Experienced surgeons don’t necessarily wake up in the morning with sharps injuries on their minds. For most, safety precautions have become routine.
Yet that may be a dangerous thing, especially in light of the fact that deadly bloodborne pathogens such as HIV and hepatitis continue to pose risks to the health care community.
“It’s an important topic for ophthalmologists to address,” noted I. Howard Fine, MD, clinical professor of ophthalmology at Oregon Health & Science University and founding partner of Oregon Eye Associates, Eugene.
Manufacturers continue to introduce products designed to increase the safety of needles and blades. Any new devices on the horizon, however, may prove ineffective without being accompanied by common sense and a “culture of safety,” said Victoria B. Navarro, MAS, MSN, RN, director of nursing at Johns Hopkins’ Wilmer Ophthalmological Institute.
While there are no separate statistics differentiating needlestick injuries from sharps injuries, the combined numbers are sobering. According to the Centers for Disease Control and Prevention, American health care workers report more than 800,000 needlesticks and sharps injuries every year.
The AMA Council on Scientific Affairs’ report, Preventing Needlestick Injuries in Health Care Settings, said that, of these injuries, 13 percent are to doctors, and 42 percent occur between use and disposal.
Other statistics to consider:
- Needlestick injuries caused by hollow-bore needles accounted for 86 percent of all reported occupational HIV exposures.
- An estimated 12,000 health care workers are infected with hepatitis B and C through needlesticks every year, and 200 to 300 of them may die from bloodborne diseases.
The risk of infection after exposure to infected blood varies by pathogen. Jonathan M. Davidorf, MD, of the Davidorf Eye Group in West Hills, Calif., said the risk of transmission after exposure to HIV-infected blood is about 0.3 percent. However, it is estimated to be up to 100 times greater for hepatitis B virus (30 percent and could be as high as 10 percent for hepatitis C virus.
Dr. Davidorf pointed out that most general surgeons, in an effort to protect themselves from needlestick injuries in the OR, have become used to the idea of “double gloving,” which “significantly decreases the inoculum should you get stuck by a needle.” However, he said, “This practice has not caught on with ophthalmologists because dexterity is a huge issue for us.”
Nevertheless, the risk of needlestick injuries remains a concern, especially in light of the fact that they are preventable.
Developing a Culture of Safety
Ophthalmologists face unique challenges in the area of safety because of the high-volume, fast-paced nature of their work, said Ms. Navarro. Safety issues must be balanced with the need to be efficient and productive.1
“To be successful in creating a safe environment for the patient and the health care provider, it is imperative that a culture of safety is developed in your institution,” Ms. Navarro pointed out. “The concept of safety must be integrated into the day-to-day operations.”
At Wilmer, physicians, nurses and staff comply with the Hopkins Bloodborne Pathogens Control Program, which includes the following components:
- Needlestick hotline and follow-up. A 24-hour hotline provides employees with steps to follow immediately after a needle/sharp stick or a blood/body fluid splash. The Occupational Injury Clinic performs follow-up evaluation if postexposure antiviral therapy for HIV or postexposure prophylaxis is needed. Postexposure counseling also is provided, in accordance with guidelines from the CDC.
- Workplace controls. The Wilmer plan includes specific procedures for workplace controls such as handling of needles and sharps and personal protective equipment. In addition, there is an ongoing product evaluation program for such items as improved sharps containers and protective needle/sharp covers.
- Training and tracking. Employees receive bloodborne pathogen training during orientation and must comply with required annual updates. Reports of needle/sharp stick injuries are sent out quarterly, and multiyear trend analysis is done to monitor compliance with preventable injuries and measure success of safety programs, Ms. Navarro said.
Dr. Fine also mentioned the culture of safety at his surgery center. “It is not rare for surgeons to stick themselves with a knife, either during a procedure or while passing the instrument to a scrub nurse or assistant,” he said. As a result, “We have developed procedures to help ensure the safety of our personnel in the OR,” he said. “For example, we try to close the knife before passing it off. However, if we don’t, we will say ‘Blade is out.’ In addition, we have special systems for passing sharps to avoid someone getting stuck while reaching for a blade.”
Manufacturers are well aware of the need for device safety. In an ideal world, said the National Institute for Occupational Safety and Health, safety device designs would include the following:
- The device would be needleless.
- The safety feature would be an integral part of the device.
- If user activation is necessary, the safety feature could be engaged with a single-handled technique and would allow the worker’s hands to remain behind the exposed sharp.
- The user could easily tell whether the safety feature is activated.
- The safety feature could not be deactivated and would remain protective through disposal.
“Although each of these characteristics is desirable, some are not feasible, applicable or available in certain health care situations,” NIOSH acknowledged.2
Examples of safety device designs in the ophthalmic market include the following:
- Safer needles and syringes. BD Medical-Ophthalmic System’s Eclipse Injection Needles work with any luer lock syringe. With single-handed activation, the needle is locked in the activated cover and safety activation can occur immediately after injection. Another BD Medical product, the Safety-Lok Syringe, is the only safety-engineered syringe of its type to offer clear visual confirmation of the lock position.
- Safer knives. Diamatrix has introduced a safety handle on its diamond knives in what the company describes as “an effort to make sharps safe devices commonplace in the ophthalmic OR.”
About two years ago, the company introduced a protective sleeve for its diamond blades. “The protective sleeve completely covers up the blade and is slid over the blade before and after usage,” said Charles H. Williamson, MD, medical director of the Williamson Nelson Eye Center in Baton Rouge, La. “The sleeve retracts completely back over the handle so it is not in the way. In addition, this protective sleeve can be retracted with one hand.” Dr. Williamson added, “Interestingly enough, the protective sleeve also prevents the blade from touching other instruments or being damaged, which in turn allows the blade to stay sharp longer.”
And this year, BD Medical introduced a “safety platform” that includes the BD Safety Knife. The knife has an integrated safety shield that is user-activated. This “represents a great addition to the comfort level of the people passing the knife,” Dr. Fine said.
1 See also the Academy’s Information Statement Minimizing Transmission of Bloodborne Pathogens and Surface Infectious Agents in Ophthalmic Offices and Operating Rooms at www.aao.org.
2 NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings; available at www.cdc.gov.
Ms. Navarro and Drs. Davidorf, Fine and Williamson have no related financial interests.
Regulations and Fines
On the regulatory side of things, the Needlestick Safety and Prevention Act was passed in April 2001. The Act revised the OSHA Bloodborne Pathogens Standard, clarifying the need for employers to select and implement safer medical devices, involve employees in identifying and choosing such devices and maintain a log of injuries from contaminated sharps.
OSHA enforces the Act by conducting on-site inspections and issuing citations and fines when facilities are deemed out of compliance. Each OSHA citation can lead to a fine of up to $7,000, and blatant violations can result in fines as high as $70,000. Failure to use a safety product, like a safety hypodermic needle and syringe, can lead to multiple citations.