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Make the Switch to Safety Scalpels
How to tap into the power to change surgeon behaviors.
Dan O'Connor
Publish Date: October 27, 2008   |  Tags:   Staff Safety

Convincing your surgeons to convert to safety sharps is not a game for the meek and mild. Those who've done it say you must be shrewd, strong-willed, strict - even a little sneaky.

Surgeons in Harm's Way

A study of French surgeons estimated that the typical general surgeon experiences 0.8 injuries per 100 hours of operating time, or 210 injuries during his career, resulting in a 6.9 percent lifetime risk of contracting hepatitis C and a 0.15 percent lifetime risk of developing HIV.

"Have an infection control spokesperson visit with the cold hard facts on the increasing risks of hepatitis and HIV," says Lynda D. Simon, RN, administrator of the St John's Clinic: Head & Neck Surgery in Springfield, Mo. "Make sure they discuss the profound changes these infections make in the life of the injured healthcare worker and his family. Make attendance at the meeting mandatory for staff and physicians."

"Find the best safety scalpel available, and get rid of the old devices," says Sara McCallum, RN, MBA, LHRM, director of the Fond du Lac Surgery Center in Fond du Lac, Wis.

"Make sure that the safety scalpels and other devices are available at the beginning of the procedure. Hide the old ones so that there's no temptation to use them," writes Mark Davis, MD, FACOG, in his book Advanced Precautions for Today's OR (Sweinbinder Publications, 2001).

"Remove the reusable handle for the non-safety scalpels from the trays to make it more difficult to get them," says Victoria Steelman, PhD, RN, CNOR, an advanced practice nurse at the University of Iowa Hospital and Clinics in Iowa City, Iowa. "Make doing the right thing easier than doing the wrong thing."

Give surgeons a say in which safety scalpel your facility will use, but not in the decision to convert, which should be a matter of when, not if. "The people who use the scalpels need to participate in the evaluation of safety scalpels," says Dr. Davis. "Surgeons, in particular, are busy people who often have good excuses for missing meetings. Regardless, they must be relentlessly sought out for their input."

A key to convincing your surgeons to convert to safety scalpels lies in how you phrase the proposition, says Dr. Steelman. You can't expect that your surgeons will prefer the safety scalpel you've asked them to trial over the fit and feel of the scalpel they've been using. No, she says, you have to change the question to this: Is this safety scalpel safer than the one you're currently using, and does it cause a negative clinical patient outcome? If the answer comes back 'yes' to the first part and 'no' to the second, then using the safety scalpel becomes the right thing to do.

"It's not whether they like [the safety scalpel] better than or as well as the scalpel they're using," says Dr. Steelman. "That's a key point to keep in mind when having surgeons evaluate safety scalpels."

Is it safer? Will it harm patients?
It's been two years since Dr. Steelman spearheaded a project to rid Iowa's only comprehensive, tertiary-level center of traditional scalpels, the second leading cause of percutaneous injuries in the OR. "I'd like to think we're at 80 percent," she says. "What would I like us to be at? Ninety-nine."

Here's how she got there. Over the course of a couple years, surgeons evaluated every safety scalpel on the market. "We did it in several different clusters," says Dr. Steelman. In two-week stretches, surgeons trialed Scalpel A, then Scalpel B, then Scalpel C and so on. Dr. Steelman hung posters by the lockers promoting the trial and educated surgeons that they experience the most injuries from sharp objects of any healthcare worker (see "Surgeons in Harm's Way").

Safety Scalpels or Blunt-tip Suture Needles?

By a wide margin, suture needles are the leading cause of sharps injuries in the OR. So why is there more talk about converting to safety scalpels than blunt-tip suture needles? "I can do less about suture needles than I can about scalpels," says Victoria Steelman, PhD, RN, CNOR, an advanced practice nurse at the University of Iowa Hospital and Clinics in Iowa City, Iowa. "The technology available for safety scalpels is not yet there for safety sutures."

Based on 2005 data, less than 5 percent of the acute care market for reusable scalpels has converted to safety devices, says scalpel manufacturer BD.

"Many physicians have chosen not to use [safety scalpels] because they're not as easy to use as a standard product. It doesn't feel the same," says Ron Stoker, executive director of the International Sharps Injury Prevention Society in South Jordan, Utah. Safety scalpels rely on some kind of "active" technology, which is either a sheath or a retractable blade.

Mr. Stoker likens some of the early safety scalpels to box knives. "They were just really difficult to move," he says. Today's weighted products, however, fit well in the hand. "There's really no reason why people shouldn't be using a safety scalpel because they've come so far from where they began," he says.

- Dan O'Connor

Even though most surgeons and staff want protection without compromise, asking surgeons to compare safety scalpels to non-safety scalpels will torpedo your trial. "End users must evaluate the scalpels side-by-side so that they're not evaluating them against what they currently have," says Dr. Steelman. "They must evaluate them against other safety scalpels in the market."

Dr. Steelman prepared evaluation forms for surgeons to fill out for each safety scalpel they evaluated (keep the completed forms on file should you need ammo down the road, she suggests). She avoided such questions as "Do you like this?" and "Is this the best scalpel?" Again, the key questions are:

  • "Does this provide a measure of safety?"
  • "Does this have any negative clinical impact on the patient?"

A scalpel with a sheath and a reusable metal handle emerged as the winner. Most surgeons panned those with plastic handles, saying they didn't feel secure enough in their hands, says Dr. Steelman.

Keep in mind that this is not all-or-nothing. Some surgeons pointed out legitimate applications for which a safety scalpel wouldn't work well. For example, when a surgeon makes a stab incision during an arthroscopy, the sheath blocks the blade from making a complete entry. For cases such as these, surgeons are permitted to use non-safety scalpels.

Surgeon as alpha male
Does your staff perceive physicians as powerful and in control of their ability to implement policies and procedures? Probably so. One study found that surgeons' resistance to change resulted in intimidation of OR staff. Resistance to change is demonstrated by the lack of consistency in practice from room to room, according to "Perceived Barriers to Implementation of a Successful Sharps Safety Program," a February 2006 report in the AORN Journal. OR staff "make peace" to get through the day and don't report surgeons' non-compliant behaviors to managers for fear of retribution, and because past reporting has been unproductive. They perceive that hospital administrators and OR managers lack the power to change surgeon behaviors.

Include your safety measures in annual reviews, says Lynda D. Simon, RN, administrator of the St John's Clinic: Head & Neck Surgery in Springfield, Mo. "If they're not willing to protect themselves and their patients, you may not want them to be included as part of your surgical team," she says.

As you probably know, in 2000, the federal Needlestick Safety and Prevention Act became law. Enforced by OSHA, the law requires employers - including hospitals, ASCs and surgeons - to periodically evaluate and implement safety devices (such as blunt-tipped suture needles and safety scalpels) and safe work practices (such as a neutral zone for passing sharps). OSHA doesn't consider a lack of injuries to be a reason not to use safety devices, and it's not acceptable for a surgeon simply to refuse to use a safety scalpel. If engineering controls can reduce employee exposure either by removing, eliminating or isolating the hazard, they must be used.

Show surgeons a copy of the Bloodborne Pathogens Standard and the OSHA Compliance Directive, says Ron Stoker, executive director of the International Sharps Injury Prevention Society in South Jordan, Utah. "You are required to use safety products," he says. "It's not a suggestion - it's the law. Both the doctor and the institution can be cited because of non-compliance.

"The biggest problem is that individual surgeons don't want to use safety equipment," says Mr. Stoker. Nurses are more likely to want to use such equipment, he says.

"Nurses are wiling to sit still and listen to you and get over practice changes to give a safety product a halfway-decent evaluation," says Renee Gould, RN, an advanced practice nurse responsible for quality and safety improvements at the University of Iowa Hospitals and Clinics. "Surgeons won't sit still and listen to how to use a product. Maybe they just don't want to change. Is it really that the safety scalpel won't work for you? Or is that you just don't want to change?"

As Gina Pugliese, RN, MS, vice president of the Premier Safety Institute, says, "Purchasing the scalpel is not the issue. It's getting surgeons to use the scalpel."