Recommended Practices for

Sharps Safety

Mary J. Ogg, MSN, RN, CNOR June 27, 2013

Thank you

Funded through the AORN Foundation and

supported by a grant from Aspen Surgical

Mary J. Ogg is a perioperative nursing specialist at the Association of periOperative Registered Nurses (AORN). She is responsible for creating products and education materials that support the perioperative professional’s safe workplace practice. Mary managed the development of AORN tool kits for sharps safety, surgical smoke evacuation, workplace safety, and safe patient handling and movement. She has authored several recommended practices including Moderate Sedation/Analgesia, Electrosurgery, Lasers, and Sharps Safety; "Clinical Issues" columns and other professional journal articles. Mary has practiced in multiple settings including hospital based operating rooms, ambulatory surgery centers, and office based operating rooms in management and clinical practice roles. Her education background includes a diploma in Nursing from Jewish Hospital School of Nursing, Cincinnati, Ohio; a Bachelor’s in Health Science from Chapman University in Orange, California; and a Masters in Science in Nursing Administration from George Mason University, Fairfax, Virginia.

Mary J. Ogg, MSN, RN, CNOR

Disclosure Information

Speaker:

Mary J. Ogg, MSN, RN, CNOR

No Conflict

Accreditation Statement

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on

Accreditation.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS

EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY

REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

Planning Committee:

Ellice Mellinger MS, BSN, RN, CNOR

Perioperative Education Specialist, AORN

No Conflict

AORN’s policy is that the subject matter experts for this product must disclose any financial relationship

in a company providing grant funds and/or a company whose product(s) may be discussed or used

during the educational activity. Financial disclosure will include the name of the company and/or

product and the type of financial relationship, and includes relationships that are in place at the time of

the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are

indicated according to the following numeric categories:

1. Consultant/Speaker’s Bureau 2. Employee

3. Stockholder 4. Product Designer

5. Grant/Research Support 6. Other relationship (specify)

7. No conflict of interest

1. Discuss the AORN evidence rating

process.

2. Explain the difference between work

practice controls and engineering

controls in preventing sharps injuries.

3. Explain how perioperative personnel

can implement evidence based

practices to prevent sharps injuries.

Objectives

Evidence-rated RPs – The New Generation

Johns Hopkins Nursing

Evidence-Based Practice

Model

Research

Single studies Multiple studies

- Experimental - Systematic reviews

- Quasi-experimental • with or without

- Non-experimental meta-analysis or

- Qualitative meta-synthesis

Non-Research

• Non-research evidence includes

- Summaries of evidence (eg, clinical practice

guidelines)

- Organizational experience (eg, quality

improvement)

- Expert opinion (eg, commentary, case reports)

- Community standards

- Clinician experience

- Consumer preferences

AORN Research Appraisal Tool

AORN Non-Research Appraisal Tools

Guidance statement Recommended

Practice

• 2005 –AORN Guidance Statement: Sharps Injury Prevention in the

Perioperative Setting

• 2010 -Surveillance data

6.5% increase in injuries in the OR

31.6% decrease in nonsurgical settings

• Consequences of sharps injury

Increased risk to surgical patients and the perioperative team for a BBP

exposure

Heavy emotional and economic burden

• 2013- AORN transitioned the guidance statement to a

recommended practice.

Why is sharps safety important?

500,000 health care workers injured

each year

Injuries associated with occupational

transmission of HBV, HCV, & HIV

132 documented cases of health care

provider to patient transmission of

HBV, HCV, or HIV

OSHA’s Bloodborne Pathogen Standard

29CFR 1910.1030

Hierarchy of Controls

• Elimination of the hazard

• Engineering controls

• Work practice controls

• Administrative controls

• PPE

Hierarchy of Controls

Elimination of the hazard

• Recommendation I

• Health care facilities must establish a written

exposure control plan

Engineering controls

• Recommendation II

• Perioperative personnel must use sharps with

safety-engineered devices

Hierarchy of Controls

Work practice controls

• Recommendation III

• Perioperative personnel must use work

practice controls when handling sharp devices

• Sharp devices must be contained and

disposed of safely.

Hierarchy of Controls

Administrative controls

• Recommendation I, VI,VII, VIII, IX

• Health care facilities must establish a written exposure control plan.

• Personnel should receive initial and ongoing education competency

validation of their understanding of the principles and performance of

the processes for sharps safety.

• Documentation should reflect activities related to sharps safety.

• Policies and procedures for sharps safety processes and practices

should be developed,…

• Perioperative team members should participate in a

variety of quality improvement activities.

Hierarchy of Controls

PPE

– Recommendation IV

– Perioperative

personnel must use

PPE.

Recommendation II

• Engineering controls

– safety-engineered devices that isolate or remove the risk of a

bloodborne pathogen exposure

• Examples

– safety or sheathed scalpels,

– blunt suture needles,

– safety syringes and needles, and

– cutting devices

Perioperative personnel must use sharps

with safety-engineered devices

Recommendation II

Indications

-Muscle

-Fascia

Blunt suture needles should be used

when clinically indicated

Recommendation II

• Cochrane review of ten randomized controlled trials evaluated blunt versus sharp needles for preventing percutaneous exposure incidents in surgical staff.

• Using blunt needles versus sharp suture needles reduced glove perforation risk by 54% and reduces the risk of infectious disease transmission.

Blunt suture needles should be used when

clinically indicated

Blunt Suture Needles

• The use of these needles was rated as

acceptable in five out of six studies.

• “…the use of blunt needles appreciably reduces

the risk of contracting infectious diseases

for surgeons and their assistants over a

range of operations by reducing the

number of needle stick injuries.” Parantainen

Wound closure devices

• A systematic review of 14 randomized controlled trials

evaluated the tissue effects on surgical wound healing

when tissue adhesives were used for skin closure.

• No significant difference

– Infection

– Patient and user satisfaction

– Cost

Wound closure devices

• Sutures were better than adhesives for minimizing

wound dehiscence in ten trials, and significantly faster to

use.

• Adhesive tapes were faster to use than adhesives.

Safety scalpels

• Single use

– no disassembly required

• Re-useable

– shielded or sheathed

– retracting scalpel blades

Work practice controls reduce the likelihood of

exposure by changing the method of performing

a task to minimize the risk of exposure to blood

or other potentially infectious material (OPIM).

Recommendation III

Perioperative personnel must use work practice

controls when handling sharp devices

Sharp devices

• scalpels

• hypodermic needles

• suture needles

• bone fragments

• K-wires

• burrs

• saw blades

• retractors

• drill bits

• trocars

• razors

• bone cutters

• towel clips

• scissors

• electrosurgical tips

• skin hooks

Recommendation III

Surgical team members

should use a neutral

zone or hands-free

technique for passing

sharp instruments,

blades, and needles

Neutral or hands-free zone

A pre-intervention and post-intervention study investigated

whether preventative practice changes during orthopedic

procedures would decrease the risk of blood exposure for the

surgical technologist, first assistant, surgeon, and patient.

­ During the pre-intervention phase there were

24 incidents (ie, 13 injuries, 11 glove perforations)

during 6.8% of procedures

­ During the post-intervention phase there

were 10 incidents (ie, 6 injuries and 4

glove perforations) during 2.7% of

procedures.

Recommendation III

A no-touch technique should be used when

handling sharps.

No-touch technique

• The most common site of percutaneous injuries in the

perioperative setting is to the non-dominant hand during

suturing

• In a randomized clinical trial the rate of glove perforations of the

non-dominant hand of the surgeon occurred in 88% of the

procedures and in 78% of the procedures for assistants

• The researchers found that use of a blunt instrument-assisted

technique reduces the need for finger contact with the suture

needle or the tissue being sutured

No-touch technique

• Minimizes manual handling of sharp devices and

instruments reducing risk of injury

• Suture needles should not be manipulated with

gloved hands

• A blunt instrument (eg, forceps) should be used to

manipulate and guide the suture needle through

tissue to avoid finger contact with the suture needle or

the tissue being sutured

Recommendation IV

• Double gloving

– Scrubbed team members should

wear two pairs of surgical gloves,

one over the other, during surgical

and other invasive procedures

that have the potential for

exposure to blood, body fluids, or

OPIM

Perioperative personnel must use PPE

Double gloving evidence

A systematic review of thirty-one randomized

controlled trials of gloving practices

demonstrated that double-gloving minimizes

health care worker's exposure risk to blood

during invasive procedures by providing a

protective barrier.

Double gloving evidence

• Double gloving (eg, two pairs of gloves, indicator glove

with over glove) is more effective than single gloving in

reducing glove perforations.

• Wearing two pairs of gloves reduces the risk of glove

perforation and percutaneous injury.

• Double gloving can reduce the risk of exposure to blood

and body fluid by as much as 87% if the outer glove is

punctured.

When double gloves are worn, perforation

indicator systems should be used

•A perforation indicator system uses a

colored pair of gloves worn beneath a

standard pair of gloves.

•When glove perforation occurs,

moisture from the surgical field seeps

through the perforation between the

layers of gloves, revealing the

underlying color and signaling a

perforation

Perforation indicator systems

Perforations are detected more frequently and reliably

with perforation indicator glove system.

Perforation indicator systems

A double-blind randomized study

• Evaluated ability of participants to locate a 30-micron

size hole in various glove configurations during

simulated surgery.

• While wearing indicator system participants detected

84% of perforations with the latex system and 56% of the

perforations with the synthetic system. Florman

Recommendation I

Health care facilities must establish a written

bloodborne pathogens exposure control plan.

• reviewed and updated at least annually and whenever

new or modified tasks or procedures are implemented

• exposure determination of any employee with the

potential for exposure to bloodborne pathogens

• organization’s plan to reduce sharps injuries

• exposure control plan must be accessible to all

employees

Product selection & evaluation

A multidisciplinary committee that includes frontline

workers should develop, implement, and

evaluate a plan to reduce sharps injuries in the

perioperative setting and to evaluate sharps

safety devices. The composition of the team will

vary depending on the device being evaluated.

Multidisciplinary Team

Representatives from

– clinical staff,

– materials management,

– infection prevention and control,

– risk management,

– administration,

– occupational health,

– sterile processing,

– environmental cleaning services, and

– waste management

• Priorities will be identified and be based on the

– mechanism of sharps injuries,

– frequency of injuries,

– procedure-specific risks,

– relative risk of disease transmission, and

– the devices involved in sharps injuries.

• Highest priority will be given to the device that will have

the greatest effect on reducing sharps injuries

Product selection & evaluation

Product selection & evaluation

• Device selection factors include

– patient and worker safety,

– efficiency,

– user acceptability, and

– overall performance.

• Safety features are

– simple,

– reliable,

– clear, and

– easily understood.

• Safety device design may be

– passive,

– active,

– integrated,

– an accessory

Product selection & evaluation

• Product evaluation is completed by a representative

group of frontline users of the safety device who have

been educated and trained in the correct use of the

device

• A survey tool includes the criteria and measures for the

evaluation.

• Final product selection is based on data analysis of the

completed product evaluation forms

Product selection & evaluation

Cost analysis of the product includes

– the cost of the sharps safety product,

– the potential cost savings of reducing or

eliminating sharps injuries, and

– the cost of educating and training personnel

Product selection & evaluation

• After the introduction of a new safety device, an assessment is

performed to evaluate

– acceptance,

– correct usage,

– usage rate,

– device performance, and

– the effect on the rate of sharps injuries.

• Safety-engineered devices must be evaluated annually.

– Current devices should be evaluated for efficacy in reducing or

preventing sharps injuries.

– New devices should be evaluated if current devices are not

preventing sharps injuries.

Culture of safety

Health care organizations that support and

promote safety may have a reduction in

occupational exposures to bloodborne

pathogens.

Creating a culture of safety

Management initiatives

• Patient and health care personnel safety

• Health care personnel participation in safety

planning

• The availability of appropriate PPE and safety

devices for the identified tasks

• The influence of group norms regarding

appropriate safety practices

• The facility’s socialization process for newly hired

personnel

Safety Climate & Worker Behavior

Safety

Climate

Influences the

Adoption of

Safety Behaviors

Influences

Co-Workers

Behaviors

Leads to a Safer

Work

Environment

Leads to Increased

Perception of a Safe

Environment

Sharps Safety

Law!

• OSHA 29 CFR 1910.1030 (1992)

• Needlestick Safety & Prevention Act (2000)

Evidence supports sharps safety measures

Support and recommendation of perioperative

organizations

AORN Sharps Safety Survey Results

Obstacles preventing compliance:

– Conventional sharps readily available: 55%

– Lack of multidisciplinary support: 52%

– Perceived lack of empowerment: 32%

– Training methods & frequency: 29%

– Lack of culture of safety: 27%

– Budget or cost-reduction: 24%

– Not supported by management: 15%

Implementation Sharps Safety Tool Kit

• Educational power points

(perioperative staff &

surgeons)

• Implementation plan for a

trialing blunt tip needles

• Evaluation of sharps safety

devices

• Analysis of sharps injuries

• Sharps safety poster “how

to”

• List of online resources

• Frequently Asked Questions

• Evidence-based Posters

References

1. Aarnio P, Laine T. Glove perforation rate in vascular surgery--a comparison between single and double gloving. Vasa. 2001;30(2): 122-124. [IA]

2. Bessinger CD Jr. Preventing transmission of human immunodeficiency virus during operations. Surg Gynecol Obstet. 1988;167(4): 287-289. [VA]

3. 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)(5): CD004287. doi:10.1002/14651858.CD004287.pub3. [IA]

4. Florman S, Burgdorf M, Finigan K, Slakey D, Hewitt R, Nichols RL. Efficacy of double gloving with an intrinsic indicator system. Surg Infect (Larchmt). 2005;6(4): 385-395. doi:10.1089/sur.2005.6.385. [IIB]

5. Fry DE. Occupational risks of blood exposure in the operating room. Am Surg. 2007;73(7): 637-646. [VB]

6. 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. doi:10.1016/j.jamcollsurg.2009.12.018. [VA]

7. 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. [IA]

8. Ly J, Mittal A, Windsor J. Systematic review and meta-analysis of cutting diathermy versus scalpel for skin incision. Br J Surg. 2012;99(5): 613-620. doi:10.1002/bjs.8708; 10.1002/bjs.8708. [IA]

9. 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.. Infection Control & Hospital Epidemiology. 2004;25(7): 556-562. [VB]

10. 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: CD009170. [IA]

11. 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. doi:10.1016/j.ajic.2006.01.004. [VB]

12. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2009;3: CD003087. doi:10.1002/14651858.CD003087.pub2. [IA]

13. Weiss ES, Makary MA, Wang T, et al. Prevalence of blood-borne pathogens in an urban, university-based general surgical practice. Ann Surg. 2005;241(5): 803-7; discussion 807-9. [VA]

NOTICE/COPYRIGHT NOTICE

The content in this publication is provided on an “as is” basis.

TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC. DISCLAIMS ALL WARRANTIES,

EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT

LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OR

THIRD PARTIES RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE.

COPYRIGHT

AORN’s training and educational materials are protected under federal copyright and trademark

law. Only registered students may use our materials. Any unauthorized use of our materials is

strictly prohibited. Violations of these requirements or of our valuable intellectual property rights

may incur substantial penalties, including statutory damages of up to $150,000 for a single willful

violation of AORN’s copyrights.

PRESENTATION/SPEAKER INFORMATION

Presenters are responsible for the content of their presentations and for obtaining permission to

use any copyrighted material. AORN recognizes the sessions as continuing education for RNs.

This recognition does not imply that AORN or the American Nurses Credentialing Center’s

Commission on Accreditation approves or endorses products mentioned in the activity. AORN is

not responsible for and does not assume any liability for presentations.