CONTINUING EDUCATION Implementing AORN Recommended Practices for Sharps Safety
2.2
DONNA A. FORD, MSN, RN-BC, CNOR, CRCST
www.aorn.org/CE Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #14503 Session: #0001 Fee: Members $17.60, Nonmembers $35.20 The CE contact hours for this article expire January 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to preventing sharps injuries and bloodborne pathogen exposure.
Objectives 1. Discuss legislation related to preventing bloodborne pathogen transmission. 2. Discuss causes of percutaneous injury in perioperative settings. 3. Identify hazards associated with percutaneous injury. 4. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Ms Ford has no declared affiliation that could be perceived as posing potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
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RECOMMENDED PRACTICES Implementing AORN Recommended Practices for Sharps Safety 2.2 DONNA A. FORD, MSN, RN-BC, CNOR, CRCST
www.aorn.org/CE
ABSTRACT Prevention of percutaneous sharps injuries in perioperative settings remains a challenge. Occupational transmission of bloodborne pathogens, not only from patients to health care providers but also from health care providers to patients, is a significant concern. Legislation and position statements geared toward ensuring the safety of patients and health care workers have not resulted in significantly reduced sharps injuries in perioperative settings. Awareness and understanding of the types of percutaneous injuries that occur in perioperative settings is fundamental to developing an effective sharps injury prevention program. The AORN “Recommended practices for sharps safety” clearly delineates evidence-based recommendations for sharps injury prevention. Perioperative RNs can lead efforts to change practice for the safety of patients and perioperative team members by promoting the elimination of sharps hazards; the use of engineering, work practice, and administrative controls; and the proper use of personal protective equipment, including double gloving. AORN J 99 (January 2014) 107-117. Ó AORN, Inc, 2014. http:// dx.doi.org/10.1016/j.aorn.2013.11.013 Key words: sharps injuries, sharps injury prevention, engineering controls, work practice controls, administrative controls, blunt-tip needles, neutral zone, double gloving.
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ven with legislation in place that requires safeguards and practice controls, perioperative team members continue to experience occupational percutaneous injuries at unacceptable levels.1 Eight years after the passage of the Needlestick Safety and Prevention Act,2 Jagger et al1,3 reported that although sharps injuries had decreased 31.6% in nonsurgical settings, they had increased
6.5% in surgical settings. Percutaneous injuries can result in occupational transmission of hepatitis B, hepatitis C, and HIV.4 The purpose of the new “Recommended practices for sharps safety”5 is to prevent percutaneous injuries by helping perioperative nurses identify potential sharps hazards, implement best practices, and develop policies and procedures related to safe
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practices and postexposure protocols. AORN recommended practices represent what is considered to be optimal and achievable perioperative nursing practice and are based on the highest level of evidence available. This article highlights the most significant recommendations of the “Recommended practices for sharps safety,” including those that can have the largest effect on sharps injury reduction. More in-depth information and a review of evidence for each recommendation can be found in the complete recommended practices (RP) document.5 WHAT’S NEW The new “Recommended practices for sharps safety” supersedes the “AORN guidance statement: Sharps injury prevention in the perioperative setting,”6 developed in 2005. The intent of the guidance statement was to assist perioperative RNs in developing sharps injury prevention programs and overcoming obstacles to compliance with the suggested and mandated practices. Federal regulations and strong research evidence provided support for a stronger position on sharps safety, so the RP document was developed to replace the guidance statement. Although many of the responsibilities and riskreduction strategies from the guidance statement have been carried over into the RP document, the new document provides the format of recommendations followed by evidence-based rationales, evidence-rated intervention statements, and supporting activity statements. The evidence supporting the recommendations is derived from regulatory controls, randomized controlled trials, and Cochrane systematic reviews. RATIONALE Approximately 500,000 health care workers each year experience percutaneous injuries.3,7 Percutaneous injuries are associated with occupational transmission of hepatitis B virus, hepatitis C virus, and HIV, which can result in lifelong health concerns.4 Percutaneous injuries also present a risk to patients; a health care provider who is infected with 108 j AORN Journal
FORD a bloodborne pathogen and who then receives a percutaneous injury can inadvertently infect a patient through contact with the contaminated sharp or contact with the health care provider’s blood through an unnoticed glove perforation. Between 1991 and 2005, 132 cases of health care providerto-patient transmission of hepatitis B, hepatitis C, or HIV were documented.8 Anyone who has experienced an occupational exposure to bloodborne pathogens knows the emotional burden of fear, worry, and concern that follows, which may be far greater than the actual physical injury. The real or potential economic burdens also can cause additional stress. Costs to the health care worker are any expenses incurred because of missed work days. Potential economic burdens include the inability to continue working because of an illness that results from the occupational exposure. Costs to the employer include the postexposure management, the laboratory tests and follow-up testing, and any necessary prophylaxis, as well as loss of productivity of the health care worker. The annual cost of percutaneous sharps injuries has been estimated at $65 million.9 The cost for a health care facility to manage an occupational exposure can range from $71 to $4,838 per exposure.10 Two significant pieces of legislation, the Bloodborne Pathogens Standard 29 CFR x1910.1030 in 199211 and the Needlestick Safety and Prevention Act in 2000,2 are aimed at reducing occupational transmission of bloodborne pathogens. The purpose of the Bloodborne Pathogens Standard is to limit health care worker exposure to bloodborne pathogens and other potentially infectious materials by requiring implementation of engineering controls (eg, use of safety-engineered devices) and work practice controls (eg, use of a neutral zone for passing sharps).12 The additional legislation in 2000 directed the Occupational Safety and Health Administration (OSHA) to make multiple revisions to the existing Bloodborne Pathogens Standard. The Needlestick Safety and Prevention Act includes requirements that annual review of exposure control
RP IMPLEMENTATION GUIDE: SHARPS SAFETY plans also should “reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.”2 Because medical technology is constantly changing and improving, more devices are becoming available that can help reduce sharps injuries.13 In addition to AORN, a number of professional associations have issued statements supporting sharps injury prevention practices. These associations include the American Academy of Orthopaedic Surgeons,14 the American College of Surgeons,15 the Association of Surgical Technologists,16 and the Council on Surgical and Perioperative Safety.17 In 2012, the International Healthcare Worker Safety Center at the University of Virginia, Charlottesville, released a consensus statement endorsed by 20 organizations citing improved sharps safety in surgical settings as the highest priority in reducing percutaneous sharps injuries.18 Three governmental agencies, the US Food and Drug Administration, the National Institute for Occupational Safety and Health, and OSHA, issued a joint safety communication in May 2012 encouraging the use of blunt-tip suture needles.19 Accrediting bodies (eg, The Joint Commission, the Accreditation Association for Ambulatory Health Care) and regulatory organizations (eg, OSHA, the Centers for Medicare & Medicaid Services) may survey for sharps safety during visits to health care facilities. Key points in a survey could include review of the exposure control plan, which must be in compliance with the federal legislation and should meet the criteria established in the Needlestick Safety and Prevention Act.13 Surveyors also may look to ensure that sharps containers are located close to the point of use and glove boxes and personal protective equipment (PPE) are placed in convenient locations. Other potential points in a survey include a review of policies, sharps injury logs, and documentation of safety training. Surveyors may observe use of PPE and question personnel about safety procedures.20
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DISCUSSION Implementing a sharps injury prevention program can be a challenging process in any setting. The “Recommended practices for sharps safety” provides information that can assist with developing a bloodborne pathogens exposure control plan11; eliminating the hazards; and implementing engineering controls, work practice controls, and administrative controls.5 Engineering controls are practices that remove the hazard from the workplace, such as the use of safety-engineered devices.11 Work practice controls minimize the risk of exposure to blood and other potentially infectious materials by changing the method of performing a task.11,21,22 Administrative controls include developing policies and procedures and providing education and training on prevention of bloodborne pathogen exposure. Recommendation I Health care facilities must have a bloodborne pathogens exposure control plan, as required by OSHA.11 The exposure control plan is a component of administrative controls, which are important to the success of a sharps safety program. The plan must include an exposure determination for employees who have the potential to be exposed to blood and body fluids; a plan to reduce sharps injuries, including prioritized risk-reduction strategies; and a process to monitor sharps injury data. The plan must be reviewed and updated at least annually and any time new practices are implemented. Ensuring compliance with the exposure control plan and related policies is important to show commitment to prevention of sharps injuries. Administrators and managers, in collaboration with occupational health and infection prevention practitioners, can develop the exposure control plan. Frontline personnel, including perioperative RNs and surgeons, should be involved in identifying control methods to prevent sharps injuries by using the hierarchy of controls to prioritize prevention interventions (Figure 1).23 At the top of the hierarchy (ie, the most effective strategy) is AORN Journal j 109
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Figure 1. The hierarchy of controls. Illustration reprinted with permission from AORN, Inc, Denver, CO. All rights reserved.
eliminating the hazard by completely removing it from use. Eliminating the hazard (eg, a sharp item or instrument) involves identifying alternative ways to perform the necessary task without using sharps, such as by using a tissue adhesive and adhesive strips or a skin stapler to close a skin incision. A systematic review of 14 randomized controlled trials that evaluated surgical wound healing when tissue adhesives were used for skin closure showed there was no significant difference in infection rates, patient and user satisfaction, or cost between use of sutures and use of adhesives.24 Therefore, when clinically indicated, it could be appropriate to use adhesives in place of suture to help prevent needlestick injuries. The highest priority should be eliminating the device that has the potential to cause the most injuries.5 If eliminating use of the device is not feasible, controls at lower levels of the hierarchy should be considered, such as using engineering controls, work practice controls, administrative controls, and PPE.23 Recommendation II When elimination of sharps is not feasible, perioperative team members must use sharps with safety-engineered devices that “isolate or remove the risk of bloodborne pathogen exposure.”11 Sharps 110 j AORN Journal
FORD with engineered sharps injury protection have a built-in safety feature and include blunt-tip suture needles,4,15,17,25-28 safety scalpels,11 and safetyengineered syringes and needles.11,23 Alternative wound closure devices and needleless systems are effective in preventing percutaneous injuries11 and include fascial closure devices, tissue staplers, tissue adhesives, and adhesive skin closure strips.29-31 Strong evidence supports the use of blunt-tip suture needles for muscle and fascia closure. In a Cochrane review of 10 randomized controlled trials, researchers found that using blunt-tip suture needles instead of sharp-tip suture needles reduced the incidence of glove perforation by 54%, thereby reducing the risk of infectious disease transmission.25 Managers can identify devices with engineering controls through contact with vendors, attending vendor displays at conferences, and professional networking. A multidisciplinary committee including direct users should be part of the process for selecting and evaluating safety-engineered devices.2 Educators can plan a product fair to help personnel identify safety-engineered devices and other sharps safety products to select for an evaluation. Perioperative RNs can encourage team members to provide objective evaluations of safetyengineered devices. After products are selected, the educator may want to set up a sharps safety skills fair to allow personnel and surgeons an opportunity to have hands-on practice with the trial devices. Recommendation III Hand-to-hand passing of sharps, such as needles, blades, and sharp instruments, accounts for the majority of percutaneous injuries.3 Perioperative personnel must use work practice controls when handling any type of disposable or reusable sharp. Work practice controls change the way a task is performed when sharp devices are used. For example, surgical team members should use a neutral zone for passing any sharp device (eg, blade, instrument, needle) rather than passing items
RP IMPLEMENTATION GUIDE: SHARPS SAFETY from hand to hand.14-17,29,32-37 A neutral zone helps ensure that the surgeon and scrub person do not touch the same sharp instrument at the same time. This technique, also called hands-free technique, is accomplished by designating a neutral zone on the sterile field and placing sharp items within the zone for transfer between scrubbed personnel.5 A modified neutral zone may be needed when the surgeon is using a microscope; sharps are carefully placed in the surgeon’s hand, and the surgeon returns the sharp to the neutral zone after use.14,33,38-42 The no-touch technique should be used to minimize manual handling of sharps by gloved hands. For example, when loading a suture in the needle holder, the scrubbed team member should keep the needle in the suture packet and use the suture packet to position the needle in the needle holder (Figure 2). The scrubbed team member should then use a one-handed technique to reposition a needle before placing it in a needle box on the sterile field. Additional work control practices include maintaining “situational awareness” when sharps are in use, communicating the location of sharps on the sterile field, removing needles before tying suture,
Figure 2. Use of the no-touch technique.
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and using instruments instead of hands for tissue retraction. Personnel should use caution at all times when handling sharps and should follow safe injection practices.11 To successfully implement work practice controls, perioperative team members need to understand potential hazards with a current practice, be willing to change their practice, actually make the practice change, and then consistently perform the practice in the new, safer way. The importance of education in this process cannot be understated. Managers and educators can reinforce the principles of work practice controls and the importance of communication and situational awareness during use of sharps. The educator has a key role in providing assistance to individual team members and surgical teams implementing work practice controls and learning new ways to safely perform tasks. Practice with the no-touch technique gives personnel the opportunity to try various ways of manipulating sharps with minimal handling. Role play and simulation activities can help team members determine acceptable ways of implementing use of a neutral zone for different surgical procedures and different patient positions. Perioperative RNs and other team members can collaborate with the educator to help personnel develop these skills. Recommendation IV Proper use of PPE is required by the OSHA Bloodborne Pathogens Standard.11 For example, strong evidence exists to support the practice of double gloving to reduce the risk of glove perforation and percutaneous exposure.43 In one study, the overall perforation rate of gloves was 15.8%, which presents concerns about bloodborne pathogen exposure, breaks in sterile technique, and surgical site infection.44 When two pairs of gloves are worn and a perforation occurs, often only the outer glove is perforated.43 Research has shown that if both gloves are perforated, the volume of blood on a solid sharp device can be reduced by as much as 95% compared with perforation of a single glove.45-47 AORN Journal j 111
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Often, glove perforations are not detected by the user. Use of a perforation indicator system (ie, a colored glove under a standard glove) is recommended for personnel wearing double gloves, because perforations are easier to see and allow detection more frequently (Figure 3).43 Gloves should be monitored for punctures as a way to help ensure barrier protection against transmission of microorganisms and bloodborne pathogens to the surgical field. Virus-inhibiting gloves, which reduce the amount of virus transmitted if a glove becomes perforated, may be worn, especially during procedures for which there is a higher risk of glove perforation.48-50 Perioperative RNs should model the use of standard precautions; wear appropriate PPE, including protective eyewear, mask, and gloves; and encourage other team members to wear PPE and bloodborne pathogen protection. The RN circulator also can help monitor scrubbed team members’ gloves for signs of perforation.43 Recommendation V Safe handling of sharps includes ensuring that sharps are contained in a safe manner and using proper disposal practices. Sharps injuries can be sustained
Figure 3. Glove perforation of an outer glove with an inner indicator system glove. Reprinted with permission from “Recommended practices for sterile technique.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:98.
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FORD because sharps are left on the floor or a table or are protruding from a trash bag or disposal container.51 Sharps containers should be puncture and leak resistant and large enough to hold the types of sharps that will need to be placed in them.52 The container should be recognizable, visible, and placed in proximity to the point of use.52 After the container has reached a visible fill level, the container should be replaced.11 Personnel should use counting devices to contain needles and sharps on the sterile field.11 Perioperative RNs can advocate for others through careful use of sharps disposal containers, such as by placing containers close to the point of use, using care when putting sharps into the container, and ensuring the containers are not overfilled. Careful identification and separation of contaminated disposable and reusable sharps is important to protect personnel in the decontamination area from injury. Reusable sharps should be clearly segregated on the case cart for easy identification.11 Recommendation VI Perioperative RNs should maintain an awareness of personal and professional responsibilities for sharps injury prevention and serve as role models for other team members. This includes observing all local, state, and federal regulations pertaining to handling of sharps and prevention of bloodborne pathogens. Perioperative RNs can protect themselves by wearing appropriate PPE, getting immunized against hepatitis B virus, using sharps devices with safety features provided by the health care facility, and complying with other policies and procedures designed to protect against disease transmission. If a perioperative RN sustains a sharps injury, he or she should immediately report the injury and receive prophylactic treatment for bloodborne pathogen exposure. If a team member experiences a sharps injury, the perioperative RN can assist the team member with the reporting process. Perioperative RNs can be leaders in the sharps injury prevention process by being a “champion” of sharps safety.
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Procedure Templates, 3rd edition,54 provides a The Final Four The final four recommendations in each AORN RP collection of 30 sample policies and customizable document discuss education/competency, docutemplates based on AORN’s Perioperative Stanmentation, policies and procedures, and quality dards and Recommended Practices.55 Quality assessment and improvement activities assist in assurance/performance improvement, as applievaluating the quality of patient care, the presence cable. These four topics are integral to the impleof environmental safety hazards, and the formulamentation of AORN practice recommendations. tion of plans for taking corrective actions. For details Personnel should receive initial and ongoing eduon the final four practice recommendations that are cation and competency verification as applicable specific to the RP document discussed in this article, to their roles. Implementing new and updated recplease refer to the full text of the RP document. ommended practices affords an excellent opportunity to create or update competency materials and verification tools. AORN’s perioperative compeAMBULATORY PATIENT SCENARIO tencies team has developed the AORN PerioperaIt is a busy day in a freestanding ambulatory surtive Job Descriptions and Competency Evaluation gery center (ASC). The surgical team is finishing a Tools53 to assist perioperative personnel in develleft knee arthroscopy on a 20-year-old male patient, oping competency evaluation tools and position the third patient of six that day in the orthopedic descriptions. OR. The instrument table is moved away, and the Documentation is used as a method to monitor scrubbed team members remove the drapes. As the compliance with regulations, measure performance RN circulator places a single hollow-bore needle with sharps safety measures, maintain employee into the sharps container, the patient begins to wake records of education and competency verification, and move around. As the RN looks back to assist the and track occupational exposures. Implementing patient, she is stuck in the right index finger by a new or updated recommended practices may warEducational Resources rant a review or revision of the relevant documentation n AORN Video Library: Hand Hygiene, Gowning & Gloving being used in the facility. Practices in the Perioperative Setting [DVD]. http://cine-med.com/ Policies and procedures index.php?nav¼aorn&cat¼all. should be developed, ren AORN Video Library: Prevention of Transmissible Infections in viewed periodically, revised the Perioperative Practice Setting [DVD]. http://cine-med.com/ as necessary, and readily index.php?nav¼aorn&cat¼all. available in the practice n AORN Video Library: Risk Management for the Perioperative setting. New or updated Nurse [DVD]. http://cine-med.com/index.php?nav¼aorn& recommended practices cat¼all. may present an opportunity n Recommended practices for prevention of transmissible infor collaborative efforts fections in the perioperative practice setting. In: Perioperative among nurses and personnel Standards and Recommended Practices. Denver, CO: AORN, from other departments Inc; 2013:331-363. in the facility to develop n Sharps Safety Tool Kit. AORN, Inc. https://www.aorn.org/ organization-wide policies Clinical_Practice/ToolKits/Tool_Kits.aspx. and procedures that support the recommended practices. Web site access verified November 1, 2013. The AORN Policy and AORN Journal j 113
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small-gauge K-wire that was removed from the first patient of the day and is sticking out of the opening in the sharps container. After the patient is settled, the RN treats the minor percutaneous injury. Knowing that she should report the exposure, she considers the challenges. The first patient of the day had undergone a procedure under a block anesthesia and moderate sedation and might already have been discharged from the ASC; thus, obtaining a blood sample for testing from the suspected source patient might not be possible. If obtained, the blood sample would have to be sent to a hospital laboratory in the vicinity for processing. Also, the ASC contracts with a hospital for occupational health services, so the postexposure evaluation would be more difficult and time consuming, requiring follow-up appointments at another facility. Because there are still three more patients scheduled in her OR, the RN knows it will be difficult to get away before the schedule is completed, and she needs to hurry home at the end of her shift to drive her daughter to soccer practice.
The RN also considers reasons she might not be at risk for bloodborne pathogen exposure. She received the hepatitis B vaccination, and because the percutaneous injury was caused by a K-wire and not a hollow-bore, blood-filled needle, she believes she is at lower risk for acquiring hepatitis B, hepatitis C, or HIV. Based on the patient’s age and medical history, the RN makes the assessment that he was probably at low risk for hepatitis C infection. Despite these considerations, the RN knows it is in her best interest to report the exposure as soon as possible. In addition to concerns about her own health, she is concerned about the health implications for others in her family and possibly her patients as well. Between scheduled surgeries, she contacts the charge nurse and reports the exposure. The charge nurse arranges relief for the RN so she can complete the employee incident form and contacts the occupational health nurse to report the exposure. The suspected source patient has already been discharged from the ASC, so the exposure is treated as an “unknown source” exposure. Fortunately, her results are negative after one full year of testing.
Resources for Implementation n n n
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AORN SyntegrityÒ Framework. AORN, Inc. http://www.aorn .org/syntegrity. ORNurseLinkTM. http://ornurselink.aorn.org. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. http:// www.aorn.org/JobDescriptions. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_Publi cations/AORN_Publications/Policy_and_Procedure_Templates .aspx. The Roadmap to ASC Compliance [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/ Ambulatory_Surgery_Center_Resources.aspx.
Editor’s note: Syntegrity is a registered trademark and ORNurseLink is a trademark of AORN, Inc, Denver, CO. Web site access verified November 1, 2013.
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HOSPITAL PATIENT SCENARIO A 66-year-old woman with a metastatic colon carcinoma is undergoing an open left hepatic lobectomy. The patient is obese and diabetic. A certified surgical technologist (CST) in orientation to the specialty is being trained by another CST, so both CSTs are scrubbed in. During the procedure, the patient has several periods of hemodynamic instability caused by bleeding. Thee surgeon finishes repairing a bleeding vessel and quickly hands the cut suture with needle back to the CST in
RP IMPLEMENTATION GUIDE: SHARPS SAFETY training. As the CST grasps the suture from the surgeon’s hand, the needle perforates both layers of the CST’s double gloves. The contaminated needle is handed off to the RN circulator and the experienced CST takes over until the patient’s bleeding is controlled, allowing the CST in training to break scrub, treat the injury, and contact the occupational health nurse on-call to report the exposure. The postexposure evaluation is performed, and blood is drawn from the patient. The source patient is at low risk for bloodborne pathogens and, by being double gloved, the CST took precautions to help prevent or reduce the risk of bloodborne pathogen exposure. Her tests are negative for disease exposure. Although an exposure control plan and sharps safety program had been established at this hospital in the early 1990s and modifications were made annually, this and other percutaneous injury occurrences spur a renewed effort by the hospital safety committee to bring sharps injury prevention to the forefront. Educators plan a safety fair that is held during a staff development session to show various ways to minimize the risk of sharps injuries. Safety committee members present on the topics of double gloving, using a neutral zone, and handling sharps safely, as well as provide occupational exposure data. Later in the year, members of the safety committee present a staff development session in which they review the pertinent legislation, position statements from professional associations, and evidence-based recommendations. In addition, the CST and another staff member who had experienced recent percutaneous exposures consent to tell the stories of their experiences. This combination of topics helps reinforce the current legislative requirements, what can be done to minimize the risk of sharps injuries, and what can happen when someone experiences an occupational exposure from a sharps injury. CONCLUSION The AORN “Recommended practices for sharps safety” is a thorough review of every aspect of
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sharps injury prevention and associated evidencebased recommendations. Key takeaways include the following: n
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Sharps injury prevention is a concern and a responsibility of all members of the perioperative team. Knowing the causes and types of injuries that occur in the practice setting is a critical component of developing a sharps injury prevention program. Prioritizing risk-reduction strategies involves giving the highest priority to the device that can have the greatest effect on sharps injury reduction. Eliminating the hazard (eg, removing the sharp object from use) and using safety-engineered devices are the most effective ways to prevent sharps injuries. Sharps injuries occur most frequently when sharps are passed hand to hand, so scrubbed team members should use a neutral zone. Double gloving minimizes the risk of bloodborne pathogen exposure.
Perioperative RNs should be aware of methods to prevent sharps injuries and occupational transmission of bloodborne pathogens. The “Recommended practices for sharps safety” delineates how perioperative personnel should practice within the recommendations. Perioperative nurses should review the RP document with colleagues and serve as a resource and role model for safe sharps practices. Acknowledgment: The author thanks Mary J. Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN, Inc, for her assistance with writing this manuscript. References 1. Jagger J, Perry J, Gomaa A, Phillips EK. The impact of US policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health. 2008;1(2):62-71. 2. Needlestick Safety and Prevention Act of 2000. PL 106.430. http://www.gpo.gov/fdsys/pkg/PLAW-106pu
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bl430/html/PLAW-106publ430.htm. Accessed October 16, 2013. Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg. 2010;210(4):496-502. Fry DE. Occupational risks of blood exposure in the operating room. Am Surg. 2007;73(7):637-646. Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:e1-e24. AORN guidance statement: Sharps injury prevention in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 573-577. Panlilio AL, Orelien JG, Srivastava PU, et al. Estimate of the annual number of percutaneous injuries among hospital-based healthcare workers in the United States, 1997-1998. Infect Control Hosp Epidemiol. 2004;25(7): 556-562. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control. 2006;34(5):313-319. Lee WC, Nicklasson L, Cobden D, Chen E, Conway D, Pashos CL. Short-term economic impact associated with occupational needlestick injuries among acute care nurses. Curr Med Res Opin. 2005;21(12):1915-1922. O’Malley EM, Scott RD 2nd, Gayle J, et al. Costs of management of occupational exposures to blood and body fluids. Infect Control Hosp Epidemiol. 2007;28(7): 774-782. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. http://www.gpo.gov/fdsys/pkg/CFR2011-title29-vol6/pdf/CFR-2011-title29-vol6-sec19101030.pdf. Accessed October 13, 2013. OSHA’s bloodborne pathogens standard [risk analysis]. Healthc Risk Control. 2008;4(Infection Control 13.1): 1-20. The Joint Commission. Preventing needlestick and sharp injuries. Sentinel Event Alert. August 1, 2001;22. http:// www.jointcommission.org/assets/1/18/SEA_22.pdf. Revised September 28, 2001. Accessed November 18, 2013. Information statement: Preventing the transmission of bloodborne pathogens. February 2001. Revised June 2008. Reviewed June 2012. American Academy of Orthopaedic Surgeons. http://www.aaos.org/about/papers/ advistmt/1018.asp. Accessed October 16, 2013. [ST 58] Statement on sharps safety. American College of Surgeons. http://www.facs.org/fellows_info/statements/ st-58.html. Accessed October 16, 2013. Recommended standards of practice for sharps safety and use of the neutral zone. August 2006. Association of Surgical Technologists. http://www.ast.org/pdf/Standards_ of_Practice/RSOP_Sharps_Safety_Neutral_Zone.pdf. Accessed October 16, 2013. Sharps Safety #5: The CSPS endorses sharps safety measures to prevent injury during perioperative care. Sharps safety measures should include double-gloving, blunt suture needles for fascial closure, and the neutral zone when appropriate to avoid hand to hand passage of sharps (Adopted 7.15.07, Modified 2.5.09). Council on
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Surgical & Perioperative Safety. http://cspsteam.org/sharps safety/sharpssafety.html. Accessed October 16, 2013. Moving the sharps safety agenda forward in the United States: consensus statement and call to action. International Healthcare Worker Safety Center at the University of Virginia. http://healthsystem.virginia.edu/pub/epinet/ ConsensusStatementOnSharpsInjuryPrevention.pdf. Accessed October 16, 2013. FDA, NIOSH, & OSHA joint safety communication: blunt tip surgical suture needles reduce needlestick injuries and the risk of subsequent bloodborne pathogen transmission to surgical personnel. May 30, 2012. US Food and Drug Administration. http://www.fda.gov/ downloads/MedicalDevices/Safety/AlertsandNotices/ UCM306035.pdf. Accessed August 12, 2013. DeJohn P. Is your ASC ready for closer scrutiny on sharps safety? OR Manager. 2012;28(2):1-3. http://www.ormana ger.com/wp-content/uploads/pdf/ORMVol28No2ASCSha rpsSafety.pdf. Accessed November 18, 2013. Perry J, Parker G. Jagger J. EPINet Report: 2007 percutaneous injury rates. August 2009. International Healthcare Worker Safety Center. University of Virginia Health System. http://www.healthsystem.virginia.edu/pub/epinet/ epinet-2007-rates.pdf. Accessed October 16, 2013. Thomas S, Agarwal M, Mehta G. Intraoperative glove perforationdsingle versus double gloving in protection against skin contamination. Postgrad Med J. 2001; 77(909):458-460. Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. Centers for Disease Control and Prevention. http://www.cdc.gov/sharpssafety/ pdf/sharpsworkbook_2008.pdf. Accessed October 16, 2013. Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2010;(5):CD004287. Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database Syst Rev. 2011;(11):CD0009170. Nordkam RA, Bluyssen SJ, van Goor H. Randomized clinical trial comparing blunt tapered and standard surgical needles in closing abdominal fascia. World J Surg. 2005;29(4):441-445. Use of blunt-tip suture needles to decrease percutaneous injuries to surgical personnel. DHHS (NIOSH) Publication No. 2008-101. 2008. http//www.cdc.gov/niosh/ docs/2008-101/pdfs/2008-101.pdf. Accessed October 16, 2013. Miller SS, Sabharwal A. Subcuticular skin closure using “blunt” needle. Ann R Coll Surg Engl. 1994; 76(4):281. Dagi TF, Berguer R, Moore S, Reines HD. Preventable errors in the operating roomdpart 2: retained foreign objects, sharps injuries, and wrong site surgery. Curr Probl Surg. 2007;44(6):352-381. Makary MA, Pronovost PJ, Weiss ES, et al. Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice. World J Surg. 2006;30(7):1224-1229.
RP IMPLEMENTATION GUIDE: SHARPS SAFETY 31. Bhattacharyya M, Bradley H. Intraoperative handling and wound healing of arthroscopic portal wounds: a clinical study comparing nylon suture with would closure strips. J Perioper Pract. 2008;18(5):194-196, 198. 32. Hidalgo JA, MacArthur RD, Crane LR. An overview of HIV infection and AIDS: etiology, pathogenesis, diagnosis, epidemiology, and occupational exposure. Semin Thoracic Cardiovasc Surg. 2000;12(2):130-139. 33. Folin A, Nyberg B, Nordstr€om G. Reducing blood exposures during orthopedic surgical procedures. AORN J. 2000;71(3):573-582. 34. Jeong IS, Park S. Use of hands-free technique among operating room nurses in the Republic of Korea. Am J Infect Control. 2009;37(2):131-135. 35. Stringer B, Haines AT, Goldsmith CH, Berguer R, Blythe J. Is use of the hands-free technique during surgery, a safe work practice, associated with safety climate? Am J Infect Control. 2009;37(9):766-772. 36. Stringer B, Haines T. The hands-free technique: an effective and easily implemented work practice. Perioper Nurs Clin. 2010;5(1):45-58. 37. Stringer B, Haines T, Goldsmith CH, et al. Hands-free technique in the operating room: reduction in body fluid exposure and the value of a training video. Public Health Rep. 2009;124(Suppl 1):169-179. 38. Bessinger CD Jr. Preventing transmission of human immunodeficiency virus during operations. Surg Gynecol Obstet. 1988;167(4):287-289. 39. Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theater injuries. Occup Environ Med. 2002;59(10): 703-707. 40. Cunningham TR, Austin J. Using goal setting, task, clarification, and feedback to increase the use of handsfree technique by hospital operating room staff. J Appl Behav Anal. 2007;40(4):673-677. 41. Eggleston MK Jr, Wax JR, Philput C, Eggleston MH, Weiss MI. Use of surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997; 6(4):245-247. 42. Stringer B, Haines T, Goldsmith CH, Blythe J, Harris KA. Perioperative use of the hands-free technique: a semistructured interview study. AORN J. 2006;84(2):233-248. 43. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2002;(3): CD0003087. 44. Ersozlu S, Sahin O, Ozgur AF, Akkaya T, Tuncay C. Glove punctures in major and minor orthopaedic surgery with double gloving. Acta Orthop Belg. 2007;73(6):760-764.
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45. Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg. 2004;199(3):462-467. 46. Aarnio P, Laine T. Glove perforation rate in vascular surgeryda comparison between single and double gloving. Vasa. 2001;30(2):122-124. 47. Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double gloving system. Am J Surg. 2001;181(6): 564-566. 48. Caillot JL, Voiglio EJ. First clinical study of a new virusinhibiting protective glove. Swiss Med Wkly. 2008;138 (1-2):18-22. 49. Krikorian R, Lozach-Perlant A, Ferrier-Rembert A, et al. Standardization of needlestick injury and evaluation of a novel virus-inhibiting protective glove. J Hosp Infect. 2007;66(4):339-345. 50. Bricout F, Moraillon A, Sonntag P, Hoerner P, Blackwelder W, Plotkin S. Virus-inhibiting surgical gloves to reduce the risk of infection by enveloped virus. J Med Virol. 2003;69(4):538-545. 51. Grimmond T, Bylund S, Anglea C, et al. Sharps injury reduction using a sharps container with enhanced engineering: a 28 hospital nonrandomized intervention and cohort sturdy. Am J Infect Control. 2010;38(10): 799-805. 52. Selecting, evaluating, and using sharps disposal containers. NIOSH publication no. 97-111. 1988. National Institute for Occupational Safety and Health. http://www.cdc.gov/niosh/ pdfs/97-111.pdf. Accessed November 1, 2013. 53. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. 54. Policy and Procedure Templates. 3rd ed. [CD-ROM]. Denver, CO: AORN, Inc. 2013. 55. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013.
Donna A. Ford, MSN, RN-BC, CNOR, CRCST, is a nursing education specialist, Division of Surgical Services, Department of Nursing, Mayo Clinic, and an assistant professor of nursing, Mayo Clinic College of Medicine, Rochester, MN. Ms Ford has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION
2.2
CONTINUING EDUCATION
Implementing AORN Recommended Practices for Sharps Safety
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PURPOSE/GOAL To provide the learner with knowledge specific to preventing sharps injuries and bloodborne pathogen exposure.
OBJECTIVES 1. 2. 3. 4.
Discuss legislation related to preventing bloodborne pathogen transmission. Discuss causes of percutaneous injury in perioperative settings. Identify hazards associated with percutaneous injury. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
After passage of the Needlestick Safety and Prevention Act, sharps injuries __________ in nonsurgical settings and __________ in surgical settings. a. decreased, decreased b. decreased, increased c. increased, decreased d. increased, increased An 1. 2. 3.
exposure control plan must include a plan to reduce sharps injuries. a process to monitor sharps injury data. an exposure determination for employees who may be exposed to blood and body fluids. 4. prioritized risk-reduction strategies.
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a. 1 and 4 c. 1, 2, and 3
b. 2 and 3 d. 1, 2, 3, and 4
3.
The highest level of the hierarchy of controls to help prevent sharps injuries is to a. develop policies and procedures. b. eliminate the hazard. c. implement work practice controls. d. use a safety-engineered device.
4.
In a Cochrane review of 10 randomized controlled trials, researchers found that using blunt-tip suture needles instead of sharp-tip suture needles reduced the incidence of glove perforation by a. 10%. b. 32%. c. 54%. d. 75%.
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CE EXAMINATION 5.
The majority of percutaneous injuries are caused by a. failure to double glove. b. hand-to-hand passing of sharps. c. using sharp-tip rather than blunt-tip needles. d. using safety-engineered devices.
6.
Use of a neutral zone helps ensure the surgeon and scrub person do not touch the same instrument at the same time. a. true b. false
7.
Communicating the location of sharps on the sterile field is a. an administrative control. b. an engineering control. c. a work practice control.
8.
Personnel may choose to wear virus-inhibiting gloves during procedures in which there is a higher risk of glove perforation. a. true b. false
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9.
A sharps container should be 1. large enough to hold the types of sharps that will need to be placed in them. 2. placed far from the point of use to prevent accidental contact with the container. 3. puncture and leak resistant. 4. replaced when it reaches a visible fill level. a. 1 and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
10.
Perioperative RNs can demonstrate personal and professional responsibility in preventing sharps injuries and bloodborne pathogen transmission by 1. getting immunized against hepatitis B virus. 2. immediately reporting a percutaneous injury. 3. observing local, state, and federal regulations pertaining to handling of sharps. 4. receiving prophylactic treatment for bloodborne pathogen exposure when necessary. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for Sharps Safety
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss legislation related to preventing bloodborne pathogen transmission. Low 1. 2. 3. 4. 5. High 2. Discuss causes of percutaneous injury in perioperative settings. Low 1. 2. 3. 4. 5. High 3. Identify hazards associated with percutaneous injury. Low 1. 2. 3. 4. 5. High 4. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. Low 1. 2. 3. 4. 5. High 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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2.2 www.aorn.org/CE
8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: _______________________________ 9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 10. Our accrediting body requires that we verify the time you needed to complete the 2.2 continuing education contact hour (132-minute) program: _________________________________
Ó AORN, Inc, 2014
2.2
DONNA A. FORD, MSN, RN-BC, CNOR, CRCST
www.aorn.org/CE Continuing Education Contact Hours
Accreditation
indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Event: #14503 Session: #0001 Fee: Members $17.60, Nonmembers $35.20 The CE contact hours for this article expire January 31, 2017. Pricing is subject to change.
Purpose/Goal To provide the learner with knowledge specific to preventing sharps injuries and bloodborne pathogen exposure.
Objectives 1. Discuss legislation related to preventing bloodborne pathogen transmission. 2. Discuss causes of percutaneous injury in perioperative settings. 3. Identify hazards associated with percutaneous injury. 4. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission.
Approvals This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.
Conflict of Interest Disclosures Ms Ford has no declared affiliation that could be perceived as posing potential conflict of interest in the publication of this article. The behavioral objectives for this program were created by Liz Cowperthwaite, senior managing editor, and Rebecca Holm, MSN, RN, CNOR, clinical editor, with consultation from Susan Bakewell, MS, RN-BC, director, Perioperative Education. Ms Cowperthwaite, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support No sponsorship or commercial support was received for this article.
Disclaimer AORN recognizes these activities as CE for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2013.11.013
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Ó AORN, Inc, 2014
RECOMMENDED PRACTICES Implementing AORN Recommended Practices for Sharps Safety 2.2 DONNA A. FORD, MSN, RN-BC, CNOR, CRCST
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ABSTRACT Prevention of percutaneous sharps injuries in perioperative settings remains a challenge. Occupational transmission of bloodborne pathogens, not only from patients to health care providers but also from health care providers to patients, is a significant concern. Legislation and position statements geared toward ensuring the safety of patients and health care workers have not resulted in significantly reduced sharps injuries in perioperative settings. Awareness and understanding of the types of percutaneous injuries that occur in perioperative settings is fundamental to developing an effective sharps injury prevention program. The AORN “Recommended practices for sharps safety” clearly delineates evidence-based recommendations for sharps injury prevention. Perioperative RNs can lead efforts to change practice for the safety of patients and perioperative team members by promoting the elimination of sharps hazards; the use of engineering, work practice, and administrative controls; and the proper use of personal protective equipment, including double gloving. AORN J 99 (January 2014) 107-117. Ó AORN, Inc, 2014. http:// dx.doi.org/10.1016/j.aorn.2013.11.013 Key words: sharps injuries, sharps injury prevention, engineering controls, work practice controls, administrative controls, blunt-tip needles, neutral zone, double gloving.
E
ven with legislation in place that requires safeguards and practice controls, perioperative team members continue to experience occupational percutaneous injuries at unacceptable levels.1 Eight years after the passage of the Needlestick Safety and Prevention Act,2 Jagger et al1,3 reported that although sharps injuries had decreased 31.6% in nonsurgical settings, they had increased
6.5% in surgical settings. Percutaneous injuries can result in occupational transmission of hepatitis B, hepatitis C, and HIV.4 The purpose of the new “Recommended practices for sharps safety”5 is to prevent percutaneous injuries by helping perioperative nurses identify potential sharps hazards, implement best practices, and develop policies and procedures related to safe
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practices and postexposure protocols. AORN recommended practices represent what is considered to be optimal and achievable perioperative nursing practice and are based on the highest level of evidence available. This article highlights the most significant recommendations of the “Recommended practices for sharps safety,” including those that can have the largest effect on sharps injury reduction. More in-depth information and a review of evidence for each recommendation can be found in the complete recommended practices (RP) document.5 WHAT’S NEW The new “Recommended practices for sharps safety” supersedes the “AORN guidance statement: Sharps injury prevention in the perioperative setting,”6 developed in 2005. The intent of the guidance statement was to assist perioperative RNs in developing sharps injury prevention programs and overcoming obstacles to compliance with the suggested and mandated practices. Federal regulations and strong research evidence provided support for a stronger position on sharps safety, so the RP document was developed to replace the guidance statement. Although many of the responsibilities and riskreduction strategies from the guidance statement have been carried over into the RP document, the new document provides the format of recommendations followed by evidence-based rationales, evidence-rated intervention statements, and supporting activity statements. The evidence supporting the recommendations is derived from regulatory controls, randomized controlled trials, and Cochrane systematic reviews. RATIONALE Approximately 500,000 health care workers each year experience percutaneous injuries.3,7 Percutaneous injuries are associated with occupational transmission of hepatitis B virus, hepatitis C virus, and HIV, which can result in lifelong health concerns.4 Percutaneous injuries also present a risk to patients; a health care provider who is infected with 108 j AORN Journal
FORD a bloodborne pathogen and who then receives a percutaneous injury can inadvertently infect a patient through contact with the contaminated sharp or contact with the health care provider’s blood through an unnoticed glove perforation. Between 1991 and 2005, 132 cases of health care providerto-patient transmission of hepatitis B, hepatitis C, or HIV were documented.8 Anyone who has experienced an occupational exposure to bloodborne pathogens knows the emotional burden of fear, worry, and concern that follows, which may be far greater than the actual physical injury. The real or potential economic burdens also can cause additional stress. Costs to the health care worker are any expenses incurred because of missed work days. Potential economic burdens include the inability to continue working because of an illness that results from the occupational exposure. Costs to the employer include the postexposure management, the laboratory tests and follow-up testing, and any necessary prophylaxis, as well as loss of productivity of the health care worker. The annual cost of percutaneous sharps injuries has been estimated at $65 million.9 The cost for a health care facility to manage an occupational exposure can range from $71 to $4,838 per exposure.10 Two significant pieces of legislation, the Bloodborne Pathogens Standard 29 CFR x1910.1030 in 199211 and the Needlestick Safety and Prevention Act in 2000,2 are aimed at reducing occupational transmission of bloodborne pathogens. The purpose of the Bloodborne Pathogens Standard is to limit health care worker exposure to bloodborne pathogens and other potentially infectious materials by requiring implementation of engineering controls (eg, use of safety-engineered devices) and work practice controls (eg, use of a neutral zone for passing sharps).12 The additional legislation in 2000 directed the Occupational Safety and Health Administration (OSHA) to make multiple revisions to the existing Bloodborne Pathogens Standard. The Needlestick Safety and Prevention Act includes requirements that annual review of exposure control
RP IMPLEMENTATION GUIDE: SHARPS SAFETY plans also should “reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.”2 Because medical technology is constantly changing and improving, more devices are becoming available that can help reduce sharps injuries.13 In addition to AORN, a number of professional associations have issued statements supporting sharps injury prevention practices. These associations include the American Academy of Orthopaedic Surgeons,14 the American College of Surgeons,15 the Association of Surgical Technologists,16 and the Council on Surgical and Perioperative Safety.17 In 2012, the International Healthcare Worker Safety Center at the University of Virginia, Charlottesville, released a consensus statement endorsed by 20 organizations citing improved sharps safety in surgical settings as the highest priority in reducing percutaneous sharps injuries.18 Three governmental agencies, the US Food and Drug Administration, the National Institute for Occupational Safety and Health, and OSHA, issued a joint safety communication in May 2012 encouraging the use of blunt-tip suture needles.19 Accrediting bodies (eg, The Joint Commission, the Accreditation Association for Ambulatory Health Care) and regulatory organizations (eg, OSHA, the Centers for Medicare & Medicaid Services) may survey for sharps safety during visits to health care facilities. Key points in a survey could include review of the exposure control plan, which must be in compliance with the federal legislation and should meet the criteria established in the Needlestick Safety and Prevention Act.13 Surveyors also may look to ensure that sharps containers are located close to the point of use and glove boxes and personal protective equipment (PPE) are placed in convenient locations. Other potential points in a survey include a review of policies, sharps injury logs, and documentation of safety training. Surveyors may observe use of PPE and question personnel about safety procedures.20
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DISCUSSION Implementing a sharps injury prevention program can be a challenging process in any setting. The “Recommended practices for sharps safety” provides information that can assist with developing a bloodborne pathogens exposure control plan11; eliminating the hazards; and implementing engineering controls, work practice controls, and administrative controls.5 Engineering controls are practices that remove the hazard from the workplace, such as the use of safety-engineered devices.11 Work practice controls minimize the risk of exposure to blood and other potentially infectious materials by changing the method of performing a task.11,21,22 Administrative controls include developing policies and procedures and providing education and training on prevention of bloodborne pathogen exposure. Recommendation I Health care facilities must have a bloodborne pathogens exposure control plan, as required by OSHA.11 The exposure control plan is a component of administrative controls, which are important to the success of a sharps safety program. The plan must include an exposure determination for employees who have the potential to be exposed to blood and body fluids; a plan to reduce sharps injuries, including prioritized risk-reduction strategies; and a process to monitor sharps injury data. The plan must be reviewed and updated at least annually and any time new practices are implemented. Ensuring compliance with the exposure control plan and related policies is important to show commitment to prevention of sharps injuries. Administrators and managers, in collaboration with occupational health and infection prevention practitioners, can develop the exposure control plan. Frontline personnel, including perioperative RNs and surgeons, should be involved in identifying control methods to prevent sharps injuries by using the hierarchy of controls to prioritize prevention interventions (Figure 1).23 At the top of the hierarchy (ie, the most effective strategy) is AORN Journal j 109
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Figure 1. The hierarchy of controls. Illustration reprinted with permission from AORN, Inc, Denver, CO. All rights reserved.
eliminating the hazard by completely removing it from use. Eliminating the hazard (eg, a sharp item or instrument) involves identifying alternative ways to perform the necessary task without using sharps, such as by using a tissue adhesive and adhesive strips or a skin stapler to close a skin incision. A systematic review of 14 randomized controlled trials that evaluated surgical wound healing when tissue adhesives were used for skin closure showed there was no significant difference in infection rates, patient and user satisfaction, or cost between use of sutures and use of adhesives.24 Therefore, when clinically indicated, it could be appropriate to use adhesives in place of suture to help prevent needlestick injuries. The highest priority should be eliminating the device that has the potential to cause the most injuries.5 If eliminating use of the device is not feasible, controls at lower levels of the hierarchy should be considered, such as using engineering controls, work practice controls, administrative controls, and PPE.23 Recommendation II When elimination of sharps is not feasible, perioperative team members must use sharps with safety-engineered devices that “isolate or remove the risk of bloodborne pathogen exposure.”11 Sharps 110 j AORN Journal
FORD with engineered sharps injury protection have a built-in safety feature and include blunt-tip suture needles,4,15,17,25-28 safety scalpels,11 and safetyengineered syringes and needles.11,23 Alternative wound closure devices and needleless systems are effective in preventing percutaneous injuries11 and include fascial closure devices, tissue staplers, tissue adhesives, and adhesive skin closure strips.29-31 Strong evidence supports the use of blunt-tip suture needles for muscle and fascia closure. In a Cochrane review of 10 randomized controlled trials, researchers found that using blunt-tip suture needles instead of sharp-tip suture needles reduced the incidence of glove perforation by 54%, thereby reducing the risk of infectious disease transmission.25 Managers can identify devices with engineering controls through contact with vendors, attending vendor displays at conferences, and professional networking. A multidisciplinary committee including direct users should be part of the process for selecting and evaluating safety-engineered devices.2 Educators can plan a product fair to help personnel identify safety-engineered devices and other sharps safety products to select for an evaluation. Perioperative RNs can encourage team members to provide objective evaluations of safetyengineered devices. After products are selected, the educator may want to set up a sharps safety skills fair to allow personnel and surgeons an opportunity to have hands-on practice with the trial devices. Recommendation III Hand-to-hand passing of sharps, such as needles, blades, and sharp instruments, accounts for the majority of percutaneous injuries.3 Perioperative personnel must use work practice controls when handling any type of disposable or reusable sharp. Work practice controls change the way a task is performed when sharp devices are used. For example, surgical team members should use a neutral zone for passing any sharp device (eg, blade, instrument, needle) rather than passing items
RP IMPLEMENTATION GUIDE: SHARPS SAFETY from hand to hand.14-17,29,32-37 A neutral zone helps ensure that the surgeon and scrub person do not touch the same sharp instrument at the same time. This technique, also called hands-free technique, is accomplished by designating a neutral zone on the sterile field and placing sharp items within the zone for transfer between scrubbed personnel.5 A modified neutral zone may be needed when the surgeon is using a microscope; sharps are carefully placed in the surgeon’s hand, and the surgeon returns the sharp to the neutral zone after use.14,33,38-42 The no-touch technique should be used to minimize manual handling of sharps by gloved hands. For example, when loading a suture in the needle holder, the scrubbed team member should keep the needle in the suture packet and use the suture packet to position the needle in the needle holder (Figure 2). The scrubbed team member should then use a one-handed technique to reposition a needle before placing it in a needle box on the sterile field. Additional work control practices include maintaining “situational awareness” when sharps are in use, communicating the location of sharps on the sterile field, removing needles before tying suture,
Figure 2. Use of the no-touch technique.
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and using instruments instead of hands for tissue retraction. Personnel should use caution at all times when handling sharps and should follow safe injection practices.11 To successfully implement work practice controls, perioperative team members need to understand potential hazards with a current practice, be willing to change their practice, actually make the practice change, and then consistently perform the practice in the new, safer way. The importance of education in this process cannot be understated. Managers and educators can reinforce the principles of work practice controls and the importance of communication and situational awareness during use of sharps. The educator has a key role in providing assistance to individual team members and surgical teams implementing work practice controls and learning new ways to safely perform tasks. Practice with the no-touch technique gives personnel the opportunity to try various ways of manipulating sharps with minimal handling. Role play and simulation activities can help team members determine acceptable ways of implementing use of a neutral zone for different surgical procedures and different patient positions. Perioperative RNs and other team members can collaborate with the educator to help personnel develop these skills. Recommendation IV Proper use of PPE is required by the OSHA Bloodborne Pathogens Standard.11 For example, strong evidence exists to support the practice of double gloving to reduce the risk of glove perforation and percutaneous exposure.43 In one study, the overall perforation rate of gloves was 15.8%, which presents concerns about bloodborne pathogen exposure, breaks in sterile technique, and surgical site infection.44 When two pairs of gloves are worn and a perforation occurs, often only the outer glove is perforated.43 Research has shown that if both gloves are perforated, the volume of blood on a solid sharp device can be reduced by as much as 95% compared with perforation of a single glove.45-47 AORN Journal j 111
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Often, glove perforations are not detected by the user. Use of a perforation indicator system (ie, a colored glove under a standard glove) is recommended for personnel wearing double gloves, because perforations are easier to see and allow detection more frequently (Figure 3).43 Gloves should be monitored for punctures as a way to help ensure barrier protection against transmission of microorganisms and bloodborne pathogens to the surgical field. Virus-inhibiting gloves, which reduce the amount of virus transmitted if a glove becomes perforated, may be worn, especially during procedures for which there is a higher risk of glove perforation.48-50 Perioperative RNs should model the use of standard precautions; wear appropriate PPE, including protective eyewear, mask, and gloves; and encourage other team members to wear PPE and bloodborne pathogen protection. The RN circulator also can help monitor scrubbed team members’ gloves for signs of perforation.43 Recommendation V Safe handling of sharps includes ensuring that sharps are contained in a safe manner and using proper disposal practices. Sharps injuries can be sustained
Figure 3. Glove perforation of an outer glove with an inner indicator system glove. Reprinted with permission from “Recommended practices for sterile technique.” In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:98.
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FORD because sharps are left on the floor or a table or are protruding from a trash bag or disposal container.51 Sharps containers should be puncture and leak resistant and large enough to hold the types of sharps that will need to be placed in them.52 The container should be recognizable, visible, and placed in proximity to the point of use.52 After the container has reached a visible fill level, the container should be replaced.11 Personnel should use counting devices to contain needles and sharps on the sterile field.11 Perioperative RNs can advocate for others through careful use of sharps disposal containers, such as by placing containers close to the point of use, using care when putting sharps into the container, and ensuring the containers are not overfilled. Careful identification and separation of contaminated disposable and reusable sharps is important to protect personnel in the decontamination area from injury. Reusable sharps should be clearly segregated on the case cart for easy identification.11 Recommendation VI Perioperative RNs should maintain an awareness of personal and professional responsibilities for sharps injury prevention and serve as role models for other team members. This includes observing all local, state, and federal regulations pertaining to handling of sharps and prevention of bloodborne pathogens. Perioperative RNs can protect themselves by wearing appropriate PPE, getting immunized against hepatitis B virus, using sharps devices with safety features provided by the health care facility, and complying with other policies and procedures designed to protect against disease transmission. If a perioperative RN sustains a sharps injury, he or she should immediately report the injury and receive prophylactic treatment for bloodborne pathogen exposure. If a team member experiences a sharps injury, the perioperative RN can assist the team member with the reporting process. Perioperative RNs can be leaders in the sharps injury prevention process by being a “champion” of sharps safety.
RP IMPLEMENTATION GUIDE: SHARPS SAFETY
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Procedure Templates, 3rd edition,54 provides a The Final Four The final four recommendations in each AORN RP collection of 30 sample policies and customizable document discuss education/competency, docutemplates based on AORN’s Perioperative Stanmentation, policies and procedures, and quality dards and Recommended Practices.55 Quality assessment and improvement activities assist in assurance/performance improvement, as applievaluating the quality of patient care, the presence cable. These four topics are integral to the impleof environmental safety hazards, and the formulamentation of AORN practice recommendations. tion of plans for taking corrective actions. For details Personnel should receive initial and ongoing eduon the final four practice recommendations that are cation and competency verification as applicable specific to the RP document discussed in this article, to their roles. Implementing new and updated recplease refer to the full text of the RP document. ommended practices affords an excellent opportunity to create or update competency materials and verification tools. AORN’s perioperative compeAMBULATORY PATIENT SCENARIO tencies team has developed the AORN PerioperaIt is a busy day in a freestanding ambulatory surtive Job Descriptions and Competency Evaluation gery center (ASC). The surgical team is finishing a Tools53 to assist perioperative personnel in develleft knee arthroscopy on a 20-year-old male patient, oping competency evaluation tools and position the third patient of six that day in the orthopedic descriptions. OR. The instrument table is moved away, and the Documentation is used as a method to monitor scrubbed team members remove the drapes. As the compliance with regulations, measure performance RN circulator places a single hollow-bore needle with sharps safety measures, maintain employee into the sharps container, the patient begins to wake records of education and competency verification, and move around. As the RN looks back to assist the and track occupational exposures. Implementing patient, she is stuck in the right index finger by a new or updated recommended practices may warEducational Resources rant a review or revision of the relevant documentation n AORN Video Library: Hand Hygiene, Gowning & Gloving being used in the facility. Practices in the Perioperative Setting [DVD]. http://cine-med.com/ Policies and procedures index.php?nav¼aorn&cat¼all. should be developed, ren AORN Video Library: Prevention of Transmissible Infections in viewed periodically, revised the Perioperative Practice Setting [DVD]. http://cine-med.com/ as necessary, and readily index.php?nav¼aorn&cat¼all. available in the practice n AORN Video Library: Risk Management for the Perioperative setting. New or updated Nurse [DVD]. http://cine-med.com/index.php?nav¼aorn& recommended practices cat¼all. may present an opportunity n Recommended practices for prevention of transmissible infor collaborative efforts fections in the perioperative practice setting. In: Perioperative among nurses and personnel Standards and Recommended Practices. Denver, CO: AORN, from other departments Inc; 2013:331-363. in the facility to develop n Sharps Safety Tool Kit. AORN, Inc. https://www.aorn.org/ organization-wide policies Clinical_Practice/ToolKits/Tool_Kits.aspx. and procedures that support the recommended practices. Web site access verified November 1, 2013. The AORN Policy and AORN Journal j 113
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small-gauge K-wire that was removed from the first patient of the day and is sticking out of the opening in the sharps container. After the patient is settled, the RN treats the minor percutaneous injury. Knowing that she should report the exposure, she considers the challenges. The first patient of the day had undergone a procedure under a block anesthesia and moderate sedation and might already have been discharged from the ASC; thus, obtaining a blood sample for testing from the suspected source patient might not be possible. If obtained, the blood sample would have to be sent to a hospital laboratory in the vicinity for processing. Also, the ASC contracts with a hospital for occupational health services, so the postexposure evaluation would be more difficult and time consuming, requiring follow-up appointments at another facility. Because there are still three more patients scheduled in her OR, the RN knows it will be difficult to get away before the schedule is completed, and she needs to hurry home at the end of her shift to drive her daughter to soccer practice.
The RN also considers reasons she might not be at risk for bloodborne pathogen exposure. She received the hepatitis B vaccination, and because the percutaneous injury was caused by a K-wire and not a hollow-bore, blood-filled needle, she believes she is at lower risk for acquiring hepatitis B, hepatitis C, or HIV. Based on the patient’s age and medical history, the RN makes the assessment that he was probably at low risk for hepatitis C infection. Despite these considerations, the RN knows it is in her best interest to report the exposure as soon as possible. In addition to concerns about her own health, she is concerned about the health implications for others in her family and possibly her patients as well. Between scheduled surgeries, she contacts the charge nurse and reports the exposure. The charge nurse arranges relief for the RN so she can complete the employee incident form and contacts the occupational health nurse to report the exposure. The suspected source patient has already been discharged from the ASC, so the exposure is treated as an “unknown source” exposure. Fortunately, her results are negative after one full year of testing.
Resources for Implementation n n n
n
n
AORN SyntegrityÒ Framework. AORN, Inc. http://www.aorn .org/syntegrity. ORNurseLinkTM. http://ornurselink.aorn.org. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. http:// www.aorn.org/JobDescriptions. Policy and Procedure Templates [CD-ROM]. 3rd ed. Denver, CO: AORN, Inc; 2013. http://www.aorn.org/Books_and_Publi cations/AORN_Publications/Policy_and_Procedure_Templates .aspx. The Roadmap to ASC Compliance [CD-ROM]. Denver, CO: AORN, Inc; 2012. http://www.aorn.org/Education/Ambulatory/ Ambulatory_Surgery_Center_Resources.aspx.
Editor’s note: Syntegrity is a registered trademark and ORNurseLink is a trademark of AORN, Inc, Denver, CO. Web site access verified November 1, 2013.
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HOSPITAL PATIENT SCENARIO A 66-year-old woman with a metastatic colon carcinoma is undergoing an open left hepatic lobectomy. The patient is obese and diabetic. A certified surgical technologist (CST) in orientation to the specialty is being trained by another CST, so both CSTs are scrubbed in. During the procedure, the patient has several periods of hemodynamic instability caused by bleeding. Thee surgeon finishes repairing a bleeding vessel and quickly hands the cut suture with needle back to the CST in
RP IMPLEMENTATION GUIDE: SHARPS SAFETY training. As the CST grasps the suture from the surgeon’s hand, the needle perforates both layers of the CST’s double gloves. The contaminated needle is handed off to the RN circulator and the experienced CST takes over until the patient’s bleeding is controlled, allowing the CST in training to break scrub, treat the injury, and contact the occupational health nurse on-call to report the exposure. The postexposure evaluation is performed, and blood is drawn from the patient. The source patient is at low risk for bloodborne pathogens and, by being double gloved, the CST took precautions to help prevent or reduce the risk of bloodborne pathogen exposure. Her tests are negative for disease exposure. Although an exposure control plan and sharps safety program had been established at this hospital in the early 1990s and modifications were made annually, this and other percutaneous injury occurrences spur a renewed effort by the hospital safety committee to bring sharps injury prevention to the forefront. Educators plan a safety fair that is held during a staff development session to show various ways to minimize the risk of sharps injuries. Safety committee members present on the topics of double gloving, using a neutral zone, and handling sharps safely, as well as provide occupational exposure data. Later in the year, members of the safety committee present a staff development session in which they review the pertinent legislation, position statements from professional associations, and evidence-based recommendations. In addition, the CST and another staff member who had experienced recent percutaneous exposures consent to tell the stories of their experiences. This combination of topics helps reinforce the current legislative requirements, what can be done to minimize the risk of sharps injuries, and what can happen when someone experiences an occupational exposure from a sharps injury. CONCLUSION The AORN “Recommended practices for sharps safety” is a thorough review of every aspect of
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sharps injury prevention and associated evidencebased recommendations. Key takeaways include the following: n
n
n
n
n
n
Sharps injury prevention is a concern and a responsibility of all members of the perioperative team. Knowing the causes and types of injuries that occur in the practice setting is a critical component of developing a sharps injury prevention program. Prioritizing risk-reduction strategies involves giving the highest priority to the device that can have the greatest effect on sharps injury reduction. Eliminating the hazard (eg, removing the sharp object from use) and using safety-engineered devices are the most effective ways to prevent sharps injuries. Sharps injuries occur most frequently when sharps are passed hand to hand, so scrubbed team members should use a neutral zone. Double gloving minimizes the risk of bloodborne pathogen exposure.
Perioperative RNs should be aware of methods to prevent sharps injuries and occupational transmission of bloodborne pathogens. The “Recommended practices for sharps safety” delineates how perioperative personnel should practice within the recommendations. Perioperative nurses should review the RP document with colleagues and serve as a resource and role model for safe sharps practices. Acknowledgment: The author thanks Mary J. Ogg, MSN, RN, CNOR, perioperative nursing specialist at AORN, Inc, for her assistance with writing this manuscript. References 1. Jagger J, Perry J, Gomaa A, Phillips EK. The impact of US policies to protect healthcare workers from bloodborne pathogens: the critical role of safety-engineered devices. J Infect Public Health. 2008;1(2):62-71. 2. Needlestick Safety and Prevention Act of 2000. PL 106.430. http://www.gpo.gov/fdsys/pkg/PLAW-106pu
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bl430/html/PLAW-106publ430.htm. Accessed October 16, 2013. Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg. 2010;210(4):496-502. Fry DE. Occupational risks of blood exposure in the operating room. Am Surg. 2007;73(7):637-646. Recommended practices for sharps safety. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013:e1-e24. AORN guidance statement: Sharps injury prevention in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013: 573-577. Panlilio AL, Orelien JG, Srivastava PU, et al. Estimate of the annual number of percutaneous injuries among hospital-based healthcare workers in the United States, 1997-1998. Infect Control Hosp Epidemiol. 2004;25(7): 556-562. Perry JL, Pearson RD, Jagger J. Infected health care workers and patient safety: a double standard. Am J Infect Control. 2006;34(5):313-319. Lee WC, Nicklasson L, Cobden D, Chen E, Conway D, Pashos CL. Short-term economic impact associated with occupational needlestick injuries among acute care nurses. Curr Med Res Opin. 2005;21(12):1915-1922. O’Malley EM, Scott RD 2nd, Gayle J, et al. Costs of management of occupational exposures to blood and body fluids. Infect Control Hosp Epidemiol. 2007;28(7): 774-782. 29 CFR 1910.1030. Occupational exposure. Bloodborne pathogens. 2009. http://www.gpo.gov/fdsys/pkg/CFR2011-title29-vol6/pdf/CFR-2011-title29-vol6-sec19101030.pdf. Accessed October 13, 2013. OSHA’s bloodborne pathogens standard [risk analysis]. Healthc Risk Control. 2008;4(Infection Control 13.1): 1-20. The Joint Commission. Preventing needlestick and sharp injuries. Sentinel Event Alert. August 1, 2001;22. http:// www.jointcommission.org/assets/1/18/SEA_22.pdf. Revised September 28, 2001. Accessed November 18, 2013. Information statement: Preventing the transmission of bloodborne pathogens. February 2001. Revised June 2008. Reviewed June 2012. American Academy of Orthopaedic Surgeons. http://www.aaos.org/about/papers/ advistmt/1018.asp. Accessed October 16, 2013. [ST 58] Statement on sharps safety. American College of Surgeons. http://www.facs.org/fellows_info/statements/ st-58.html. Accessed October 16, 2013. Recommended standards of practice for sharps safety and use of the neutral zone. August 2006. Association of Surgical Technologists. http://www.ast.org/pdf/Standards_ of_Practice/RSOP_Sharps_Safety_Neutral_Zone.pdf. Accessed October 16, 2013. Sharps Safety #5: The CSPS endorses sharps safety measures to prevent injury during perioperative care. Sharps safety measures should include double-gloving, blunt suture needles for fascial closure, and the neutral zone when appropriate to avoid hand to hand passage of sharps (Adopted 7.15.07, Modified 2.5.09). Council on
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Surgical & Perioperative Safety. http://cspsteam.org/sharps safety/sharpssafety.html. Accessed October 16, 2013. Moving the sharps safety agenda forward in the United States: consensus statement and call to action. International Healthcare Worker Safety Center at the University of Virginia. http://healthsystem.virginia.edu/pub/epinet/ ConsensusStatementOnSharpsInjuryPrevention.pdf. Accessed October 16, 2013. FDA, NIOSH, & OSHA joint safety communication: blunt tip surgical suture needles reduce needlestick injuries and the risk of subsequent bloodborne pathogen transmission to surgical personnel. May 30, 2012. US Food and Drug Administration. http://www.fda.gov/ downloads/MedicalDevices/Safety/AlertsandNotices/ UCM306035.pdf. Accessed August 12, 2013. DeJohn P. Is your ASC ready for closer scrutiny on sharps safety? OR Manager. 2012;28(2):1-3. http://www.ormana ger.com/wp-content/uploads/pdf/ORMVol28No2ASCSha rpsSafety.pdf. Accessed November 18, 2013. Perry J, Parker G. Jagger J. EPINet Report: 2007 percutaneous injury rates. August 2009. International Healthcare Worker Safety Center. University of Virginia Health System. http://www.healthsystem.virginia.edu/pub/epinet/ epinet-2007-rates.pdf. Accessed October 16, 2013. Thomas S, Agarwal M, Mehta G. Intraoperative glove perforationdsingle versus double gloving in protection against skin contamination. Postgrad Med J. 2001; 77(909):458-460. Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program. Centers for Disease Control and Prevention. http://www.cdc.gov/sharpssafety/ pdf/sharpsworkbook_2008.pdf. Accessed October 16, 2013. Coulthard P, Esposito M, Worthington HV, van der Elst M, van Waes OJ, Darcey J. Tissue adhesives for closure of surgical incisions. Cochrane Database Syst Rev. 2010;(5):CD004287. Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database Syst Rev. 2011;(11):CD0009170. Nordkam RA, Bluyssen SJ, van Goor H. Randomized clinical trial comparing blunt tapered and standard surgical needles in closing abdominal fascia. World J Surg. 2005;29(4):441-445. Use of blunt-tip suture needles to decrease percutaneous injuries to surgical personnel. DHHS (NIOSH) Publication No. 2008-101. 2008. http//www.cdc.gov/niosh/ docs/2008-101/pdfs/2008-101.pdf. Accessed October 16, 2013. Miller SS, Sabharwal A. Subcuticular skin closure using “blunt” needle. Ann R Coll Surg Engl. 1994; 76(4):281. Dagi TF, Berguer R, Moore S, Reines HD. Preventable errors in the operating roomdpart 2: retained foreign objects, sharps injuries, and wrong site surgery. Curr Probl Surg. 2007;44(6):352-381. Makary MA, Pronovost PJ, Weiss ES, et al. Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice. World J Surg. 2006;30(7):1224-1229.
RP IMPLEMENTATION GUIDE: SHARPS SAFETY 31. Bhattacharyya M, Bradley H. Intraoperative handling and wound healing of arthroscopic portal wounds: a clinical study comparing nylon suture with would closure strips. J Perioper Pract. 2008;18(5):194-196, 198. 32. Hidalgo JA, MacArthur RD, Crane LR. An overview of HIV infection and AIDS: etiology, pathogenesis, diagnosis, epidemiology, and occupational exposure. Semin Thoracic Cardiovasc Surg. 2000;12(2):130-139. 33. Folin A, Nyberg B, Nordstr€om G. Reducing blood exposures during orthopedic surgical procedures. AORN J. 2000;71(3):573-582. 34. Jeong IS, Park S. Use of hands-free technique among operating room nurses in the Republic of Korea. Am J Infect Control. 2009;37(2):131-135. 35. Stringer B, Haines AT, Goldsmith CH, Berguer R, Blythe J. Is use of the hands-free technique during surgery, a safe work practice, associated with safety climate? Am J Infect Control. 2009;37(9):766-772. 36. Stringer B, Haines T. The hands-free technique: an effective and easily implemented work practice. Perioper Nurs Clin. 2010;5(1):45-58. 37. Stringer B, Haines T, Goldsmith CH, et al. Hands-free technique in the operating room: reduction in body fluid exposure and the value of a training video. Public Health Rep. 2009;124(Suppl 1):169-179. 38. Bessinger CD Jr. Preventing transmission of human immunodeficiency virus during operations. Surg Gynecol Obstet. 1988;167(4):287-289. 39. Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theater injuries. Occup Environ Med. 2002;59(10): 703-707. 40. Cunningham TR, Austin J. Using goal setting, task, clarification, and feedback to increase the use of handsfree technique by hospital operating room staff. J Appl Behav Anal. 2007;40(4):673-677. 41. Eggleston MK Jr, Wax JR, Philput C, Eggleston MH, Weiss MI. Use of surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997; 6(4):245-247. 42. Stringer B, Haines T, Goldsmith CH, Blythe J, Harris KA. Perioperative use of the hands-free technique: a semistructured interview study. AORN J. 2006;84(2):233-248. 43. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2002;(3): CD0003087. 44. Ersozlu S, Sahin O, Ozgur AF, Akkaya T, Tuncay C. Glove punctures in major and minor orthopaedic surgery with double gloving. Acta Orthop Belg. 2007;73(6):760-764.
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45. Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg. 2004;199(3):462-467. 46. Aarnio P, Laine T. Glove perforation rate in vascular surgeryda comparison between single and double gloving. Vasa. 2001;30(2):122-124. 47. Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double gloving system. Am J Surg. 2001;181(6): 564-566. 48. Caillot JL, Voiglio EJ. First clinical study of a new virusinhibiting protective glove. Swiss Med Wkly. 2008;138 (1-2):18-22. 49. Krikorian R, Lozach-Perlant A, Ferrier-Rembert A, et al. Standardization of needlestick injury and evaluation of a novel virus-inhibiting protective glove. J Hosp Infect. 2007;66(4):339-345. 50. Bricout F, Moraillon A, Sonntag P, Hoerner P, Blackwelder W, Plotkin S. Virus-inhibiting surgical gloves to reduce the risk of infection by enveloped virus. J Med Virol. 2003;69(4):538-545. 51. Grimmond T, Bylund S, Anglea C, et al. Sharps injury reduction using a sharps container with enhanced engineering: a 28 hospital nonrandomized intervention and cohort sturdy. Am J Infect Control. 2010;38(10): 799-805. 52. Selecting, evaluating, and using sharps disposal containers. NIOSH publication no. 97-111. 1988. National Institute for Occupational Safety and Health. http://www.cdc.gov/niosh/ pdfs/97-111.pdf. Accessed November 1, 2013. 53. Perioperative Job Descriptions and Competency Evaluation Tools [CD-ROM]. Denver, CO: AORN, Inc; 2012. 54. Policy and Procedure Templates. 3rd ed. [CD-ROM]. Denver, CO: AORN, Inc. 2013. 55. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013.
Donna A. Ford, MSN, RN-BC, CNOR, CRCST, is a nursing education specialist, Division of Surgical Services, Department of Nursing, Mayo Clinic, and an assistant professor of nursing, Mayo Clinic College of Medicine, Rochester, MN. Ms Ford has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
This RP Implementation Guide is intended to be an adjunct to the complete recommended practices document upon which it is based and is not intended to be a replacement for that document. Individuals who are developing and updating organizational policies and procedures should review and reference the full recommended practices document.
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EXAMINATION
2.2
CONTINUING EDUCATION
Implementing AORN Recommended Practices for Sharps Safety
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PURPOSE/GOAL To provide the learner with knowledge specific to preventing sharps injuries and bloodborne pathogen exposure.
OBJECTIVES 1. 2. 3. 4.
Discuss legislation related to preventing bloodborne pathogen transmission. Discuss causes of percutaneous injury in perioperative settings. Identify hazards associated with percutaneous injury. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission. The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www.aorn.org/CE.
QUESTIONS 1.
2.
After passage of the Needlestick Safety and Prevention Act, sharps injuries __________ in nonsurgical settings and __________ in surgical settings. a. decreased, decreased b. decreased, increased c. increased, decreased d. increased, increased An 1. 2. 3.
exposure control plan must include a plan to reduce sharps injuries. a process to monitor sharps injury data. an exposure determination for employees who may be exposed to blood and body fluids. 4. prioritized risk-reduction strategies.
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a. 1 and 4 c. 1, 2, and 3
b. 2 and 3 d. 1, 2, 3, and 4
3.
The highest level of the hierarchy of controls to help prevent sharps injuries is to a. develop policies and procedures. b. eliminate the hazard. c. implement work practice controls. d. use a safety-engineered device.
4.
In a Cochrane review of 10 randomized controlled trials, researchers found that using blunt-tip suture needles instead of sharp-tip suture needles reduced the incidence of glove perforation by a. 10%. b. 32%. c. 54%. d. 75%.
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CE EXAMINATION 5.
The majority of percutaneous injuries are caused by a. failure to double glove. b. hand-to-hand passing of sharps. c. using sharp-tip rather than blunt-tip needles. d. using safety-engineered devices.
6.
Use of a neutral zone helps ensure the surgeon and scrub person do not touch the same instrument at the same time. a. true b. false
7.
Communicating the location of sharps on the sterile field is a. an administrative control. b. an engineering control. c. a work practice control.
8.
Personnel may choose to wear virus-inhibiting gloves during procedures in which there is a higher risk of glove perforation. a. true b. false
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9.
A sharps container should be 1. large enough to hold the types of sharps that will need to be placed in them. 2. placed far from the point of use to prevent accidental contact with the container. 3. puncture and leak resistant. 4. replaced when it reaches a visible fill level. a. 1 and 3 b. 2 and 4 c. 1, 3, and 4 d. 1, 2, 3, and 4
10.
Perioperative RNs can demonstrate personal and professional responsibility in preventing sharps injuries and bloodborne pathogen transmission by 1. getting immunized against hepatitis B virus. 2. immediately reporting a percutaneous injury. 3. observing local, state, and federal regulations pertaining to handling of sharps. 4. receiving prophylactic treatment for bloodborne pathogen exposure when necessary. a. 1 and 2 b. 3 and 4 c. 2, 3, and 4 d. 1, 2, 3, and 4
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LEARNER EVALUATION CONTINUING EDUCATION PROGRAM
Implementing AORN Recommended Practices for Sharps Safety
T
his evaluation is used to determine the extent to which this continuing education program met your learning needs. The evaluation is printed here for your convenience. To receive continuing education credit, you must complete the online Examination and Learner Evaluation at http://www .aorn.org/CE. Rate the items as described below. OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Discuss legislation related to preventing bloodborne pathogen transmission. Low 1. 2. 3. 4. 5. High 2. Discuss causes of percutaneous injury in perioperative settings. Low 1. 2. 3. 4. 5. High 3. Identify hazards associated with percutaneous injury. Low 1. 2. 3. 4. 5. High 4. Identify controls (ie, engineering, work practice, administrative) that can be used to help prevent sharps injuries. Low 1. 2. 3. 4. 5. High 5. Describe actions perioperative RNs can take to assist in preventing sharps injuries and bloodborne pathogen transmission. Low 1. 2. 3. 4. 5. High CONTENT 6. To what extent did this article increase your knowledge of the subject matter? Low 1. 2. 3. 4. 5. High 7. To what extent were your individual objectives met? Low 1. 2. 3. 4. 5. High
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2.2 www.aorn.org/CE
8. Will you be able to use the information from this article in your work setting? 1. Yes 2. No 9. Will you change your practice as a result of reading this article? (If yes, answer question #9A. If no, answer question #9B.) 9A. How will you change your practice? (Select all that apply) 1. I will provide education to my team regarding why change is needed. 2. I will work with management to change/ implement a policy and procedure. 3. I will plan an informational meeting with physicians to seek their input and acceptance of the need for change. 4. I will implement change and evaluate the effect of the change at regular intervals until the change is incorporated as best practice. 5. Other: _______________________________ 9B. If you will not change your practice as a result of reading this article, why? (Select all that apply) 1. The content of the article is not relevant to my practice. 2. I do not have enough time to teach others about the purpose of the needed change. 3. I do not have management support to make a change. 4. Other: ________________________________ 10. Our accrediting body requires that we verify the time you needed to complete the 2.2 continuing education contact hour (132-minute) program: _________________________________
Ó AORN, Inc, 2014
