Sharps Injury Prevention in the OR

October 1, 2001

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.

Objectives:

1. To recognize the incidence of sharps injuries.
2. To identify the methods and techniques of reducing OR sharps injuries.
3. To examine the different areas of risk and how to minimize these
dangers.

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.

No-Hands Passing

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.

Effective Communication

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.

Conclusion

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
sweinpub@aol.com.

Test Questions: True or False

1. Universal Precautions prevent sharps injuries.
2. Blunt suture needles can be advantageous and their use should increase
once surgeons are educated about this new option.
3. A ubiquitous kidney basin is a good choice for a no-hands passing
field.
4. It is the responsibility of the person gowning surgical team members to
check if proper PPE is in place.
5. The loss of a glove's barrier protection is directly tied to the length
of the procedure.
6. Convenient access to the sharps disposal container is not important as
long as the opening is of adequate size.
7. The surgeon is the "captain of the ship" and shouldn't be
second-guessed.
8. Single-layer gloves are more adequate than double gloving.
9. Face masks should be chosen with anticipated risk factors in mind.
10. The most common site of scalpel and suture injuries are the thumb and
index finger of the non-dominant hand.


Answers

1. F
2. T
3. F
4. T
5. T
6. F
7. F
8. F
9. T
10. T