Sharps Injury Prevention in the OR
By Mark S. Davis, MD, FACOG
New federal regulation has added a sense of urgency to the existing need for changes in traditional surgical practice. The operating room and delivery room are uniquely hazardous worksites. Needlesticks, scalpel cuts, and other injuries are common and underreported. The 2000 Needlestick Safety and Prevention Act and the revised Occupational Safety and Health Administration (OSHA) Compliance Directive specify the need for evaluation, selection, and implementation of engineering controls and work practices that effectively eliminate or minimize injuries. Frontline healthcare workers must be involved in all phases of the change.
1. To recognize the incidence of sharps injuries.
Universal Precautions, while important, do not prevent sharps injuries. Advances in safer technology, work practices, and administrative controls are reflected in the new federal regulation. Suture needles and collisions between workers' hands are two very prominent causes of injuries in the OR. Both the user and the non-user of sutures and scalpels may be injured. Consequently, blunt suture needles and no-hands passing of sharps have great potential for preventing injuries. Why do these interventions remain underutilized today? A likely reason is they depart from traditional surgical practice. Although OSHA requires that hospitals, as employers, provide education on exposure prevention annually, surgeons--most of whom are non-employees of hospitals--may be left out of the hospital's education loop. This need must be addressed, as surgeons are the workers who determine what kind of sutures are used and how instruments are passed. Federal regulation demands worker input, but how many hospital administrators ask surgeons for their input and cooperation in altering these traditional practice issues? How often do hospital administrators provide coordinated education for the surgical staff as well as for their employees in the OR?
Incidence of Sharps Injury During Surgical Procedures
Two studies using dedicated RN observers to monitor surgical procedures showed an incidence of sharps injury of 7%, and 15%, respectively. An EPINet study of scalpel blade injuries showed 39% of injuries were self-inflicted, while 61% were inflicted by the user on assistants. The majority of scalpel injuries occurred during transfer between personnel. The majority of reported sharps injuries in surgery and obstetrics are due to suture needlesticks. The EPINet study showed 33% of suturing injuries were inflicted on another worker by the person using the needle. Approximately 25% of suture needle injuries occurred during transfer between personnel. A multicenter study by the CDC comparing blunt and sharp sutures in gynecological procedures showed a 6% injury rate with sharp curved suture needles as compared to zero injuries with blunt suture needles. In addition to eliminating injuries, blunt needles reduced the incidence of blood contacts resulting from glove perforations eightfold.
The modern blunt suture needle, not as blunt as the first ones to reach the market in the early 1990s, may be successfully used during most general surgical, trauma, thoracic, gynecologic, and obstetric procedures, and are extremely advantageous for incisional closure (all layers except skin). Episiotomy and perineal or vaginal laceration repair may be easily accomplished using suture needles with minimally blunt points. There is no reason why these needles should not gain wide acceptance by surgeons, once they are educated in their use.
A recent study of the effectiveness of the no-hands passing technique showed a 59% reduction of injuries, contaminations, and glove tears in surgeries with greater than 100cc blood loss. Various devices for no-hands passing, such as mats, trays, basins, all or part of an instrument stand, or a designated area on the field may be used. Some work better than others, and some may actually be dangerous. An example of a poor choice is the ubiquitous kidney basin: items are hard to pick up, fingers tend to wind up inside--in close proximity to the sharp--and these basins tend to tip over. Ideally, a device selected for no-hands passing should be of sufficient size to adequately contain the sharps used, not easily tipped over, and easily mobile.
The No-Touch Technique
Sites of scalpel and suture injuries are most commonly the thumb and index finger of the non-dominant hand, because the non-dominant hand is often used to reposition or reach for needles, hold tissue being cut or sutured, used as a retractor to protect adjacent viscera during cutting or suturing, during mounting or repositioning the needle in the needle holder, or mounting the scalpel blade on the handle. Injury may occur during suturing when the fingers are used as a backstop or guide, when tissue is hand-held during suturing, when sewing toward fingers of the surgeon or assistant, when adjacent structures are protected by the hand of the surgeon or assistant, when manual tissue retraction or wound exposure is employed, when tying with the needle attached, and when needles are left on field, or held in the hand or needle holder while tying. The use of no-touch technique, retractors instead of hands, blunt sutures and no-hands passing of sharps can prevent most OR injuries.
Other blunt alternatives include:
- Staples for skin closure as an alternative to sharp suture needles
- Scissors with rounded rather than pointed tips
- Non-penetrating towel clips
- Blunted retractors in place of sharp versions
- Synthetic sutures in place of wire sutures
- Hemostatic clips vs. sutures where appropriate
- Alternatives to scalpel for cutting tasks, e.g., scissor or cautery
- LLETZ loop for cervical conization vs. pointed scalpel
Effective Selection of Eye and Face Protection
Disposable plastic face shields worn over a mask provide excellent protection for the eyes, nose, and mouth. Face shields help eliminate the problem of gaps around the edges of most other types of eyewear, and the foam brow band provides a seal at the forehead to prevent blood from running into the eyes from above. In case someone has forgotten to wear eye protection, the circulator may easily apply a face shield to a person who has finished a surgical scrub. It should be the responsibility of the person gowning other surgical team members to check for omissions, assisted by the circulator. To prevent face shields from fogging, use with an anti-fog mask.
Goggles or eyeglasses with top and side protection are readily available, some with prescription glass if needed. Splashes over the top may occur, therefore always select equipment appropriate to the anticipated risk of exposure.
Face masks with an integrated clear plastic eye shield are another reasonably effective option. Again, splashes over the top of the shield may occur; therefore, match the equipment to the anticipated risk of exposure.
Surgical Glove Selection
In a study of 3,018 gloves from 800 surgical procedures, it was shown that the loss of barrier protection increased with the length of the procedure. Glove failure rates for procedures lasting less than one hour were 13%, one to three hours, 27%, three to five hours, 47%, and more than five hours, 58%. Studies have shown that newly opened unused surgical gloves may leak up to 4% of the time. A large body of evidence suggests that a single layer of gloves provides less than adequate or effective protection, and that routine double gloving may be appropriate.
Safe Sharps: Disposal in Surgery
Containers should be puncture proof, have an opening of adequate size to accept the sharps used in the worksite, and the "full" line should be readily visible, indicating when it is time for the container to be replaced.
In labor and delivery rooms, hollow-bore venipuncture needles, injection needles, and IV catheters carry the greatest risk of infecting caregivers with bloodborne pathogens. If a nurse or other care giver has to cross the room to reach the sharps disposal container, the risk of puncture is increased. The container should be placed as close as possible to the point of use, ideally within arm's reach. The worker must be able to see and reach the opening of the container easily, and access to the opening should be unrestricted.
Communication between members of the surgical team should be spontaneous and continuous. A major change in aviation protocol was the concept that the captain of the airplane's judgment or opinion could be questioned. This is called "cockpit resource management." Any member of the flight crew who perceives an impending hazard is required to bring it to the attention of the captain. If the surgeon is the "captain of the ship," the same should apply when another member of the OR team perceives a sharps injury or exposure about to happen.
Causative factors for sharps injury and blood exposure have been identified. Education and implementation of safer devices and work practices has become mandated by the Needlestick Safety and Prevention Act, to be enforced by OSHA. Although it may take some deviation from traditional surgical practice, members of the surgical and obstetrical team can easily and significantly reduce occupational risk.
Mark S. Davis, MD, is an ObGyn surgeon and a safety and infection control consultant. In March 2001, the second edition of his safety handbook, Advanced Precautions for Today's OR; The Operating Room Professional's Handbook for the Prevention of Sharps Injuries and Bloodborne Exposures was published by Sweinbinder Publications LLC. For more details, call (404) 261-4595 or e-mail [email protected].
|Test Questions: True or False
1. Universal Precautions prevent sharps injuries.