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By Mark S. Davis, MD, FACOG
New federal regulation has added a sense of urgency to the existing need forchanges in traditional surgical practice. The operating room and delivery roomare uniquely hazardous worksites. Needlesticks, scalpel cuts, and other injuriesare common and underreported. The 2000 Needlestick Safety and Prevention Act andthe revised Occupational Safety and Health Administration (OSHA) ComplianceDirective specify the need for evaluation, selection, and implementation ofengineering controls and work practices that effectively eliminate or minimizeinjuries. Frontline healthcare workers must be involved in all phases of thechange.
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 arereflected in the new federal regulation. Suture needles and collisions betweenworkers' hands are two very prominent causes of injuries in the OR. Both theuser and the non-user of sutures and scalpels may be injured. Consequently,blunt suture needles and no-hands passing of sharps have great potential forpreventing injuries. Why do these interventions remain underutilized today? Alikely reason is they depart from traditional surgical practice. Although OSHArequires that hospitals, as employers, provide education on exposure preventionannually, surgeons--most of whom are non-employees of hospitals--may be left outof the hospital's education loop. This need must be addressed, as surgeons arethe workers who determine what kind of sutures are used and how instruments arepassed. Federal regulation demands worker input, but how many hospitaladministrators ask surgeons for their input and cooperation in altering thesetraditional practice issues? How often do hospital administrators providecoordinated education for the surgical staff as well as for their employees inthe OR?
Incidence of Sharps Injury During Surgical Procedures
Two studies using dedicated RN observers to monitor surgical proceduresshowed an incidence of sharps injury of 7%, and 15%, respectively. An EPINetstudy of scalpel blade injuries showed 39% of injuries were self-inflicted,while 61% were inflicted by the user on assistants. The majority of scalpelinjuries occurred during transfer between personnel. The majority of reportedsharps injuries in surgery and obstetrics are due to suture needlesticks. TheEPINet study showed 33% of suturing injuries were inflicted on another worker bythe person using the needle. Approximately 25% of suture needle injuriesoccurred during transfer between personnel. A multicenter study by the CDCcomparing blunt and sharp sutures in gynecological procedures showed a 6% injuryrate with sharp curved suture needles as compared to zero injuries with bluntsuture needles. In addition to eliminating injuries, blunt needles reduced theincidence of blood contacts resulting from glove perforations eightfold.
The modern blunt suture needle, not as blunt as the first ones to reach themarket in the early 1990s, may be successfully used during most generalsurgical, trauma, thoracic, gynecologic, and obstetric procedures, and areextremely advantageous for incisional closure (all layers except skin).Episiotomy and perineal or vaginal laceration repair may be easily accomplishedusing suture needles with minimally blunt points. There is no reason why theseneedles should not gain wide acceptance by surgeons, once they are educated intheir use.
A recent study of the effectiveness of the no-hands passing technique showeda 59% reduction of injuries, contaminations, and glove tears in surgeries withgreater than 100cc blood loss. Various devices for no-hands passing, such asmats, trays, basins, all or part of an instrument stand, or a designated area onthe field may be used. Some work better than others, and some may actually bedangerous. An example of a poor choice is the ubiquitous kidney basin: items arehard to pick up, fingers tend to wind up inside--in close proximity to thesharp--and these basins tend to tip over. Ideally, a device selected forno-hands passing should be of sufficient size to adequately contain the sharpsused, not easily tipped over, and easily mobile.
The No-Touch Technique
Sites of scalpel and suture injuries are most commonly the thumb and indexfinger of the non-dominant hand, because the non-dominant hand is often used toreposition or reach for needles, hold tissue being cut or sutured, used as aretractor to protect adjacent viscera during cutting or suturing, duringmounting or repositioning the needle in the needle holder, or mounting thescalpel blade on the handle. Injury may occur during suturing when the fingersare used as a backstop or guide, when tissue is hand-held during suturing, whensewing toward fingers of the surgeon or assistant, when adjacent structures areprotected by the hand of the surgeon or assistant, when manual tissue retractionor wound exposure is employed, when tying with the needle attached, and whenneedles are left on field, or held in the hand or needle holder while tying. Theuse of no-touch technique, retractors instead of hands, blunt sutures andno-hands passing of sharps can prevent most OR injuries.
Other blunt alternatives include:
Effective Selection of Eye and Face Protection
Disposable plastic face shields worn over a mask provide excellent protectionfor the eyes, nose, and mouth. Face shields help eliminate the problem of gapsaround the edges of most other types of eyewear, and the foam brow band providesa 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 easilyapply a face shield to a person who has finished a surgical scrub. It should bethe responsibility of the person gowning other surgical team members to checkfor 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 ofexposure.
Face masks with an integrated clear plastic eye shield are another reasonablyeffective 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 thatthe loss of barrier protection increased with the length of the procedure. Glovefailure rates for procedures lasting less than one hour were 13%, one to threehours, 27%, three to five hours, 47%, and more than five hours, 58%. Studieshave shown that newly opened unused surgical gloves may leak up to 4% of thetime. A large body of evidence suggests that a single layer of gloves providesless than adequate or effective protection, and that routine double gloving maybe appropriate.
Safe Sharps: Disposal in Surgery
Containers should be puncture proof, have an opening of adequate size toaccept the sharps used in the worksite, and the "full" line should bereadily visible, indicating when it is time for the container to be replaced.
In labor and delivery rooms, hollow-bore venipuncture needles, injectionneedles, and IV catheters carry the greatest risk of infecting caregivers withbloodborne pathogens. If a nurse or other care giver has to cross the room toreach the sharps disposal container, the risk of puncture is increased. Thecontainer should be placed as close as possible to the point of use, ideallywithin arm's reach. The worker must be able to see and reach the opening of thecontainer easily, and access to the opening should be unrestricted.
Communication between members of the surgical team should be spontaneous andcontinuous. A major change in aviation protocol was the concept that the captainof the airplane's judgment or opinion could be questioned. This is called"cockpit resource management." Any member of the flight crew whoperceives an impending hazard is required to bring it to the attention of thecaptain. If the surgeon is the "captain of the ship," the same shouldapply when another member of the OR team perceives a sharps injury or exposureabout to happen.
Causative factors for sharps injury and blood exposure have been identified.Education and implementation of safer devices and work practices has becomemandated by the Needlestick Safety and Prevention Act, to be enforced by OSHA.Although it may take some deviation from traditional surgical practice, membersof the surgical and obstetrical team can easily and significantly reduceoccupational risk.
Mark S. Davis, MD, is an ObGyn surgeon and a safety and infection controlconsultant. In March 2001, the second edition of his safety handbook,Advanced Precautions for Today's OR; The Operating Room Professional's Handbookfor the Prevention of Sharps Injuries and Bloodborne Exposures was publishedby Sweinbinder Publications LLC. For more details, call (404) 261-4595 or firstname.lastname@example.org.
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.