The Changing Impact of Low PPE and Safety Device Use and Compliance in the OR

By Amber Hogan Mitchell, DrPH, MPH, CPH

The quality and vitality of the operating room is often a balance between managing patients known or suspected with infectious disease and managing potential staff occupational exposure risks associated with treating patients.  With exposure risks to emerging and re-emerging microorganisms at an unparalleled high, measuring, analyzing, and preventing exposures among surgical staff is more important now than ever.

Given the rise in hepatitis C infection in the Baby Boomer population, unprecedented hepatitis B prevalence among non-Americans accessing U.S. healthcare, and less than 20 percent of people knowing their HIV status, preventing occupational exposures to bloodborne pathogens may be more important now than when the OSHA Bloodborne Pathogens Standard was promulgated in the early 1990s.1-3 

Occupational blood and body fluid exposures (BBFEs) (splash and splatter) incident data tells us that overall, compliance with or use of PPE during employee reported exposures is low.  One might say, of course if an employee reports a BBF exposure incident that they are by nature not wearing PPE.  However when other types of blood exposures (e.g., percutaneous needlesticks) are reported not only is PPE use in comparison to the use of other controls (e.g. safety engineered disposable syringes) low, but it is nearly three times lower when there is a BBFE.4 This is true in all departments of a hospital.  It is even true in the OR where one would expect all PPE use to be higher than on general medicine floors or in patient rooms.

Since BBFEs to mucus membranes like the eyes represent the highest risk exposure type (vulnerable to not only bloodborne pathogens, but also bacteria and multidrug resistant organisms), it is helpful to provide a snapshot of what PPE (eye protection) use looks like in operating room settings compared to all other hospital departments. When thinking about the intersection of occupational BBFEs among high-risk worker populations like those performing orthopedic surgeries for example in the OR, colonization with multidrug resistant organisms like MRSA or MSSA can range from 1.5 percent to 59 percent among surgeons.5 Therefore, a priori precedent established in the peer-reviewed literature informs risk to both provider and patient when these types of exposures occur.

The following incident data is pulled from the International Safety Center’s Exposure Prevention Information Network (EPINet®) aggregate hospital network data and was presented in its entirety at OR Manager Conference 2016.6 Data show that for all BBFEs reported (2012-2014) through EPINet, that the greatest percent occur in the OR compared to 11 other hospital departments.

Additionally, when looking at eye exposures only an even greater percentage is reported in the OR compared to other hospital departments/units.  What is alarming given the increase in emerging infectious disease preparedness building is that greater overall numbers of incidents are being reported meaning healthcare personnel remain unprepared.
If we glance at exposure incidents over time in the OR specifically, again focusing solely on eyes as the biggest risk exposure, we can see that they may not be changing (as an average) over time, but eye protection (PPE) use is declining.  This is the opposite of what we would hope to be true.

Let’s explore what might be happening (based on what we know) and how we can build safer programs (based on what we sometimes for-get) and influence safer behaviors (both personal and institutional).

Here’s what we know. 
We know that performing surgeries in the OR is critical to saving lives, extending lifespan, and improving health.  We know that surgeons and surgical teams are some of the most highly trained and experienced health professionals in the world.  We know that safe and quality pre-, peri-, and post-operative care is essential to preserving life and ensuring the best possible surgical outcomes.  We know that risks associated with infectious disease and emerging infections are changing.  We know that surgical teams are at risk of exposure to bloodborne and infectious disease.  We know that wearing PPE reduces exposure to infectious disease for both worker and patient.

Here’s what we sometimes forget. 
We sometimes forget that one of the best ways to provide the highest continuity of quality care for patients is the care of self and staff.  Overall safety and quality is an equal combination of patient, worker, and environmental safety. While PPE protects patient from healthcare personnel, it is essentially designed to protect personnel from patient. BBF exposures do not just occur to those at the perioperative site (operating on the patient), they also occur frequently to others on the surgical team. 

An unacceptable percentage of all sharps injuries occur to non-users, downstream.7 We sometimes forget that sharps safety is not just in place for the safety of the clinical user, but also for anyone that may come into contact with a contaminated sharp downstream, through its lifespan.  We sometimes forget that not all risks are acceptable risks and that occupational BBFEs and sharps injuries are frequently 100 percent preventable.

Here are three ways we take what we know and what we sometimes forget and build better, safer occupational safety and health pro-grams to prevent BBFEs and sharps injuries in the OR.

1. Improve eye protection use
Since eye BBFEs are the highest risk exposures occurring in the OR with the potential for transmission of the most types of infectious micro-organisms, focusing on improving eye protection in the OR is a great place to begin.  Some of the best, safest programs require eye protection use for the entire surgical team – meaning everyone that walks into an OR during a surgical procedure.  Putting a requirement like this in place promotes uniformity.  Just like key badges are needed to get into secure locations, eye protection is needed to gain entry into an OR.
A couple ways to assist in rolling out this policy include:
• Working with materials management, infection control, employee/occupational health, and facilities professionals to brainstorm spacing and location of eye protection (goggles, faceshields) caddies/shelving;
• Assigning eye protection to every new employee when they get their ID badge.  This does not mean that each employee/personnel will use that eye protection during all surgeries (infection control will need to assist with best protocols to swap out eye protection, disinfect, dispose, etc,), but it firms up a mindset that eye protection is part of the uniform, part of the everyday.
• Work with vendors/PPE manufacturers to provide feedback on what is working and not working. Collect staff anecdotes, opinions, feed-back, exposure data and create a regular feedback loop to vendors, suppliers, distributors, manufacturers so that they are constantly assisting with needs, improving designs, collaborating on programs.

2. Decrease Non-User Sharps Injuries.
Do not be resolved to the perception that sharps injuries are an acceptable risk in the OR. Do not let staff and teams get complacent about sharps safety -- from cradle to grave. Since more than 25 percent of contaminated sharps injuries occur to non-users in all hospital departments, the use of safety engineered devices is important to not just clinical users, but to those on surgical teams and downstream – this includes environmental services, laundry, laboratorians, and waste haulers to name a few.7
A few tried-an- true methods for reducing non-user sharps injuries include:
• Using safety engineered devices (safety scalpels, safety syringes, needleless iv adapters) and activating the safety feature.  Based on soon to be released 2015 EPINet data, in the OR 84.2 percent indicate that they were not using a device with a safety design.  Of those that indicated they were using a device with a safety design, 72.2 percent did not activate the safety mechanism.  Of the incidents reported in 2015, 30.5 percent occurred to someone who was not the original user of the device.  If safety device use and safety feature activation improves, these injuries can be directly reduced or eliminated.
• Use no-hands passing, neutral zones. This we know and it can be categorized as something we sometimes forget.  Neutral zones are in place to keep teams safe.  Perhaps we should consider renaming them to “safe zones.”

3. Improve Exposure and Injury Incident Reporting.
I have been writing about sharps injuries and BBFEs for a long time. Over the years, I have submitted many papers to peer-reviewed journals and almost always, there is familiar scientific constructive criticism – due to egregious under-reporting of occupational incidents, it is nearly impossible to draw statistical significance and subsequently generalize data to any other worker group.

Just because we may not know exactly how many healthcare personnel sustain sharps injuries or mucocutaneous BBFEs, does not mean that we cannot generalize experiences to any and all worker groups. This is especially true in the OR.  Patients are patients.  Procedures are procedures.  Blood is blood.  Bloodborne and infectious diseases are bloodborne and infectious diseases. Sharp instruments are used to cut through and puncture things.  Workers (for the most part) are using these sharp instruments.

This does not change if one person reports an incident or all 100 do. What does change, what improving reporting does do -- is allow healthcare facilities and worker safety and health advocates to be better equipped to identify the problem, determine the best solution, implement meaningful change and save the lives of surgical personnel and their patients. 

Report incidents.  Promote a culture of openness and not blame or embarrassment. Collect those incidents and experiences and use them to create a safer environment.  Safer work environments promote safer patient experiences, better staff retention, stronger teams, and ultimately better public health. 

EPINet is free to use for anyone in the world (http://internationalsafetycenter.org/use-epinet/).  If your facility is not using it now, feel free to download and start using for the next injury or exposure that occurs in your workplace.  If you have a preference for a different surveillance system, use that.  Just use something more than your OSHA 300, 300A, and Sharps Injury Log so that you can capture more information about exposures and injuries and work with your colleagues to put controls in place to prevent the spread of occupational infectious disease.

In summary, as we think about building better workplace programs, some occupational health and safety colleagues recently reminded me of an important fundamental concept.  The Chinese word for “crisis” is composed of two characters – ‘danger’ and ‘critical point’.  As it relates to occupational infection and illness control and prevention, we can take what we know and what we sometimes forget to overcome danger at this critical point, manage the crisis before us, and emerge better and safer for ourselves, our families, our communities, and our patients.

Amber Hogan Mitchell, DrPH, MPH, CPH, is president and executive director of the International Safety Center.

References
1. Centers for Disease Control and Prevention. Hepatitis C: Testing Baby Boomers Saves Lives. https://www.cdc.gov/features/vitalsigns/hepatitisc/
2. Centers for Disease Control and Prevention. Screening for Hepatitis During the Domestic Medical Examination. https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/hepatitis-screening-guidelines.html#hbv
3. Centers for Disease Control and Prevention. HIV in the United States: At A Glance. https://www.cdc.gov/hiv/statistics/overview/ataglance.html
4. International Safety Center.  Exposure Prevention Information Network 2014 Summary Reports.  http://internationalsafetycenter.org/exposure-reports/        
5. R Schwarzkopf et al. Prevalence of Staphylococcus Aureus Colonization in Orthopaedic Surgeons and Their Patients: A Prospective Cohort Controlled Study. J Bone Joint Surg Am. 92 (9), 1815-1819. 2010 Jul 07.     
6. Mitchell, A. Quantifying Occupational Risk in the or from Blood and Body Fluid Splashes.  OR Manager Conference 2016 Poster Gallery.  http://www.eventscribe.com/2016/posters/ORMC/SplitViewer.asp?PID=NTQ3NjE0ODAwMQ      
7.  International Safety Center.  Exposure Prevention Information Network Needlestick and Sharp Object Injury Summary Report, 2014. http://internationalsafetycenter.org/wp-content/uploads/2016/08/Official-2014-NeedleSummary.pdf