Sharps Handling Practices Among Junior Surgical Residents – A Video AnalysisSharps Handling Practices Among Junior Surgical Residents – A Video AnalysisDavid Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MDDavid Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MD

Division of Pediatric General Surgery, BC Children’s HospitalDivision of Pediatric General Surgery, BC Children’s Hospital

INTRODUCTIONINTRODUCTIONA survey of surgical residents at over 17 medical centers found that 99% of surgeons in training had sustained a needlestick injury by their final year of training (2) 53% involved patients with a history of HIV, hepatitis B or C, or intravenous-drug use  In differentiating the mechanisms of injuries due to sharps, Bakaeen and colleagues found that

69% of OR injuries were inflicted by suture needles 9% from hollow-bore needles 34% from sharp instruments (3)

Specifically, injuries from sharps can occur when Loading suture needle into driver/repositioning needle

with fingers During hand-to-hand passing of sharps Suturing muscle and fascia when needle manipulated

with fingers Retraction of tissue with hands Surgeon sews towards own hand or assistant's hand Tying a suture while needle is attached Suture is left unattended on operative field after use (4)

REFERENCESREFERENCES(1) O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch.Intern.Med. 1992 Jul;152(7):1451-1456. (2) Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, et al. Needlestick injuries among surgeons in training. N.Engl.J.Med. 2007 Jun 28;356(26):2693-2699. (3) Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, et al. Epidemiology of exposure to blood borne pathogens on a surgical service. Am.J.Surg. 2006 Nov;192(5):e18-21.

PURPOSEPURPOSETo examine sharps handling practices of junior surgical residents performing an operation Evaluate whether experience correlates with a decrease in unsafe sharps behavior

Hypothesis: Safety performance is not expected to improve with operative experience in the absence of formal training on sharps

practices

Sharps Task Safe UnsafePersonal Sharp Tasks

Suture needle Using forceps to load or reposition needle

Using fingers to load or reposition needle

Tying Sutures Needle is on driver during tying, and is protected

Needle is exposed while tying suture

Tissue Retraction Using instrument to retract wound edge when using sharps

Using hand/fingers to retract wound edge, when suturing towards hand/fingers

Injection Needle Handling

Injecting away from hand/fingers, no 2-handed needle re-capping

Injecting towards hand/fingers, 2 handed needle capping

Sharps Placement on Operative Field

Placing sharps back onto a neutral hands free zone while not in use

Sharps left on operative field unattended

Passing of SharpsPassing of Sharps Passing suture with

needle in driver handle first, scalpel handle first, use of neutral hands free zone

Passing of suture with needle exposed, blade first

Verbal NotificationVerbal notification when passing sharp instruments

Clear verbal notification when passing sharps

Unclear/No verbal notification when passing sharps

Table 1: Definitions of safe and unsafe sharps tasks used to assess safety performance

Resident safety performance was assessed in three areas:1. Personal sharps tasks

E.g. Suture needle handling2. Passage of sharps

E.g. Scalpel , injection needle3. Verbal notification when passing of sharps

E.g. “There’s a needle up.”   Second video was taken of the resident after the technical

performance feedback session and safety performance was compared between the two procedures.

Video reviewer blinded to resident level & video order

01020

30405060

708090

100

Initial Video (n=8) Final Video (n=8)

personal passage communication

Figure 2. Graph of mean percentage of safe tasks performed by surgical residents as seen in the initial and final videos (n=8) taken during an inguinal hernia repair.

Description SafetyInitial video

(mean)

Standard Deviatio

nSuture needle manipulation

  

Safe 4.3 2.7Unsafe 4.7 4.0

% Safe 53.7% 33.8%

Tying sutures  

Safe 3.5 1.5Unsafe 0.5 1.0% Safe 86.9% 25.6%

Tissue retraction  

Safe 1.8 0.8Unsafe 0.5 0.8% Safe 83.3% 28.3%

Injection needle handling

Safe 0.4 0.5Unsafe 0.2 0.5% Safe 72.2% 44.1%

Overall Personal Sharps Tasks % Safe 66.3% 23.1%

Table 2. Summary of safe and unsafe personal sharps tasks for all initial videos of surgical residents (n=19).

RESULTSRESULTS19 surgical residents videoed

15 general surgery residents (PGY-2) 4 plastic surgery residents (PGY-1)

Initial videos (n=19): Sharps tasks performed safely = 66.3% Safe passing of sharps = 90.4% Verbal notification when passing = 10.1% Unsafe sharps practices mostly with handling of

suture needle 4.7 unsafe actions per surgery All residents demonstrated safe handling of the

scalpel blade No actual injuries to the surgical resident/ team  

Second video follow-up (n=8) No statistically significant differences between initial

and final procedures with regards to Personal sharps tasks (p=0.17), Passing of sharps instruments (p=0.14) or Verbal notification (p=0.29)

4.4 missed opportunities to use of verbal cues to alert team members when passing sharp instruments (SD=1.2)

DISCUSSIONDISCUSSIONJunior surgical residents consistently passed sharp instruments in a safe mannerTasks relating to manipulation of sharps were less likely to be performed safelyMinority of residents verbally notified team members when passing sharp instrumentsReview of technical performance of the surgical procedure did not significantly improve safe sharps handling practices

Explicit instruction and feedback on sharps handling should Explicit instruction and feedback on sharps handling should become an integral part of surgical residency programs and become an integral part of surgical residency programs and surgical culture (4-7)surgical culture (4-7) 

Figure 1. Examples of safe and unsafe manipulation of the suture needle. 1) Unsafe handling of suture needle using fingers. 2) Safe handling of suture needle using forceps.

METHODSMETHODSJunior surgical residents:

PGY-2 general surgery & PGY-1 plastic surgery residents 2 month rotation in pediatric general pediatric surgery at BC

Children’s Hospital in Vancouver, British Columbia Videotaped performing pediatric indirect inguinal hernia repairs:

Junior surgical residents as principle operator, attending surgeon assisting

Technical feedback was given by the attending surgeon on review of the videotape footage with resident

Residents were not given specific feedback on sharps handling technique

Safe/unsafe practices Based on the Association of Perioperative Nurses and the

American College of Surgeons guidelines (4,7). Videos reviewed, each sharp episode judged “safe” or “unsafe” 

(4) Association of periOperative Registered Nurses. AORN guidance statement: sharps injury prevention in the perioperative setting. AORN J. 2005 Mar;81(3):662, 665-6, 669-71. (5) Camilleri AE, Murray S, Squair JL, Imrie CW. Epidemiology of sharps accidents in general surgery. J.R.Coll.Surg.Edinb. 1991 Oct;36(5):314-316. (6) Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and surgical residents: who is most at risk? J.Surg.Educ. 2007 Nov-Dec;64(6):395-398. (7) Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J.Am.Coll.Surg. 2004 Sep;199(3):462-467.

RESULTSRESULTS