Sharps Safety

Purpose

This document provides guidance to the perioperative team for identifying potential sharps hazards and developing and implementing best practices to prevent sharps injuries and reduce bloodborne pathogen exposure for perioperative patients and personnel.

Health care workers are at risk for percutaneous injury, exposure to bloodborne pathogens, and occupational transmission of disease.¹  It is estimated that more than 2 million health care workers worldwide sustain a percutaneous injury with a contaminated sharp object each year and that 25% to 90% of these injuries go unreported.²  An estimated 385,000 percutaneous injuries occur among hospital health care workers in the United States annually.³  Physicians are most frequently injured in operating and surgical settings (70.5%) when using sutures (47%) and scalpels (8.3%).⁴  A surgeon will sustain a sharps injury during approximately one in 10 surgical procedures, as determined in a meta-analysis and meta-regression of 45 studies published between 2000 and 2017 on the incidence of sharps injuries in surgical units.⁵ 

Percutaneous injuries are associated with epidemiologic, economic, and emotional burdens. The epidemiologic burden is the occupational transmission of bloodborne pathogens (eg, hepatitis B virus [HBV], hepatitis C virus [HCV], human immunodeficiency virus [HIV]). In the United States, an estimated 2.4 million people are living with HCV.⁶  Approximately 25% of the estimated 1.2 million people living with HIV in the United States are coinfected with HCV, and 10% are coinfected with HBV.⁷  An occupational exposure carries the potential for seroconversion to multiple pathogens.

The odds of a health care worker contracting an HCV infection are 1.6 times greater than for the general public.⁸  Health care professionals who are at high risk for blood contact have 2.7 times greater odds of contracting an HCV infection than the general public.⁸  The number of HBV infections in health care workers has declined significantly with the widespread adoption of HBV immunizations and standard precautions.⁹  Between 1985 and 2013, 58 documented and 150 possible cases of occupationally acquired HIV infection among health care workers were reported to the Centers for Disease Control and Prevention (CDC).¹⁰  Published case reports describe occupational transmission of additional pathogens, including viruses (eg, hepatitis G,¹¹  cytomegalovirus,¹²  herpes simplex type 1¹³ ), bacteria (eg, Mycobacterium tuberculosis,^14-16  Corynebacterium striatum¹⁷ ), protozoa (eg, Plasmodium falciparum^18,19 ), parasites, and yeasts.²⁰ 

The epidemiologic burden also extends to surgical patients. If a perioperative team member infected with a bloodborne pathogen experiences a percutaneous injury and glove perforation, the health care worker’s blood could contact the patient’s blood and place that patient at risk for transmission of the bloodborne disease.²¹  Published case reports include provider-to-patient transmission of HBV,²²  HCV,²³  and HIV.²⁴ 

The economic burden of a percutaneous injury includes the costs of laboratory testing for the injured health care worker and the source patient if known, postexposure prophylaxis, short- and long-term treatment of chronic blood-borne pathogen infections, lost productivity, staff replacement, counseling for the injured employee, and potential legal consequences and compensation claims.^25-27  In a systematic review of 12 studies, Lee et al²⁵  determined that the cost of a single needlestick injury ranged from $51 to $3,766 (2002 US dollars). The costs varied by the institutional protocol for management of an occupational exposure. In the least expensive situations, the source patient was negative for HIV, HBV, and HCV, and no postexposure prophylaxis was required. In the most expensive situations, the source patient tested positive for HIV and the injured worker required postexposure prophylaxis.

Mannocci et al²⁸  reviewed 14 studies on needlestick injury costs from Europe, America, Asia, and Australia. The median of the means for aggregate (direct and indirect) costs was Int$747 with a range of Int$199 to Int$1,691 (2016 dollars). Leigh et al²⁹  analyzed the estimated combined cost of $188.5 million for 644,963 needlestick injuries, which included $107.3 million for medical costs and $81.3 million (2007 dollars) for lost productivity. The combined costs make up approximately 0.1% of all occupational injury and illness costs for all types of jobs in the economy.

The emotional burden of experiencing a percutaneous injury and the possibility of an occupationally acquired infection manifests as stress,^25,30,31  post-traumatic stress disorder,^27,32  anxiety,^27,33,34  anger,^33,34  and depression.^27,34,35 

The perioperative setting is a high-risk environment for exposure to bloodborne pathogens from percutaneous injuries due to the presence of large quantities of blood and other potentially infectious body fluids, prolonged exposure to open surgical sites, frequent handling of sharp instruments, and the requirement for coordination between team members while passing sharp surgical instruments.^36,37  Understanding the etiology of percutaneous injuries in the perioperative setting is paramount in developing a sharps injury prevention program. Jagger et al³⁶  compared percutaneous injury surveillance data of 87 participating hospitals before and after the passage of the Needlestick Safety and Prevention Act of 2000. The analysis showed a 6.5% increase in injuries in the surgical setting compared to a 31.6% decrease in nonsurgical settings.³⁶  Between 1993 and 2006, surgical personnel reported 7,186 sharps injuries. When surgeons and surgical residents sustained a sharps injury, they were the original user of the device 81.9% and 67.3% of the time, respectively. Nurses and surgical technologists were injured by devices used by others 77.2% and 85.1% of the time, respectively. Data from 2018 showed an increase in sharps injuries for physicians (84%), although injuries for nurses remained almost the same (77.3%).⁴  Most of the injuries sustained by surgeons and surgical residents occurred during use, while the sharps injuries to nurses and surgical technologists occurred during passing, disassembling, and disposal.

The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens standard, 29 CFR 1910.1030, became effective March 6, 1992.³⁸  The purpose of the Bloodborne Pathogens standard is to limit health care worker exposure to HBV, HCV, HIV, and other potentially infectious materials in the workplace through the implementation of engineering controls and work practice controls (eg, personal protective equipment [PPE]), vaccinations, postexposure follow-up, employee training, and record keeping).³⁹  The Needlestick Safety and Prevention Act, signed into law on November 6, 2000, directed OSHA to revise the Bloodborne Pathogens standard.^39,40  The revisions included the addition of engineering control definitions and requirements for technology changes that eliminate or reduce bloodborne pathogen exposure in exposure control plans; input from frontline, nonmanagerial employees in the identification, evaluation, and selection of safety-engineered devices and work practice controls; annual documentation of the evaluation in the exposure control plan; employee input into the exposure control plan; and maintenance of a sharps injury log.³⁹ 

The hierarchy of controls provides structure for prioritizing interventions to reduce bloodborne pathogen exposure.⁴¹  The hierarchy starts with elimination of the hazard if possible, followed by use of engineering controls, work practice controls, administrative controls, and PPE. Elimination of the hazard includes removing the sharp object from use (eg, using electrosurgery instead of a scalpel for the incision). When the hazard cannot be eliminated, use of engineering controls can mitigate injuries. Safety-engineered devices such as blunt sutures needles or needleless IV connectors are examples of engineering controls. Work practice controls reduce the likelihood of exposure by changing the method by which a task is performed, to minimize the risk of exposure to blood or other potentially infectious materials.³⁸  An example of a work practice control is using a neutral or safe zone for passing sharp instruments and devices. Administrative controls include developing policies and procedures, incorporating sharps safety prevention into a new or existing committee structure, implementing an exposure control plan, and providing education and training. The OSHA Bloodborne Pathogens standard requires the use of PPE where there is a risk for occupational exposure to blood, body fluids, or other potentially infectious materials after engineering and work practice controls are implemented.³⁸ 

Sharps safety is a priority in the perioperative environment and includes considerations for standard precautions, health care worker vaccination, postexposure protocols and follow-up treatment, and treatment for health care workers infected with a bloodborne pathogen. These topics are addressed in other AORN guidelines, and although they are mentioned briefly where applicable (eg, standard precautions), broader discussions of these topics are outside the scope of this document.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2013 through December 2018. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until February 2019. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included accidents (occupational), bacteria-inhibiting gloves, blood exposure accident, bloodborne pathogens, blood-borne pathogens, blunt tip needles, double gloving, hands-free passing, hypodermic needles, hypodermic syringe, industrial accidents, infection control (instruments, equipment and supplies, methods, standards), needles, needlestick injuries, neutral zone, occupational blood exposure, occupational exposure, occupational injuries, occupational-related injuries, percutaneous exposure, percutaneous injury, protective devices, recapping, safety devices, safety scalpels, safety-engineered sharps, scalpel injuries, scalpels, sharps, sharps injuries, standard precautions, surgical hooks, surgical instruments, surgical staples, surgical stapling, sutures, syringes, universal precautions, virus-inhibiting gloves, wirestick injuries, and wire-stick injury.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Historical studies were also included. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1

Flow Diagram of Literature Search Results

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted if there was a disagreement between the lead author and the primary evidence appraiser. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. Embase is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL.