American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Statement on Sharps Safety

This statement was developed by the College’s Committee on Perioperative Care and approved by the Board of Regents at its June 2007 meeting.

Sharps injuries and surgical glove tears continue to expose surgeons and operating room (OR) personnel to the risk of human immunodeficiency virus, viral hepatitis B, viral hepatitis C, and bacterial infections from patients. Patients’ blood makes contact with the skin or mucous membranes of OR personnel in as many as 50 percent of operations, with cuts or needlesticks occurring in as many as 15 percent of operations. Surgeons and first assistants are at highest risk for injury, sustaining up to 59 percent of the injuries in the operating room. Scrub personnel have the second highest frequency of injuries in the OR (19%), followed by anesthesiologists (6%) and circulating nurses (6%). For surgeons, suture needles are the most frequent source of sharps injuries.

The American College of Surgeons supports work practices that strive to eliminate, protect, or standardize the use of sharp instruments in the OR. The ACS also recommends the use of structured evaluations and user-based criteria that include performance standards, task analysis, simulation, and training programs for devices intended to reduce sharps injuries in the OR.

A team approach to sharps safety is critical to reduce the risk of blood-borne infections resulting from sharps injuries in the operating room. Hospitals and health care facilities should make sharps injury-reduction techniques and instruments available for surgeons and OR personnel.

Recommended OR work practices

Double gloving. Glove barrier failure is common with reported perforation rates as high as 61 percent for thoracic surgeons and 40 percent for scrub personnel. Double gloving reduces the risk of exposure to patient blood by as much as 87 percent when the outer glove is punctured. Double gloving has certain disadvantages such as decreased tactile sensation. In certain types of surgery (such as neurosurgery), where delicate manipulation of instruments and tissues is required, double gloving may impair the surgeon’s ability to safely perform the procedures. Despite a large body of data documenting the benefits of double gloving, this technique has not received wide acceptance by surgeons. In many cases, a period of adaptation and “retraining” seems to be required before practitioners feel comfortable with the technique. New specially designed undergloves have recently become available to make the process of double gloving more acceptable to surgeons.

  • The ACS recommends the universal adoption of the double glove (or underglove) technique in order to reduce body fluid exposure caused by glove tears and sharps injuries in surgeons and scrub personnel. In certain delicate operations, and in situations where it may compromise the safe conduct of the operation or safety of the patient, the surgeon may decide to forgo this safety measure.

Blunt tip suture needles

Suture needle injuries pose the greatest risk of sharps injury to the surgeon and scrub personnel. The effectiveness of the use of blunt tip suture needles in reducing sharps injuries is supported by a number of randomized studies and case series that demonstrate decreases in the rates of glove puncture from as high as 38 percent down to 6 percent—and down to zero in some cases—following the adoption of blunt suture needles. The use of blunt suture needles requires no changes in work practices for surgeons. A new generation of blunt suture needles is now on the market with a slightly more tapered tip profile that may provide for easier suturing compared to the earlier needles used in the referenced studies.

  • The ACS recommends the universal adoption of blunt tip suture needles for the closure of fascia and muscle in order to reduce needle-stick injuries in surgeons and OR personnel.

The neutral zone

The hands-free technique (HFT) requires the surgical team to designate a sharps neutral zone (for example, a towel, Mayo stand, magnetic pad, and so on) for the pickup and release of surgical sharps such as needle-holders, scalpels, and syringes with needles. In this manner, there is no direct handing of instruments from scrub person to surgeon and back. If the surgeon must not break eye contact with the surgical field during critical parts of the operation where patient safety or workflow might be compromised, a partial HFT may be used whereby sharps are directly handed by the scrub person to the surgeon, but then returned to the scrub person via a neutral zone.

The use of the neutral zone to transfer sharps is supported by the Occupational Safety and Health Administration and the Association of periOperative Registered Nurses as a method to reduce health care workers’ risk of sharps injury during surgery. The data supporting the use of HFT are inconclusive at present, with one large study reporting lower needlestick rates when the HFT technique was used more than 75 percent of the time, and another smaller randomized controlled trial reporting no difference in needlestick rates with HFT use. The HFT technique is mandatory in a significant minority of hospitals in the U.S. while research continues in this area.

  • The ACS recommends the use of HFT as an adjunctive safety measure to reduce sharps injuries during surgery except in situations where it may compromise the safe conduct of the operation, in which case a partial HFT can be used.

Engineering sharps injury prevention devices

Engineering sharps injury prevention (ESIP) mechanical devices hold promise in providing varying degrees of mechanical protection from sharps injuries involving suture needles and scalpel blades. Manufacturers of ESIP devices approved by the U.S. Food and Drug Administration have been allowed to claim prevention of sharps injury as a feature of their use. There are no studies published to date that demonstrate the clinical effectiveness of ESIP devices. The design and quality of these devices has been variable and their acceptance by surgeons limited. Nevertheless, these devices may contribute to minimizing sharps injuries in the OR. The use of safety scalpels is mandatory in most U.S. hospitals today.

  • The ACS recommends the use of ESIP devices as an adjunctive safety measure to reduce sharps injuries during surgery except in situations where it may compromise the safe conduct of the operation or safety of the patient.

Additional resources

  • International Sharps Injury Prevention Society: Education, information and product knowledge to help reduce the number of sharps injuries; www.isips.org
  • International Healthcare Worker Safety Center EPInet—Exposure Prevention Information Network: www.healthsystem.med.virginia.edu/internet/epinet/about_epinet.cfm
  • The Joint Commission Sentinel Alert. Preventing Needle stick and Sharps Injuries. August 2001; www.jointcommission.org/sentinel/sentineleventalert/sea_22.htm
  • Davis MS. Advanced Precautions for Today’s O.R. In: The Operating Room Professional’s Handbook for the Prevention of Sharps Injuries and Bloodborne Pathogen Exposures. Atlanta, GA: Sweinbinder Publications LLC; 2001.
  • Training for the Development of Innovative Control Technologies Project (TDICT) Project: www.tdict.org

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Reprinted from Bulletin of the American College of Surgeons
Vol.92, No. 10, October 2007