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					                                         Sharps Handling Practices Among Junior Surgical Residents – A Video Analysis
                                                                          David Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MD
                                                                                               Division of Pediatric General Surgery, BC Children’s Hospital

A survey of surgical residents at over 17 medical centers                    Resident safety performance was assessed in three areas:                                                                                       RESULTS
found that
                                                                             1. Personal sharps tasks
99% of surgeons in training had sustained a needlestick injury                         E.g. Suture needle handling
                                                                                                                                                       19 surgical residents videoed
by their final year of training (2)                                          2. Passage of sharps                                                          15 general surgery residents (PGY-2)
53% involved patients with a history of HIV, hepatitis B or C, or                     E.g. Scalpel , injection needle                                    4 plastic surgery residents (PGY-1)                            100
intravenous-drug use                                                         3. Verbal notification when passing of sharps                             Initial videos (n=19):                                              90
                                                                                       E.g. “There’s a needle up.”                                        Sharps tasks performed safely = 66.3%
In differentiating the mechanisms of injuries due to sharps,                                                                                                                                                               80
Bakaeen and colleagues found that                                               Second video was taken of the resident after the technical
                                                                                                                                                           Safe passing of sharps = 90.4%                                  70
    69% of OR injuries were inflicted by suture needles                         performance feedback session and safety performance                       Verbal notification when passing = 10.1%                        60
    9% from hollow-bore needles                                                 was compared between the two procedures.                                  Unsafe sharps practices mostly with handling of
    34% from sharp instruments (3)                                                                                                                                                                                         50
                                                                                                                                                             suture needle
                                                                             Video reviewer blinded to resident level & video order                        4.7 unsafe actions per surgery                                  40
Specifically, injuries from sharps can occur when                                                                                                                                                                          30
   Loading suture needle into driver/repositioning needle                                                                                                 All residents demonstrated safe handling of the
    with fingers                                                                                                                                             scalpel blade                                                  20
   During hand-to-hand passing of sharps                                                                                                                  No actual injuries to the surgical resident/ team               10
   Suturing muscle and fascia when needle manipulated                                                                                                                                                                      0
    with fingers
                                                                                                                                                       Second video follow-up (n=8)                                                     Initial Video (n=8)                        Final Video (n=8)
   Retraction of tissue with hands
   Surgeon sews towards own hand or assistant's hand                                                                                                      No statistically significant differences between initial
   Tying a suture while needle is attached                                                                                                                  and final procedures with regards to Personal sharps                                personal       passage       communication
   Suture is left unattended on operative field after use (4)                                                                                               tasks (p=0.17), Passing of sharps instruments
                                                                                                                                                             (p=0.14) or Verbal notification (p=0.29)                      Figure 2. Graph of mean percentage of safe tasks
                                                                        Figure 1. Examples of safe and unsafe manipulation of the suture needle.
                                                                        1) Unsafe handling of suture needle using fingers. 2) Safe handling of             4.4 missed opportunities to use of verbal cues to alert        performed by surgical residents as seen in the initial
PURPOSE                                                                 suture needle using forceps.                                                         team members when passing sharp instruments                   and final videos (n=8) taken during an inguinal hernia
To examine sharps handling practices of junior surgical residents
performing an operation
                                                                                                                                                             (SD=1.2)                                                      repair.
Evaluate whether experience correlates with a decrease in unsafe            Sharps Task                 Safe                        Unsafe
sharps behavior                                                                                   Personal Sharp Tasks
                                                                       Suture needle             Using forceps to load or   Using fingers to load or
 Hypothesis: Safety performance is not expected to improve with                                  reposition needle          reposition needle                                                                              Junior surgical residents consistently passed sharp instruments in
 operative experience in the absence of formal training on sharps      Tying Sutures             Needle is on driver        Needle is exposed while                                                                        a safe manner
                             practices                                                           during tying, and is       tying suture                                                                                   Tasks relating to manipulation of sharps were less likely to be
                                                                                                                                                                                               Initial video   Standard
                                                                                                 protected                                                                                                                 performed safely
                                                                       Tissue Retraction         Using instrument to        Using hand/fingers to              Description          Safety       (mean)        Deviation
                                                                                                                                                                                                                           Minority of residents verbally notified team members when passing
                                                                                                 retract wound edge         retract wound edge,                                      Safe            4.3          2.7
METHODS                                                                                          when using sharps          when suturing towards                                                                          sharp instruments
                                                                                                                                                       Suture needle manipulation   Unsafe           4.7          4.0
Junior surgical residents:                                                                                                 hand/fingers                                                                                   Review of technical performance of the surgical procedure did not
      PGY-2 general surgery & PGY-1 plastic surgery residents                                                                                                                      % Safe        53.7%         33.8%      significantly improve safe sharps handling practices
                                                                       Injection Needle          Injecting away from        Injecting towards
      2 month rotation in pediatric general pediatric surgery at BC   Handling                  hand/fingers, no 2-        hand/fingers, 2 handed                                   Safe          3.5           1.5
                                                                                                 handed needle re-          needle capping
                                                                                                                                                              Tying sutures                                                Explicit instruction and feedback on sharps handling should
       Children’s Hospital in Vancouver, British Columbia                                                                                                                           Unsafe         0.5           1.0
                                                                                                 capping                                                                                                                   become an integral part of surgical residency programs and
                                                                                                                                                                                    % Safe        86.9%         25.6%
Videotaped performing pediatric indirect inguinal hernia repairs:                                                                                                                                                         surgical culture (4-7)
                                                                       Sharps Placement on       Placing sharps back        Sharps left on operative                                 Safe          1.8           0.8
      Junior surgical residents as principle operator, attending      Operative Field           onto a neutral hands       field unattended                Tissue retraction
                                                                                                 free zone while not in use                                                         Unsafe         0.5           0.8
       surgeon assisting
                                                                                                                                                                                    % Safe        83.3%         28.3%      REFERENCES
       Technical feedback was given by the attending surgeon on                                     Passing of Sharps
                                                                                                                                                                                     Safe          0.4           0.5       (1) O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among
       review of the videotape footage with resident                   Passing of Sharps         Passing suture with          Passing of suture with                                                                       residents and medical students. Arch.Intern.Med. 1992 Jul;152(7):1451-1456.
      Residents were not given specific feedback on sharps handling                             needle in driver handle      needle exposed, blade                                 Unsafe         0.2           0.5       (2) Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, et al. Needlestick
                                                                                                 first, scalpel handle first, first                     Injection needle handling   % Safe        72.2%         44.1%
                                                                                                                                                                                                                           injuries among surgeons in training. N.Engl.J.Med. 2007 Jun 28;356(26):2693-2699.
       technique                                                                                                                                                                                                           (3) Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, et al. Epidemiology of exposure
                                                                                                 use of neutral hands free
                                                                                                 zone                                                    Overall Personal Sharps                                           to blood borne pathogens on a surgical service. Am.J.Surg. 2006 Nov;192(5):e18-21.
Safe/unsafe practices                                                                             Verbal Notification                                             Tasks            % Safe        66.3%         23.1%      (4) Association of periOperative Registered Nurses. AORN guidance statement: sharps injury
                                                                                                                                                                                                                           prevention in the perioperative setting. AORN J. 2005 Mar;81(3):662, 665-6, 669-71.
      Based on the Association of Perioperative Nurses and the        Verbal notification when Clear verbal notification   Unclear/No verbal                                                                              (5) Camilleri AE, Murray S, Squair JL, Imrie CW. Epidemiology of sharps accidents in general
                                                                       passing sharp instruments when passing sharps        notification when          Table 2. Summary of safe and unsafe personal sharps                 surgery. J.R.Coll.Surg.Edinb. 1991 Oct;36(5):314-316.
       American College of Surgeons guidelines (4,7).
                                                                                                                            passing sharps             tasks for all initial videos of surgical residents (n=19).          (6) Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and surgical residents: who is most at
      Videos reviewed, each sharp episode judged “safe” or “unsafe”                                                                                                                                                       risk? J.Surg.Educ. 2007 Nov-Dec;64(6):395-398.
                                                                                                                                                                                                                           (7) Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J.Am.Coll.Surg.
                                                                       Table 1: Definitions of safe and unsafe sharps tasks used to assess safety                                                                          2004 Sep;199(3):462-467.