Sharps Injuries

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					     Sharps Safety

     Sharps Injuries
                                                                                                                 by Ron Stoker

                 ach year the United States sees many car         The same thought holds true in operating rooms around the
                 accidents that result in severe injury or   country. We come to work, step up to the operating field and expect to
                 death. In fact, during 2003 there were      get through it without injury. If, by chance, we do get stuck, we view it
     more than 6,328,000 auto accidents1 resulting in 2.9    as inconvenient but not as a possible life-altering event. Now what
     million injuries, $230 million in economic losses and   would have been a fifteen minute break in between patients is taken up
     42,643 auto accident deaths. And yet, every day, we     with paper work and a trip to the lab for a blood draw. We seldom seem
     get behind the wheel of our cars and take for granted   to recognize the seriousness of the events. And with this type of an atti-
     that we will safely get to our destination.             tude many clinicians end up with a potentially life-threatening illness.

            More than 25 percent of
            hospital-based needlesticks and
            cuts occur in the operating room.

14    MANAGING INFECTION CONTROL                                                                                           November 2008
     Sharps Safety

     Needlesticks and Sharps Exposure throughout                            are involved in as many as 77 percent of injuries.6 Scalpels
     the United States                                                      are the second most frequent mechanism of injuries.
          Every year, healthcare workers report hundreds of thousands       Needlesticks and cuts are often self- inflicted.
     of exposures to blood.2 At least 1,000 healthcare workers are
     estimated to contract serious infections annually as a result of
     these exposures.3 A study done by the Centers of Disease Control
     and Prevention (CDC) concluded that on average 50 percent or
     more of needlesticks and sharps exposures go unreported.4 More
     than 80 percent of needlestick injuries can be prevented with
     the use of safety devices, which in conjunction with worker
     education and work practice control, can reduce injuries by more
     than 90 percent.

     Cost of Sharps Injuries
           Follow up routine treatment of exposed healthcare workers is
     estimated to range from $500 to $3,000.5 Unpublished documen-
     tation provided to the author from several institutions indicates      Some institutions allow the placement of needles on
                                                                            the surgical field without having a neutral zone in which
     that the previously published estimates are much too low. Several
                                                                            to place them.
     institutions have provided cost of $7,500 to $9,000 per needlestick
     or scalpel injury, and that is without any seroconversion.
     According to the American Hospital Association, one case of
     serious infection by bloodborne pathogens can soon add up to $1
     million or more in expenditures for testing, follow up, lost time
     and disability payments.

     Where Do Injuries Occur?
          Data collected in a survey done by Niosh showed that 40
     percent of needlesticks and cuts occur on inpatient units; particu-
     larly medical floors, intensive care units, and in operating rooms.
     More than 25 percent of these injuries were in surgery.
          The number of inpatient nurses greatly out numbers the
     surgery nurses. And yet, surgery nurses are accountable for 25
     percent of all needlesticks and cuts—one explanation, this means
     that many surgical nurses are getting stuck numerous times!
     Observational studies have demonstrated that perioperative
     personnel experience the highest percutaneous injury rates, but 70     Scalpel blade being placed on mayo stand without
                                                                            a neutral zone.
     percent to 96 percent of exposures were underreported. Research
     indicates that injuries from sharp devices or instruments occur in
     7 percent to 15 percent of all surgical procedures. Procedures         AORN Recommended Practice
     identified as posing the highest risk of injury are trauma, burn,           Although most of us are aware of the Association of
     thoracic, emergency, orthopedic, major vascular, intra abdominal       periOperative Registered Nurses (AORN) recommended
     and gynecology.                                                        practices regarding the handling of sharps, very few, if any
          With the challenges of bloodborne pathogen exposures there        hospitals, meet the recommended practices regarding
     is a great risk to contract hepatitis B, hepatitis C or even HIV.      sharps in the OR. This is partly due to the limited avail-
                                                                            ability of products on the market, but it also has to do with
     When Do Injuries Occur?                                                unwillingness to change old habits. Some nurses feel
          According to the CDC, 41 percent of injuries occur after use      AORN recommended practices are unnecessary because
     and before disposal of a sharp device. About 39 percent happen         there are no citations and fines issued if AORN guidelines
     during use of a sharp device on a patient and 16 percent occur         are not being met. While that is true, in the event of a
     during or after disposal. Suture needles have been identified as the   lawsuit, one of the first things an attorney will look at is if
     most frequent mechanism of percutaneous injury in the OR; they         AORN standards were met.

16    MANAGING INFECTION CONTROL                                                                                              November 2008
     Sharps Safety

         So what are the standards AORN recommends when              has their own way of handing their sharps off; hand-to-hand,
     handling sharps in the OR? AORN recommends:                     placing or tossing on the field, placing or tossing on the mayo
      Whenever possible, sharps must be handed to and               stand, etc. The surgeon’s focus is on what he is working on, not
         from the surgeon on an exchanged basis, using a             always 100 percent of where he is placing the sharps after use. Due
         neutral zone or a hands-free method.                        to the intensity of some cases and the pace at which the surgeon
      Open sharps on the sterile field should be confined           works, surgical personnel may turn their attention away from the
         and contained.                                              surgeon to get the next instrument or suture ready. In those few
      Used sharps on the sterile field should be kept in a          seconds, when no eyes are on the sharps, cuts and sticks can occur.
         disposable, puncture-resistant container.                   This is why continuity in technique is so important for preventing
      Sharps should be transported in a puncture-resistant          needlesticks and cuts.
         container. Containing contaminated sharps in imper-
         vious containers helps prevent injuries to personnel        What Makes a Safe Neutral Zone?
         cleaning the room or equipment after use.                         An effective neutral zone should be puncture-resistant. The size
      Disposable sharps should be placed in a puncture-             of the neutral zone is also very important; if it is too big it defeats the
         resistant container as soon as possible after use.          purpose and if it is too small to accommodate your sharps, it can add
                                                                     to your risk for cuts and needlestick injuries. An effective neutral zone
     Do You Use a Neutral Zone or                                    should be well defined. Having a neutral zone with raised sides
     Hands-free Method?                                              prevents personnel from leaning onto or into the zone. If the sides are
          On the floors, nurses are in control of their needles,     flat, such as using a towel or magnetic instrument pad, personnel have
     and for the most part they are handing them one at a time,      a habit of forgetting the zone’s main purpose and will lay sponges and
     spaced out over an eight to 12 hour time period. In the         other instruments on the zone.
     OR, however, there are at least three people up at the field,         The zone should be conveniently located so the surgeon does
     and for those of who work at teaching hospitals there           not have to reach for it, and should not have to go across other
     could be up to five. At least two of those people, along        personnel to get to it. The zones are also set securely on the field.
     with the person scrubbing, will be handling sharps.
     Studies show that in the operating room 6 percent to 16         Risks Associated with Poor Neutral Zone Locations
     percent of injuries occur during hand-to-hand passing of             It is extremely important to have a neutral zone where sharps
     sharps. Twenty-four percent of sharp objects causing            can be carefully placed. But is any neutral zone better than no
     injuries were held by coworkers.7 Once the sharps are           neutral zone? Let’s examine some of the risk associated with
     handed off the OR nurse loses control. Because there is no      creating a neutral zone without much forethought.
     continuity in the practice of handing sharps, each surgeon
                                                                     Risk associated with using the mayo stand as a neutral zone
                                                                          Using the mayo stand as a neutral zone places others at risk for
                                                                     sharps injuries. If the surgeon must reach across personal, this can put
                                                                     others at risk. Typically a lot of equipment and supplies are needed up
                                                                     on the mayo stand. The act of the surgeon reaching to the mayo stand
                                                                     can become a risk factor. With the amount of equipment and supplies
                                                                     needed on the mayo stand and the constant activity involved during
                                                                     surgery cases, hands can collide as the surgeon reaches up to place
                                                                     sharps back on the mayo stand and scrub personnel are getting ready
                                                                     to hand off instruments or suture needles.

                                                                     Risk associated with using a towel as a neutral zone
                                                                          Some hospitals have incorporated the practice of opening a
                                                                     towel and placing it onto the surgical field as their neutral zone.
                                                                     This is also a concern because a towel is not puncture-resistant. If
                                                                     your neutral zone takes up a large area it defeats the purpose and
                                                                     won’t be used appropriately. Since a towel has no raised edges,
                                                                     personnel tend to forget that it is a neutral zone and lean into towel
     Surgery procedures are high intensity interactions
     between professionals trying to take care of a difficult        or rest their hands or sponges on it. Sharps also tend to get placed
     job. Because of this intensity, sometimes injuries occur.       at an angle or hang out the side of the towel neutral zone.

18    MANAGING INFECTION CONTROL                                                                                                  November 2008
     Sharps Safety

                                                                         Using a emesis basin as a neutral zone or hands-free zone
                                                                              The small size of the emesis basin does not accommodate
                                                                         the longer sharp handles and large needle drives.Because of the
                                                                         height of the sides, longer sharps that lay at a raised angle are
                                                                         at risk for getting bumped and flipping out of the basin or
                                                                         sticking into the hands of clinicians.

                                                                         Box-style Needle Counters
                                                                               Although there is risk of needlesticks with any needle
                                                                         counter if poor technique is used, some do pose more of a
                                                                         risk to collections than others. One of the most common style
                                                                         needle counters used in hospitals throughout the United
                                                                         States is the box-style needle mat. The box-style needle
                                                                         counter has a top and a bottom that is hinged together.
                                                                         Because they take up so much space on the field, surgical
                                                                         staff has a habit of taking the lid off to use only the counting
     Towels do not make an effective neutral zone and offer no           side during the case. At the end of the case they attempt to
     protection.                                                         reconnect the lid.
                                                                               Doesn’t this sound dangerous to you? The law does not
     Risk if sharps are laid down directly on the surgical field         allow healthcare workers to recap a syringe by hand and yet
          Some ORs simply pick out an area on the field and              clinicians are being asked to try to re-connect a hinged lid to
     designate that as a neutral zone. This is not a change in           a box full of contaminated needles and blades! Many times it
     practice; this technique is what most people without a neutral      is impossible to close the lid due to the different sizes of
     zone use. Where ever a person initially drops his sharps            needles used throughout the case, forcing clinicians to carry
     becomes the “neutral zone” for the rest of the case. Since there    it at the end of the case to the secondary container opened.
     is no visual “neutral zone” personnel tend to forget that it is a
     neutral zone and lean into it or rest their hands close to it.
     When this technique is used it is not uncommon for sponges
     and instruments, along with other things used throughout the
     surgery, to be placed within the neutral zone. In other words, a
     neutral zone lay down directly on the surgical field becomes
     “no neutral zone.”

                                                                            Closing needle boxes can be hazardous to your
                                                                            health, with many opportunities of getting injured by
                                                                            a needle or scalpel blade.

                                                                               This style of needle box gives a false sense of security.
                                                                         If a clinician is able to close the box, the assumption is that
                                                                         all the sharps are contained within it. Clinicians do not give it
                                                                         a second look. However, because the seam is located on the
     Using a basin as a neutral zone poses many problems for
                                                                         side of the box in the common event when the fine tips of
     clinicians, with longer sharps being raised at an angle that        needles stick out of the seam, it is possible to get stuck when
     places clinicians at risk for sharps injuries.                      picking up the closed box.

20    MANAGING INFECTION CONTROL                                                                                             November 2008
     Sharps Safety

          Some box styles have a latch on the side that must           Some needle boxes have a blade removal device integrated
     be slid over to lock the lid for transport; this can put     into it that can be difficult to use and the nurse must hold down
     clinicians at risk for sticks from needles and blades that   the mat full of used sharps to use it. This integral blade remover
     stick out from the sides.                                    device can leave a hole in the side of the box when closed; it is
                                                                  not uncommon for loose sharps to fall through this opening.
                                                                       The magnetic side of the needle mat is meant to hold blades,
                                                                  but it can be very difficult to take blades back off if needed. If the
                                                                  nurse has attempted unsuccessfully to pick up the blade using a
                                                                  needle driver, they attempt to pick it up with their fingers,
                                                                  placing them at risk for a sharps injury. In addition, the magnetic
                                                                  side of the mat exposes the needle holder to its magnetic field.
                                                                  Eventually the needle holder can become magnetized creating
                                                                  other problems.

                                                                  Don’t Use Your Fingers!
                                                                       When counting needles many clinicians have the habit of
                                                                  using their fingers to point to the sharps, and some nurses go as
                                                                  far as touching each suture needle. Using an instrument to
     Some needle counting boxes have a blade removal device       count rather than your finger puts distance between you and
     where sharps such as needles or scalpels can fall through.   blood-contaminated sharps.

                                                          Reader Service No. 63

22    MANAGING INFECTION CONTROL                                                                                           November 2008
     Sharps Safety

                                                                         carrying sharps in an unopened basin there is always the risk of
                                                                         bumping into someone, tripping or dropping the container.
                                                                         Carrying sharps in plastic bags to get them altogether provides
                                                                         no barrier against needlestick and is a high risk method.

     Some clinicians have a bad habit of using their fingers to
     point to the sharps as they count, thus exposing themselves
     to sharps injuries.

     Turning Your Needles                                                    When carrying any sharps in a plastic bag it places
         In some hospitals the surgeons turn the suture needle inward        clinicians at risk for sharps injuries.
     toward the needle driver in an effort to protect nursing staff.
     Unfortunately this means that the nurse must turn the suture
     around to place it in the needle box. Every time a nurse has to          If a clinician is bringing the sharps container to the field and
     have hand contact with the sharp it places him or her at risk.      then tossing sharps into the container, there is always the risk of
                                                                         sharps bouncing off the sides or missing the container
     Containing Sharps on the Open Field                                 completely as you attempt to throw the sharps into the container.
           Loaded scalpel handles, saw blades, bladder suspension
     devices, trocars, spinal needles and orthopedic pins are among      Introduction of New Safety Product
     the growing number of sharps that are on the mayo stand and              I recently had the opportunity of reviewing a new type of
     back table. Leaving these sharps simply lying out on the field is   safety product that eliminates many of these operating room
     a dangerous habit. We risk puncture every time we approach          challenges. It is called the DC Safety and Compliance Kit and
     table covers and mayo stand. There is always the possibility of     can help hospitals meet AORN and OSHA guidelines. The kit
     the sharps getting accidentally covered with sponges and suture
     packets or even instruments during the fast pace of the surgery,
     especially during closure when the nurse or surgery technician
     is attempting to hand the suture to the surgeon and complete his
     or her instrument, sponge and suture counts.
           All sharps on the sterile field, including scalpels, should
     be contained in a disposable puncture-resistant container.
     Puncture-resistant containers provide you with a method to
     transfer your sharps safely after the case to the secondary
     container, without having to handle your sharps. Remember,
     every time you have to gather your sharps up you are placing
     yourself at risk, so one less time means one less risk.

     How Do You Transport Sharps to the
     Secondary Container at the End of the Case?
          One of the most common practices found is simply picking                                                    The DC Safety
                                                                                                                      and Compliance
     up all the contaminated sharps by hand and caring them to the                                                    Kit from DC
     secondary container. Many times you have surgical personal                                                       Surgical
     carrying an open needle box along with sutures and other                                                         Instruments.
     sharps—it is easy to see how this puts us at risk. If you are

24    MANAGING INFECTION CONTROL                                                                                                November 2008
is designed to provide you with the tools to
work safer and to help you meet AORN and
AST standards.
     The kit includes a puncture-resistant
container with a lid. During the case the lid
of the container can be used as a hands-free
transfer method as sharps are passed between
surgeon and staff.

  The lid of the container can be used as
  a hands-free transfer method as
  sharps are passed between clinicians.

     For cases where your work area is tilted,
such as back surgeries and cases that position
the patient in leg fins such as GYN laparo-
scopic cases and lower anterior bowel
resections, the base of the container provides
you with a neutral zone that can be placed at
a slight slant. The sides of the tray contain
and restrict movement of your surgery tools.
     On your back table the container can be
used as a safe zone for your longer sharps,
such as spinal needles, trocars and ortho
pins. Having sharps enclosed in a container
that can be used for transport of sharps after   Reader Service No. 27
the case means one less time sharps have to
be picked up and moved by hand, resulting in
one less chance for needle sticks.

November 2008     MANAGING INFECTION CONTROL                             25
     Sharps Safety

                                                                          personal to keep their eyes on the needle counter as they are
                                                                          handling it.

                                                                               The operating room is fast-paced with lifesaving
                                                                          procedures taking place on a daily basis. It is important that
                                                                          during those procedures, management protects healthcare
                                                                          workers from life-altering experiences created by needlestick
                                                                          and other sharps injuries with bloodborne pathogen exposure.
                                                                          This is much more than just using a safety scalpel. The use of
                                                                          safety products to minimize bloodborne pathogen exposure is
                                                                          necessary to protect a vital work resource. Hospitals should
                                                                          always evaluate new safety products and implement them to
                                                                          help protect their valuable workforce.
     Enclosing sharps within a container decreases
                                                                               For more information on this unique product, please
     the opportunity for a needlestick injury.
                                                                          contact DC Surgical Solutions at 888.529.5594 or visit the
                                                                          company’s Web site at ✛
          At the end of the case the container, along with the lid,
     provides a safe method for transporting your needle counter          References
                                                                          1.   National Highway Traffic Safety Administration,
     and unused suture, along with other sharps from your field to             stsi/State_Info.cfm?Year=2003&State=CO&Accessible=0.
     the secondary container. Unlike the commonly used boxed-             2.   United States department of labor Occupational safety and health
     style needle counters, the DC Safety and Compliance Kit has               administration (USDOL-OSHA).
                                                                          3.   International Health Care Worker Safety Center, 1999.
     no seam on the side. Because of this it meets OSHA standards         4.   Workbook for designing, implementing, and evaluating a sharps
     for transporting sharps, which states puncture-resistant                  injury prevention program, Centers for Disease Control and
     containers should be leak-proof and seamless on the bottom                Prevention,
                                                                          5.   Ibid; also unpublished data ISIPS, International Sharps Injury
     and sides of the container.                                               Prevention Society.
                                                                          6.   AORN Guidance Statement: Sharps injury Prevention in the
                                                                               Perioperative Setting. Standards, Recommended Practices, and
                                                                               Guidelines (Denver: AORN, Inc, 2005) 199-204.
                                                                          7.   Reducing Blood Exposures During Orthopedic Surgical Procedures.
                                                                               AORN Volume 71, issue 3, pages 573-582 (March 2000) Ann Folin,
                                                                               RN, Bjorn Nyberg, MD, Gun Norstrom, RN

                                                                               Ron Stoker is the founder and executive director of the
                                                                          International Sharps Injury Prevention Society (ISIPS).
                                                                          Mr. Stoker has a graduate degree in Bioengineering from the
                                                                          University of Utah with an undergraduate degree from
                                                                          Brigham Young University, Utah. He has been involved in the
                                                                          medical device industry for more than 28 years in a variety
     The DC Sharps and Compliance Kit has no seam on the side             of settings, including research and development, business
     and is leak-proof.
                                                                          development, marketing and public relations, and has six
                                                                          patents issued in his name. He writes frequently about sharps
            The needle counter/scalpel holder meets all AORN and          safety and infection control issues and speaks internationally.
     AST standards while taking up less space on the mayo stand           Mr. Stoker is co-author of the Compendium of Infection Control
     and back table. The needle counter was designed with no lid.         Technology that is available at
     This takes away the dangerous practice of taking lids off for        He is currently involved on providing safety product seminars
     use during the case and then attempting to replace the lid after     to hospitals and clinics. For more information on these
     it is full of used sutures and blades. It also encourages surgical   presentations send an email to

26    MANAGING INFECTION CONTROL                                                                                                   November 2008