Getting unstuck: Hospital finds safe zone in the OR

Sharps injuries decline, but challenges remain

Never let up. That is what Greenville (SC) Hospital System learned about reducing sharps injuries in the operating room. It takes a sustained effort to keep rates down.

The three-hospital system has been on the forefront of sharps safety, implementing safety devices in 1991, about 10 years before the Needlestick Safety and Prevention Act provided a national mandate. When other hospitals were evaluating safety products, Greenville Hospital System was monitoring compliance.

But one challenge remained. The operating room still had consistently high rates of blood and body fluid exposure. "Because the safety devices have reduced injury in other areas, the OR stands out," says Connie Steed, RN, CIC, director of infection control.

So an action team created a new objective: "To decrease OR health care worker exposures by implementing a hands-free neutral zone during surgery and ensuring the appropriate use of safety devices and personal protection equipment.

Easier said than done.

The hospital placed an emphasis on maintaining a neutral zone for the passing of sharps. They should no longer be passed directly between a surgical technician or nurse and the surgeon.

"It took more than a year to get compliance," says clinical nurse specialist Sue Seitz, RN, MSN, CNOR. "We faced several barriers. We educated about the neutral zone policy; we educated about hepatitis C and the devastating effects it can have. Despite the education, there was not any behavioral change."

Monitoring behavior in the OR and providing feedback on sharps injuries eventually made the difference, she points out.

Rounds focus on safety hazards

Seitz continually relayed information to the OR staff and physicians about who was being stuck, how were they being stuck, how it could have been prevented, and what it was costing the hospital.

Infection control staff made rounds in the OR and noted safety hazards. For example, they recommended that fewer people hover around the OR table, which meant some students needed to step back a few paces and provide more room for safe maneuvering.

Nurse managers made rounds and reminded staff about the neutral zone. They use "award" and "alarm" sheets to give feedback about compliance.

Meanwhile, the hospital system’s vice president of medical affairs offered his strong commitment, which was the key to surgeon support of the changes. The hospital brought in Marc Davis, MD, a former surgeon who has become a national champion of sharps safety in the OR, to speak to medical staff.

The hospital purchased special relay trays for passing suture needles and gave surgeons four options for the neutral zone: a magnetic pad, a folded towel, an emesis basin, or the tray. "We set up a display for our surgeons outside of their lounge so they could see examples of what they could expect [from surgical technicians]," says Seitz.

From 2002 to 2003, the OR exposures declined from 5.55 to 3.73 per 1,000 procedures. By 2003, the rate climbed again, to 4.72. Margaret Baker, RN, the hospital system’s exposure control nurse, tracked the quarterly rates and investigated why the exposures went up. Nurse managers told her they had slacked off on rounds.

The rounds started up again, and Seitz reminded the OR staff to keep up the neutral zone. The rate dropped back down to 3.48 in the second quarter of 2004.

"After three years [of effort], we have a success story," says Seitz.

Suture needles remain a challenge

Challenges remain in the OR, as they do for hospitals around the country. Surgeons have resisted using blunt sutures, saying the devices change their technique and affect patient care.

"Two or three years ago, I talked to the surgical groups to facilitate interest," she notes. "We had a lot of surgeons volunteer to try it. Some of them tried it and didn’t like it."

Nationally, suture needles are the second greatest source of sharps injuries, accounting for 18% of injuries, says Jane Perry, MA, director of communications for the International Healthcare Worker Safety Center at the University of Virginia Health System in Charlottesville.

The center collects sharps injury data from hospitals participating in its EPINet network. The EPINet database, established in 1993, now includes more than 25,000 sharps exposure incidents.

"Our data show that sharp-tip suture needles continue to be a significant source of injury to health care workers, but there’s been very little change in the injury rate for this device over the last 10 years because safer technology and techniques haven’t been widely adopted," she says.

A 1997 study by the Centers for Disease Control and Prevention showed blunt suture needles were effective in reducing sharps injuries in gynecologic surgery without impacting outcomes,1 Perry notes.

"I think manufacturers of blunt suture needles need to do a better job of promoting this technology as a safety measure for surgeons and those who work with them," she says. "Surgeons need to be educated about what this technology is and how it can be used."

Greenville Health System will continue to try to educate surgeons about blunt suture needles and other safer technologies. "We’re not going to give up," Steed explains.

Here are some of the lessons that were learned at Greenville about reducing sharps injuries in the OR:

  • Track your rate, not your numbers. If your sharps injuries go up, you need to know whether your procedures or patient population went up as well.
  • Your past performance is your best benchmark. If you compare your rates to those of other facilities, you may not know if you’re calculating your injuries in the same manner. "Some hospitals don’t [include nonemployees, such as surgeons], so it looks like they have lower rates," says Baker. "We decided not to compare ourselves with others."
  • Collect your data monthly but analyze it quarterly. On a month-by-month basis, you may have a lot of fluctuation that can be confusing, says Baker.
  • Look at sharps injuries by occupation. For example, Greenville Health Systems noticed sharps injuries were going up among medical residents, which prompted a closer look at that group.

Reference

1. Centers for Disease Control and Prevention. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures — New York City, March 1993-June 1994. JAMA 1997; 277(6):451-452.