Discover evidence-based practices to prevent sharps injuries and to reduce blood borne pathogen exposure to perioperative patients and personnel. This presentation is from a recent AORN webinar. Listen to the replay for free at http://bit.ly/1asAKXx. When registering for the replay, you can also earn one contact hour through June 27, 2014.

1. Recommended Practices for
Sharps Safety
Mary J. Ogg, MSN, RN, CNOR
June 27, 2013

2. Thank you
Funded through the AORN Foundation and
supported by a grant from Aspen Surgical

3. 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

4. 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
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1. Consultant/Speaker’s Bureau 2. Employee
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5. Grant/Research Support 6. Other relationship (specify)
7. No conflict of interest

5. 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

6. Evidence-rated RPs – The New Generation
Johns Hopkins Nursing
Evidence-Based Practice
Model

7. Research
Single studies Multiple studies
- Experimental - Systematic reviews
- Quasi-experimental • with or without
- Non-experimental meta-analysis or
- Qualitative meta-synthesis

8. 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

9. AORN Research Appraisal Tool

10. AORN Non-Research Appraisal Tools

11. 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.

12. 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

13. OSHA’s Bloodborne Pathogen Standard
29CFR 1910.1030
Hierarchy of Controls
• Elimination of the hazard
• Engineering controls
• Work practice controls
• Administrative controls
• PPE

15. 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

16. 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.

17. 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.

18. Hierarchy of Controls
PPE
– Recommendation IV
– Perioperative
personnel must use
PPE.

19. 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

20. Recommendation II
Indications
-Muscle
-Fascia
Blunt suture needles should be used
when clinically indicated

21. 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

22. 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

23. 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

24. 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.

25. Safety scalpels
• Single use
– no disassembly required
• Re-useable
– shielded or sheathed
– retracting scalpel blades

26. 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

27. 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

28. Recommendation III
Surgical team members
should use a neutral
zone or hands-free
technique for passing
sharp instruments,
blades, and needles

29. 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.

30. Recommendation III
A no-touch technique should be used when
handling sharps.

31. 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

32. 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

33. 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

34. 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.

35. 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.

36. 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

37. Perforation indicator systems
Perforations are detected more frequently and reliably
with perforation indicator glove system.

38. 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

39. 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

40. 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.

41. 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

42. • 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

43. 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

44. 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

45. 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

46. 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.

47. Culture of safety
Health care organizations that support and
promote safety may have a reduction in
occupational exposures to bloodborne
pathogens.

48. 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

49. 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

50. 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

51. 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%

52. 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

53. 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]

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