Cut Down Stubbornly High Sharps Injury Rates

Safety devices and neutral zones combined with efforts to minimize interruptions during wound closures make the OR safer for everyone.

Juan A. Sanchez, MD, FACS, describes the OR as a “target-rich environment for sharps injuries.” Dr. Sanchez is the chair of the committee on Perioperative Care at the American College of Surgeons, and he says a perfect storm of factors in operating rooms across this country continue to make sharps safety a daunting challenge and perennial concern for healthcare facilities. That said, there are plenty of simple and practical solutions you can — and should — put in place to safeguard your ORs.

The pandemic effect

The very nature of surgery requires sharp instruments, suture needles and other equipment designed to penetrate tissue. What’s more, the stress of the pandemic on healthcare employees elevated the risk of sharps injuries. “The pandemic has also removed the focus from sharps injuries prevention programs and other occupational safety efforts,” says Dr. Sanchez.

Granted, sharps injuries were already a big problem in pre-COVID times, and perioperative staff are among the top healthcare workers at the highest risk for these injuries. Since the passage of the Needlestick Safety and Prevention Act in 2000, the rate of surgical sharps injuries has increased by 6.5%. Despite the best efforts of healthcare professionals and organizations, these injury rates remain stubbornly high for several reasons.

Most sharps injuries happen in the OR while passing instruments among operating room staff, capping or transferring sharps from one location to another, or during decontamination and processing of used devices. There’s also a continuous increase in the acuity of patients today and the level of care needed at healthcare facilities.

Distractions and ‘threat windows’

Safety devices have helped tremendously in reducing sharps injuries in areas outside the OR. Unfortunately, many believe there are few good alternatives for safety devices that can be used in the OR. Surgeons often work in tight spaces, and the safety devices can be too cumbersome or awkward to use during surgery.

Research shows that the highest percentage of sharps injuries in the operating room are caused by suture needles, with the injury occurring during wound closure. Blunt suture needles with slightly rounded tips were developed to reduce sharps injuries, as they don’t penetrate as easily or directly as their razor-sharp counterparts. But they haven’t had the impact many had hoped for. “Regrettably, blunt suture needles can’t be used on every type of closure, and it takes a little more pressure to push the needle through the tissue,” says Barbara L. DiTullio, DNP, RN, MA, CNOR, NEA-BC, senior clinical operations liaison of perioperative services at Beth Israel Deaconess Medical Center in Boston.

Much of Dr. DiTullio’s research on sharps safety has focused on the impact of distractions and interruptions during wound closure. She says any distraction that takes a nurse’s attention momentarily away from the task at hand, even if only for a few seconds, can prove critical and cause an accident. “Research suggests that this gap in time away from the task is serious,” says Dr. DiTullio. “As each interruption occurs during a procedure, a ‘threat window’ expands and increases potential risk.”

Wound closure marks the end of the procedure where the critical portion of the surgery is done. With the primary goal finished, there’s a natural tendency for OR teams to let their thoughts wander to what comes next. Closing the wound is the only remaining thing to do before moving on, and it’s naturally seen as less serious and important. Plus, multiple activities happen simultaneously during wound closure, like surgical counts, plans for the patient’s following stages and the next destination in discharge.

“The combination of a somewhat relaxed demeanor combined with multiple activities make wound closure a far more important time than many of us may realize,” says Dr. DiTullio, who adds that she’s witnessed a lot of issues observing wound closure as a standalone process during her research. In one case, she watched a less-experienced scrub nurse passing sutures amid multiple distractions of every type. As a result, she suffered a sharps injury when a suture was passed back to her. Dr. DiTullio concluded that because the nurse was less experienced, screening out some of the distractions while staying focused on the task at hand wasn’t a skill she had fine-tuned yet.

We all pride ourselves on our ability to multitask, but our ability to handle multiple requests simultaneously is finite, especially for less experienced personnel. Over time, OR staff can improve their ability to screen out distractions, and they know which ones to pay attention to and which can be disregarded. This led Dr. DiTullio to believe minimizing interruptions and distractions during wound closure could significantly reduce sharps injuries in the OR.

She said it’s crucial to keep this in mind: Staff must be relieved during long cases for a shift change or much-needed breaks, but be mindful about providing relief, particularly during wound closure when injuries can happen.

The exchange of information during staff changeover can tremendously impact case flow. When this happens during wound closure, it’s especially challenging because it adds to the interruptions during a vulnerable time. Minimizing distractions is part of many safety awareness campaigns — and not just in the healthcare field. For instance, Dr. DiTullio points out that driving laws in the U.S. have changed in recent years to combat distractions, such as not using cell phones or texting while driving. Some cell phones today even have features for auto messaging while driving so the call or text can be answered later. These efforts aren’t exactly new, so pushing an anti-distraction safety campaign on OR personnel to reduce the risk of sharps injuries should resonate.

EXTRA PROTECTION Data shows that double-gloving during invasive surgical procedures reduces the risk of sharps injuries.

Improving the safety climate

Another safety idea that has garnered much attention is the hands-free technique (HFT), where nurses simply place surgical instruments in a container and pass the container to the surgeon. Research has shown that the HFT can reduce sharps injuries by up to 59% in some cases. The best device for HFT, also known as a neutral passing zone, is big enough to hold sharps, isn’t easily tipped over and is mobile. One sharp at a time is put in the neutral zone, while blunt instruments can still be passed hand-to-hand. When the device is placed in the neutral zone, the staff calls out “sharp” to alert the rest of the OR team.

Double-gloving during invasive surgical procedures is another way to reduce the risk of sharps injuries. Research indicates that tears and perforations occur between 6% and 12% of the time in the OR, especially when gloves are worn for extended periods. That means surgical staff should change gloves every 90 to 150 minutes during invasive procedures. The indicator glove is designed to be used as the under glove and should be a different color than the regular glove. The different color makes it easier to identify tears and punctures to the outer glove, and research shows the different colors make a difference. Case in point: When healthcare employees wore a tear-indicator glove, 77% of punctures were identified, compared to 21% when standard double gloves were worn.

Problem is many facilities still don’t require double-gloving. And even when it’s required, many staff simply opt not to double-glove. Some resistance comes from the perception that double-gloving reduces dexterity and tactile sensation in the OR. For others, getting a comfortable fit with double-gloving is challenging. No single method of double-gloving works for all OR staff, so it’s essential for staff to try different glove combinations and sizes. Some OR staffers wear two of the same-sized gloves, others wear a half-size larger than the usual inner glove, and still others wear a half-size larger than the outer glove. It comes down to personal preference and getting a comfortable fit.

Creating a safer OR

By now, OR staff likely know which situations are at the highest risk for sharps injuries. Wound closure is particularly fraught, and interruptions and distractions play a crucial role. Analyzing the root causes of each injury or near miss can help teams and organizations reduce the occurrence of sharps injuries.

In Dr. Sanchez’s mind, the most effective way to reduce sharps injuries is to improve the safety climate of surgical teams. “The safety climate needs to focus on patient and worker safety,” he says. “This involves optimal team communication practices and encouraging psychological safety among surgical team members.”

The OR is a unique area in every facility. Surgical teams must work together closely under intense time constraints while using sharp, dangerous instruments. While Dr. Sanchez is right that the OR is — and always will be — a “target-rich” environment for sharps injuries, the rate of sharps injuries doesn’t need to be stubbornly high. Safety devices, neutral zones and minimizing interruptions during wound closures are simple, effective steps that all surgical teams can take to make the OR safer. OSM