Behind the Curtain of Sharps Injury Prevention and Device Reprocessing

By Karen A. Daley, PhD, RN, FAAN, and Amber H. Mitchell, DrPH, MPH, CPH

Current efforts to reduce sharps injuries (SIs) are most typically associated with those occurring to direct care staff.  Less apparent are risks to those working behind the scenes. Ongoing efforts to enhance sharps safety include research, advancements in medical science and safety technology, policy engagement, injury surveillance, regulatory enforcement and public awareness initiatives surrounding injuries and their impact.                                                                                                                                              

In November 2017, Infection Control Today published a report summarizing the ongoing work of the ANA SI Prevention Stakeholder Group – a group of sharps safety experts and advocates who have been participating in quarterly conference calls for the past three years to network and discuss ongoing issues, activities and strategies related to SI prevention across the U.S.                                                                                                                                   

In July 2017, the group held a sentinel meeting at ANA headquarters in Silver Spring, Md., during which workgroups were formed to focus on actionable strategies with the potential to advance SI prevention in the U.S. What follows is an update of that ongoing work as well as a discussion of SI risks and considerations for healthcare workers who function in a critical, but often underappreciated role – device and instrument reprocessing.                                                                                                                       

ANA SI Prevention Stakeholder Workgroup Updates                                                                                                         
The ANA SI Prevention Stakeholder workgroups have been targeting four important areas: terminology; media; policy; and safer operating rooms   The Terminology Workgroup was formed to address continuing language and acronym inconsistencies used by researchers, policy experts and industry leaders that contribute to widespread confusion around the meaning of terminology.  The workgroup has been engaged in ongoing efforts to simplify language that can be more clearly understood and universally applicable with simple acronyms, particularly as they relate to sharps devices with SI prevention features. The primary definition and acronym currently proposed by the Terminology Workgroup are: sharps with injury protections (SIPs). SIPs are defined as: devices with integral features to prevent percutaneous injuries that may cause exposure to bloodborne pathogens. Efforts are underway to find opportunities to publish letters or commentary to generate further discussion and feedback.                                                                                                                                                                                       
The Media Workgroup will function ad hoc as the need arises to initiate communications and craft informational notices.  They will disseminate communications whenever there is a topic, product or project that warrants media or public attention.                                                                                                                          

The Policy Workgroup has been identifying SI prevention standards and engaging with accrediting and licensing agencies to encourage their adoption and incorporation as part of site surveys and/or inspection processes. In the early 2000s, shortly after the Needlestick Safety and Prevention Act was incorporated into the OSHA Bloodborne Pathogens Standard, accrediting bodies like the Joint Commission were quite active incorporating elements of sharps safety into their surveys. This focus has diminished in recent years and as such, the Joint Commission will be the first organization we hope to work with.                                                                                  

The Policy Workgroup has concluded that state-level advocacy and engagement may provide the best opportunity for greater enforcement of existing policies and enhancement of safer practices. Focusing on local efforts allows for more targeted discussions about gaps in SI prevention policies and practices, and access to appropriate technologies. A groundswell of state-based education and awareness initiatives that motivate federal lawmakers could lead to expanded national policy to promote safer working environments for the delivery of healthcare. Stay tuned for future activities regarding to state and local policy including the development of guidance for healthcare institutions.                                                                                                                                                       

Injuries in the operating room (OR) most often involve suture needles, disposable hypodermic needles and syringes, and scalpel blades.  According to incident data from the Massachusetts Sharps Injury Surveillance System and the Exposure Prevention Information Network (EPINet), more than 50 percent of these injuries are reported by physicians.  Injuries can occur before use with tearing or sharps penetration of a contaminated glove, during use, between steps of a multi-step procedure with a device that may be used many times during one procedure, and after use. The injuries that occur between steps and after use are historically associated with “passing” injuries that happen when a no-hands passing (neutral zone) practice is not in place.  Implementation of safer programs for workers is directly related to safer outcomes for patients and should include not only instituting safer technologies and practices, but openness to collaborations, new ideas and innovative technologies that improve outcomes and minimize or eliminate injuries.                                                                                                                               

To focus on decreasing injuries in the OR, the Safe OR Pilot Workgroup was formed.  The Workgroup is currently recruiting facilities to pilot a Safe OR “bundled” approach that includes improving uptake of SIPs, activation of SIP mechanisms, alternatives to sutures for skin closure, use of no-hands passing neutral zones, and double gloving. The Safe OR Pilot Workgroup will begin working with a small number of facilities to gather injury data, develop targeted interventions, educational campaigns and evaluation tools, and determine impact over time.  It will then identify which program elements and collaborative relationships work best and offer it as a program to a larger number of facilities.                                                                       

Metrics of the Safe OR Pilot may include injuries, usage rates of SIP devices compared to non-SIP devices, compliance with safer practices and personal protective equipment (PPE) use. Metrics can include differences pre- and post-pilot for the use of scalpels and blades with SIP features, blunt sutures and skin closure alternatives, no-hands passing neutral zones, and double gloving.                                                                                                                                                    

The next face-to-face meeting of the ANA SI Prevention Stakeholder Group will be held at ANA headquarters in Silver Spring, Md. July 25-26, 2019.                                                                                                                          

Safety Concerns Relating to Device and Instrument Reprocessing                                 
According to EPINet, approximately 25 percent of all sharps injuries occur to downstream non-users.  The Safe OR Pilot Workgroup will attempt to help pilot facilities reduce OR injuries, but SIs also occur during device reprocessing.                                                                    

Professionals who encounter risks based on their work in sterile processing (SP) and central supply (CS) departments of healthcare facilities are often overlooked because they are not responsible for direct patient care. SP/CS employees are responsible for collecting, counting, cleaning, disinfecting, sterilizing and repackaging all reusable medical devices and equipment used by clinical and diagnostic teams. They are often exposed to bloodborne and infectious pathogens as they experience SIs and splashes and splatters, so protecting them is central to any SI prevention program.                                                                                                                           

The Safe OR Pilot workgroup will include elements to ensure continued focus on protecting this critical workforce and the impact they have on safe surgical outcomes for staff and patients alike. According to EPINet incident data, exposures frequently occur when: disassembling and cleaning surgical instruments that are caked with blood and tissue; lifting, transporting, and emptying trays filled with instruments; sorting instrument trays when disposable devices have not been discarded safely; and cleaning patient care items (e.g., wheelchairs) when devices have been left in them.                                                                        

Medical devices with SIPs are not in place just to protect the users of those devices, but also those who may come into contact with them downstream. Of utmost importance is the need for direct users to remember that there is no substitution for safe disposal of single use devices.  

Reprocessing SI Prevention Measures                                                                                           
There are several actions that can be taken to prevent injuries among workers in CS and SP. Donning appropriate PPE, including gloves, gowns, and face shields, minimize risk of exposure from splashes. Minimizing risk of a SI can also often be achieved by double gloving. Utilizing baskets to move devices and instruments from one cleaning stage to the next minimizes manual handling of instruments.  This can be employed in CS and SP as well as in operating and procedure rooms where devices are used and then placed in a solution for soaking immediately after use. Working with staff in operating and procedure rooms to ensure that instruments are placed in baskets or other containers with the sharp ends facing in the same direction helps those in CS and SP in the event they reach into a basin for a device. Ideally, tools (e.g., forceps) are used to pick up individual instruments, and brushes or sponges with handles are used for initial cleaning of the instruments.                                                                                            
Healthcare facilities can greatly reduce their SIs in their sterile processing department by collaborating with the OR staff to eliminate all disposable sharps sent for reprocessing. The OR staff should dispose of sutures, needles, and blades immediately after the surgical procedure, so that the kits and trays sent to SP present lower risk of injury.

While injuries among staff in CS and SP departments may constitute a small percentage of SIs facility-wide, their impact on the injured worker can be significant. Workers in these departments should be encouraged to report any SIs or splashes immediately to ensure appropriate post-exposure follow-up. This is particularly important as CS and SP staff may not know who the source patient is, thus limiting the ability for learning their serostatus – information which impacts post-exposure care and treatment.                                                        

SI surveillance and prevention is often focused on direct care staff.  Healthcare facilities are encouraged to review processes at each stage in the life cycle of devices and instruments and engage staff in implementing prevention measures appropriate for each stage. 

Karen A. Daley, PhD, RN, FAAN, is a nationally recognized sharps safety expert and policy advocate and served as president of the American Nurses Association from 2010 to 2014.

Amber Hogan Mitchell, DrPH, MPH, CPH is the president and executive director of the International Safety Center. The Center is a 501c3 non-profit organization that provides the Exposure Prevention Information Network (EPINet®) to healthcare facilities around the world for free.