Occupational Health: Sharps Safety in the OR

By Kelly M. Pyrek

Infection Control Today spoke with Mary J. Ogg, MSN, RN, CNOR, a perioperative nursing specialist with the Association of periOperative Registered Nurses (AORN), regarding sharps safety-related issues in the operating room.

Q: What are the most common sharps injuries in the OR and why?
A: Suture needles are the most common cause of injury, accounting for 43.4 percent of all injuries; scalpel blades rank second, accounting for 17.1 percent; disposable syringes accounted for 12.1 percent. Most suture needle injuries occur to the non-dominant hand of the surgeon while grasping or repositioning the suture needle in the needle holder, or when the suture needle punctures the glove of the surgeon or assistant retracting the tissue being sutured.  Injuries also occur when the loaded needle holder is passed hand to hand, and when the suture is tied with the needle is still attached. Using blunt suture needles for fascia and muscle tissue closure has the potential to reduce glove perforations by 54 percent. Scalpel blade injuries occur most frequently during the hand to hand passing of the instrument. Using a neutral or hands-free zone where no two people touch a sharp instrument at the same time is another technique to potentially reduce glove perforations.

Q: Why are sharps injuries in the operating room persisting when it has been shown that other areas of the hospital have demonstrated decreases?
A: The perioperative environment poses unique challenges that are not faced by other hospital departments. OR personnel are not working in isolation. They are part of a team. The decision of one team member may affect the risk of a sharps injury for the other team members. In addition, surgeries may be bloody, use multiple types of sharp equipment, be performed in low light environments, and involve intense interaction between the team members. The early safety-engineered devices designed for the OR were considered by many as unacceptable from a performance aspect. They did not cut as well. Their feel was different than traditional sharp devices  necessitating a drastic change in surgeons practice. The devices have greatly improved over time but gaining their acceptance has been extremely difficult. The initial unfavorable experiences have tainted the willingness of practitioners to try and accept the newer devices. This is an opportunity for the OR team to work with device manufacturers to design the safer devices needed in the operating room.

Q: Does this speak to a closed-door culture in the OR?
A: Perioperative nurses are aware of this perception and are  working diligently to change it by inviting risk managers, and infection preventionists into the department.  As a result  we are seeing increased collaboration to create solutions that are effective in the OR.

Q: What can be done to address this?
A:Solutions should be targeted to the unique needs of the OR. For example, AORN developed a Sharps Safety Tool Kit two years ago and enhanced it this past year to address the issues of sharps safety. AORNs Clinical Nursing Practice Committee involved all members of the team in the tool kit development including representatives from the American College of Surgeons and the Association of Surgical Technologists. The new tool kit presents the evidence that double gloving, blunt suture needles and the neutral (hands free) zone all reduce the incidence of sharps injuries. The tool kit also outlines the organizational support of NIOSH, CSPS (Council on Surgical and Perioperative Safety), ACS (American College of Surgeons), CDC,  OSHA, ANA, and AORN. 

Q: When it comes to sharps safety, what level of responsibility does the individual play?
The individual is responsible for their own practice. The individual has the obligation to protect oneself with immunizations, safe work practices, personal protective equipment to prevent exposure (e.g., double gloving), establishing a neutral or hands free zone when passing sharp objects, using appropriate sharps containers, participating in education,  following the organizations exposure control plan, and always reporting exposures. The individual can also educate others about the risks of a sharps injury and mitigation strategies and support them in implementing sharps safety practices.

Q: What about the OR team?
A: Sharps safety is everyones responsibility. The decision of one team member may affect the entires teams risk to a percutaneous injury.  Being extra careful is not adequate protection against the risk of exposure to hepatitis C and HIV.

Q: And the hospital leadership?
A: First is to have a sharps safety program that includes education.  Twenty percent of respondents to a 2011 AORN sharps survey indicated that their facility did not have a sharps education program or did not know if there was a program. The hospital leadership/administration/ management is responsible by law 29CFR to have yearly BBP exposure training, and  yearly evaluation  of safety engineered devices. The hospital is required to provide Hepatitis B immunizations, recordi all sharps injuries, do source testing, risk analysis and post-exposure prophylaxis. The hospital should encourage reporting and provide processes to make reporting easy and accessible to departments like the OR.

Q: What steps can be taken to create and maintain a culture of (sharps) safety in the OR?
A: A culture of sharps safety requires a commitment from the top down and from the bottom up. If there is no administrative buy-in for the safer practices, they will fail from lack of support. Some administrators have gone to the extreme of removing non-safety devices from the perioperative suite. AORN surveyed our membership in 2011 on sharps safety. One key finding was the presence of conventional sharp items was the cause of non-compliance with 55 percent of the respondents. Staff needs to know that administration is behind them and will stand up for them when they receive unfavorable comments and feedback regarding sharps safety practices.  Another key finding of our survey was the lack of multidisciplinary support for sharps safety.  If there is no staff support, the safer practices will quickly fall by the wayside. Commitment of your front line workers to implement sharps safety practices and products is crucial. The staff must encourage and promote their use every day for every case.
 
Q: What kind of response to its sharps safety campaigns and educational efforts has AORN seen?
A: AORN had had very positive response from perioperative nurses and facilities that have used the Sharps Safety Tool Kit  and implemented the education and interventions. The sharps safety education sessions at AORN Congress and the online webinars have been very well attended with lively question and answer periods that lead to the creation of a FAQ document in the tool kit.

Q: How can infection preventionists help perioperative staff with greater buy-in?
A: Two approaches come to mind. One is to share the evidence to make the case that double gloving; blunt suture needles; the neutral zone; and safety engineered devices reduce sharps injuries. The evidence will be in the recommended practices for Sharps Safety due for release in the first quarter of 2013. AORNs Sharps Safety Tool Kit has educational presentations with the evidence and a very short power point with only the evidence. The evidence slides can be printed and posted in the OR as a quick way to share the facts with all perioperative personnel. Our health care colleagues respond to evidence.  We have the strongest evidence available, randomized controlled trials and the Cochrane reviews, to support double gloving and the use of blunt suture needles to reduce the incidence of percutaneous injuries. The second is to help tell stories of real life examples that grab the staffs attention. There are numerous examples in the literature. They may even know someone in your own facility that has had a sero-conversion after a sharps injury that may be willing to share their story.  All too frequently the feeling is that it will never happen to me.  In my experience as a perioperative nurse practicing in a period of 10 years at a large metropolitan area hospital, three of our anesthesiologists underwent treatment for hepatitis. None was able to indentify when or where they were exposed.  All lost nearly a year from clinical practice and one needed to take early retirement.

Q: Anything new on the horizon in terms of bolstering sharps safety compliance?
A: AORN is in the process of converting the sharps safety guidance statement into a recommended practice which is scheduled for release during the first quarter of 2013. All the literature citations are being appraised using the Johns Hopkins Nursing Evidence-based practice model.
The collective evidence supporting each intervention within a specific recommendation will be summarized and used to rate the strength of the evidence using the Oncology Nursing Society Putting Evidence into Practice (ONS PEP®) schema. Factors considered in review of the collective evidence will be the quality of research, quantity of similar studies on a given topic, and consistency of results supporting a recommendation. The evidence rating will be noted in brackets after each intervention. The sharps safety recommended practice will be submitted to the National Guideline Clearing House upon completion.