Perioperative Sharps Safety Requires Teamwork, Education

By Kelly M. Pyrek

Editor's note: In the November 2010 issue of ICT, we explored the state of sharps safety in the 10 years following passage of the Needlestick Safety and Prevention Act (NSPA), signed into law Nov. 6, 2000. Now, we take a look at sharps safety imperatives in the perioperative setting.

While clinical activities on hospital floors such as injections or starting IVs pose the constant threat of percutaneous injuries, nowhere is the danger more real than in the fast-paced operating room environment. Knowing this, the Association of periOperative Registered Nurses (AORN), released at this year's Congress a sharps safety toolkit that puts into the hands of perioperative professionals the educational materials they need to advance their knowledge of safe practices when using sharps.    

A renewed focus on sharps safety is being championed by a number of individuals and associations, including AORN and the Council on Surgical and Perioperative Safety (CSPS), an incorporated multi-disciplinary coalition of seven professional organizations (including AORN) whose members are involved in the care of surgical patients. This awareness incorporates key sharps safety measures during perioperative practice, including double-gloving, blunt suture needles for fascial closure, and creating a neutral/safe zone when appropriate to avoid hand-to-hand passage of sharps. The new AORN toolkit offers perioperative professionals a comprehensive set of tools, including PowerPoint presentations, guidance documents, a video and much more, that appeals to everyone on the perioperative team.

"We involved a surgeon, Dr. Ramon Berguer, who has been at the forefront of sharps safety with the American College of Surgeons, as well as Sherri Alexander, CST, who is the president of the Association of Surgical Technologists. We are all working together to help reduce the number of sharps injuries in the operating room."   "A truly multidisciplinary team worked on the toolkit," says Mary Ogg, RN, MSN, CNOR, a nursing specialist in AORN's Nursing Department and staff liaison for AORN Clinical Nursing Practice Committee.

There is, however, an emphasis on reaching more surgeons with the sharps safety message. Writing in the AORN Journal, Berguer notes, "The recent publication of data that clearly demonstrated that OR sharps injuries have actually increased by 6 percent since 2004 is making an impact in surgical societies, and there is the realization that surgeons have not really acted on this information." Berguer notes further, "What has become clear is that sharps injury prevention in the OR is a team effort in which the hospital administrators, surgeons, and OR staff members play key roles. Recently published data clearly show that nurses and surgical technologists sustain 80 percent of the sharps injuries in the OR but are not the ones who decide whether to use a sharps safety device or technique. Surgeons must be made aware of the effects of their decisions. I would hope to see surgeons incorporate the work practices of the hands-free technique and the use of safety engineered devices (e.g., scalpels), along with blunt suture needles and double gloving as a routine part of our work. "

Ogg agrees, noting, "In a lot of what we do, the surgeon has the final say and his decision can affect the level of risk for the whole perioperative team. So it's important to get our surgeons onboard with the sharps safety agenda." To that end, Ogg says that the AORN toolkit includes two versions of a PowerPoint presentation on sharps safety; one version can be used by nurses for their individual edification, or the department educator can use it as part of a more formal in-service, as well as an abridged version designed for surgeons' use. "The shorter version that Dr. Berguer developed has fewer slides and it's designed to hit surgeons with the key data they are looking for," Ogg adds. "It has the facts and figures in a concise manner."

Perioperative personnel should implement a neutral/safe zone in the operating field instead of doing what they see on television, namely a nurse slapping a scalpel or a loaded needle holder into the surgeon's hand. In a neutral/safe zone, the sharp implement is laid down by the nurse and then the surgeon picks it up."   Ogg says that the toolkit also provides sharps safety-related policies and procedures for the facilities that need them, as well as instruction on how to create a neutral/safe zone in the OR. "The toolkit includes a video made by an AORN member in Canada, Bernadette Stringer, who has been one of the pioneers of the concept of the neutral/safe zone. That's a very important part of sharps safety and definitely within the realm of the nurse's purview.

On more than one occasion I have heard from perioperative nurses who say their surgeons have tried safety scalpels and someone got injured using it, so they decided they weren't going to use them after that. It is imperative that perioperative team members know the correct way to use the technology rather than using them without receiving the proper training and in-servicing."   In addition to the neutral/safe zone, Ogg says perioperative team members should be double-gloving, as well as reporting any sharps injuries in a proper and timely fashion. Ogg, who is one of the clinical specialists who work AORN's consult line, says she has heard a number of horror stories about both issues. "I have heard about surgical technologists who wanted to double glove and the OR manager told them they were not allowed to do so because it cost the facility too much money," Ogg says. "And I do continue to hear about how sharps injuries occur.

Ogg continues, "People got on the sharps safety bandwagon when OSHA regulations were introduced and needlestick legislation was passed. I think the reason why the OR is lagging behind sharps safety injury reductions in other parts of the hospital is because some of the first-generation safety-engineered devices were not quite acceptable to surgeons, particularly the safety-engineered scalpels. Surgeons said the safety devices had a different feel to them, and even though they tried them, they were still reluctant to use them, or even try the newer ones on the market. I think the newer safety devices will have more success among surgeons, but the challenge lies in getting them to try them." Ogg says she heard about a hospital that had tried blunt tip suture needles, and one of the surgeons using them wasn't even aware of the difference. "When he was asked how he liked the needle after the surgery he said, 'Was I using them?' and when they told him yes, he said, 'I guess they are OK then,'" Ogg recalls. "So there have been improvements made to the safety-engineered devices, and with professional organizations like the American Nurses Association having a renewed interest in sharps safety, I think these efforts are bringing sharps safety back to the forefront. A lot of the information about sharps safety has been out there, but I think our toolkit puts it all in one place where nurses can access it very easily and implement these safety strategies."

Ogg says it behooves perioperative team members to safeguard their health by avoiding sharps injuries. "In the past we have put patient safety first, as well we should," she says. "But one of my committee member's favorite lines is 'You can't have patient safety without workplace safety.' Healthcare workers must be safe in order to deliver safe care to patients. But sometimes healthcare providers get rushed, especially in places like the emergency department, where they are not as careful as they should be. We hear over and over how shortcuts get taken and that's when something unfortunate happens. There are so many costs involved when someone is injured and sero-converts. It can be as much as $100,000 in medication and treatment costs, and of course there are the intangible costs to the injured individual and their families."

Ogg says the perioperative community must address the attitudes that could precipitate a needlestick or other sharps-related injury. "I think as a newbie, you might be unsure of yourself and not have the manual dexterity that you develop with time," Ogg says. "Inversely, sometimes the more experienced nurses become a little cavalier about sharps safety so they might be exposed in that way. I am a more seasoned nurse, and in the old days we didn't wear gloves to do most of the things people wear gloves to do these days, like starting an IV or giving an injection. I remember squeezing a blood bag for an emergency patient and having blood all over my hands and I didn't think twice about it. Once the AIDS epidemic started OSHA came out with its bloodborne pathogen standard, and you wouldn't think of doing risky procedures without wearing gloves. It is my hope that younger professionals are coming to the field already knowing enough to double-glove or to always wear eye protection."

What the AORN toolkit may represent is a shared opportunity for perioperative professionals and infection preventionists to engage in teachable moments that benefit both departments. "I think a lot of infection preventionists may be afraid of the OR, but I would challenge them to get to know their OR folks, maybe ask the OR director to lunch, and start a relationship," Ogg suggests. "If they could spend an hour or two together once a month or even have the infection preventionist spend a whole day in the OR to observe what's happening, that could really facilitate collaboration. One of the things that comes out from our consult line is that I'll ask a perioperative nurse who is calling about an issue whether they have talked to their IP yet and I get this long pause on the other end of the line. So I would encourage infection preventionists to go behind those double doors -- I don't think they are as barred as they used to be. We are all so interconnected with everything we are doing, from the perspective that if you did get a sharps injury in the OR you could be exposed to hepatitis or HIV, but on the flip side, the patient could be exposed if the healthcare provider happened to have either disease. So safety on both sides is integral to what we do."

The AORN toolkit is free to AORN members and is available on the AORN website.