Perioperative professionals are among the healthcare professionals at highest risk for sharps injuries—getting stuck by a suture needle or cut by a scalpel. About 30% of sharps injuries occur in surgical settings. What’s more, since passage of the Needlestick Safety and Prevention Act in 2000, the rate of nonsurgical sharps injuries has declined while surgical sharps injuries have increased 6.5%.
Given these alarming statistics, we urge all nurses to review the American Nurses Association’s (ANA) Code of Ethics, provisions 5 and 6:
The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
The nurse participates in establishing, maintaining and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
These passages underscore our responsibility to keep ourselves safe and provide high-quality health care. To highlight exactly how we can do this, this article explores the current state of sharps safety practice and barriers to best practices, and outlines the key elements of an effective perioperative sharps safety plan and policy.
Safety measures and barriers to sharps safety
Since 2000, numerous improvements have been made in safety scalpels and blunt-tip suture needle technology. Nurses, surgeons, and technologists have received many hours of education and training on double-gloving, the neutral (safe) passing zone, and appropriate use of blunt-tip suture needle technology. Yet surveys by the Association of PeriOperative Registered Nurses (AORN) and others show that many facilities still don’t follow best practices for sharps safety and vastly underreport needlestick injuries.
For instance, in 2011 AORN surveyed 1,111 perioperative staff nurses and unit directors on surgical sharps safety. Two of five respondents (43%) said either their organization didn’t have a sharps-prevention education plan or they didn’t know if it did. About one-third (30%) said they didn’t double-glove. When asked to identify obstacles to compliance with sharps safety best practices, 55% cited the fact that conventional sharp items are readily available; 52% cited lack of multidisciplinary support for sharps safety.
This isn’t surprising. While working in various facilities over the years, we’ve found significant barriers to implementing sharps safety plans and policies. These include organizational resistance to change; surgeons’ perceptions of the quality of safety needles; nurse intimidation and sense of powerlessness; the perception that safety costs more; and inaccurate beliefs, including “It’s not going to happen to me.” Many people have suffered sharps injuries and haven’t contracted an illness, so they erroneously think they’re invincible.
To make best practices a reality, nurses should first get buy-in from the entire perioperative team (surgeons, technologists, and managers) by citing statistics, Occupational Safety and Health Administration (OSHA) regulations, and AORN-recommended practices. Next, they should use their champions to win administrative support for change. Finally, nurses should form a multidisciplinary team—along with physicians, the hospital safety officer, and representatives from risk management, work health, and infection control—to write and execute sharps injury-prevention plans and policies.
The case for blunt-tip suture needles
An analysis of injury surveillance data from 87 U.S. hospitals from 1993 to 2006 found 37.1% of surgical injuries occurred in surgical technicians, 30.3% in operating-room (OR) nurses, 17% in surgical residents and fellows, and 15.6% in surgeons. Injuries to nurses and technicians most often occurred when they passed or disassembled devices and during or after device disposal. Overall, suture needles were the most common cause of percutaneous injury in the OR, involved in up to 43% of such injuries.
Blunt-tip suture needles, available in almost all sizes and materials, are part of the solution. Although they require a bit more directed force than sharper needles, they can be used to suture less-dense tissue, such as muscle, fascia, and subcutaneous tissue. Their use was recommended in a joint safety communication issued in May 2012 by OSHA, the Food and Drug Administration, and the National Institute for Occupational Safety and Health: “Although blunt-tip suture needles currently cost some 70 cents more than their standard suture needle counterparts, the benefits of reducing the risk of serious and potentially fatal bloodborne infections for healthcare personnel support their use when clinically appropriate.” The agencies strongly encourage healthcare professionals in surgical settings to use blunt-tip suture needles when appropriate.
Safe practices call for nurses to get involved in the solution. To get started, nurses should lead efforts to ensure that employers provide a selection of sutures in blunt-tip needle sizes comparable to previously used sharp suture needles. They should partner with materials management and worker health representatives, who can perform a cost analysis and analyze the financial implications of the more expensive blunt-tip suture needles versus the costs incurred from sharps injuries.
As a next step, nurses should update surgeons’ preference cards and list blunt needles on every card. They should work with suture company representatives to provide charts listing comparable needle sizes. Finally, nurses should identify a surgeon who uses blunt needles and is willing to champion the cause.
Scalpels are responsible for up to 17% of surgical sharps injuries—the second most frequent cause of these injuries. The solution is to use safety scalpels, which come in two forms: sheathed and retractable. Sheathed scalpels have a retractable plastic case that encloses the blade before and after use. Retractable scalpels let the surgeon or scrub person slide the blade into the handle with one gloved hand. Reported barriers to their use include complaints that safety scalpels lack the same weight and feel as metal-handled scalpels and aren’t as usable (the blades aren’t as sharp and can’t cut as deeply), and the perception that safety scalpels cause more injuries.
To promote safe practices, we recommend OR nurses advocate that their facility join sharps safety device trials to determine if one of the available safety scalpels would work for their facility. To get administrators’ buy-in, they should familiarize themselves with OSHA’s bloodborne pathogens standard, which requires annual evaluation and documentation of review of the use of engineering and work-practice controls to eliminate exposure to potential injury or reduce it to the lowest extent possible. Safety scalpels are an example of an engineering control that hospitals and ambulatory surgery centers could implement.
Hands-free technique or neutral passing zone
Although getting perioperative team buy-in is optimal, nurses can initiate the hands-free technique (HFT) on their own simply by placing items in a container and passing the container to the surgeon. Research shows HFT reduces sharps injuries by up to 59%.
When using HFT, the scrub nurse places a suitably sized, puncture-resistant container, magnetic pad, or towel on the operating field between herself and the surgeon. The ideal device for HFT (also called a neutral passing zone) is large enough to hold sharps, not easily tipped over, and mobile. One sharp at a time is placed in the neutral zone before and after use. (Blunt instruments can still be passed hand-to-hand.) As the instrument is placed using the HFT, the user calls out “sharp” to alert the surgical team.</p.
Nurses should educate surgeons and OR staff members about HFT, noting it can be customized to each patient and surgery. For example, surgeons can identify situations when HFT won’t work, such as during ophthalmologic or microsurgical procedures. In those cases, nurses still may place instruments directly in the surgeon’s hand and then have the instrument returned to the neutral zone.
Glove punctures increase the risk of bloodborne pathogen trans-mission during surgery. Some research shows tears and perforations occur 6% to 12% of the time in the OR, especially when gloves are worn for long periods. During invasive surgical procedures, staff should change surgical gloves every 90 to 150 minutes. The Centers for Disease Control and Prevention, American College of Surgeons, Association of Surgical Technologists, and AORN recommend double-gloving during such procedures.
Wearing double gloves or using an indicator glove system helps protect healthcare workers from needlestick injuries. Designed to be used as the underglove, the indicator glove is a different color than a regular glove. Thus, tears and punctures are more easily visible, allowing surgical staff to more easily see breaches in the outer glove. Double-gloving itself acts as a protectant because punctures are more likely to breach the outer glove than the inner glove. Evidence shows that when healthcare workers wore a perforation-indicator glove, 77% of punctures were detected, compared to 21% detected when standard double gloves were worn.
Still, many facilities don’t require double-gloving, and even when they do, many perioperative personnel don’t double-glove. Resistance stems from the perception that double-gloving reduces their dexterity and tactile sensation. Another obstacle for some is the challenge of obtaining a comfortable fit.
As with other sharps safety techniques, to build compliance for double-gloving, nurses can start by using evidence to educate staff and adapting the technique to the individual facility. No single method of double-gloving works for everyone, so perioperative professionals should try different glove combinations and sizes to find a comfortable fit. Possible combinations include wearing two of the same-size gloves, wearing a half-size larger than the usual-size inner glove, and wearing a half-size larger as the outer glove. It’s a matter of personal preference and getting used to a different feel.
The ethics of sharps safety
The OR is unique in the healthcare facility: It requires close teamwork, with team members working under intense time pressure; reliance on limited visual cues; and extensive use of sharp, dangerous instruments. These circumstances put perioperative professionals at special risk for sharps injuries. (See Support sharps awareness by clicking the PDF icon above.)
What’s more, healthcare workers aren’t the only potential victims of sharps injuries. Surgical patients have open wounds that are susceptible to contamination. If a scrub nurse or surgeon sustains a hand injury, their blood may contaminate patient wounds. Since 1991, 131 documented cases of healthcare worker-to-patient transmission of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus have occurred during invasive surgery worldwide.
Although every healthcare facility is unique, use of blunt-tip suture needles, safety-engineered devices, HFT for passing, and double-gloving have been found to reduce risk of sharps injuries across all settings. To uphold ANA’s Code of Ethics, nurses must use available devices for sharps injury prevention, educate others about their importance, and make sure our work environments are as safe as possible for every patient and every worker, every day.
Charlotte Guglielmi is a perioperative nurse specialist at Beth Israel Deaconess Medical Center in Boston, Massachusetts. Mary J. Ogg is a perioperative nursing specialist at the Association of periOperative Registered Nurses in Denver, Colorado.
To read another article from this supplement, Moving the Sharps Safety Agenda Forward, please click below: