Needlesticks, blood exposures falling everywhere but in the OR

"It's become kind of a standoff."

Thanks to safer devices, health care workers are sustaining many fewer needlesticks than they did a decade ago. But hospitals have yet to face up to the challenge of one unsafe zone: The operating room.

According to a recent analysis of sharps injury data at 87 hospitals around the country, sharps injuries in the operating room actually rose by 6.7% from 1993 to 2006. Other sharps injuries declined by 31.6% during that same period.1

Surgeons and their surgical teams have not adopted safer devices or work practices that would reduce the risk of injury, says Ramon Berguer, MD, FACS, chief of surgery at Contra Costa Regional Medical Center in Martinez, CA, and co-author of the study.

"The pressure just simply hasn't been great enough. That's the simplistic, overall answer," he says.

Surgeons have their reasons for reluctance to embrace sharps safety. It was difficult to penetrate tissue with the early blunt suture needles, and they came in very limited sizes. Safety scalpels, with sheaths for the blade, didn't have the right weight or feel. The current technology of both devices has improved considerably, says Berguer.

Hands-free passing of instruments, a work practice designed to reduce the risk of sharps exposure to nurses and other members of the surgical team, hasn't been embraced, either. "The surgeons are used to receiving instruments in their hand," he says. "When they don't, they have to take their eyes off the field. That has made it unpopular with surgeons.

"[At many hospitals,] it's become kind of a standoff between the nursing community, which has advocated it, and physicians who have resisted it," he says.

Surgeons endorse blunt needles

Within the hospital, the OR has its own culture and traditions. While hospitals responded swiftly to the 2000 federal law, the Needlestick Safety and Prevention Act, the OR had a unique set of devices and barriers to implementation. "There is a culture that's a little more insulated than the rest of the hospital," says co-author Elayne Kornblatt Phillips, RN, MPH, PhD, director of research at the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville.

As the years have passed, change has been elusive. The American College of Surgeons has sought to turn that around. In 2005, the ACS endorsed "universal adoption of blunt suture needles as the first choice for fascial suturing to minimize or eliminate needlestick injuries from surgical needles."

The ACS went farther in 2007, endorsing the use of double-gloving and a hands-free neutral zone for passing of instruments, provided those techniques didn't adversely affect the procedure. The college also supported the use of blunt suture needles, safety scalpels, and other safety devices. (www.facs.org/fellows_info/statements/st-58.html)

The Council on Surgical & Perioperative Safety, a coalition of seven professional organizations that includes the ACS and the Association of periOperative Registered Nurses (AORN) also has endorsed sharps safety, including double-gloving, blunt suture needles, and use of the neutral zone.

With better technology, ample data, and support from professional societies, it's now time for increased awareness about the sharps injury risks in the OR, says Berguer.

Nurses, techs most likely to be injured

The sharps injury analysis looked at data from the Exposure Prevention Information Network (EPINet) of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville. Of 31,324 sharps injuries, 7,186 occurred in surgical settings.

Suture needles were associated with a greater portion of the injuries (43%) than other devices. And most injuries occurred during use or passing of instruments or between steps of a multistep procedure.

Interestingly, nurses and surgical technicians were significantly more likely to be injured (30.3% and 37.1%) than surgeons (15.6%).

"One of the most dramatic findings of the data is that the risk is shared unequally throughout the team," says Berguer. "The [sharps safety] decisions that are made by the surgeon disproportionately affect other members of the team."

That means that surgeons must adopt a team perspective on safety, says Phillips. "Oftentimes people who work in high risk situations say, 'I'm willing to take that risk.' But you're not taking that risk just for yourself. There are consequences for everybody else," she says.

Surgeons themselves are also at significant risk. A survey of about 700 surgical residents at 17 medical centers found that 99% had sustained a sharps injury by their final year of training, and 53% of those involved a patient with a history of HIV, hepatitis B or C, or intravenous drug use.2

Armed with data, the availability of better products, and the support of professional societies, Berguer says he is committed to pressing a sharps safety agenda in the nation's operating rooms. "There's no reason for anyone in the operating room to accept a sharps injury as a necessary, unmitigated risk of their work," he says.

As ORs adopt patient safety checklists, perhaps they should incorporate a sharps safety checklist, says Phillips. The analysis of OR sharps injuries could be convincing data, she says.

"We think surgeons do care about their staff as well as their patients. Sometimes it's a matter of raising people's consciousness," she says. "Hopefully that can have an impact on changes in behavior."

Reference

1. Jagger J, Berguer R, Phillips EK, et al. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg 2010; 210:496–502.