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Sharps Safety - AORN Recommended Practices

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Information about Sharps Safety - AORN Recommended Practices
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Published on July 17, 2013

Author: aornsocialmedia

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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.
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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.

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