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  • Measure Summary
  • NQMC:010047
  • Oct 2015
  • NQF-Endorsed Measure

Ambulatory surgery: percentage of Ambulatory Surgery Center (ASC) admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream for all other surgical sites.

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: ASC Quality Collaboration. ASC quality measures: implementation guide. Version 2.0. Ambulatory Surgery Center; 2014 Jan. 32 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of Ambulatory Surgery Center (ASC) admissions who have appropriate surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream for all other surgical sites.

Rationale

Razors can cause microscopic cuts and nicks to the skin, not visible to the eye. Use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use or no hair removal at all (Seropian & Reynolds, 1971).

Clinical Practice Guidelines
The Centers for Disease Control and Prevention's (CDC's) guidelines for the prevention of surgical site infection include recommendations which specifically address preoperative hair removal practices. The CDC guidelines state that providers should not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. If hair is removed, it should be removed immediately before the operation, and preferably with electric clippers. See the Guideline for Prevention of Surgical Site Infection (Mangram et al., 1999).

The Association of Operating Room Nurses (AORN, 2002) standards of recommended practice are in alignment with this measure.

Evidence for Rationale

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

Association of Operating Room Nurses. Recommended practices for skin preparation of patients. AORN J. 2002 Jan;75(1):184-7. PubMed External Web Site Policy

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999 Apr;20(4):250-78; quiz 279-80. [497 references] PubMed External Web Site Policy

Seropian R, Reynolds BM. Wound infections after preoperative depilatory versus razor preparation. Am J Surg. 1971 Mar;121(3):251-4. PubMed External Web Site Policy

Primary Health Components

Ambulatory Surgery Center (ASC); surgical site; hair removal

Denominator Description

All Ambulatory Surgery Center (ASC) admissions with surgical site hair removal (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Ambulatory Surgery Center (ASC) admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream from all other surgical sites

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

The measures included in this implementation guide have been developed using a multi-step process. Each has been vetted with both an internal panel of technical experts and an external panel of individuals and/or organizations with relevant expertise. All of the measures have been pilot tested in Ambulatory Surgery Centers (ASCs) and assessed for validity, feasibility and reliability.

Evidence for Extent of Measure Testing

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Public reporting

Measurement Setting

Ambulatory Procedure/Imaging Center

Professionals Involved in Delivery of Health Services

Does not apply to this measure (e.g., measure is not provider specific)

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

All ages

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness

Safety

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Encounter

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All Ambulatory Surgery Center (ASC) admissions* with surgical site hair removal

*Admission: Completion of registration upon entry into the facility.

Exclusions
ASC admissions who perform their own hair removal

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Ambulatory Surgery Center (ASC) admissions with surgical site hair removal with a razor or clippers from the scrotal area, or with clippers or depilatory cream for all other surgical sites

Exclusions
None

Numerator Search Strategy

Encounter

Data Source

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Sample Data Collection Sheet: Appropriate Surgical Site Hair Removal
  • Sample Data Collection Log: Surgical Site Hair Removal

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Appropriate surgical site hair removal.

Measure Collection Name

Ambulatory Surgery Center (ASC) Quality Measures

Submitter

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Developer

Ambulatory Surgery Center (ASC) Quality Collaboration - Health Care Quality Collaboration

Funding Source(s)

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations

Composition of the Group that Developed the Measure

Ambulatory Surgery Center (ASC) providers; nursing, physician, and provider associations; provider accrediting organizations

Financial Disclosures/Other Potential Conflicts of Interest

None

Endorser

National Quality Forum

NQF Number

0515

Date of Endorsement

2012 Jan 31

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: ASC Quality Collaboration. ASC quality measures: implementation guide. Version 2.0. Ambulatory Surgery Center; 2014 Jan. 32 p.

Source(s)

ASC Quality Collaboration. ASC quality measures: implementation guide. Version 3.2. Saint Petersburg (FL): ASC Quality Collaboration; 2015 Oct. 37 p.

Measure Availability

Source available from the Ambulatory Surgery Center (ASC) Quality Collaboration Web site External Web Site Policy.

For more information, contact the ASC Quality Collaboration's Executive Director, Donna Slosburg, at E-mail: donnaslosburg@ascquality.org; Web site: ascquality.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on December 17, 2008. The information was verified by the measure developer on February 18, 2009.

This NQMC summary was retrofitted into the new template on May 31, 2011.

This NQMC summary was updated by ECRI Institute on July 10, 2012. The information was verified by the measure developer on August 1, 2012.

This NQMC summary was updated again by ECRI Institute on August 3, 2015. The information was verified by the measure developer on September 11, 2015.

Copyright Statement

No copyright restrictions apply.

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