Eye of the needle: Surgeons reluctant to trade suture sharps for 'blunt' safety
Will calls for change, new designs finally get point across?
Sharps safety finally may permeate the nation's operating rooms, the last bastion of resistance in American hospitals. Surgeons have been reluctant to use blunt suture needles, but new messages from the American College of Surgeons (ACS), the U.S. Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health may get their attention. Those organizations are actively promoting the use of blunt suture needles.
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They have a difficult mission. Suture needles are responsible for about one-fifth (21%) of all blood and body fluid exposures, according to 2004 data from EpiNet, a multihospital database of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville. The operating room has been the slowest part of hospitals to adopt the use of the safer devices, which are required by OSHA's bloodborne pathogen standard.
"Blunt needles are underused in the United States. We are trying to let all of the 60,000 fellows of the college know about this issue," says William Schecter, MD, FACS, chairman of the ACS Committee on Perioperative Care and chief of surgery at San Francisco General Hospital. "This technology is out there. It can be used."
It has been two years since the American College of Surgeons first issued a position statement endorsing the use of blunt suture needles for fascia closure, but Hospital Employee Health found that surgeons still are reluctant to adopt the technology. About 59% of all suture injuries occur while suturing fascia.1
"Surgeons remain ignorant of sharps injury rates," says Ramon Berguer, MD, FACS, clinical professor of surgery at the University of California Davis and chief of surgery at Contra Costa Regional Medical Center in Martinez, CA. "They remain a little wary on the use of blunt suture needles. Some of the early blunt suture needles were really blunt and difficult to use."
Berguer, a general surgeon and member of the ACS Committee on Perioperative Care, uses blunt suture needles and tries to eliminate sharp devices by using electric cautery and skin staples. "I get stuck at least once a year, and I think every surgeon just accepts that," he says. "I don't think we have to accept that. That's the mentality we have to change."
In fact, a recent study found that 99% of surgical residents have at least one sharps injury during their training, but only about half of them are reported.
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Hospitals are required to evaluate blunt suture needles, just as they do blood collection devices. In a joint bulletin on blunt suture needles, OSHA and NIOSH note that "employers must use safer devices to replace corresponding conventional sharp-tip suture needles in their workplaces when clinically appropriate."
If the hospital uses conventional needles, justification must be documented in the exposure control plan.
"The surgeons' preferences are secondary to [the regulatory requirements]," says Sheila Arbury, RN, MPH, COHN-S, health scientist in OSHA's Directorate of Science, Technology and Medicine. "If they're able to do the procedure using blunt sutures without any harm to the procedure, the patient, or [other clinical concerns], they really need to try this."
OSHA inspectors rarely venture into the OR arena. Most of OSHA's inspections are triggered by complaints, and complaints are rare from members of the tight-knit OR teams. So OSHA and NIOSH are trying to promote blunt suture use through their alliances and partnerships — by encouraging The Joint Commission to call for their use, by working with vendors to improve the availability of various needles and suture materials, and by spreading the word among health care workers.
Still, despite surgeons' recalcitrance, hospitals are subject to citation if they don't use blunt suture needles where clinically appropriate, says Dionne Williams, MPH, team leader in OSHA's Directorate of Enforcement Programs.
"It can't be infeasible in every single surgical procedure [to use blunt suture needles]," she says. "If we're looking at [a hospital's] exposure control plan and they're writing that they're infeasible altogether, that would raise a question in our minds. It's not going to be appropriate in every single situation, but if it is appropriate for some procedures, we'd like to see that incorporated in the plan."
Blunt needles reduce injuries
However, even surgeons who support the use of blunt suture needles have found impediments. Janet Stein, MD, participated in a study of blunt suture needles in gynecologic surgery sponsored by the Centers for Disease Control and Prevention. The study, published in 1997, showed that blunt suture needles could significantly reduce needlestick injuries in the OR. Each increase in the use of blunt suture needles was associated with a decrease in injuries.
Based on the findings, CDC estimated that if half of the curved suture needles were replaced with blunt needles, injuries would drop by 87%. Surgeons reported technical difficulties with the blunt suture needles in only 6% of the cases, and patient care was not affected.2
"It's a no-brainer to me. If it's available, why would you use anything else?" says Stein, who is now vice chair and director of the residency program in the department of obstetrics/gynecology at Beth Israel Medical Center in New York City and the Manhattan campus of Albert Einstein College of Medicine.
However, in the years after the study, surgeons no longer used the blunt suture needles at the hospital. Often, the preferred suture material wasn't available with the needles or had to be special ordered, Stein says. Other advances in the OR such as laparoscopy and the use of cautery led to reduced injuries. In addition, other safer practices, such as hands-free passing of instruments became routine. But surgeons never became fully comfortable with the blunt suture needles, she says.
"Calling something a 'blunt needle' really turns surgeons off," she says. "We really wanted to call them safety needles, and we thought people would be a lot more interested in using them if we called them safety needles."
Stein hopes a resurgence of interest in blunt suture needles will lead to increased acceptance among surgeons.
Surgeons need to request the products that will work best for them, stressed Schecter. "I think the profession as a whole is going to have to deal with this issue and work with industry," he says. "Industry will provide whatever we need if we ask for it."
The Association of Perioperative Registered Nurses (AORN) also supports the use of blunt suture needles, as well as other techniques to reduce injuries, such as double-gloving. Employee health professionals should work with the OR educator as well as leaders, such as the surgery medical director, advises Carol Petersen, RN, BSN, MAOM, CNOR, perioperative nursing data set manager with AORN.
They need to present detailed data about the types of sharps injuries occurring in the OR. They should work through the OR steering committee or other multidisciplinary teams to implement changes, she says. Surgeons will want scientific evidence that new devices will improve safety while safeguarding patient care. "Always go into those meetings prepared," she says.
(Editor's note: The American College of Surgeons position statement is available at www.facs.org/fellows_info/statements/st-52.html.)
1. Jagger J, Bentley M, and Tereskerz PM. Patterns and prevention of blood exposures in operating room personnel: A multi-center study. AORN J 1998; 67:979-996.
2. Centers for Disease Control and Prevention (CDC). Evaluation of blunt suture needles in preventing percutaneous injuries among healthcare workers during gynecologic surgical procedures — New York City, March 1993-June 1994. MMWR 1997; 46:25-29.