Blunt assessment: Surgeons stuck by suture needles endanger themselves and patients

OR still the wild, wild West of needle safety

Ramon BerguerVeteran surgeon Ramon Berguer, MD, routinely stitches up patients in suture seams as tight as a quarter-inch or less, with the needle tip drawing perilously close to his gloved opposite hand. Occasionally it hits with the force to cause a needlestick, but what results is not an injury — but a memory.

"I think, 'Wow, if this was a sharp needle, I would have just had a puncture,'" he says. Berguer is among the minority of surgeons who have transitioned to tapered, "blunt" safety needles for most procedures, avoiding many suture needlesticks that are too often considered part of the job of surgery.

"Sometimes when you are closing the abdomen, you can't really see properly how to put the stitch in, so we put our hands inside, lifting the abdominal wall," says Berguer, chief of surgery at Contra Costa Medical Center in Martinez, CA. "In many of those situations, I have felt the tip of the needle touch my glove."

But instead of incurring a sharps puncture, Berguer feels the reassuring "pop" of the safety needle coming through patient tissue, a sound and sensation he has come to associate with his personal protection from bloodborne viruses.

"After using the blunt needles for a while, I've come to like the little 'pop' that they make," he says. "It's sort of like feeling the seat belt tug against your chest in the car. You just know you are using a needle that — if you happen to drop it or someone pulls on the end of the suture or any one of the small little hiccups that can occur during a case — that the tip isn't going to stick into you or a nurse or the assistant."

As a member of the perioperative committee of the American College of Surgeons, Berguer helped craft the group's most recent statement on sharps injury prevention in the OR.

"As part of our drafting that [2007] statement, we reviewed the available data on various devices and techniques and it was pretty clear that the evidence supporting the use of blunt suture needles was very compelling," he says. "[Conventional suture needles] remain the No. 1 cause of sharps injuries in the operating room. The studies clearly show a dramatic reduction in injuries, so the American College recommends that [blunt needles] be used in all operations for the closure of muscle and fascia."

The ACS recommendation was followed by a joint bulletin by the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) stating "employers must use safer devices to replace corresponding conventional sharp-tip suture needles in their workplaces when clinically appropriate." NIOSH and OSHA estimated that sharp-tip suture needles are the leading source of percutaneous injuries to surgical personnel, causing 51% to 77% of those incidents.1,2

Jane PerryHowever, the general perception is that little has changed and the OR remains subject to high rates of sharps injuries with traditional suture needles.

"I'm not sure what it will take — I think it would be helpful if OSHA really started citing ORs for not using them," says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville. "There is a real opportunity here because we know that if blunt suture needles were implemented on a widespread basis for doing internal suturing like muscle and fascia that it could have a big impact on reducing needlestick injuries in surgery settings. The problem is that surgeons, especially older surgeons, have been hard to convince to switch over to the most recent blunt suture needles — which are actually a lot sharper than the older safety suture needles."

Another issue is that the blunt safety needles can not be used for all surgical procedures. "I use them pretty much on everything except skin and bowel right now," Berguer says. "The dermal layer in the skin is very tough. The blunt needles and the data to support them are only for the use of closure of muscle and fascia."

Martin A. MakaryThat means traditional sharp suture needles still are needed on hand and the vast majority of surgeons continue to favor them. "The [blunt needles] work well, but they are only useful for certain steps of the operation," says Martin A. Makary, MD, MPH, an associate professor of surgery and director of the Johns Hopkins Center for Surgical Outcomes Research. "I use them relatively routinely as do a few other surgeons that I know. For the most part, the national uptake of those needles has been poor — we think less than 10% of surgeons are using the new safety needles. That, in spite of the fact that the ACS official position statement endorses their use."

In addition to blunt needles, Makary uses other equipment for "sharpless surgery" when possible (i.e., electrocautery for skin incision).3 "We found that we are able to do about half of our general surgery operations with a sharpless protocol or without [traditional] needles," he says.

Such practices are the exception however, as the surgical suite remains something of an anachronism in an age when needle safety syringes and sharps disposal containers are in common use throughout the hospital. Though new and improved safety suture needles are being embraced by Berguer and other surgeons, the majority of physicians in the profession still prefer the feel and performance of a traditional sharp suture needle.

"The 'feel' of using the blunt needles is overstated as a problem," Berguer says. "They require a little bit more force initially and surgeons have sort of focused on that as a complaint. The first generation of blunt needles were really blunt and were tough to use, but the new generation of blunt needles have a different taper which makes them easier to use."

Previously difficult to obtain, the blunt needles are now being widely marketed even as education efforts struggle forward. "There still really is very little education of surgeons about the sharps problem and the importance of using blunt suture needles," he says.

As a result, sharps injuries are prevalent in the nation's ORs, though most are not reported because of the perceived hassle and stigma historically associated with a needlestick. There is massive underreporting of injuries in part because the reporting, documentation and prophylaxis process can be burdensome and incompatible with the busy work practice and patient commitments of most surgeons.

"I've probably averaged like most surgeons about one needlestick a year during my career, sometimes more," Berguer says. "I admit to not reporting two-thirds of those for logistical reasons. It's simply not possible to stop operating."

Having undergone prophylaxis for a potential HIV exposure following a sharps injury four years ago, Berguer is well aware of a process that is both laborious and stressful. "I have not had a needlestick now for about two years and I would like to believe that is due in part to the blunt suture needles," he says. "It is also due to implementing a sharps policy that includes the hands-free passing of sharps instruments and so forth."

Many think the resistance to surgical sharps safety will give way as newer surgeons come into the field, particularly at a time when patient safety has become a consumer advocacy issue.

"Clearly, the way to bring about change is to work with the young surgeons," Berguer says. "They have definitely come out of a different culture towards patient safety and hopefully toward staff safety as well. Things like wearing eye protection, double-gloving, and so forth I think are more widespread among the younger generation of surgeons who are not willing to accept the risk of needlesticks as simply part of their jobs."

And the band played on

However, research by Makary and colleagues is finding that most surgeons are still being trained to use traditional sharps and hold fast to the culture that has long closed out innovation to replace them. For example, surgical trainees may learn early on that there are disincentives to reporting suture stick injuries. For one, they may be subject to grading by superiors who will not be amused if they leave the OR for a prolonged visit to the occupational health service.

"Hospitals are not creating a culture of speaking up," says Makary. "If people are not speaking up regarding their own safety concerns, it's probably a surrogate marker of people not speaking up about patient safety concerns. Many people tell us that they find reporting to be a very cumbersome process for which they have to either collect signatures or be put in long cues or wait lists. They are not provided any coverage of their clinical responsibilities. That, coupled with the stigma as well as the fact that students and residents are often being graded or evaluated by their peers, creates a significant sum total of barriers."

As a result — somewhat remarkably given that we're several decades into a worldwide epidemic of a deadly bloodborne virus — too many surgeons still consider a suture injury during an operation business as usual in 2010.

"There is a mentality that exists that surgeons feel it is just part of the job," Makary says "People are not always concerned about the risks as they should since there is a macho mentality that sometimes permeates the field."

In a recently published study, Makary and colleagues surveyed surgery residents at 17 medical centers. Of 699 respondents, 415 (59%) said they had sustained a needlestick injury as a medical student.4 Many said they were stuck more than once; the median number of injuries per injured respondent was two.

"The operating room is just a very high-risk environment," he says. "There are a lot of needles being based back and forth. There is a lot of stitching involved — a typical operation could involve hundreds of stitches. There are often people in the room who are not accustomed to working together as a team."

Of 89 residents who sustained their most recent needlestick injury during medical school, 42 (47%) did not report their injury to an employee health office — thereby avoiding an evaluation as to whether they needed treatment to prevent HIV or hepatitis C virus, the study found. The survey did find, however, that medical students were very likely (92%) to report the needlestick if they perceived that the patient was at high risk for having a virus such as HIV or hepatitis, compared with 47% of injuries involving "low-risk" patients. The most commonly given reason in the study for why the medical students didn't report needle injuries was the amount of time involved in making a report.

Most of the needlesticks among medical students were self-inflicted and occurred in the operating room when the student felt "rushed," Makary says. Respondents who sustained a needlestick injury in medical school were more likely to sustain a needlestick injury during residency. The researchers concluded that needlestick injuries and underreporting of the injuries are common among medical students and place them at risk for HCV and HIV. Strategies aimed at improving reporting systems and creating a culture of reporting should be implemented by medical centers, they recommended.

"Medical schools are not doing enough to protect their students and hospitals are not doing enough to make medical school safe," Makary says. "We, as a medical community, are putting our least skilled people on the front lines in the most high-risk situations. Most trainees are still forced to learn to sew and stitch on patients, which puts both providers and patients at risk."

Medical schools should take advantage of advances in simulation technology and do less training on actual human beings, he adds. At Johns Hopkins Hospital, for example, a hotline has been instituted for all occupational blood exposures. After such a report is received, a rapid response team is activated to deliver appropriate care while preserving confidentiality.

"Some hospitals have excellent simulation centers and some hospitals are making a point of having high-risk patients undergo a sharpless protocol," Makary tells Hospital Infection Control & Prevention, "but a lot of training is still occurring by 'practicing' on patients, whereas high-tech simulators now can allow us to rehearse those techniques before people are in the real world."

Safety checklist for the OR

References

  1. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposure in OR personnel. AORN J 1998; 67(5):979-981, 983-984, 986-987 passim.
  2. Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg 2004; 199(3):462-467.
  3. Makary MA, Pronovost PJ, Weiss ES. Sharpless surgery: A prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice. World J Surg 2006; 30(7):1,224-1,229.
  4. Sharma G, Gilson MM, Nathan H, et al. Needlestick injuries among medical students: Incidence and implications. Acad Med2009; 84(12):1815-1,821.