Cover Story: Don’t stick it to me
Reducing sharp injuries where they occur most
Sharps safety has concerned nurses and surgeons for as long as needles and scalpels have existed. But the issue received broad—and some would say, long-overdue—attention a decade ago with the passage of the Federal Needlestick Safety and Prevention Act of 2000, which was followed by revisions to the Bloodborne Pathogens Standard a year later. Since, sharps safety advocates have developed new safety techniques, and sharps manufacturers have debuted safety features. Still, sharps injuries remain highest in surgical settings, where adoption of safety devices has been “limited when compared to nonsurgical settings,” according to the Centers for Disease Control and Prevention (CDC).
The Needlestick Safety and Prevention Act covers a wide range of areas related to needlesticks and infections from bloodborne viruses, including sharps disposal practices, safety-engineered sharp devices, personal protective equipment, sharps safety training and recordkeeping for needlestick injuries.
Meanwhile, all U.S. health care facilities are required by law to comply with the regulations of the Bloodborne Pathogens Standard. It requires employers to utilize safer engineering controls that eliminate (or at least minimize) the risk of exposure to bloodborne pathogens via needlestick or sharps related injuries.
Progress made, but work remains
The data reveal that these measures have helped reduce needlesticks, blood exposures and the risk of infection from bloodborne viruses among health care workers. However, preventable sharps injuries and blood exposures continue to occur in health care settings. According to the CDC, 385,000 needlestick and other sharps-related injuries are sustained by hospital-based health care personnel each year. The CDC estimates that half of sharps injuries go unreported.
The International Healthcare Worker Safety Center at the University of Virginia has been collecting data on sharps injuries in U.S. hospitals since 1992. In a recent study, the Center reported that sharps injuries are occurring most often in the surgical setting, which is the site of about one third of the injuries. And nurses are sustaining the largest share of sharps injuries in the OR—again, about one-third of all injuries. In 2009, 92 percent of reported sharps injuries occurred with contaminated instruments.
“The state of sharps safety has us concerned,” says Mary Foley, PhD, RN, the chairperson of Safe in Common. Foley was president of the American Nurses Association when the Needlestick Prevention Act was adopted in 2001. “While we recently celebrated the 10th anniversary of the Federal Needlestick Prevention Act, our work is not yet done.”
Foley points to a 2010 study by the CDC that found that between 2001 and 2006, sharps injuries increased in surgical settings by 6.5 percent while decreasing in all other hospital settings by more than 31 percent. “This is unacceptable,” says Foley, who attributes it primarily to the failure of available safety products to properly address the safety and functionality needs of health care personnel.
A renewed emphasis
Organizations such as Safe in Common, the Council on Surgical and Perioperative Safety (CSPC) and the Association of periOperative Registered Nurses (AORN) are emphasizing the importance of sharps safety. For example, AORN has produced a new sharps safety toolkit that includes a video, PowerPoint presentations, guidance documents and more tools designed to help perioperative nurses increase sharps safety in the OR. The toolkit can be downloaded from the AORN website at www.aorn.org/Sharps_Safety_ Toolkit. And AORN will release a new Recommended Practice for Sharps Safety in early 2013.
According to Mary Ogg, RN, MSN, CNOR, a nursing specialist in AORN’s Nursing Department, the sharps safety toolkit was developed with input from surgeon Ramon Berguer, M.D., and the president of the Association of Surgical Technologists, Sherri Alexander, CST. “We are all working together to help reduce the number of sharps injuries in the operating room,” says Ogg.
Foley points out that suture needles and scalpel blades cause a majority of injuries in the surgical setting, and most occur during instrument passing and after use. “Injuries to nurses and surgical technologists are most often caused by devices originally used by others, such as surgeons.”
A wide range of different types of needles and safety devices are used during procedures in the OR. The products vary depending on the case: guide wires with a blunting feature, blunt tip suture needles, blades with safety guards, armored gloves, robotic procedures and less invasive scopes, for example. “While blunt suture needles can prevent injuries during suturing of internal tissue and fascia, they are vastly underutilized by surgeons, despite recommendations from AORN and other surgical professionals,” Foley says.
Jennifer Taylor, LVN, an OSHA Safety Officer at Cityview Surgery Center in Fort Worth, Texas, says that Cityview’s surgeons have been using stainless steel safety knives with sliding protective sheaths for ophthalmic cataract surgeries for the past three years. “We have had no sharps injuries from knives since. Our physicians have adjusted to these blades with no complaints or problems, and our surgical scrubs and sterile processing staff appreciate them very much.”
Making the call
Nurses and surgical technologists sustain the vast majority of sharps injuries in the OR, but they usually are not the ones who get to decide whether sharps safety devices or techniques are used. “The surgeon has the final say and his decision can affect the level of risk for the whole perioperative team,” says Ogg. “So it’s important to get our surgeons onboard with the sharps safety agenda.”
This agenda includes both sharps safety tools and devices like those noted above, as well as specific sharps safety procedures and techniques, like double-gloving and creating a neutral/safe zone in the operating field where hand-to-hand passage of sharps is avoided. However, Foley believes that passing techniques and double-gloving are mostly ineffective in and of themselves when it comes to reducing sharps injuries.
“What we need instead is greater adoption of technologies like safety scalpels, blunt suture needles and other similar products that can prevent the risk of harm upfront. For device categories like suture needles, the majority of health care personnel are still using products without safety features, or products with first-generation safety devices that were launched even before sharps injury prevention laws came into effect.”
Ogg points out that many surgeons were slow to embrace some of the first-generation safety-engineered devices (especially safety scalpels) because they had a different “feel” to them. “Surgeons tried them, but were reluctant to use them or try newer safety devices on the market. I think the newer safety devices will be more accepted by surgeons, but the challenge lies in getting surgeons to try them.”
From her perspective, Foley believes it’s time to require the use of “safety devices with automatic and integrated safety features where they are available and compliant to routine procedures.” She would also like to see better innovation within a number of device categories to make them more convenient for health care workers.
“Safety products must be intuitive and not get in the way of clinical best practices,” says Foley. “The industry needs to continue to create safer engineering controls and work practices, especially for the OR setting.
“We have surgeons, nurses, anesthesiologists and other health care personnel who continue to experience injuries that could have been prevented,” Foley adds. “This is due to a lack of device innovation, caregiver complacency and gaps in education. We need to increase the focus on safer, simpler products and compliance with best practices to eradicate injuries.”
Penny-wise … and pound foolish
One of the biggest challenges when it comes to increasing sharps safety is convincing health care managers not to base procurement decisions for safety products simply on upfront costs. “Instead, facilities have to seriously consider the potential costs of not using the safest products,” Foley says. “This includes testing and treatment of the injured employee, as well as potential liability and OSHA fines.”
According to some estimates, needlestick injuries can cost at least $3,000 for testing and prophylactic treatment, while an actual infection with hepatitis C or HIV can cost over $1 million – and change the life of the health care worker and his or her family forever. “The few cents more it may cost to purchase a safety product compared to a standard syringe should not cause one second’s hesitation,” Foley says.
“I firmly believe that every sharps injury is preventable with the right equipment, the right procedures and the right culture,” she stress. “Until these are achieved, the state of sharps injuries will remain too high.”