A Call to Arms to Prevent Sharps Injuries in Our ORs

In the last decade, numerous improvements have been made in safety scalpels and blunt suture needle technology. Educational efforts have been widely disseminated to nurses, physicians, surgical technologists, and other members of the perioperative team; yet, in many institutions, the neutral zone is not used, double gloving is not utilized, and needle-stick injuries remain vastly underreported. Considering that the well-being of our present and future workforce is in jeopardy, I hope that through our shared dialogue, we can begin to think differently about the relevance and importance of the issue of preventing harm from needle-stick injuries. Therefore, I have invited our distinguished panel to offer their opinions and commentary on the following question: What challenges do you believe surgical team members encounter in implementing sharps injury prevention strategies in their facilities? When I posed this question to an orthopedic surgeon I work with who is very compulsive about using a hands-free sharps passing technique, he stated that surgeons—and I believe this applies to the entire team—do not like change. He also told me it is his belief that there is a lack of empirical evidence to support the need for change and that treatment for potentially transmitted diseases is so much better now that they are seen to be less of a risk. According to Jagger et al,4 the rate of needle injuries in areas outside the OR has decreased, but the rate of these injuries during surgical procedures has not. This statement is based on a study performed from 1993 to 2006, after implementation of the Occupational Safety and Health Administration Bloodborne Pathogens Standard5 that mandated the use of safer products. when passing surgical instruments and syringes with uncapped hypodermic needles used to administer local anesthesia, during use of suture needles, when the assistant uses his or her hands to retract tissue, and during postprocedure cleanup. For many years, the phrase "a culture of safety" has been used by the health care community to let patients know that we are doing everything we can to care for them in a manner that will result in the most positive outcomes possible; however, that culture has not applied equally to the safety of team members caring for the patient. The entire team must champion and embrace a change in practice and culture. From the beginning of the process, all members of the team should be involved in committees that review safety concerns, infection control practices, and value analysis efforts to select products for the team to test. The evidence available in the Occupational Safety and Health Administration 300 log in each facility will support the need for change, but change itself requires a thoughtful group process. In my opinion, the most difficult change to manage is the implementation of safety scalpels. Industries have spent time, money, and effort to develop a scalpel that surgeons will find similar to the blades they are accustomed to using, but this continues to be the most problematic issue. Therefore, it makes sense to find a hands-free passing system that works for the facility and can be customized to the procedure and patient position. I have seen change during the past several years. The use of unsterile gloves for routine care by unscrubbed personnel like the RN circulator and anesthesia care provider is much more prevalent now, as is double gloving by scrubbed personnel. Our surgical colleagues have supported the use of blunt suture needles during closure, and this practice is beginning to catch on. The Centers for Disease Control and Prevention Workbook for Designing, Implementing and Evaluating a Sharps Injury Prevention Program6 is an outstanding tool that is available for download to assist with this work. AORN, under the leadership of President Guglielmi and in collaboration with the American College of Surgeons and the Association of Surgical Technologists, is again bringing this issue to the forefront. It takes a team to care for patients, and it takes a team to embrace change in the perioperative setting. This is the second wave in the sharps injury prevention movement; the first wave began around the year 2000 with the Bloodborne Pathogens Standard.5 The standard obviously has had an effect on non-OR sharps-related injuries, but it has had no effect on OR-related injuries.4 The recent publication of data that clearly demonstrated that OR sharps injuries have actually increased by 6% since 20004 is making an impact in surgical societies, and there is the realization that surgeons have not really acted on this information. I think there have been other factors as well. State and federal regulatory agencies did not enforce the standard or levy fines until recently, and industry has only recently provided reasonable blunt needle and suture choices for surgeons. Until now, we have lacked the three parts of the solution: proactive education and awareness from professional societies, good product choices, and a tighter regulatory climate to implement change. At a local level, there is significant underreporting of sharps injuries in the OR. The way the reporting is conducted and the time that is involved remain significant barriers to sharps awareness and data collection. There are some similarities and differences among nurses, surgical technologists, and surgeons as to why they would not report. I think they are all faced with the tremendous inconvenience and time burden of the reporting, which in the middle of a busy day is simply unworkable if one is to continue performing and taking care of the patients who are scheduled to have surgery in a busy OR. There are also employment issues that are different among nurses, surgical technologists, and surgeons. Most surgeons are not employees of the hospital; hence, they may not believe that there would be any compensation for the injury. In addition, surgeons feel responsible for their patients and their care and for performing their surgery in a timely matter. Most surgeons could not even think about taking two or three hours off in the middle of the day because they stuck themselves, whereas those who are employees of the hospital are bound by union laws and employment requirements to report, and they would be more likely to receive some kind of disability compensation. What has become clear is that sharps injury prevention in the OR is a team effort in which the hospital administrators, surgeons, and OR staff members play key roles. Recently published data clearly show that nurses and surgical technologists sustain 80% of the sharps injuries in the OR but are not the ones who decide whether to use a sharps safety device or technique.4 Surgeons must be made aware of the effects of their decisions. I would hope to see surgeons incorporate the work practices of the hands-free technique and the use of safety engineered devices (eg, scalpels), along with blunt suture needles and double gloving as a routine part of our work. A group of health care professionals and epidemiologists, with the support of the CSPS and various leading professional societies, is currently working collaboratively to implement a national sharps safety program with all the stakeholders in the OR. We are developing an OR sharps safety bundle, including a template OR sharps safety policy through the CSPS, individual professional societies, the American Hospital Association, the Joint Commission, and the Committee of Interns and Residents. I believe we now have the necessary combination of knowledge and products to make significant advances in reducing OR sharps injuries. Surgeons may find it cumbersome or time consuming to use scalpels with retractable covers. Some have stated the scalpels with retractable covers do not work as well as regular scalpels. The team is rushed during procedures, which does not allow time for the "neutral zone" to be effective. Double gloving is not used by many surgical team members because it can be uncomfortable and decrease tactile sensation. The scrub person's hands may go numb or tingle because of the tightness or thickness of the gloves, or the sense of touch may be lessened with double gloves. Members of the surgical team have a false sense of security, thinking sharps injuries will not happen to them "this time" or "we have always done it this way, why change?" What happens when the surgical team members decide to make available the time and money and accept change? The future of surgery is refined. For example, we no longer reuse all of our equipment and supplies. We do not thread our suture needles. We are no longer just talking about laparoscopic and endoscopic procedures, we are performing them; robotic surgery is part of daily practice, not science fiction. We know the realities and constraints of our world and how to overcome them. Implementing a successful sharps prevention strategy will take commitment from the entire team. Although we may find new policy implementation to be somewhat counterproductive and cumbersome for a short time, much like the learning curve for laparoscopic surgeries, sharps injury prevention techniques will become the gold standard of patient care when the entire surgical team embraces the opportunity to make a difference for ourselves and our team members. We teach integrity, aseptic technique, and surgical safety to all of our students and orientees; however, when they get to the OR for their clinical experience, our personnel are not always consistent regarding polices and procedures for their facilities or the recommended standards of practice from their professional organizations. The key to the success of implementing sharps injury prevention is simply to get the buy-in from the entire surgical team, incorporated with the updated and enhanced education of our new perioperative personnel. As an infection preventionist, I am excited to see growing efforts on the part of employee health professionals, infection preventionists, and perioperative nurses who collaborate to prevent infections in both patients and staff members. Sharps safety is commonly in the purview of employee health professionals who need to provide guidance to employees and physicians to improve workplace safety. In some hospitals, the role of employee health falls to the infection preventionist. Either way, there is a need to work closely with the professionals in high-risk areas, including the OR, who are the true experts regarding where infection risk is the greatest. It has been my experience that any effort aimed at reducing infection risk, whether in patients or staff members, is complex, and it is difficult to ensure perfect compliance. Certainly this is the case with prevention of bloodborne pathogen exposure in the OR. Sharps safety has grown into a specialized area, with a rapidly growing arsenal of products and practices aimed at reducing the risk of exposure of surgical staff members to the primary bloodborne pathogens: HIV, hepatitis B, and hepatitis C. I have observed great strides over the years that have helped make the OR a safer place. Much like the goal for the prevention of health care-associated infections, however, the goal for employee blood exposure is zero, and most facilities are not there yet. When sharps safety devices and practices have been provided and compliance is not 100%, efforts must be made to determine the reasons why. As with hand hygiene compliance, there is no silver bullet to achieve perfect, reliable, 100% compliance. Certainly safe sharps device evaluation and implementation are critical, in a manner that keeps pace with new technologies as they are introduced to the market. This should include the use of blunt suture needles, which can best be guided with product usage guidelines. Staff member education and training are also critical, including consistent use of the neutral zone so that sharps are not handed person to person but are dropped in a safe place for pickup. Double gloving for higher-risk procedures is also used by some surgeons to reduce the amount of blood exposure in the event of a puncture wound. There is evidence to guide what to do, but the question is how to ensure that it happens consistently and reliably for every patient and every health care worker and every surgeon every time. One tool to support compliance that is not always used to full advantage is story telling. Watching a video clip or hearing a story from a colleague who was exposed to blood and contracted hepatitis B or C can have a tremendous effect. Additionally, to successfully change culture, there must be leadership from the top down and from the bottom up. From the top, it is critical to have engaged surgeon leaders as well as labor leaders. From the bottom, where employees are unionized, it is helpful to have engagement of labor groups. AORN advocates for policies and procedures that support the prevention of sharps injuries in the OR.7 One solution will not fit all settings, however, and administrators and practitioners at each health care facility should examine their policies and procedures and implement quality improvement measures to reduce the risk of injuring health care workers.7 AORN endorses the American College of Surgeons statement on sharps safety, which recommends the universal adoption of blunt-tip suture needles for the closure of fascia and muscle to reduce needle-stick injuries.8 Perioperative nurses should consistently remind the surgeon of the blunt needles available for specific procedures and suggest that preference cards be changed to support this change in technique. The statement also supports hands-free technique that requires the surgical team to identify a sharps neutral zone for picking up and releasing surgical sharps, such as needle holders and scalpels.8 The neutral zone can be a basin, a towel, or a magnetic mat. With the use of this technique, there is no direct handing of sharp instruments from scrub person to surgeon and back to the scrub person. When an injury to a team member occurs, we support the use of a root cause analysis of the injury. This requires an in-depth review of the circumstances surrounding the injury, an analysis of the contributing factors from all staff members who were involved in the procedure, and identification of learning opportunities to prevent another occurrence of the injury. In addition to the root cause analysis, a corrective action plan must be developed. The action plan should address system and process failures identified in the root cause analysis, as well as provide a blueprint for developing and implementing improvement strategies to ensure that injuries are prevented in the future. Trending of this information by surgeon and by procedure will provide facility leaders and boards of directors with specific information that may require action to prevent future injuries to employees.