustrates me is that there is legislation in place here that mandates that "all" tissues removed from a patient be sent to pathology for analysis. It sounds reasonable enough, but in practice it means that for instance, any bone, epidural fat, whatever I remove doing a laminectomy has to be sent, even though there is nothing "pathological" about them, and it gets decalcified and examined microscopically. Any cervical or lumbar discectomy, we have to send the disc tissue. These do not need pathological analysis and it's a waste of resources, but so far we have not managed to get them on the exemption list. Other centres have looked at this and concluded there is no reason to do this (theoretically I suppose one might pick up an undiagnosed malignancy?? but if it didn't show on imaging, pre-op bloodwork, or gross examination of the tissue, the yield is so low as to be ridiculous.)

Skeptical Scalpel said...

Jayne, some scrub techs and circulators can be difficult. I've seen many a passive-aggressive one over the years. A while ago I adopted a new strategy, which was to cheerfully acquiesce whenever they tried to start a confrontation. it totally disarms them.

RobertL39 said...

Maybe, just maybe, instead of all of us bending over for a new one we should ask to see the EVIDENCE on which this practice is to be based. Stand up to the 'authorities'. Say "NO!" You have only your silly rules to lose. Otherwise they're just gonna' keep coming and changing and making everybody soooooo happy.

Skeptical Scalpel said...

RobertL39, I've tried to get them to show me evidence. Their response is what resulted in this post. There is no evidence. It's a rule someone made up, but since it's a "standard," they think it should be followed. It's hopeless.

RobertL39 said...

Just tell them that you're not going to practice evidence-based medicine unless they agree to do it with you! They think it needs to be followed because some accreditation monkey needed something else to check on his rounds, else he might not have any work to do! So he made this one up and now everyone has to be accountable. If nobody stands up to them, you're hosed. A simple "No" suffices. We really are in control; we just don't exercise it and let ourselves get pushed around. We deserve what we get.

Skeptical Scalpel said...

Gwynedd, Sorry that I missed your comment and was so late in posting it. I agree about sending scraps of tissue for path. I have been in places where the rule was enforced so strictly that we sent chemotherapy ports, nails and sewing needles that we removed from feet.

Phil said...

This showed up a few days ago:


What say you?

Skeptical Scalpel said...

Thanks for the question. I had seen that article. It is old news. We've known for more than 20 years that shaving increases the risk of wound infection, especially if it's done the night before. The only reason I clip (with a clipper, not a razor) hair is to help keep a dressing from falling off and to lessen the pain of removing tape from the patient's skin. The clipping is always done by me right before the surgery. For laparoscopic cases, I don't even clip. We use glue for the skin and no dressing is needed.

Anonymous said...

A silly example of nursing dogma that drives me nuts: You MUST turn off the tube feeding before lowering the head of the bed to reposition the patient.

Most of my colleagues are convinced that the infinitesimal amount of tube feeding that goes in [@45ml, or 3 tablespoons, an hou] over the 5 minutes the HOB is down will make the patient more likely to aspirate. The looks of horror if I don't comply with this (or the noble expressions if they fix my "mistake") are funny.

Hmm...maybe someone could publish a study on how likely this dangerous practise is to cause patient injury? My explanations of why this practise is based on an old wives tale are insufficient to overcome their indoctrination.

(Sorry, I'm late to the discussion...and I'm not going to admit how long I've been reading your back posts today)

~A.W. (RN)

Skeptical Scalpel said...

Thanks for the comments. If it makes you feel any better, the practice of turning off tube feedings for repositioning is not unique to your hospital. I agree that it is not evidence-based.

I am also aware of places that have a rule that tube feedings must be stopped for gastric residuals as low as 50 mL, which is often lower than the delivery rate. That is absurd and results in many needless interruptions.

Anonymous said...

I find it funny that everyone walks around the OR without a mask and when it's time to open the case masks up and the air is magically clean!

Skeptical Scalpel said...

Yes, there are many inconsistencies about the way things are done.

Anonymous said...

From the last anon's comment: everyone walks around with their masks down and when its time to open masks up and the air is magiacally clean.... there was an earlier posting about condensation on instruments and SS said if it is sterile what does it matter. Well I think the above comment is the reason it matters. The air is not sterile and contaminants do fall on instruments probably at a higher rate when there is moisture in the air due to the difference in weight of the air droplets saturated with moisture.
Sounds good anyway.
I think there are a lot of rules that are silly. Lets face it as long as there are infections and administrators who need to justify their jobs, there will be useless rules!
We now can only wear our cloth scrub caps if we cover them with a disposable hat. I guess because the germs will jump off my hat! I still continue to have contact with my hat. ?? makes no sense. Also, now we must wear disposable jackets that are ill fitted in the sleeves. We are now being asked to prep with sleeves down. I thought the rational was good, I wouldn't be shedding on to the prepped area, however, now my sleeve (which I am sure is more contaminated than my arm) is now coming into contact with my prep. I have recognized this and now prep sleeveless, but what about the preps I did and did not notice the contam.? I prepped sleeveless for years and not once did anyone tell me I had a patient with post op infection. i followed our board regularly to make sure that my pts were not listed, so that if they were I could correct my practice! Basically if they want a sterile prep then the circ. is going to have to sterile gown and glove prior to prepping!
And talk about inconsistencies, I work on weekends and I had a surgeon ask if we had to wait the drying time of 3 minutes for the chloraprep because it was a weekend! I told him that fires happen on weekends too and yes we would be waiting! I wasn't completely sold on drying time for some procedures until in our facility they had a small fire (very small, no injury, no burn through drape, but the drape did catch fire), during a laparoscopic surgery from the cautery. They said that immediately when the cautery button was pushed the spark flamed and they got it out immediately, but could have been much worse. So it is only because I tell that story that I am able to get the surgeon who does not want to wait or think it is important to wait. Like you said it is hard for people to get on board or adopt things if they don't fully believe in it. But I ramble on....and on and on...LOL

Skeptical Scalpel said...

Great comments, thanks. I'm not so sure about your theory on condensation though.

What would be the point of wearing a cloth cap if you have to put a paper one over it? :-)

Hospital epidemiologists are obsessed with sleeves.

Excellent point about the near fire.

George Gasman said...

(Old anesthesiologist here...)

The "Department of Public Health" paid a surprise visit to a place I used to work. They cited the hospital because a surgeon was wearing a piece of religious jewelry around his neck (a cross) into the operating room.

He wrote them an interesting letter. It went sort of like this:

"It is my understanding that the mission of the "Department of Public Health" is to ensure safety of the patients who are under our care. During a recent visit, I was cited for wearing a cross into the operating room. You felt that I endangered my patient in this way, despite the fact that I was gowned and the dangerous object was covered.

I submit that your department is also complicit in endangering the patient. When I walked into the room, no one from the DPH stopped me from proceeding with the operation. If I was such a danger, why was I allowed to proceed?"

Of course, he got no response.

Kellie Newman said...

Cloth hat controversy
Circulators wearing warm up jackets to prevent "skin cells from shedding".
No briefcases.

Sigh. Ridiculous.

Skeptical Scalpel said...

George, great story. That's an excellent point. If the cross was endangering a patient, the state should have stopped the surgeon from operating.

Kellie, I share your frustration.

Anonymous said...

Someone with access to the AORN guidelines, please quote me the paragraph that states disposable hats are required, and the references attached to that recommendation. God! I hate dogma.

Skeptical Scalpel said...

Don't hold your breath for that reference.

George Gasman said...

Sigh. New Nazis...oops, I mean new leadership in the nursing department of our small OR. As of today, "surgeon's caps" like I've worn for the last 34 years in the OR are verboten. It's a bouffant cap for everyone. This evening, all the boxes containing surgeon's caps disappeared from the locker rooms.

When confronted, I will ask how the hairs from my head can migrate to the open wound when I'm sitting behind the blood-brain barrier...oops, I mean "ether screen."

Skeptical Scalpel said...

George, according to the AORN, hair is autonomous. It can go wherever it wants to. It has a predilection for operative wounds, [Reference: AORN Standards]

Anonymous said...

Do you have to remove your hat when you leave the OR if you are remaining the facility? Thoughts on lab coats over scrub attire when leaving the OR but remain in facility

Skeptical Scalpel said...

Yes, removing one's OR cap if one left the OR was a rule at the last place I worked. Lab coat over scrubs when outside the OR suites was also a rule. I don't believe either rule has any basis in fact. I didn't mind the lab coat rule because I needed the pockets to carry my stuff in anyway. The cap rule? I have no idea why it exists.

Anonymous said...

Very interesting discussion. On the topic of clipping in the OR or before coming into the OR, I would point out that clipping hair is normally performed before any prepping has been done. So, the loose hair from clipping is not clean or aseptic. In contrast to that, the patient is prepped if hair is not clipped, so the hair on the patient at surgery is clean and hopefuly aseptic. So the argument that if prepped hair on the patient is OK, then loose dirty hair is OK seems illogical to me.

I would think there is a big difference between loose dirty hair and intact prepped hair.

But you are absolutely correct, no studies have addressed this question in the medical literature.

Have medical professionals looked to other types of standards, like clean rooms, to see whether any work has been done on this for other fields? Or has anyone figured out how clean the air in an OR needs to be to reduce SSI, and then figured out what contribution hair makes to particles in the air? That is an indirect way to find out if it is something to worry about.

FYI, I am a veterinary surgeon, and my hosptial clips in the OR, and I really don't like it. I am trying to get the standard changed.

During clipping, I can see dander and little hair particles floating in the air when the operating lights are at the right angle. Obviously veterinary patients (horses in my case) have more hair than a typical human patient. So, it might be easier to see more the effect of clipping in the OR. I would guess that the hair on humans would behave the same way, but to a lesser extent. But, this is an educated guess, and not EBM.

Skeptical Scalpel said...

Anon, thank you for commenting. You are right about the loose hair not being involved with the antiseptic prep. However, we do remove all loose hair from the patient before we prep the skin.

I'm not sure about the air cleanliness question. I know that ORs have a specific number of air exchanges that must occur per hour. I would hope that is based on some research.

I have a question for you. Would an unsedated horse stand still and let you clip its hair?

Anonymous said...

Oh, I see, I thought the rationale for not clipping in the OR was the air quality, not the surgical site itself. I wouldn't worry about the surgical site, just the air, so I agree on that point.

To answer your question, some horses are fine with being clipped without sedation. It depends on the horse, but it also depends on the anatomic location. For elective procedures, we wash the horse, clip as much as possible, and wash the area again prior to induction. We do that with the horse standing, either unsedated or sedated. But, there is always a little hair to clip once the horse is on the table.

For emergent procedures, we seldom have the chance to prep like that. We end up clipping if we can control the horse's pain while it is standing in induction area, then finish on the table. We have central vacuums to remove all the visible hair in the ORs.

Some of the comments above imply it is easy enough to clip before the patient rolls into the OR, but that is a little problematic in our setting. Think 1200# horse, on a 700# hydraulic table, plus 200# ventilator to be moved with the horse.

I find there are two mindsets that can be frustrating: "we never had a problem, so why do we need to change", and "we need to do it this way because I say (or whomever they are listening to says) it is better". Both these extremes are faulty in my eyes. Our surgery credentialling organization (ACVS) is pushing for not clipping in the OR to be the standard. Currently, it is recommended. It may become obligatory.

So, I found your blog while searching for evidence (either way) on this topic. FYI, veterinary ORs follow the same air exchange guidelines. Maybe the air exchange takes all that dander away before it can settle on the site.

Nice blog, BTW.


Skeptical Scalpel said...

Jen, thanks for the insight into the world of large animal surgery and for the compliment. I hope you will keep reading.

Anonymous said...

I think that all of these rules have gone way too far, and there is no where to draw the line. If we use the current way of thinking from whatever governing body your facility follows, than we should really be changing scrubs, hats,shoe covers , all of it between patient care. Show me the data that shows a massave drop or any drop in infection rates sense the ostracization of cloth hats, and short sleeve scrub tops. Guess what there isn't any! Remember these rules are made by people whom do not have to actually follow them, because they are probably not working in a opperating room. It is easy to make rules that are a pain in the butt for other people when you dont have to follow them. And dont get me started on all the rule changes i have seen when it comes to charting and documentation in the last 20 years. Circulators are more stenographer then they are medical professionals in the room. Lets get back to basicics and use some common sence when it comes to patient care. Next we will all be in space suits trying to deliver care

Skeptical Scalpel said...

I agree. The rules have gone too far. Yes, circulators are too busy charting to circulate. We may need to hire a third person to do the real work for every OR.

Unknown said...

I have yet to find any "research" that proves that while circulating and sitting bare-armed at the computer across the room in any way harms the patient undergoing surgery. HOWEVER, I have found many research articles that show that sweating personnel in the operating room DOES INCREASE THE BACTERIA COUNT IN THE ROOM, and the bacteria that was grown was skin normal flora. Dripping with sweat because I am now not allowed to take off my jacket is far more harmful to the patient than having my arms exposed.
Not to mention the inconsistencies of this ridiculous new law that everyone is all gung-ho on..... why don't my bare hands, bare neck and portions of my bare face have to be covered at all times??
Also, compromise of normothermia has been proven to decrease performance and thus becomes a risk to the patient Seeing that the average age of OR nurses is 47-55, most of these nurses are menopausal or getting close to it. This means that we easily overheat. Forcing us to be in a position where we cannot remove our jackets to maintain normothermia is ageism and sexism. The "ice-vests" that are provided in some hospitals so staff does not get too hot adds unnatural bulk to the upper body, risking repeated contamination to the sterile field because we are not use to the added bulk and thus accidentally rub up against things.
Now it is being said that "oops, no this recommendation is NOT research driven, but comes from "expert opinion". I'm interested to know if these "experts" are getting a kick-back from the companies who provide the jackets that we are now forced to wear at all times. Nobody else seems to be getting any benefit out of it.

Skeptical Scalpel said...

Rebecca, thanks for the interesting comments. You raised several issues I had not thought of. I agree that many of the rules lack scientific validity. That's why I wrote this post.

Anonymous said...

I'm a patient - I like to know what I'm getting into, so I checked - no removal is best. I don't want shaved OR clipped, apart from the absolute minimum if it's in the way. Femoral line does not need 6 inch square on each side of my penis. Use smaller dressings - a 2 inch diameter circle is the maximum if you have to clip at all. Try a different dressing and just leave my hair alone - it's not hygiene that's the issue, but adhesive drapes and dressings that won't come off fairly easily when required. Medics are just as prone to irrational behaviour as the rest of us - just less likely to listen.

Skeptical Scalpel said...

Anonymous, thank you for your comment. I was with you right up to the end.

Clipping of hair has not been associated with any significant complications.

As I said in the post, I only clipped enough here to allow for a secure dressing to be placed. If you don't clip enough hair, removing the dressing will not only hurt, it may pull out hair causing potential irritation to the skin. I don't think preventing pain is irrational.

Anonymous said...

Sorry if I appeared a bit stroppy - it was the argument I was having to persuade them that a clip high on my thigh 1 inch either side where the incision was up to the top of my hip line was sufficient for a secure -and sticky- dressing, without giving me a clip across my entire pubes on grounds of " it's policy". I likewise got an argument from them about hygiene, not hair being pulled out. It should be possible to really minimise clipping, because to me it looks like some procedures go for big clips that are justified by adhesive drapes of limited or even negative value, and unduly large dressing requirements for fairly small dressings. Some effort into better adhesive design would help, but there is no incentive to do this

Skeptical Scalpel said...

It's OK to be stroppy [easily annoyed and difficult to deal with]. I used to be that way too when confronted with irrational rules.

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