Needlestick and sharps injuries among theatre care professionals.
Article Type: Report
Subject: Occupational health and safety (Research)
Penetrating wounds (Diagnosis)
Penetrating wounds (Care and treatment)
Medical personnel (Health aspects)
Author: Benna, Sammy Al-
Pub Date: 12/01/2010
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Dec, 2010 Source Volume: 20 Source Issue: 12
Topic: Event Code: 310 Science & research
Product: Product Code: 8000500 Employee Health & Safety; 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 245167479
Full Text: Health care professionals are exposed to blood and other body fluids in the course of their work (Al-Benna et al 2008). The World Health Organisation (2003) estimates that 9% of the 35 million healthcare professionals worldwide will experience percutaneous exposure to bloodborne pathogens each year (WHO 2003). In the UK about 100,000 sharps injuries occur in NHS hospitals each year (Trim & Elliott 2003). This is 17% of all accidents involving NHS staff (NAO 2003). Four percent of NHS staff sustain from 1 to 6.2 sharps injuries each year. These injuries occur mainly in clinical areas such as wards and theatres, but also in non-clinical areas due to accidental handling of inappropriately discarded sharps (Trim & Elliott 2003, Waterson 2004). Percutaneous injuries involving hollowbore needles remain the most commonly reported occupational exposures in the healthcare setting (HPA 2010). Consequently, workers are at risk of infection with bloodborne viruses including human immunodeficiency virus, hepatitis B virus, hepatitis C virus and bacterial infections (Al-Benna et al 2008).

KEYWORDS Needlestick injuries / Sharps injuries / Penetrating wounds / Stab wounds

Occupational exposure to blood can result from percutaneous injury (needlestick or other sharps injury), mucocutaneous injury (splash of blood or other body fluids into the eyes, nose or mouth) or by contact with non-intact skin (Al-Benna et al 2008). Healthcare professionals working in operating theatres have a high risk of exposure (Al-Benna et al 2008). The risk of infection for health workers depends on the prevalence of disease in the patient population and the nature and frequency of exposures. Patients' blood makes contact with the skin or mucous membranes of operating theatre professionals personnel in as many as 50% of operations, with cuts or needlestick occurring in as many as 15% of operations (Gerberding et al 1990, Quebbeman et al 1991).

Over the last three decades, theatre care practitioners have been increasingly aware of the potential morbidity and mortality associated with contact with infected blood and body fluids (HPA 2008). In response to this increasing awareness, the Department of Health (1998) issued guidelines for contamination involving blood and body fluid from patients and began requiring the use of universal precautions. Although this standard has been revised and updated several times, most recently in 2009 (DH 2009), the published literature indicates that healthcare professionals, in particular surgeons, continue to demonstrate poor compliance with universal precautions (Kerr et al 2009). Equally unsatisfactorily, the Department of Health guidelines do not appropriately address the requirements of the high-risk operating theatre environment (HPA 2008, NAO 2003). Therefore, sharps injuries to theatre personnel continue to occur.

The operating theatre

It is challenging to provide a safe operating theatre environment as surgeons, surgical trainees, scrub nurses, and operating theatre technicians work intimately together in a compact area. Therefore, these personnel can all be injured in similar ways with similar equipment and unfortunately, often by one another. In order to minimise sharps injuries, operating teams must as a group study their injury patterns in theatre.

Studies have reported that operating theatre professionals have contact with patient blood in up to half of all operations, and needlestick, scalpel or other sharps injuries may occur in up to one-sixth of all operations (Quebbeman et al 1991, Gerberding et al 1990). The higher risks of percutaneous injury are associated with longer, more-invasive and higher blood loss operations (Gerberding et al 1990, Panlilio et al 1991, Popejoy & Fry 1991, Quebbeman et al 1991, White & Lynch 1993). The majority of injuries are self-inflicted but as many as one-quarter are caused by other members of the team (Quebbeman et al 1991, Wright et al 1991, Tokars et al 1992, Jagger et al 1998). The non-dominant hand is the part of the body which is injured most often (Wright et al 1991, Jagger et al 1998, Tokars et al 1992).

Surgeons, followed by their first assistant, are the most commonly injured theatre personnel, and sustain 59.1% of operating theatre injuries (Jagger et al 1998) (Table 1). Scrub nurses followed by scrub technicians sustain the next highest frequency of injuries (19.1%), followed by anaesthetists (6.2%) and circulating nurses (6.0%) (Jagger et al 1998). The risk of injury and potential exposure is different for each healthcare professional group, but the risk is never nil (Jagger et al 1998).

The suture needle is the most common source of injury and has been associated with 77% of all injuries (Tokars et al 1992). Although most injuries are caused with curved suture needles, straight suture needles cause a higher overall proportion of injuries with respect to the numbers used (CDC 1997). Injuries are most common when fingers are used to manipulate needles and soft tissue, particularly when suturing muscle and fascia (Tokars et al 1992, White et al 1993).

From 6-16% of injuries are reported to be due the passing of instruments from hand to hand (Tokars et al 1992, Jagger et al 1998). Almost one third of medical devices that cause injuries come into contact with the patient after the injury to the healthcare professional (Tokars et al 1992, Jagger et al 1998). Fortunately, less than 0.5% of injuries to healthcare professionals are high risk, that is injuries from hollow bore vascular access needles. Unfortunately, surgeons fail to report as many as three quarters of their injuries, and therefore may fail to receive post-exposure prophylaxis (Kerr et al 2009).

Double gloving

Operating theatre professionals appreciate that glove protection failure is common. The surgical glove failure rate is as high as 8.8% for new unused sterilised gloves (Fell et al 1989). Perforation rates as high as 61% for thoracic surgeons and 40% for scrub nurses have been reported (Hollaus et al 1999). The first intra-operative glove perforation occurs a mean of 40 minutes into an operation and is not detected by the operating theatre professional in up to 83% of cases (Hentz et al. 2001, Thomas et al 2001, Hollaus et al 1999).

The practice of double gloving offers an improved level of protection to patient blood by up to 87% when the external glove is perforated (Caillot et al 1999, Jensen 2000, Naver & Gottrup 2000, Aarnio & Laine 2001, Laine & Aarnio 2001,). Even though perforation of the external glove is common, matching perforation of the internal glove was rare (Caillot et al 1999, Jensen 2000, Naver & Gottrup 2000, Aarnio & Laine 2001, Laine & Aarnio 2001). Also, the amount of blood on a solid suture needle is decreased by up to 95% when passing through two glove barriers, therefore decreasing the potential viral load when percutaneous injury occurs (Bennett & Howard 1994). As operating theatre professionals may be unaware of intraoperative glove perforations, double gloving may avoid extended undetected contact with potentially contaminating body fluid.

Caillot et al (1999) electronically evaluated the value of double gloving and demonstrated that barrier breakdown was present during 62% of operating time which lead to prolonged contact with potentially contaminating body fluids. In addition, they demonstrated that double gloving reduced the number of perforation and porosity alarms twofold in both superficial and deep surgical procedures. A number of other studies have also demonstrated that the addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves and may prevent iatrogenic infection of the patient (van den Broek et al 1985, Wooster et al 1985, Esteban et al 1996, Harpaz et al 1996, McNeil et al 2001). Triple gloving, knitted outer gloves and glove liners also significantly reduce perforations to the innermost glove (Tanner & Parkinson 2006). Perforation indicator systems result in significantly more innermost glove perforations being detected during surgery (Tanner & Parkinson 2006).

Operating surgeons have been reluctant to embrace this safety measure, mainly due to the pervasive idea that double gloving reduces hand dexterity and sensation. One study, performed outside theatre, compared knot-tying competency and moving two-point discrimination tests between single- and double-gloved surgeons and found no significant differences (Webb & Pentlow 1993). In addition, it has been shown that double-gloved surgeons had reduced hand sensation during study of pressure sensitivity and moving two-point discrimination, but that static two-point discrimination was not affected (Novak et al 1999). A subjective study examining surgeons' satisfaction, sensation and dexterity under single- and double-gloved conditions suggested subjective impairment of all these parameters (Matta et al 1988, Wilson et al 1996). It is interesting to note that the surgeons involved in these clinical studies removed the external glove prior to the end of an operation in 26% of cases (Matta et al 1988, Wilson et al 1996). Despite this, surgeons who always double glove reported that a period of two days in most cases is required to completely adjust to double gloving. In addition, surgeons who always double glove reported reduced hand sensation far less often than those who do not (Patterson et al 1998). Therefore, a spell of adjustment and conditioning is required for operating theatre professionals prior to acclimatise to double gloving.

Use of blunt suture needles

Curved suture needles used during fascial closure cause up to 59% of suture needle injuries in theatre (CDC 1997) (Table 2). Blunt suture needles (i.e. curved suture needles that have a relatively blunt tip) may be less likely to cause percutaneous injuries because they do not easily penetrate skin. In order to reduce this risk of needlestick injury, the use of blunt suture needles has been advanced and studied. Prospective randomised trials have shown that blunt suture needles result in a significant fall, and in some cases, total absence of, suture needle injuries in operating theatre professionals (Wright et al 1993, Hartley et al 1996, Mingoli et al 1996, Rice et al 1996).

Studies during elective orthopaedic surgery demonstrated that the use of blunt suture needles significantly reduced glove perforations in hip arthroplasties (Wright et al 1993), and completely eliminated needlestick injuries during total hip replacement surgery (Mingoli et al 1996). With regard to the total hip replacement study, there were glove perforations in 16% of operations and needlestick injuries in 6% (Mingoli et al 1996). Another study demonstrated a seven-fold reduction of glove perforations with the use of blunt suture needles for abdominal wall closure (Rice et al 1996). Blunt-tipped needles, while not eliminating the risk, significantly reduced the incidence of surgical glove puncture from 38% versus 6.5% during mass closure of the abdomen (Hartley et al 1996). In addition, it has been demonstrated that the use of blunt suture needles reduced needlestick injuries from 1.9 per 1000 for curved suture needles to 0 per 1000 for blunt needles (CDC 1997).

A number of case series also support the safety and utility of blunt suture needles. One even demonstrated the complete elimination of needlestick injuries to operating theatre professionals with blunt suture needles and also showed that blunt suture needles were practical for colonic anastomosis, hernia repair and abdominal wall closure (Dauleh et al 1994). Another study demonstrated the ease of use and no needlestick injuries with blunt needles in abdominal wall closure (Montz et al 1991). In one study, surgeons reported technical difficulties in a quarter of cases using blunt needles, including problems penetrating tissue, tearing of tissue, needle slippage, and bleeding when the needle entered the tissue. However, none of these were reported to be clinically important (CDC 1997).

Thus, there is much evidence advocating the standard use of blunt suture needles for suture of fascia and muscle. Further research may demonstrate that blunt suture needles may be safe and suitable for suturing other tissues.

Use of the neutral zone to transfer sharps

The neutral zone has been described as 'a previously agreed upon location on the field where sharps are placed from which the surgeon or scrub can retrieve them. Therefore, hand-to-hand passing of sharps is limited' (Stringer et al 2002). The use of the neutral zone to transfer sharps [equivalent to the hands-free technique] has been proposed as a method to reduce exposure of theatre personnel to blood during surgery.

The data supporting the use of neutral zone are inconclusive at present, with one large study of almost 4,000 operations demonstrating that when the neutral zone was ascertained to have been used at least three-quarters of the time during operations, the number of incidents fell by 59% in operations with a blood loss of 0.1l or greater (Stringer et al 2002). Incidents were defined as sharps injuries, cutaneous blood exposure, or glove perforations. In contrast, a smaller prospective randomised controlled trial reported no difference in incidents with the neutral zone technique compared with control (Eggleston et al 1997).

The evidence regarding the efficacy of neutral zone technique is inconclusive, but this technique is recommended by several leading professional organisations and its use is obligatory in a significant minority of hospitals as a safety measure to reduce sharps injuries during operations while research continues in this area.

The European Union Sharps Directive (Commission of the European Communities 2010) gives legal effect to a framework agreement concluded by the European Hospital and Healthcare Employers' Association and the European Federation of Public Service Unions. An integrated approach is required to implement the directive. This should include comprehensive user training, safer working practices and the use of medical devices incorporating safety-engineered protection mechanisms to prevent the majority of needlestick injuries, as failure to implement any one of these three elements has been shown to result in a significantly reduced impact (Table 3).

Discussion

Sharps injuries remain an important health risk to operating theatre professionals. The high failure rate for gloves does give cause for concern as gloves are commonly thought to protect operating theatre professionals from infection and to protect patients from iatrogenic infection. Unfortunately, operating theatre professionals will, inevitably, become infected via glove perforations. Immunisation will protect operating theatre professionals against hepatitis B but comprehensive training of operating theatre professionals in safer working practices such as double gloving, the use of blunt suture needles when possible and the use of the neutral zone to transfer sharps, as mandated by the June 2010 European Union Sharps Directive, will reduce the risk of percutaneous sharps injury (Commission of the European Communities 2010).

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Task 1

Reflect

Assessing the risk

Identify the potential hazards and risk within your practice that may lead to yourself or others having a needlestick injury.

The hazards might include where your needles are placed on your sterile trolley, or how needles are transferred to others during the surgical procedure.

Notional Learning Hours 20 mins

Knowledge and Skills Dimension

Core: Communication

Core: Health, safety and security

Core: Service improvement

Core: Quality

Task 2

Project

Preventing and controlling the risk

List some methods of how you can prevent and control a risk of needlestick injury.

You may consider how sharps are stored and discarded. Equally, you may consider how staff fatigue might raise the risk of a needlestick occurring.

Notional Learning Hours 30 mins

Knowledge and Skills Dimension

Core: Communication

Core: Health, safety and security

Core: Service improvement

Core: Quality

Task 3

Review

Compliance for protection

The European Union Sharps Directive (2010) is a key document in preventing sharps injuries within the healthcare sector; please take the opportunity to read. Then consider three ways of changing perioperative practice to prevent injuries occurring.

Notional Learning Hours 1 hour

Knowledge and Skills Dimension

Core: Communication

Core: Health, safety and security

Core: Service improvement

Core: Quality

About the author

Sammy Al-Benna MB ChB, PhD, MRCS, PGC Nano

Plastic and Reconstructive Surgeon, St Bartholomew's Hopital, London

No competing interests declared

Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk.

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Correspondence address: Sammy Al-Benna, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE. Email: sammyalbenna@doctors.org.uk

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2010.
Table 1 Risk of needlestick injuries in the
operating theatre

                                      Percentage of total
Job category                          needlestick injuries

Surgeons                              59.1
Theatre nurses                        19.1
Anaesthetists                          6.2
Circulating nurses                     6.0
Medical students                       3.1
Operating 0.8 department assistants
Others                                 5.7

Source: Jagger et al 1998

Table 2 Needlestick injuries relative to type of
needle in the operating theatre

                         Injuries per 1000
Type of needle           needle used

Blunt suture needle       0
Straight suture needle   14.2
Curved suture needle      1.9

Source: Center for Disease Control and
Prevention 1997

Table 3 Strategies for exposure prevention

Strategy                           Implementation

1. The neutral zone is dedicated   1. Identify the neutral zone in
   for sharps only. All other         consultation between the
   instruments are passed             scrub nurse and the surgeon.
   hand-to-hand. Only one sharp
   in the neutral zone at a
   time.

2. Do not hold the neutral zone    2. Place the neutral zone device
   device.                            in the designated area
                                      keeping the fingers out of
                                      the way.

3. Orient the sharp in the         3. Alert the surgeon that the
   neutral zone to facilitate         sharp item has been placed in
   the surgeon being able to          the neutral zone and is ready
   pick it up with her/his            to be picked up.
   dominant hand without having
   to turn or reposition body.

4. Avoid need to reposition the    4. Ensure that suture needles
   needle holder in the               are correctly positioned and
   surgeon's right or left hand.      clamped.

5. Move neutral zone as needed     5. Open and positive verbal
   to accommodate the surgeon.        communication is maintained
                                      between the theatre nurse and
                                      surgeon.

6. Avoid contact with the suture   6. Keep sharp end of suture
   needle when surgeon has            needles grasped between the
   finished using.                    needleholder when finished
                                      using.

7. Use no-touch technique when     7. Use a grasping instrument to
   placing drains.                    position drains.

8. When finished using a sharp,    8. Surgeon returns the sharp to
   the surgeon continues to use       the neutral zone and avoids
   the neutral zone.                  passing it back directly to
                                      the theatre nurse.
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