WITHIN REACH Sharps safety policies should address how and when instruments can be passed.

There was no formal sharps handling policy in place at my ASC when I took the reins as its administrative director early last year. The OR staff was clearly fortunate to have avoided many sharps injuries up to that point, but when sticks and cuts began to occur with greater frequency, we knew safeguards were needed. Shielding staff took more than just switching out traditional scalpels for safety-engineered sharps, however. Here's a step-by-step guide for implementing our sharps handling policy, the one OSHA representatives cite as an example of sharps safety done right.

SHARPS SAFETY

The OSHA-Recommended Policy

Here's my surgery center's neutral zone policy, which aims to decrease percutaneous injuries and bloodborne pathogen exposures through the implementation of work practice controls.
—Vangie Dennis, RN, BSN, CNOR, CMLSO

Neutral Zone Policy

Neutral and Passing Neutral Zone

DRAWING THE LINE Neutral zones can ensure the safe handling of sharp instruments.

1. Work practice controls for sharps must be utilized during transfer of contaminated sharps, based on the needs of the operation.
2. Controls may include the use of magnet pads, transfer tray, or designated area of the mayo, back table, or over-the-bed table.
3. Before the incision or injection is made, the passing neutral zone (An area that does away with 2 individuals touching the same instrument simultaneously) is selected and designated by the surgeon in consultation with the person passing instruments. The passing neutral zone may be moved at will and by agreement to accommodate the surgeon's needs.
4. The passing neutral zone and neutral zone (an additional area designated on the sterile field where multiple sharps are located) are dedicated to sharps only; all other instruments are passed hand-to-hand as appropriate.
5. When the surgeon is unable to avert his/her eyes during a procedure, exceptions will be allowed to accommodate the surgeon. These exceptions are:
   1. Due to focusing of the eyes via a microscope or loupe.
   2. During the use of an endoscope (with no video/monitor/camera), due to heavy bleeding or an emergency.
   3. When the surgeon may lose site of tissue edges being sutured.
6. The scrub person may pass the clean sharp to a surgeon in a hand-to-hand manner.
7. The surgeon should pass the contaminated sharp to a passing neutral zone when returning the sharp.
8. Use self-retaining retractors whenever possible to reduce sharp injuries during the procedure.
9. Avoid sponging of tissue when a sharp is in use by the surgeon.

Steps to Safe Assembly and Disassembly of Sharps

1. Mount and remove scalpel blades and needles with safety devices designed for this purpose.
2. If hypodermic needles are reused during a procedure for incremental injection, grasping instruments are used to safely handle needles.

1. Recognize barriers to safety
Why didn't my center have effective sharps safety protocols? It could be the culture of surgery itself. Historically, the OR attitude has been one of stoic toughness. Blood on the gown and spray on the mask were once seen as badges of honor. Today, bloodborne pathogens are a known hazard and vigilant barrier protection is the rule, but you still have to change the culture to protect those who work in surgery from careless sharps handling and exposure risks.

Then there's the fact that sharps injuries aren't always consistently reported. Nurses or techs fear punishment. And surgeons are sure they've never stuck anybody with a needle. As a result, you might overlook the importance of examining and correcting clinical practices to prevent future incidents.

What's more, implementing safer sharps handling practices may seem to slow down the natural rhythm of surgery: When the surgeon asks for instruments or supplies, pass them fast and he'll put them wherever he wants. Sharps safety can seem like an efficiency-killer, and nurses and techs who want to keep cases moving can easily slide back into old, unsafe habits.

Honor, apprehension or efficiency only carry weight until someone's accidentally sliced by a blade or jabbed with a suture needle. Then you're saddled with the costly and time-consuming burden of injury reports, medical tests, precautionary treatments, lost work-hours and potential litigation.

2. Follow recommended practices
In matters of sharps safety, OSHA is the chief arbiter, although it's not the only overseer with an interest. The CDC's National Institute for Occupational Safety and Health, accreditation agencies such as the Joint Commission and professional organizations such as AORN have also issued recommendations on identifying sharps risks and putting safer alternatives into practice.

OSHA's Bloodborne Pathogens Standard (tinyurl.com/4f8mcwb), which incorporates the Needlestick Safety and Prevention Act, requires you to develop a written blood-and-body-fluid exposure control plan and to review and update it annually. According to OSHA, developing such a plan means more than just ensuring your surgical suite is sufficiently stocked with gloves and other personal protective equipment. It should "reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; and [d]ocument annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure."

Safety-engineered scalpels, blunt suture needles, reusable scalpel-blade removers, passing trays: OSHA wants to see evidence that you routinely give them a trial. "If an effective and clinically appropriate safety-engineered sharp exists, an employer must evaluate and implement it," unless such a product failed to meet standards for patient safety and medical integrity, says OSHA. And your staff must have a say in the selection. You must "solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps and document the solicitation in the exposure control plan."

3. Reconcile the ideal with the real
I helped manage a large medical center before arriving at my present ASC, and my experience on a sharps-and-exposure review committee when those risks and incidents became an issue there taught me a thing or two about implementing safety efforts.

First: Whether you're managing 28 ORs spread across 2 campuses or a 3-OR ASC, you can't just draft a policy and expect change. Sure, an administrator can say, "Here are the rules of how it's going to be from now on," but you know as well as I do that's not going to fly.

Second: In spite of safety advocates' most enthusiastic endorsements, safety sharps are unfortunately not 100% of the solution. Most surgeons aren't likely to close with blunt suture needles. Many feel that safety syringes are not suitable for use in the OR. And even though the design and function of guarded blades have advanced far beyond early versions — which had practically no resemblance to traditional scalpels, and which surgeons had little patience for retracting the shields on when they were passed — the safer scalpels can still be a hard sell.

In short, sometimes the ideal solutions of a regulation's perfect world are difficult to reconcile with the way that work gets done in your ORs. If sharps injuries begin to occur in your center more often, implement realistic change. And if engineering controls such as safety scalpels and blunt needles aren't the answer, maybe changing your routine clinical practices would be.

4. Take action
Draft a neutral zone policy with the intent of reducing (if not eliminating) the hand-to-hand transfer of blades, needles, trocars, scissors, drill bits and other instruments presenting incision or puncture risks at the point of use.

The policy should mandate the establishment of a neutral zone — an area designated for the storage of multiple sharps that aren't presently in use — as well as a passing neutral zone — an area in the sterile field (agreed upon by the surgeon and the nurse or tech who'll be passing instruments) — that will prevent 2 people from touching an item at the same time.

The policy must also address situations when the physician needs an instrument but cannot avert his eyes from the field. Only then can you pass a clean sharp hand-to-hand to the surgeon. The surgeon, however, isn't permitted to pass it back: He must return the instrument to the passing neutral zone.

You'll note that this policy doesn't implement an engineering control and demand that surgeons give up the instruments they're used to working with. Instead, it's a work practice control, a workaround that puts sharps safety into effect and is still compliant with OSHA's standards and others' recommendations.

SAFETY STARS Assigning "sheriffs" to educate staff on sharps safety protocols exchanges a punitive approach for a positive one.

SHARPS SAFETY "SHERIFFS"

Policy Police on Patrol

When it comes to enforcing sharps safety rules, consider a positive approach instead of a punitive one, and maybe even get creative. That made a big difference when I revised the sharps safety policy at my previous facility. We'd enlisted nurse educators to act as sharps safety "sheriffs" — we gave them star-shaped badges — to observe and report. Staff members who demonstrated solid compliance were rewarded, while areas for improvement appeared on our "Most Wanted for Compliance" bulletin board. (See "Rustling Up OR Safety" in the January 2008 issue of Outpatient Surgery Magazine: tinyurl.com/9ycoe2r.)

— Vangie Dennis, RN, BSN,
CNOR, CMLSO

5. Stay compliant
Putting a policy in place is one thing, but maintaining the effects it's intended to deliver is another. The most important key to implementing a neutral zone policy is to develop it in cooperation with the end-users (even OSHA says so). As with any implementation of practice changes, everyone has to play a part in forming the policy, otherwise it's likely to fail.

Educate your surgeons and staff, and show them the way. Take the opportunity to teach and demonstrate the new practices, and discuss the importance of them with those who remain non-compliant. If you bring the issue to them, they will often fall into step. If they don't, discuss the matter with the chief of the department or the surgeon who's championed the effort (you made sure to recruit one, didn't you?).

6. Sustain success
As they say, you can't manage what you can't measure. We started monitoring compliance with our neutral zone policy about a month after implementation, to see how well staff took to it. We've shown high marks across the board in the second and third quarters of 2012, 100% compliance in most cases.

How long should monitoring continue? Until you're at 100% compliance, and even after that. There's always a risk that staff will fall into old habits if the new ones aren't periodically reinforced. The statistics we've compiled through peer observation monitoring of a random sample of cases every month are proof that our neutral zone policy has been a success.

It passed muster with OSHA, too (see "The OSHA-Recommended Policy" on page 8). During the agency's random inspections of surgery centers in Georgia, Florida, Alabama and Mississippi over the past year and a half as part of a regional emphasis program on sharps safety and bloodborne pathogen exposure prevention, they paid us a visit.

OSHA inspectors are essentially environmental hygienists, not clinical experts, so when they show up at your facility, you've got to speak the language they understand. I did a bit of bragging about our successes. They were interested in seeing some examples, so I showed them our use of work practice controls over engineering controls, and the resulting compliance rates. In the agency's view, that was fine, as long as we keep evaluating engineering control options with end-users' input, and documenting it in our exposure control plan.

We've seen no sharps injuries since we implemented our neutral zone policy, but we're keeping our eyes on the task at hand: compliance in the name of safety, and process improvement should it ever be needed. We're creatures of habit, but we're also in the business of surgery and the business of safety, two areas in which you cannot rest on your accomplishments.