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Introduction

The following Guideline for Sharps Safety has been approved by the AORN Recommended Practices Advisory Board. It was presented as proposed recommendations for comments by members and others. The guideline is effective June 15, 2013. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the various settings in which perioperative nurses practice; therefore, this guideline is adaptable to various practice settings. These practice settings include traditional operating rooms (ORs), ambulatory surgery centers, physicians’ offices, cardiac catheterization laboratories, endoscopy suites, radiology departments, and all other areas where operative and other invasive procedures may be performed.

Purpose

This document provides guidance to perioperative registered nurses (RNs) in identifying potential sharps hazards and developing and implementing best practices to prevent sharps injuries and reduce bloodborne pathogen exposure to perioperative patients and personnel.

Health care workers are at risk for percutaneous injury, exposure to bloodborne pathogens, and occupational transmission of disease. 1  Annually, an estimated 384,325 hospital health care workers sustain a percutaneous injury. 2  When non-hospital health care workers are included, the number increases to more than 500,000. 3  Percutaneous injuries are associated primarily with occupational transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV, but also may be implicated in the transmission of other pathogens. 1,3-17  A 2006 review of pathogens transmitted in published cases since 1966 showed transmission of 60 pathogens or species, which included 26 viruses, 18 bacteria or Rickettsia, 13 parasites, and three yeasts. 18 

The occupational risk of HBV transmission is dependent on the level of exposure to blood and the type of hepatitis B antigens. 19  Since the widespread adoption of HBV immunizations, the number of HBV infections in health care workers has declined significantly. 19-23  The reported number of HBV-infected providers in 1983 was 10,000 compared to approximately 100 in 2009. 20,21  The rate of anti-HCV seroconversion after an occupational exposure to HCV positive blood ranges from 0% to 7% with an average rate of 1.8%. 13,19,21,24,25  Although the risk of occupational transmission of HIV depends on the type and severity of the exposure, 19,26-28  the average risk is 0.3%. 12,19,26,28,29 

Percutaneous injuries carry risks not only to perioperative personnel but to patients as well. 20,21,25,30-33  If a health care worker infected with a bloodborne pathogen experiences a percutaneous injury and the object that caused the injury reconnects with the patient or the health care worker’s glove perforation is undetected, the patient is at risk for infection. 34  There have been 132 documented cases of health care provider to patient transmission of HBV, HCV, or HIV worldwide. 17,20,31,35-37 

The bloodborne pathogens standard 29 CFR 1910.1030 became effective March 6,1992. 38  The standard includes definitions, an exposure control plan, engineering and work practice controls (eg, personal protective equipment [PPE]), vaccinations, post-exposure follow-up, employee training, and record keeping. 38  The purpose of the bloodborne pathogen 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 and work practice controls. 39 

The Needlestick Safety and Prevention Act was signed into law on November 6, 2000. 40  The act directs the Occupational Safety and Health Administration (OSHA) to revise the bloodborne pathogens standard. The revisions included adding engineering control definitions; including requirements for technology changes that eliminate or reduce bloodborne pathogen exposure in exposure control plans; including input from frontline, non-managerial employees in the identification, evaluation, and selection of safety-engineered devices and work practice controls; annually documenting the evaluation in the exposure control plan; including employee input in the exposure control plan; and maintaining a sharps injury log. 40-42 

Sharps injury prevention is a concern for all members of the perioperative team. Many perioperative professional associations have developed sharps safety position and guidance statements. AORN adopted its “Position statement on workplace safety” in 2003, identifying bloodborne pathogen exposures from percutaneous injuries as a risk in the perioperative environment. 43  The “AORN guidance statement: Sharps injury prevention in the perioperative setting,” published in 2005, assisted perioperative nurses in developing sharps injury prevention programs and provided strategies to overcome compliance obstacles. Risk-reduction strategies included double gloving, using the neutral or hands-free zone, and using safety-engineered devices. 44 

The Association of Surgical Technologists (AST) adopted its “Guideline statement for the implementation of the neutral zone in the perioperative environment” in 2006. 45  The AST “Recommended standards of practice for sharps safety and use of the neutral zone” were developed the same year to provide support for and reinforce sharps safety and the use of a neutral zone. 46 

The American Academy of Orthopaedic Surgeons issued a statement on preventing the transmission of bloodborne pathogens in 2001. 32  Prevention strategies included employers establishing a prevention and treatment-of-exposure plan, providing PPE, and promoting double gloving and the use of a neutral zone. 32 

The American College of Surgeons (ACS) developed and approved its statement on sharps safety [ST-58] in 2007. The ACS recommends the universal adoption of double gloving, using blunt suture needles to close the fascia and muscle, using hands-free techniques, and using sharps injury prevention devices. 47 

The Council on Surgical & Perioperative Safety (CSPS)—a member organization composed of AORN, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the ACS, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the AST—endorsed sharps safety measures to prevent injury during perioperative care. Sharps safety measures should include double gloving, using blunt suture needles for closing facia and muscle, and using a neutral zone when appropriate to avoid hand-to-hand passage of sharps. The CSPS sharps statement was adopted in 2007 and modified in 2009. 48 

In November 2010, a consensus statement and call to action was drafted by members of the steering committee at the 10th Anniversary of the Needlestick Safety and Prevention Act: Mapping Progress, Charting a Future Path conference, sponsored by the International Healthcare Worker Safety Center at the University of Virginia. The consensus statement was released in 2012 and endorsed by 20 organizations. It lists improving sharps safety in surgical settings as the number-one priority to reduce percutaneous injuries. 49 

In a joint safety communication, the US Food and Drug Administration (FDA), the National Institute for Occupational Safety and Health (NIOSH), and OSHA encourage health care professionals in surgical settings to use blunt-tip suture needles for suturing muscle and fascia when it is clinically appropriate. 50  Blunt-tip suture needles reduce the risk of needlestick injury and the risk of bloodborne pathogen transmission. 50 

Understanding the etiology of percutaneous injuries in the perioperative setting is paramount to developing a sharps injury prevention program. The perioperative setting is a high-risk environment for exposure to bloodborne pathogens from percutaneous injuries. 51  The International Healthcare Worker Safety Center at the University of Virginia 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. 36,51  There were 7,186 sharps injuries to surgical personnel reported between 1993 and 2006. 51  When surgeons and surgical residents sustained a sharps injury, they were the original user of the device in 81.9% and 67.3% of the injuries, respectively. Nurses and surgical technologists were injured by devices used by others in 77.2% and 85.1% of the injuries, respectively. The majority of injuries occur to surgeons and surgical residents during use, while the sharps injuries to nurses and surgical technologists occur during passing, disassembling, and disposal. 51  The perioperative environment is unique in health care. 51  Perioperative personnel are at a distinct risk of percutaneous injury because of 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. 51,52 

An economic analysis of a retrospective survey estimated the effect of an occupational exposure from a needlestick injury. Associated costs included post-exposure health services, post-exposure testing, post-exposure prophylaxis, missed work days, and loss of productivity. Based on the findings, researchers projected the national economic burden per year at $65 million. 53  A convenience sample of health care facilities provided information on the cost of managing an occupational exposure, including reporting time, follow-up, salaries, and laboratory testing of the source individual and exposed health care worker. Overall costs ranged from $71 to $4,838 per exposure. 54  An analysis of the estimated costs of needlestick injuries and subsequent infections for hospital and non-hospital-based health care workers for testing, prophylaxis, and long-term infection suggests a range of $100.7 million to $405.9 million annually based on 2004 statistics. 55  The emotional burden of an occupationally acquired infection to the health care worker and his or her family members and the time spent waiting and wondering cannot be measured. 56 

Sharps safety is a priority in the perioperative environment and includes considerations for standard precautions, health care worker vaccination, post-exposure 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 conducted a systematic review of MEDLINE®, CINAHL®, Scopus®, and the Cochrane Database of Systematic Reviews for meta-analyses, randomized and nonrandomized trials and studies, systematic and nonsystematic reviews, guidelines, case reports, and opinion documents and letters. Search terms included needlestick injuries, sharps injuries, bloodborne pathogens, occupational accidents, occupational injuries, medical staff, nurses, perioperative nursing, operating room nursing, perioperative nurses, operating room nurses, operating rooms, surgical procedures, surgical instruments, safety devices, sutures, scalpels, sharps, scalpel injuries, needlesticks, needle sticks, safety scalpels, safety-engineered sharps, blunt-tip needles, hands-free passing, neutral zone, double gloving, and double-gloving.

The lead author and medical librarian identified and obtained relevant guidelines from government agencies, other professional organizations, and standards-setting bodies. The lead author assessed additional professional literature, including some that initially appeared in other articles provided to the author.

The initial search was conducted in 2011 and was limited to articles published in English from 1992, when OSHA’s Bloodborne Pathogens Final Standard was established. The librarian established continuing alerts on sharps safety-related topics and provided relevant results to the lead author. The lead author and medical librarian also identified relevant guidelines from accreditation organizations, government agencies, and standards-setting bodies. In addition, the lead author requested other articles identified through literature appraisal and other outside sources.

Articles identified by the search were provided to the project team for evaluation. The team consisted of the lead author, three members of the Recommended Practices Advisory Board, two members of the Research Committee, and a doctorally prepared evidence appraiser. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the Johns Hopkins Evidence-Based Practice Model and the Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score as agreed upon by consensus of the team. The appraisal score is noted in brackets after each reference, as applicable. The collective evidence supporting each intervention within a specific recommendation was summarized and used to rate the strength of the evidence using the AORN Evidence Rating Model. Factors considered in review of the collective evidence were the quality of research, quantity of similar studies on a given topic, and consistency of results supporting a recommendation. The evidence rating is noted in brackets after each intervention.

 

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

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