Barriers to Successful Practice in Sharps Injuries Prevention
Contents
Introduction …………………………………………………………………………… 2
Aims of the study …………………………………………………………………… 3
Significance of the study …………………………………………………………… 4
Background …………………………………………………………………………… 5
Literature Review …………………………………………………………………… 6
Methodology ………………………………………………………………………….. 11
Preparation for the Project ………………………………………………………….. 12
Focus Group Discussion ………………………………………………………….. 13
Ethical Aspect ………………………………………………………………….. 14
Critique ………………………………………………………………………….. 15
References ………………………………………………………………………….. 16
Introduction
Between 600,000 to one million accidental needle sticks and sharp injuries occur annually in health care settings (, 1999). These injuries commonly occur when needles are recapped, intravenous lines and needles are mishandled, or needles are left at a patient’s bedside. The risk of exposure of health care workers to blood borne pathogens has led to the development of needleless devices or special needle safety devices ( & , 2004). Sharps injuries have indeed taken center stage among some of the most serious occupational health hazards plaguing healthcare professionals today, and with as many as 1 million of such injuries reported each year, the issue certainly deserves the attention.
In Hong Kong, such a situation is not uncommon. Observations of some hospitals in Hong Kong, which will not be made for reasons of privacy, have shown that there are some incidents of sharps injuries. As a result of a recent review of safety standards within health care organization, Hong Kong government and health officials recognized the need to raise awareness of health and safety legal requirements within the management structure.
Unfortunately, sterile processing departments are often overlooked when facilities weigh the inherent risks and impose sharps safety programs and standards. Typically, nurses, surgeons, operating room staff and even housekeeping personnel rank highest on the sharps injury priority scale, while health care professionals are sometimes addressed “peripherally” at best, leaving these vulnerable employees unprotected (, 2002).
The operating room (OR) setting is a high risk environment, and perioperative registered nurses are routinely faced with high risk for exposure to blood-borne pathogens from percutaneous injuries. Although the scope of the problem is not completely known, the National Institute for Occupational Safety and Health (NIOSH) estimates that 600,000 to 800,000 percutaneous injuries occur annually among heath care workers. Percutaneous injuries primarily are associated with occupational transmission of the hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV, but they may be implicated in the transmission of more than 20 other pathogens. Understanding the etiology of injuries in the operating room setting is paramount to developing a safe prevention program.\
Another problem in many communities in Hong Kong is the reuse of needles and syringes. Deaths attributable to reuse of needles and syringes equal the combined death rate of the three highest childhood killers not only in Hong Kong but all over the world – measles, tetanus and whooping cough (, 2000).
Aims of the Study
This study aims to answer the question:
What are the perceived barriers of health care professionals, specifically the registered nurses and certified surgical technologists in the implementation of successful practices in the prevention of sharps injuries in the hospital operating room?
Furthermore, this study also seeks to examine the current practices in the operating rooms of hospitals regarding sharps injuries prevention. Measures and practices that are currently used in the hospital will be examined and attitudes of the health care professionals towards it identified.
Significance of the study
The data collected about injuries and current practices will help health committees define or refine the objectives of its program and prioritize its efforts regarding sharp injuries. Ideally, a healthcare facility would be able to implement all protective measures simultaneously, thereby drastically reducing the risk of sharps injuries the moment a certain program is enacted.
The reality, however, is that different aspects of a facility’s sharps injury prevention program will be implemented over a period of time. Consequently, facilities should focus first on the applications that pose the greatest risk of sharps injuries from contaminated needles and other objects. Other applications should then be addressed in descending order of risk.
Additionally, this study can benefit the patients as well as the health care professionals who are at risk of sharps injuries in the operating room area of the hospital. Collecting and reviewing information about past sharps injuries and present work practices, such as that which is proposed in this study, is an essential step when designing or assessing a sharps injury prevention program. Similarly, assessing current work practices will help the health care settings identify procedures that may increase the risk of injuries.
Background
Sharp tools, instruments and needles have been used in the practice of medicine for thousands of years. Although uses for these types of instruments have become sophisticated over the years, disposal of these instruments has not evolved in a corresponding way. Thousands of health-care workers are incurring needlestick injuries at work every day. With our current knowledge of how incurable and sometimes fatal diseases are spread through dirty needlestick injuries, we must protect our employees from this risk. While we cannot eliminate the risk, we can take proactive measures to reduce significantly these risks. Some health professionals charged with the responsibility of managing these risks are being legislated into accepting increased accountability. This article discusses how to take a proactive approach to this problem, and perhaps avoid the potential excessive operating expenditures that some colleagues have incurred because of political legislation influenced in large part by trade unions (, 2000).
In Hong Kong, needlestick injuries are a hazard for hospital staff who deal directly with patients, such as; nurses, laboratory staff (especially phlebotomists) and medical radiation technologists. They are also a hazard for those who do not work directly with patients. Domestic and portering staff are routinely exposed to risk from needles that have not been disposed of properly, or are left on sterile procedure trays, or are lost in patients’ linen. Recently, the Ministry of Labor in Ontario was called to investigate an HSO where four housekeepers had incurred accidental needlestick injuries in the span of a month while removing garbage bags from patient treatment areas (, 2000).
Perioperative personnel work in an environment where the risk of blood and body fluid exposure is arguably greater than any other. The risks these exposures present add unnecessary stress to an already stressful work environment. In addition, the purely monetary costs associated with follow-up and necessary treatment of such exposures are high. Follow-up plus prophylaxis for a high risk exposure has been reported to be ,000. Ongoing treatment costs, if an employee becomes infected, can exceed million (, 2000).
Literature Review
Percutaneous injuries occur throughout all health care facilities, and many occur in the perioperative setting. Exposure to blood-borne pathogens occurs during all phases of the perioperative process. Research indicates that injuries from sharp devices or instruments occur in 7% to 15% of all surgical procedures. Procedures identified as posing the highest risk of injury are thoracic, trauma, burn, emergency orthopedic, major vascular, intra-abdominal, and gynecologic surgeries. Risk of a sharps injury increases during more invasive, longer procedures that result in higher blood loss. Fatigue resulting from working extended hours in combination with the fast pace of the perioperative environment also may contribute to increased risk of percutaneous injuries (, 2000).
Nurses comprise the largest segment of health care workers and are reported to sustain the highest number of percutaneous injuries overall. Observational studies have demonstrated that perioperative personnel experience the highest percutaneous injury rates, but 70% to 96% of exposures were underreported. Surgeons and first assistants have the highest risk of injury and sustain more than half (ie, 59%) of percutaneous injuries in the perioperative setting. Scrub personnel experienced the second highest frequency of percutaneous injury, followed by anesthesia care providers and circulating nurses.
Injuries from hollow bore needles constitute the majority of injuries and pose the highest risk of exposure to blood borne pathogens. Although the risk of injury from hollow bore needles is prevalent in the perioperative setting, the epidemiology of sharps injuries in the OR is different from that of other locations in health care. Suture needles have been identified as the most frequent mechanism of percutaneous injury in the OR; they are involved in as many as 77% of such injuries. Scalpels are the second most frequent mechanism of injury, followed by retractors, skin or bone hooks, and sharp electrosurgical tips (, 2000).
Percutaneous injuries often are self-inflicted. Studies indicate that 6% to 16% of these injuries occur during hand-to-hand passing of sharp instruments, suture needles, and other sharp devices. The most common body part injured is the nondominant hand ( & , 2004). Injuries from suture needles occur most often
* when loading the needle holder or repositioning the needle;
* during hand-to-hand passing of sharp devices between scrub personnel and the surgeon;
* during suturing, particularly muscle and fascia (eg, wound closure) when the needle is being manipulated and guided with fingers;
* when retracting or stretching tissue with hands;
* when the surgeon sews toward his or her own or an assistant’s hand;
* when tying suture with the needle attached;
* after the suture has just been used and remains unattended on the operative field–even if suture is unattended on the field for only a short time, the needle holder can fall off the field onto a health care worker’s foot, or scrubbed personnel may reach for it in an attempt to prevent it from sliding off the field;
* when placing the used needle in an overfilled sharps container;
Injuries from scalpels most often occur
* when loading or removing a disposable scalpel blade on a reusable knife handle;
* during hand-to-hand passing of the scalpel;
* during dissection when the tissue is being retracted or spread with hands;
* when cutting toward the surgeon’s or an assistant’s fingers;
* immediately before or after use when the scalpel is left on the operative field unattended–even if this is for only a short time, the scalpel can fall off the field onto a health care worker’s foot, or scrubbed personnel may reach for it in an attempt to prevent it from sliding off the field;
* when the scalpel is placed in an over-filled or poorly located sharps container
Glove barrier failure is a common occurrence in the perioperative setting. Glove failures can be caused by punctures, tears by sharp devices, or spontaneous failures. These failures expose the wearer to blood borne pathogens. Studies have demonstrated that glove perforations often occur after an average of 40 minutes of use during surgical procedures.
When two pairs of gloves are worn (ie, double gloving), in most instances, only the outer glove is perforated when punctured by a sharp device. In addition, research demonstrates that when two pairs of gloves are worn and a puncture occurs, the volume of blood on a solid sharp device (eg, suture needle) is reduced by as much as 95%. There is evidence that double gloving can reduce the risk of exposure to blood and body fluids, if the outer glove is punctured, by as much as 87% (, 2005).
More than half (57%) of sharps injuries in the OR are classified as occurring during the following activities:
* Using hands as tools.
* Stationary hands, holding instruments near areas where sharps are being used.
* Idle sharps on the surgical field.
* Miscellaneous actions, such as two people suturing at the same time, tying a suture and the suture cuts through the glove and skin, and probing a wound near a sharps instrument, such as a pin or trocar.
Strategies for prevention of sharps injuries:
* Eliminate the use of hands as instruments.
* Distance the hand from the site of sharp usage.
* Improve protection of the hand if the hand must remain in proximity to where sharps are being used.
* Shield or remove idle sharp instruments.
Effective programs are often developed by a sharps injury prevention committee or other safety committee in the hospital or any health care setting, which includes representatives from several areas in the facility, including administration–such as the risk manager–materials management, appropriate clinical areas–nursing, clinical laboratory, pharmacy–and housekeeping. Also, staff members such as the infection control officer, industrial hygienist, employee health officer, and medical director should be involved. Additional personnel from operating room, emergency department, nuclear medicine, and home care will likely be needed to address specific concerns. Finally, the perspectives of nonmanagerial, direct patient care providers should be considered during program development. In the United States, take for example, the Occupational Safety and Health Administration (OSHA) requires that frontline healthcare workers participate in the identification, evaluation, and selection of effective work practices and engineering controls (, 2005).
METHODOLOGY
This part of the assignment will focus on the steps the researcher will undertake to complete the research. The proposed techniques and procedures which are planned to use to gather and analyze data will be explained. Issues involved in choosing the approach and what factors shall be consider in choosing the techniques will also be examined.
This research will use a qualitative descriptive research method to provide a comprehensive summary of the data to be presented in an understandable and usable manner (, 2000). This is through the use of focus groups. It is chosen due to the limited research in the area and the possibility of promoting understanding of attitudes and perceptions of sharps injuries issues that impact on the nurses’ and other health care professionals’ ability to provide care.
Confirmability is assured by a detailed description of the research process with the inclusion of data that support conclusions ( & , 1996). The provision of a description of the study group, location, research process, and interpretation would allow the reader to evaluate the transferability of the results of the study to other settings and populations ( & , 1999)
Preparation for the Project
Before the project will begin, the researcher should seek and receive an approval from the institutional review board (IRB) of the hospital as well as the IRB of the university the researcher has attended. Surgical faculty members, OR administrators, and managers will be apprised of the project.
A letter of introduction will be mailed interdepartmentally to all RNs and certified surgical technologists (CSTs) who work at least 24 hours per week. Two weeks after the first mailing, a second letter of introduction will be printed on bright pink paper and will be mailed interdepartmentally. Depending on how many RNs and CSTs from a staff pool of will volunteer to participate in focus group discussions, the study will then be conducted.
Age and sex of the participants will not be discriminated in this study. Levels of education (ie, BSN, AD, diploma, military training) can vary among the participants, and their OR experience should ranged from less than one year to 25 years. The staff members should represent the orthopedic, cardiovascular, neurology, general surgery, and ambulatory surgery subspecialty areas to ensure a representative of the whole population.
The participants should then sign the hospital’s informed consent for participation in research before the first focus group discussion will be conducted. They will be informed that their participation is voluntary, and they could withdraw their decision to participate at any time with no repercussions. The participants will also be informed that the researcher who conducts the study would be working with an experienced researcher from the university and the quality coordinator from the hospital’s operating room services department of the hospital.
Focus Group Discussion
The focus group discussions will take place in an informal setting (ie, a conference room segregated from the OR setting) during a scheduled one-hour weekly staff education session. The sessions will be moderated by the researcher who will explain the desired outcomes of the study by stating that information gained from the focus group discussions would help identify strategies for implementing a practice change to decrease the rate of needle sticks and sharps injuries.
The members of the focus group will then be asked to respond to the following open-ended statements to identify what they perceive to be barriers to improved sharps safety:
* Describe your perception of risk of exposure to a needle stick or sharps injury in the OR.
* Describe your perceived level of power as an individual or group to implement a change in practice to decrease the incidents of needle sticks and sharps injuries.
* Describe what you perceive to be barriers to a successful practice change.
Each member of the group will be given time to reflect and respond to each statement. The consensus of the group will be determined when each statement had been adequately discussed before the next statement was addressed. Four sessions are required to allow each person to respond to each question.
The group discussions will then be audio taped. The discussions recorded on the audiotape will then be transcribed by the researcher with all names of the participants removed to maintain confidentiality. The data will be shared with the focus group as an ongoing process. Data will be collected until the researcher is able to determine that no new themes were emerging from the discussion (ie, after four discussion sessions). Data will then be integrated and analyzed to come up with the findings of the study.
Ethical Aspect
In all countries, research works that involve human subjects and animals should be carried out in accordance with high ethical standards set by various ethics committee. The privacy and dignity of every individual involved in the research should be protected. The participants should be assured confidentiality and anonymity through identification coding and reports of aggregate data. The participants involved should also be notified of the aims, methods, expected outcome, benefits and potential hazards of the research conducted.
CRITIQUE
CASP
The aims of the research proposal are clearly stated in the study. This is perceived as important by the researchers given the increasing incidents of sharps injuries worldwide. Aside from the fact of injury, it also poses rising health care costs not only to the patients but to health care professionals as well. The study used the qualitative methodology since it seeks to interpret or illuminate the actions and/or subjective experiences of the research participants – the health care workers, specifically the RNs and certified surgical technologists assigned to the operating room. The research already detailed how these participants will be recruited. These participants are selected since they are the most appropriate to provide access to the type of knowledge sought by this study. Ethical issues are carefully considered in the scope of the study, most especially given the fact that this study deals with human subjects. Other aspects of the Critical Appraisal Skills Program (CASP) such as questions regarding the data collection and statement of findings could not yet be explored given the fact that this is still a research proposal. This study needs further assessment once it is performed in order for three issues regarding research be resolved – rigour, credibility, and relevance.
Critique: RCT
Randomized controlled trial is not appropriate for the study since this study does not deal with intervention and control groups nor are the participants blind to the perceived outcome of the study.
References
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