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AORN Guidance Statement Sharps Injury Prevention in the

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					                                 AORN Guidance Statement: Sharps Injury
                                   Prevention in the Perioperative Setting

                 Introduction                            have the highest risk of injury and sustain more
                                                         than half (ie, 59%) of percutaneous injuries in the
The purpose of this guidance document is to assist       perioperative setting.6 Scrub personnel experienced
perioperative registered nurses in the development       the second highest frequency of percutaneous
of sharps injury prevention programs using identified    injury, followed by anesthesia care providers and
best practices to reduce percutaneous injuries. It       circulating nurses.6
also suggests strategies to overcome obstacles to           Injuries from hollow bore needles constitute the
compliance with established sharps safety protocols.     majority of injuries and pose the highest risk of
   The perioperative setting is a high-risk environ-     exposure to bloodborne pathogens.10 Although the
ment, and perioperative RNs are routinely faced          risk of injury from hollow bore needles is prevalent
with high risk for exposure to bloodborne pathogens      in the perioperative setting, the epidemiology of
from percutaneous injuries. Although the scope of        sharps injuries in the OR is different from that of
the problem is not completely known, the National        other locations in health care. Suture needles have
Institute for Occupational Safety and Health             been identified as the most frequent mechanism of
(NIOSH) estimates that 600,000 to 800,000 percuta-       percutaneous injury in the OR; they are involved in
neous injuries occur annually among heath care           as many as 77% of such injuries.4,6 Scalpels are the
workers.1 Percutaneous injuries primarily are associ-    second most frequent mechanism of injury, fol-
ated with occupational transmission of the hepatitis     lowed by retractors, skin or bone hooks, and sharp
B virus (HBV), hepatitis C virus (HCV), and HIV, but     electrosurgical tips.11,12
they may be implicated in the transmission of more          Percutaneous injuries often are self-inflicted.
than 20 other pathogens. 2 Understanding the             Studies indicate that 6% to 16% of these injuries
etiology of percutaneous injuries in the perioperative   occur during hand-to-hand passing of sharp instru-
setting is paramount to developing a safe prevention     ments, suture needles, and other sharp devices.
program.                                                 The most common body part injured is the non-
                                                         dominant hand. Injuries from suture needles occur
                  Background                             most often
                                                            ♦ when loading the needle holder or reposi-
Percutaneous injuries occur throughout all health              tioning the needle;
care facilities, and many occur in the perioperative        ♦ during hand-to-hand passing of sharp devices
setting.3,4 Exposure to bloodborne pathogens occurs            between scrub personnel and the surgeon;
during all phases of the perioperative process.             ♦ during suturing, particularly muscle and fas-
Research indicates that injuries from sharp devices            cia (eg, wound closure) when the needle is
or instruments occur in 7% to 15% of all surgical              being manipulated and guided with fingers;
procedures. Procedures identified as posing the             ♦ when retracting or stretching tissue with
highest risk of injury are thoracic, trauma, burn,             hands;
emergency orthopedic, major vascular, intra-                ♦ when the surgeon sews toward his or her
abdominal, and gynecologic surgeries.5 Risk of a               own or an assistant’s hand;
sharps injury increases during more invasive,               ♦ when tying suture with the needle attached;
longer procedures that result in higher blood loss.6        ♦ after the suture has just been used and remains
Fatigue resulting from working extended hours in               unattended on the operative field—even if
combination with the fast pace of the perioperative            suture is unattended on the field for only a short
environment also may contribute to increased risk              time, the needle holder can fall off the field
of percutaneous injuries.7-9                                   onto a health care worker’s foot, or scrubbed
   Nurses comprise the largest segment of health               personnel may reach for it in an attempt to pre-
care workers and are reported to sustain the high-             vent it from sliding off the field; and
est number of percutaneous injuries overall. 2              ♦ when placing the used needle in an over-
Observational studies have demonstrated that peri-             filled sharps container.3
operative personnel experience the highest percu-           Injuries from scalpels most often occur
taneous injury rates, but 70% to 96% of exposures           ♦ when loading or removing a disposable
were underreported.5 Surgeons and first assistants             scalpel blade on a reusable knife handle;


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   ♦ during hand-to-hand passing of the scalpel;          in the development and implementation of strate-
   ♦ during dissection when the tissue is being           gies to reduce the risk of sharps injuries to health
       retracted or spread with hands;                    care team members.
   ♦ when cutting toward the surgeon’s or an                 Perioperative nursing management should work
       assistant’s fingers;                               with the facility risk manager or safety officer to
   ♦ immediately before or after use when the             identify the types of sharp devices and how they
       scalpel is left on the operative field unat-       are used in the perioperative setting. Both perioper-
       tended—even if this is for only a short time,      ative nursing management and the risk manager or
       the scalpel can fall off the field onto a health   safety officer should have a thorough understand-
       care worker’s foot, or scrubbed personnel          ing of OSHA’s standards.3
       may reach for it in an attempt to prevent it          By law, an effective sharps injury and blood-
       from sliding off the field; and                    borne pathogen exposure control program must be
   ♦ when the scalpel is placed in an over-filled or      written, communicated to all workers in the peri-
       poorly located sharps container.3                  operative setting, and uniformly supported and
   Glove barrier failure is a common occurrence in        enforced by perioperative leadership.2,13 A multidis-
the perioperative setting. Glove failures can be          ciplinary team is key to the success of this process.
caused by punctures, tears by sharp devices, or           This team, using steps consistent with the continu-
spontaneous failures. These failures expose the           ous quality improvement process, must conduct a
wearer to bloodborne pathogens. Studies have              baseline assessment and set priorities for develop-
demonstrated that glove perforations often occur          ing an action plan.2,6
after an average of 40 minutes of use during surgical
procedures. When two pairs of gloves are worn (ie,                 Perioperative-Specific
double gloving), in most instances, only the outer
glove is perforated when punctured by a sharp                     Risk Reduction Strategies
device. In addition, research demonstrates that when
two pairs of gloves are worn and a puncture occurs,       ■ Adopt and incorporate safe habits into daily
the volume of blood on a solid sharp device (eg,            work activities when preparing and using sharp
suture needle) is reduced by as much as 95%. There          devices.
is evidence that double gloving can reduce the risk       ■ Focus attention on the intent of the action when
of exposure to blood and body fluids, if the outer          working with sharp items, and minimize rushing
glove is punctured, by as much as 87%.6                     and distractions while applying safety tech-
                                                            niques during critical moments.
   The Occupational Safety and Health Administra-
                                                          ■ During preparation for operative or other inva-
tion (OSHA) requires health care organizations to
                                                            sive procedures:
protect their workers and have a written exposure
                                                               inspect the surgical field for adequate lighting
control plan. Protection occurs by using universal
                                                               and space to perform the procedure;
precautions, engineering controls, work practice
                                                               organize the work area so that the sharps are
controls, organizational controls, and communica-
                                                               always pointed away from staff members;
tion. The standard also requires employers to main-
                                                               establish a separate area to place a reusable
tain a log of injuries from contaminated sharps.13
                                                               sharp for safe handling during the procedure;
            Guidance Statement                                 use standardized sterile field set-ups; and
                                                               include identification of the neutral zone in
The perioperative environment poses unique chal-               the preoperative briefing.14
lenges for reducing the risk of injuries from sharp       ■ During the operative or other invasive procedure:
devices. Surgery involves precise, regimented                  wear two pairs of gloves (ie, double gloving);
actions that require planning, communication, and              monitor gloves for punctures;
team work. These same elements can be employed                 encourage the use of blunt suture needles;
to mitigate the inherent hazards associated with               use neutral or hands-free technique for pass-
sharp devices encountered in the perioperative set-            ing sharp items whenever possible or practi-
ting. Perioperative RNs should actively participate            cal, instead of passing hand-to-hand;


 200                                                      2005 Standards, Recommended Practices, and Guidelines
                                                                         Sharps Injury Prevention




    give verbal notification when passing a sharp              do not place hands or fingers into a container
    device;                                                    to dispose of a device; and
    keep visual contact with the procedure site                keep hands behind the sharp tip when dis-
    and the sharp device;                                      posing.3,14,18
    take steps to control the location of the sharp        Health care organizations and their employees
    device;                                             are responsible for actively participating in strategies
    be aware of other staff members in the area         to reduce percutaneous injuries. The employing
    when handling a sharp device;                       facility should provide an environment that reduces
    keep track of and account for all sharp items       the risk of percutaneous injuries from contaminated
    throughout the procedure;                           sharp devices. A well-developed safety program and
    contain used sharps on the sterile field in a       support from management sends a clear message to
    designated, disposable, puncture-resistant          employees about the organization’s commitment to
    needle container, and replace it as necessary;      preventing injuries and keeping employees safe.
    check to be sure the disposable, puncture-          Fewer percutaneous injuries are reported in organi-
    resistant needle container is securely closed       zations that have a strong culture of safety. Individ-
    before handing it off the field;                    ual health care workers have a responsibility to be
    load suture needles using the suture packet to      educated about the prevalence and mode of trans-
    assist in mounting the suture needle in the         mission of bloodborne pathogens and to use meas-
    needle holder, and use the appropriate instru-      ures to protect themselves.19
    ment to adjust and unload the needle;
    remove the needle from the suture before
    tying, or use “control-release” sutures that
                                                                 Individual Perioperative
    allow the needle to be removed with a                          RNs’ Responsibilities
    straight pull on the needle holder;
    activate the safety feature of a safety engi-       ■ Observe local, state, and federal regulations (eg,
    neered device immediately after use accord-           OSHA regulations).
    ing to manufacturers’ instructions;                 ■ Comply with methods to protect yourself from
    keep hands away from the surgical site when           disease transmission (eg, get the hepatitis B
    sharp items are in use (eg, suturing, cutting);       vaccination).
    use one-handed or blunt instrument-assisted         ■ Use devices with safety features that are pro-
    suturing techniques to avoid finger contact           vided by your employer.
    with the suture needle or tissue being              ■ Prevent hollow bore percutaneous injuries dur-
    sutured;                                              ing injections or bodily fluid retrieval by using
    provide a barrier between the hands and the              needleless systems or sharps with engineered
    needle after use; and                                    sharp injury protection devices whenever
    use gloves and an instrument to pick up sharp            possible;
    items (eg, suture needles, hypodermic nee-               retractable, protective sheath or self-resheathing,
    dles, scalpel blades) that have fallen on the            self-blunting, or hinged re-cap needles to
    floor.2,3,6,13-17                                        administer local anesthetics and other injectable
■ During postprocedure clean up:                             medications;
    inspect the surgical setup used during the               blunt cannulas to withdraw medications and
    procedure for sharps;                                    fluids from vials; and
    transport reusable sharps in a closed, secure            the one-handed recapping technique, only if
    container to the designated clean-up area;               no other alternatives exist.
    inspect the sharps container for overfilling        ■ Practice using safety devices to establish famil-
    before discarding disposable sharps in it;            iarity and experience with them before using
    make sure the sharps container is large               them in practice.
    enough to accommodate the entire device;            ■ Actively participate in the safety conversion
    avoid bringing hands close to the opening of          process and help others adapt to the change.
    a sharps container;                                 ■ Use personal protective equipment.


2005 Standards, Recommended Practices, and Guidelines                                                    201
Sharps Injury Prevention




■ Use sharps receptacles that are                       ■ Evaluate the effectiveness of established risk
     identifiable (ie, orange, orange-red), closable,     reduction strategies and products, provide feed-
     and labeled with the biohazard symbol;               back, and modify them as necessary to reduce
     appropriately sized with a full line that is         the risk of percutaneous injuries.7
     readily visible;                                   ■ Establish staffing patterns that minimize
     puncture resistant and leak proof;                   extended work hours and allow for adequate
     located close to the point of use;                   recuperation to decrease the risk of fatigue-
     maintained upright when in use; and                  related injuries.20
     routinely replaced and not allowed to overfill.
■ Participate in education about bloodborne             Overcoming Obstacles to Compliance
  pathogens, and follow recommended infection
  prevention practices.                                 Psychosocial and organizational factors may
■ Support and guide perioperative team members          impede change. An employee’s risk-taking person-
  to follow these risk reduction strategies.            ality profile, perception that the organization is not
■ Encourage perioperative staff members to proac-       committed to worker safety, and a perceived belief
  tively report hazards that pose a threat of percu-    that there is a conflict between providing optimal
  taneous injury.                                       patient care and protecting oneself from exposure
■ Know the location in your department of the           contribute to an employee’s resistance to changing
  exposure control plan.                                to safer practices.2 For example, although percuta-
■ Follow exposure control policy if injured (ie,        neous injuries continue to occur in the periopera-
  wash site with soap and water, provide immedi-        tive setting, 71% of respondents in a national sur-
  ate care to the exposure site).9,13                   vey indicated that they have not evaluated blunt-tip
                                                        suture needles for use in the OR, and only 2% of
       Employer Responsibilities                        respondents have fully implemented blunt-tip
                                                        suture needles. Only 14% of respondents had
■ Comply with local, state, and federal regulations     implemented safety scalpels into their ORs.4
  regarding percutaneous injury prevention.                 Changes in attitudes about risk of exposure must
■ Create a safety-oriented culture.                     occur before practice can change to comply with
■ Encourage timely reporting of all percutaneous        sharps safety protocols. It is difficult to change
  injuries by all perioperative team members.           ingrained habits. People are most likely to change
■ Analyze needle-stick and other sharps-related         behavior when they perceive a significant personal
  injuries in the perioperative setting to identify     risk. Education about the risk of contracting a
  hazards and injury trends.                            bloodborne disease from a percutaneous injury
■ Establish a communication mechanism to seek           with a contaminated sharp device should be pre-
  input from perioperative team members regard-         sented in the early stages of a health care worker’s
  ing risks specific to the perioperative setting.      career in order to develop safe practice habits.5
■ Provide training for all perioperative personnel          Surgery involves precise, regimented actions
  that includes risk reduction strategies designed      requiring planning, communication, and team
  specifically to address the risks encountered in      work. These same elements can be employed to
  the perioperative setting.                            overcome obstacles to compliance with measures
■ Evaluate and select safety devices that are           meant to mitigate the inherent hazards of sharp
  acceptable to all members of the perioperative        devices encountered in the perioperative setting.
  team who use them. The safety device should           Suggested strategies to overcome obstacles to com-
  provide features that work effectively, are reli-     pliance include the following.
  able, do not compromise patient or worker             ■ Use frequent and multiple training methods that
  safety, and are ergonomically designed to the             include audiovisual aids, articles, hands-on clin-
  acceptable specifications of the users.                   ical practice, and visual reminders (eg, lami-
■ Provide and have readily available the appropri-          nated posters).
  ate sharps safety devices, and provide adequate       ■ Develop a multidisciplinary sharps injury pre-
  training on their use.                                    vention education plan.


 202                                                    2005 Standards, Recommended Practices, and Guidelines
                                                                              Sharps Injury Prevention




■ Incorporate sharps injury prevention instruction             products to reduce sharps injury in the OR. Staff
  into initial nursing education to promote well-              members who work with the product are key com-
  established, safe habits.                                    ponents of the team. A strong interdisciplinary com-
■ Include sharps injury prevention strategies dur-             mitment to best practices and worker safety is the
  ing orientation of new employees.                            optimal foundation necessary for change to occur.
■ Form a multidisciplinary sharps safety commit-           ■   Review the literature for research about the
  tee that includes, but is not limited to, perioper-          mechanism, frequency, time, and place of
  ative RNs, surgeons, anesthesia care providers,              injuries, as well as the role and body part of the
  surgical technologists, and first assistants. This           person sustaining the percutaneous injury to
  team could be asked to                                       determine priority areas on which to focus.
     help with the selection and evaluation of             ■   Identify the products to be evaluated. Focus on
     acceptable safety devices (eg, scalpels that              their intended use in the facility and identify any
     employ a one-handed technique or are totally              special technique or design factors that will
     disposable) and                                           influence safety, efficiency, and user acceptabil-
     work with physicians to explore alternative               ity. Seek data from all sources on the safety and
     techniques, such as adhesive skin closures;               overall performance of the devices.
     alternatives for securing catheters; use of blunt     ■   Ensure that participants in the evaluation repre-
     suture needles, rounded scalpels, or stapling             sent all of the end users. To ensure a successful
     devices, when procedurally appropriate; and               evaluation, users must have adequate training.
     use of alternative methods for cutting tissue             Use clear, objective, consistent criteria to evalu-
     (eg, harmonic scalpel, rounded scissors, laser            ate safety devices.
     devices, electrosurgery active electrodes).           ■   Continue to monitor a safety device after it has
■ Network with other facilities to learn about their           been implemented to assess performance and to
  success stories.                                             identify if there is a need for additional training.2,10
■ Collaborate with personnel who use the device,
  and facilitate change instead of dictating change.                             Summary
■ Inform perioperative team members about cur-
  rent research on disease transmission from per-          Occupational exposure to bloodborne pathogens
  cutaneous injuries and relate it to the individ-         via percutaneous injuries is one of the most serious
  ual’s experience.                                        dangers perioperative team members face on a daily
■ Work with resisters to gain buy-in to the sharps         basis. The risk of sustaining a percutaneous injury
  safety program.                                          can be decreased through employee education,
■ Remove as many conventional sharp items as               clear communication, device engineering, and
  possible from stock.                                     focused work practice controls. Risk reduction
■ Create a culture of safety in which every team           strategies should include specific practices aimed at
  member is empowered to call attention to defi-           reducing the unique risks of percutaneous injuries
  ciencies in sharps management.2,9,12,13                  encountered in the perioperative environment.
                                                           AORN recognizes the various settings in which peri-
                                                           operative RNs practice, and the suggested risk
         Selecting and Evaluating                          reduction strategies in this guidance statement are
              New Products                                 intended to be adaptable to any setting where surgi-
                                                           cal or other invasive procedures are performed.
As risk reduction strategies are identified, a multidis-
ciplinary team should evaluate and select the best         NOTES
products to meet the facility’s needs. An ongoing             1. “AORN position statement on workplace safety,” in
review process should be developed to assess, eval-        Standards, Recommended Practices, and Guidelines (Den-
uate, and modify the plan as needed. Product evalu-        ver: AORN, Inc, 2004) 169-171.
                                                              2. “Workbook for designing, implementing, and evaluat-
ation and selection should include the following.          ing a sharps injury prevention program,” Centers for Disease
■ Assemble a multidisciplinary team to develop,            Control and Prevention, http://www.cdc.gov/sharpssafety
   implement, and evaluate a process for selecting         (accessed 5 Jan 2005).


2005 Standards, Recommended Practices, and Guidelines                                                           203
Sharps Injury Prevention




    3. ECRI, “Sharps injuries in the operating room—A              13. “Regulations (Standards–29 CFR) Bloodborne
new focus for OSHA,” Operating Room Risk Management             pathogens 1910.1030,” Occupational Safety and Health
(December 2004) 1-5.                                            Administration, http://www.osha.gov/pls/oshaweb/
    4. J Perry, G Parker, J Jagger, “EPINet report: 2001 per-   owadisp.show_document?p_table=STANDARDS&p_id=
cutaneous injury rates,” Advances in Exposure Prevention        10051 (accessed 5 Jan 2005).
6 no 3 (2003) 32-36.                                               14. “Recommended practices for maintaining a sterile
    5. C L Holodnick, V Barkauskas, “Reducing percuta-          field,” in Standards, Recommended Practices, and Guide-
neous injuries in the OR by educational methods,” AORN          lines (Denver: AORN, Inc, 2004) 367.
Journal 72 (September 2000) 461-476.                               15. C Twomey, “Does double gloving double the pro-
    6. R Berguer, P J Heller, “Preventing sharps injuries in    tection?” Infection Control Today, http://www.infection
the operating room” Journal of the American College of          controltoday.com/articles/051feat3.html (accessed 5 Jan
Surgeons 199 (September 2004) 462-467.                          2005).
    7. K Hanecke et al, “Accident risk as a function of            16. “Recommended practices for sponge, sharp, and
hour at work and time of day as determined from accident        instrument counts,” in Standards, Recommended Prac-
data and exposure models for the German working popu-           tices, and Guidelines (Denver: AORN, Inc, 2004) 230-231.
lation,” Scandinavian Journal of Work, Environment, and            17. “Recommended practices for environmental clean-
Health 24 suppl (1998) 43-48.                                   ing in the surgical practice setting,” in Standards, Recom-
    8. T Roth, T A Roehrs, “Etiologies and sequelae of          mended Practices, and Guidelines (Denver: AORN, Inc,
excessive daytime sleepiness,” Clinical Therapeutics 18         2004) 273-279.
(July/August 1996) 562-576.                                        18. “Recommended practices for standard and trans-
    9. Battelle Memorial Institute, JIL Information Systems,    mission-based precautions in the perioperative practice
“An overview of the scientific literature concerning fatigue,   setting,” in Standards, Recommended Practices, and
sleep, and the circadian cycle,” Air Line Pilots Association,   Guidelines (Denver: AORN, Inc, 2004) 361.
http://cf.alpa.org/internet/projects/ftdt/backgr/batelle.htm       19. “AORN guidance statement: Safe on-call practices
(accessed 5 Jan 2005).                                          in perioperative practice settings” in Standards, Recom-
   10. National Institute for Occupational Safety and           mended Practices, and Guidelines (Denver: AORN, Inc,
Health, “Preventing needlestick injuries in health care set-    2005) 193-195.
tings,” publ 2000-108 (Washington, DC: US Department               20. K Royer, “Primer on prevention of sharps injuries”
of Health and Human Services, November 1999).                   (Sharps Safety) Outpatient Surgery Magazine 5 (Septem-
   11. J Jagger, M Bentley, P Tereskerz, “A study of patterns   ber 2004) 50.
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   12. S Wasek, “10 practical ways to implement safety          Scheduled for publication in the AORN Journal in
devices,” Outpatient Surgery Magazine 4 (December               2005.
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