Clipping vs. No Hair Removal and the Risk of Surgical Site Infection: A Randomized, Assessor Blinded Non-inferiority Clinical Trial Among Patients Undergoing General Surgical Procedures at a Community Hospital

Public health organizations, third party payers, consumer watchdog groups, health care quality organizations, and patients are increasingly scrutinizing patient safety in hospitals. Surgical site infection (SSI) rates are one of the key quality measures by which hospitals are evaluated. Centers for Disease Control (CDC) guidelines provide specific recommendations, weighted by evidence, to prevent SSI. These include the following category 1A recommendations (Strongly recommended for implementation and supported by well-designed experimental, clinical, or epidemiological studies).

• Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation
• If hair is removed, remove immediately before the operation, preferably with electric clippers.

However, a recent systematic review of randomized clinical trials concluded there was no difference in SSI among patients that had hair removed prior to surgery and those that did not. Furthermore, trials involving hair removal were largely underpowered and of marginal quality. If hair is going to be removed, previous studies have shown hair removal with clippers or depilatory creams to result in fewer SSI than shaving with a razor. However, the need for trials comparing SSI rates with and without hair removal was stressed in the recent systematic review. No prospective, randomized clinical trial evaluating no hair removal vs. hair removal by clipping, the two hair removing modalities preferred by CDC SSI prevention guidelines, has ever been reported. This study aims to assess whether hair removal via clipping is non-inferior to no hair removal in a cohort of patients undergoing general surgical procedures at a community hospital.

A non-inferiority study design will be used based upon the following rationale. CDC guidelines recommend not removing hair preoperatively unless the hair will interfere with the operation. However, there is no published evidence that clipping hair results in more SSI than no hair removal. Clipping hair is often preferred from a surgical perspective. This may be because of historical practice patterns, personal comfort level, and the either real or perceived interference of unremoved hair with performing the operation. Therefore, assessing whether clipping is non-inferior to no hair removal will provide helpful information regarding the appropriateness of the current CDC recommendation to not remove hair preoperatively unless the hair will interfere with the operation.

Patients will be assessed for enrollment after a decision has been made for elective (non-emergent) operative intervention. Patients will undergo our institution's current preoperative procedural standard of care. Patients will be specifically instructed to not shave themselves prior to the procedure. The day of the procedure patients will undergo our institution's standard preoperative skin preparation, which currently includes povidone based skin antiseptic. Preoperative antibiotics will be administered according to our institutional standards of care for their particular operation.