The sharp end of surgery10 May 2013
Needlestick injuries have long been a risk to patients and healthcare professionals alike. Legislation and innovative products from equipment manufacturers have reduced the number of such injuries in non-surgical settings, but the risk in the operating room appears to be growing. Members of the Association of Perioperative Registered Nurses reveal the wider dangers of the operating room and how they can be addressed.
Awareness about the dangers of sharps injuries in the healthcare setting has never been greater. Needlestick injuries and the potential risks they carry have inspired regulators to tighten guidelines for sharps policies and bloodborne infections, and device manufacturers have come up with safety-engineered tools - actions that have gone a long way to reducing the number of such injuries reported each year.
The real danger of needlestick injuries comes from the fact that they are often small, sometimes unnoticed, yet still carry potentially high risks; for example, most injuries from syringes will not have any significant effect on health, but in a small number of cases they can result in serious infections, such as HIV or hepatitis C. While these cases are rare, the consequences can be extremely severe.
The major bloodborne pathogens that pose a risk in needlestick injuries are hepatitis B virus, hepatitis C virus (HCV) and HIV, though other infectious agents could also potentially be transmitted, including human T-lymphotropic retroviruses I (HTLV-I) and II (HTLV-II), hepatitis D virus, GB virus C, cytomegalovirus and the Epstein-Barr virus.
Studies that have estimated the risks of seroconversion - the development of detectable antibodies to microorganisms in the blood as a result of infection - put the risk of infection at extremely low (see Seroconversion risks, page 24). Nevertheless, a Health Protection Agency report in 2012 stated that in the UK, 4,381 significant occupational exposures were reported during 2002-11, and that between 2008 and 2011, there were five hospital-acquired HCV transmissions from patients to healthcare workers following percutaneous exposure injuries. That said, the most recent case of HIV seroconversion in an occupationally exposed healthcare worker was reported in 1999.
In 2010, a study in the US showed that following the introduction of the Needlestick Safety and Prevention Act of 2000, the number of sharps injuries in non-surgical settings fell by almost a third (31.6%); however, the same study found that incidents in surgical settings rose by almost 6%. The question, therefore, is why the operating room (OR) is a riskier environment.
"Needlestick injuries should be a priority in any policy of infection control," says perioperative nursing specialist Mary Ogg. "They are a very important concern for patients and healthcare workers; for example, there is an increase in the risk of surgical site infection if there is a hole in a glove.
"In the non-surgical setting, safety-engineered devices that are easier to use for non-surgical workers have evolved, so there has been a fall in the number of needlestick injuries. Also, workers have more freedom to make their own decisions about whether to use those devices. In the OR, one person might make the decision to use a device that has not been safety engineered and that increases the risk for everyone in there. There is less autonomy over decisions."
Ogg has been looking closely at the issue of needlestick injuries as part of her role as lead author of 'Association of Perioperative Registered Nurses Recommended Practices on Sharps Safety', which is slated for release in June. In her work, she has identified the potential for resistance to change in the OR, which may be one reason why the number of sharps injuries is not falling. In performing complex procedures, often with high risks, surgeons may prefer familiar equipment and processes in the OR.
"Surgeons may put up a wall when it comes to introducing new equipment or procedures," says Ogg. "They may choose non-safety engineered devices, which have not evolved as far in the OR setting, though tools such as safety scalpels are available.
"Another factor is that there are more devices to be injured by in the OR, whether it is scalpels, syringes or suture needles. That makes it a higher-risk environment, as does the fact that the OR is a more blood-intensive environment compared with starting an IV by a patient's bedside. So, the risks of injury and infection are higher in the OR."
A safer OR
There is a lot of work still to be done to provide safer sharps equipment for the OR, but manufacturers have not been sitting on their hands; for example, the development of safety scalpels is a big step forward.
Safety scalpels are becoming increasingly popular - and cheaper - and legislation such as the Needlestick Safety and Prevention Act means they are becoming a more familiar feature in ORs. They come in two broad varieties - retractable blade or sheath models - the latter offering a more ergonomic feel that appeals to surgeons; however, they pose some problems, and the 'Needlestick and Sharp-Object Injury Report' by the US Exposure Prevention Information Network even suggested that in 2003, more injuries occurred with safety scalpels than reusable scalpels. However, the regulatory front is where the most progress has been made.
"The laws are out there," says Ogg. "We have standards on bloodborne pathogens, they just need to be enforced. In those US states where standards have been enforced, the number of needlestick injuries has fallen."
The US Occupational Safety and Health Administration's bloodborne pathogens standard, amended after the Needlestick Safety and Prevention Act of 2000, outlines safeguards to protect workers against the health hazards caused by bloodborne pathogens. Its requirements address items such as exposure control plans, universal precautions, engineering and work practice controls, and personal protective equipment.
The Needlestick Safety and Prevention Act was introduced because occupational exposure to bloodborne pathogens from accidental sharps injuries was recognised as a serious problem, and it reinforced the need for employers to identify, evaluate and implement safer medical devices, such as needleless systems and sharps with engineered sharps protections. It also put in place extra requirements for maintaining a sharps injury log, and for the involvement of non-managerial healthcare workers in identifying, evaluating and choosing effective engineering and work practice controls to eliminate or minimise employee exposure.
In Europe, the issue has also been given serious attention among regulators. In May 2013, a new law comes into force to combat needlestick injuries. The 2010 EU directive on sharps injury prevention reiterates many of the requirements that already form part of health and safety law in countries like the UK, and legislates a framework agreement by HOSPEEM, the European hospital and healthcare employers' association, and the European Federation of Public Service Unions.
In essence, the European legislation obliges healthcare organisations to take measures to prevent needlestick injuries to their staff; in particular, it advocates the use of safety-engineered medical devices such as needles, phlebotomy devices and intravenous catheters that incorporate shielding or retraction of the needle.
Simple steps to safety
Legislation is obviously a key part of any strategy to reduce the overall incidence of needlestick injuries, but there are simple steps that can be implemented in any healthcare facility to combat the problem in the OR and in non-surgical settings. For Ogg, stage one is to implement a broader culture of safety that is recognised and understood by all employees.
"The first step is for the healthcare facility's administration to have a culture of safety among its employees," she explains. "This has to be top-down and bottom-up, so it must include sharps safety policies and the right equipment needs to be made available, but it must also include commitment from workers to use that equipment. The administration has to overcome any resistance it may encounter."
A vital part of this is to spell out the risks that come with needlestick injuries and to encourage the reporting of all incidents.
"Education about the risks of infections like HIV and hepatitis C is very important," says Ogg. "In the US, there could be as many as 500,000 needlestick injuries every year if you include the statistics for outpatient facilities, and even that figure is thought to be under-reported as many people don't take the time to mention an injury that may seem very minor, especially when they are working in an environment where people are very ill or badly injured.
"Small injuries may seem less risky than they actually are, unless you know the health conditions of the patients involved; for example, you may be more aware of the risks if you are treating someone with HIV, but you don't know about the patient's underlying conditions. People tend to be cavalier about needlestick injuries."
Double-gloving is another habit that can greatly decrease the risk of infection from needlestick injuries, and it requires no advanced technologies and little extra time. Beyond that, moving to safety-engineered devices is also not a huge leap as the technology is recognisable by many, though it may take a little time to become familiar with using new tools.
Within the OR, the use of a neutral zone is a simple, yet highly effective way of reducing the risk of injury. It is a place to put sharps to ensure that no two people touch them at the same time; for example, a nurse puts a scalpel into the neutral zone, where it is picked up by the surgeon. When the surgeon is finished with it, the scalpel is returned to the neutral zone before the nurse picks it up. All it takes is for those people working in the OR to acclimatise to new procedures and tools that are not radically different to what they already know.
"No safety habit comes without an extra stop," says Ogg. "For example, putting on your seatbelt in the car takes a couple of seconds, but it soon becomes a habit, and then you feel odd when you are in a car and don't have a seatbelt on. That is the stage we need to work towards when it comes to needlestick injuries, whether in the OR or in a non-surgical setting."