Sharps Injuries: Not Part of Anyone's Job

A conversation with AORN's Mary Ogg, MSN, RN, CNOR

By Robin S. Baum

It is generally understood that police officers, firefighters, military professionals, stuntmen and women, wild animal trainers and racecar drivers accept the obvious personal risk that comes with their careers. Healthcare providers, however, do not typically think of themselves as thrill-seekers or extreme risk takers. Most nurses, physicians, surgical technologists, phlebotomists, lab technicians, radiologists and sterile processing professionals probably do not expect their lives to change forever because of an accidental jab with a contaminated hypodermic needle, suture needle, scalpel, retractor, or other sharp device. And yet, lives can be changed, literally in an instant. According to the Centers for Disease Control and Prevention (CDC), an estimated 385,000 percutaneous injuries (needle sticks, cuts, punctures and other injuries with sharp objects) occur in U.S. hospitals each year. CDC estimates that every day, more than 1,000 hospital-based professionals sustain an injury from contaminated needles and other sharp devices during the delivery of patient care. These injuries carry a risk of infection with dangerous and potentially fatal human immunodeficiency virus (HIV) and hepatitis B virus (HBV), among other pathogens. Of the HIV/AIDS infected healthcare professionals, most are nurses and laboratory workers, and most cases are contracted from percutaneous exposure.

AORN: In It From the Start
Since its members handle contaminated sharps frequently as part of their daily work and could clearly be at high risk for accidental injury, the Association of periOperative Registered Nurses (AORN) has been among the professional associations most deeply involved in this issue. It has worked for decades to raise awareness and establish sharps safety guidance to protect workers and their patients. In 2005, AORN issued its Guidance Statement for Sharps Injury in the Perioperative Setting, which laid out the “what” of this issue. In 2013, building on the requirements of the 2001 Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard, AORN posted its Recommended Practices for Sharps Safety online, providing the “why” and the “how-to” for preventing sharps injuries in surgical and procedural areas. These recommended practices have recently been published as part of AORN’s 2014 Perioperative Standards and Recommended Practices, and are available at http://www.aorn.org/Recommendedpractices/.

Complex Problem Calls for an Evidence-based Toolkit
Mary Ogg, MSN, RN, CNOR, perioperative nursing specialist and lead author of the new sharps safety recommended practices, is determined to help eliminate sharps accidents. “These injuries are not part of a perioperative professional’s job, and they can be prevented,” she insists. “But adoption of safety practices has been a challenge because this is a complex issue involving many stakeholders. It requires a multi-faceted approach, using evidence-based practices that employ all levels of the OSHA hierarchy of controls.”  The new AORN Recommended Practices for Sharps Safety provides just such a multi-level set of interventions.
In addition to the practices themselves, this document includes a new benefit for users. “In 2013 we began adding a new feature to our recommended practices,” Ogg says. “After performing an extensive literature search and evaluation, we now assign strength and quality ratings to the collected research and non-research evidence related to each practice. This gives users enhanced information that can help them to rationalize their specific practice choices. As an example, a research study using randomized controlled trials would be given a “1 A” rating, indicating the strongest (1) and highest quality (A) evidence. In addition, we apply a “1: Regulatory Requirement” priority rating to the recommended practices that are based on legislative or regulatory requirements, to better emphasize all mandated policies and procedures for our users.”

The AORN Recommended Practices for Sharps Safety lists 10 distinct recommendations:
1. Establish a written bloodborne pathogens exposure control plan
2. Use sharps with safety-engineered devices
3. Use work practice controls when handling sharps
4. Use PPE
5. Contain and dispose of sharps safely
6. Demonstrate personal and professional responsibility in preventing sharps injuries
7. Receive initial and ongoing education on sharps safety principles and practices
8. Documentation to reflect sharps safety activities
9. Develop, document, review periodically, revise and make available sharps safety policies and procedures
10. Conduct sharps safety quality improvement activities
Included within each recommendation are the related evidence and its ratings, and specific procedural recommendations to assist the user in establishing best practices, including the suggested “what, who, when, where and/or how” for each activity. When used as a whole, the document provides a thorough sharps exposure control plan to help users develop and justify their own complete sharps safety policies and procedures.

Overcoming Resistance
When asked what she believes are the primary barriers to implementing sharps safety changes that can reduce or eliminate injuries, Ogg replies, “resistance to change is human nature, so it is a common barrier. Unless there is sufficient motivation to do the work needed to institute a change, people have a tendency to do it the way they always have. Some may also have a strong preference for a particular surgical tool or procedure. There are others who, if they have not yet been injured, or have not incurred a consequence from their needle stick, assume the false logic that it “won’t happen to them,” or that they can “just be extra careful.” Insufficient training and education on the full consequences for patients and staff can also contribute to downplaying risk and resisting change. And when whole departments or facilities downplay the risk and avoid implementing safety policies and procedures, it can indicate a poor safety culture that lacks strong and consistent leadership.”

How can a perioperative department overcome these barriers? Ogg has several thoughts: “The whole team – nurses, surgeons and technicians – must work together. They should work through each AORN recommended practice, review the evidence ratings and use them to support their rationales for implementing specific procedures. The team must also be aware that all recommended practices based on the OSHA Bloodborne Pathogen Standard are the law – it is mandatory that they be compliant with these requirements. I also believe strongly that frontline workers must be directly involved in engineered safety device testing and evaluation. Those who use these devices daily are the best judges of their efficacy and usefulness, and they are more likely to become champions for successful change if they are involved in the selection process.”

The Power of One
Sharps injury prevention is an ongoing priority for healthcare regulating bodies, professional organizations and providers. “AORN will continue to collaborate, educate, guide and advocate for a culture of safety around sharps,” says Ogg. “In fact, we will soon be partnering with the American College of Surgeons on a sharps safety campaign to promote awareness of the issue and its solutions.”

“Ultimately,” Ogg continues, “sharps safety must be the personal responsibility of each individual. By making a personal commitment to practice safely, one nurse in an OR can be a catalyst for change. For example, double gloving is an individual decision; each perioperative professional can choose to make this his or her personal policy. There is considerable research evidence that double gloving reduces the risk of exposure to blood and body fluids by as much as 87%, if the outer glove is punctured. If the objection is that double gloving reduces tactile sensitivity, there is evidence that sensation readjusts after 1-2 weeks. Each person who takes charge of his or her own sharps safety practices can contribute to reduced risk for co-workers, their department, and their patients.”
Robin S. Baum is a writer with 13 years of experience writing for medical device manufacturers, research scientists, sterile processing professionals, perioperative professionals, hospital executives and other healthcare providers. She is based in the Cleveland, Ohio area.

References
1. http://www.cdc.gov/nhsn/PDFs/HPS-manual/exposure/HPS_manual.pdf
2. http://www.safeincommon.org/needlestick-statistics
3. Spruce, L., Van Wicklin, S., Hicks, R., Conner, R., Dunn, D.: Introducing AORN’s New Model for Evidence Rating. AORN Journal, Vol. 99, Issue 2, February 2014, pp.243-255.
4. 2011 Perioperative Standards and Recommended Practices; AORN Guidance Statement: Sharps Injury Prevention in the Perioperative Setting. Revised March 2005.
5. Ogg M, Conner R. Recommended Practices for Sharps Safety; 2014 Perioperative Standards and Recommended Practices, AORN, Inc., pp. 351-374.
6. OSHA Fact Sheet: OSHA’s Bloodborne Pathogens Standard (www.osha.gov).
7. https://www.osha.gov/SLTC/etools/safetyhealth/comp3.html
8. http://en.wikipedia.org/wiki/Needlestick_injury
9. http://en.wikipedia.org/wiki/Hierarchy_of_hazard_control

Hierarchy of Controls
This widely accepted system is used in industry and promoted by numerous safety organizations, including the  Occupational Safety and Health Administration (OSHA). Although these controls vary in their effectiveness at eliminating injuries, all of them contribute in some measure to a safer work environment, and can be applied to a variety of work hazards, including those in healthcare environments. From most to least effective, they are:
1. Elimination/substitution
2. Engineered controls/devices
3. Administrative/work practice controls
4. Personal Protective Equipment

For more information, visit:
https://www.osha.gov/SLTC/etools/safetyhealth/comp3.htmlhttp://en.wikipedia.org/wiki/Hierarchy_of_hazard_control