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Sharpless Surgery: A Quiet Revolution
Jane Perry
Publish Date: October 10, 2007   |  Tags:   Staff Safety

Surgeon Martin Makary, MD, MPH, is working on a quiet revolution in the operating room: sharpless surgery. He's not just trying to gain acceptance for safety sharps devices; he's eliminating sharps, whenever possible, from surgery.

He says the key to preventing the risk of needlestick injuries and blood exposures in surgery is to "engineer risk out of the system, rather than try to modify individual behaviors" - the traditional approach in surgery. "When you improve the system in which [surgeons] work and the processes by which they learn, you reduce the chance for human error," says Dr. Makary. Here's a look at his pursuit of sharpless surgery.

Seeing the problem
During his surgical training, Dr. Makary was alarmed by the high incidence and generalized acceptance of needlesticks and body fluid splashes. He also noticed that cases involving HIV- or HCV-infected patients were often the ones assigned to the least-experienced residents as part of their training. Patients with HIV or HCV are predisposed to some relatively minor conditions, such as lymph node enlargement and soft tissue abscess formation, which frequently require surgery. Because the procedures are usually simple, they're often relegated to less-experienced staff, without consideration of the risk of exposure to bloodborne pathogens.

One exposure incident with an HIV-positive patient still stands out in his mind. He was an attending surgeon and was supervising an intern performing an incision and drainage of a perirectal abscess. During the procedure, the intern passed a bloody knife over his shoulder to the scrub nurse - with the sharp end pointed toward the nurse.

"A medical student was standing right next to the intern," says Dr. Makary. "I was struck by how such a novice maneuver, part of a simple procedure, placed four people at significant risk for contracting HIV. I thought to myself: There must be a safer way to do our job."

The ideal OR
Eliminating sharps from surgery as much as technically possible is, in Dr. Makary's view, the most effective method for reducing injuries and the potential for them. Dr. Makary defines sharpless surgery as a protocol for performing an operation without any sharps that could potentially cause a percutaneous injury to OR personnel. Sharpless surgical techniques include laparoscopy, electrocautery to replace scalpel incisions, and skin clips or glue instead of sewing to close or repair wounds. Sharps are reserved for emergency-only use.

Quick Points on Sharpless Surgery

We asked Martin Makary, MD, MPH, about some of the practical issues raised by sharpless surgery. Here's what he told us.

What impact does sharpless surgery have on technique?
MM: "Many of these techniques are already routinely used in a variety of operations. What we are advocating is using them in combination, in a strategic manner, to minimize the use of sharps to the greatest extent possible."

Is it hard to get older or more experienced surgeons on board with the sharpless protocol?
MM: "Often it's just a matter of presenting the sharpless techniques with which they are already familiar in a different light, to promote their own safety. Most surgeons do have a keen interest in protecting themselves from exposure to life-altering diseases."

What is the potential for eliminating sharps from surgery?
MM: "Sharps play an important and often critical role in most of the operations we perform; they can't be totally eliminated, at least not with the technology currently at our disposal. However, there are select operations which, when properly thought through, can be performed with substitute techniques that minimize or eliminate the risk of a sharps injury. These smaller operations are often performed with sharps techniques as a matter of routine - but don't have to be."

Are there direct or indirect economic benefits to doing sharpless surgery?
MM: "It doesn't necessarily reduce the cost of individual procedures; in fact, some of the sharpless instrumentation may be a little more expensive than traditional sharp instruments. Probably the greatest economic benefit of sharpless surgery is the protection it affords to a surgeon's investment in his career, decreasing the risk that he might be infected with a bloodborne pathogen and have his career cut short."

As you work on eliminating sharps from surgery, have you had ideas about sharpless instruments that would help support this method? Is there room for product development?
MM: "Definitely. For example, many laparoscopic operations will be candidates for a completely sharpless technique once an alternative is found to closing a midline fascial defect with a sharp. The technology is very close."

- Jane Perry, MA, and Janine Jagger, MPH, PhD

Jane Perry, MA In developing protocols for sharpless surgery, Dr. Makary investigated technologies that could eliminate the need for a sharp. Next he sought to coordinate the OR team to keep sharps protected and away from the operative field unless absolutely necessary for patient safety. Some of the sharpless devices and techniques he uses have been around awhile, such as electrocautery and surgical staples; others, like skin adhesives, laparoscopic blunt and visual trocars, and laparoscopic staplers, are recent innovations.

He says the sharpless protocols he's developed are really common sense applications of existing technology. They can be used to perform a wide variety of operations, from incision and drainage of a soft-tissue abscess to an appendectomy, he says. He estimates that he now performs about 20 percent of his general surgery using exclusively sharpless techniques.

Implementing safety-engineered devices, such as retractable or shielded scalpels that protect the blade after use, are also important, he says, along with safer work practices, such as proper needle handling techniques and the use of a neutral or hands-free passing zone.

Benefits of change
Along with completely eliminating the risk of percutaneous injuries to surgeons and assisting OR personnel, sharpless surgery also creates a better working environment, according to Dr. Makary.

"Healthcare workers who feel better protected from occupational hazards will perform better," he says. "Nurses, especially, love it; they are worried about bloodborne exposures associated with their profession and find it empowering to know their health and well-being are valued."

Many of his surgical colleagues, particularly those just starting their careers, have also been receptive to the protocol - in large part because of the large number of patients infected with bloodborne pathogens.

Dr. Makary and his colleagues recently published a retrospective study in the May Annals of Surgery that investigated the incidence of HIV, HBV and HCV in patients presenting for general surgery over one year at the Johns Hopkins Hospital; 38 percent of patients were infected with at least one of these pathogens. Of the 11 most commonly performed procedures in the study, soft-tissue abcess procedures and lymph node biopsies had the highest percentage of patients testing positive, pre-surgery, for at least one pathogen (48 percent and 67 percent respectively). The good news: Many of the procedures associated with both bloodborne pathogen exposure risk and surgeon inexperience are ideal candidates for a sharpless protocol, says Dr. Makary.

Jane Perry, MA\ The culture of safety in practice
At the JHH, once a shurgeon decides to use a sharpless protocol for a particular procedure, he indicates that choice on the OR schedule. That way, the scrub and circulating nurses and technicians can have the appropriate instruments available and on standby.

For Dr. Makary, creating a culture of safety - and reducing percutaneous injury risk - includes having clear, open channels of communication to complement surgical protocols.

"In my career, I have been amazed at how often surgeons, anesthesiologists, scrub nurses and OR technicians work closely together on critical problems without even knowing one another's names," he says.

As one remedy, he started performing an operating room briefing before each case to discuss the operation as a team and help avoid potential problems. The simple briefing includes a five-question prompt that ensures, among other things, that everyone knows one another and the goals for the operation, he says.

"A change in culture begins with a recognition of the issues and a willingness to re-evaluate the traditional way in which surgical procedures are performed," says Dr. Makary. "The kind of systems approach I advocate views exposure events not as the fault of individuals alone, but more as the inevitable by-product of a system which allows surgeons to be injured so frequently. We want to change that paradigm."