Is your surgery staff vulnerable to scalpel-blade injuries such as these three real-life scenarios?

• As a surgery attendant passed a scalpel to a surgeon, the surgeon simultaneously reached for it. They bumped hands, and the attendant's left index finger was cut.
  
  
• After a cosmetic procedure, a nurse used a hemostat to remove the blade from a reusable scalpel handle. The blade slipped and the nurse cut her middle right finger.
• Having completed a hand case, a physician and nurse were cleaning the patient. As the nurse reached back for a towel, she was cut by a scalpel held by the OR technician.

From 1993 to 2001, scalpels ranked third as a cause of sharps injuries across all healthcare settings, accounting for 7 percent of injuries.1 In operating rooms (ORs) specifically, reusable and disposable scalpels caused 18 percent of injuries - second only to suture needles, with 41 percent of injuries.

Deep injuries
Scalpel blades are more likely than suture needles to cause deep or otherwise severe injuries, according to an analysis of 133 scalpel injuries in 35 surgical settings.1 About 39 percent of suture needle injuries were classified as moderate (skin cut, some bleeding) and 2 percent as severe (deep cut, profuse bleeding). That compares with 58 percent of scalpel injuries classified as moderate and 11 percent as severe.

This suggests a higher chance of significant blood contact between patients and surgical staff from injuries involving scalpel blades. Cases of HIV transmission to healthcare workers after scalpel injuries have been documented in the United States and Italy; they involved, respectively, a pathologist performing an autopsy and a surgeon.2 When a scalpel injury results in bleeding and the healthcare worker's hands are in or near the surgical site, there is a further risk of healthcare worker-to-patient blood contact and possible transmission of a bloodborne pathogen such as HIV or hepatitis C.

Reusable scalpels, which require removing the blade to reuse the handle, caused more than twice as many injuries as disposable scalpels, which eliminate this step (68 percent of scalpel injuries were caused by reusables, 32 percent by disposables). The use of reusable scalpels may be declining. In 1993-94, reusable scalpels caused 21 percent of injuries and disposables caused 0.2 percent; in 2000-2001 data, reusables caused 9.5 percent of injuries, and disposables 4.4 percent.1

The perils of passing
Data also reveals that surgery attendants sustained the largest proportion of scalpel injuries (36 percent), followed by nurses (27 percent), physicians (18 percent) and surgery technicians (9 percent). In 76 percent of cases, the injured worker was not the original user of the scalpel. This is particularly significant, because many injuries from scalpels happen when surgeons pass them to nurses or other OR personnel. The largest proportion of scalpel injuries occurred "between steps of a multi-step procedure" (41 percent or 54/133). Of these 54 cases, 12 workers specifically noted that the injury occurred during passing. Another 31 percent of scalpel injuries occurred during use and 10 percent during disassembly. An additional 14 percent of scalpel injuries occurred after use but before disposal (excluding disassembly injuries) or during or after disposal.

Safety-designed scalpels, where the blade can be covered between uses and after use, could potentially eliminate these injuries. In 90 percent of cases, workers reported that the scalpel that injured them didn't have a safety design.

The largest proportion of scalpel injuries (94 percent) were to the hands; 3 percent were to the arms and 2 percent to the feet. The right hand sustained 56 percent of injuries, and the left hand, 38 percent. This pattern may be related to hand-to-hand passing, in which the dominant hand receives instruments.

Preventing scalpel injuries
You should use a variety of prevention strategies to reduce injuries from scalpel blades.

For cutting, use alternative methods where possible, such as blunt-tip scissors, blunt electrocautery devices and laser devices. Substitute round-tip scalpel blades for sharp-tip ones.
• If appropriate, choose endoscopic instead of open surgery.
• Avoid manual tissue retraction (which puts fingers closer to the scalpel blade) by using mechanical retraction devices.
• On the non-dominant hand, wear gloves made of steel mesh, Kevlar, leather or knitted cut-resistant yarn under latex or vinyl gloves.2
• "Hands-free" transfer of sharp devices during surgery can help reduce passing-related injuries from collisions between hands and sharp instruments.
• Designate a neutral or "safe" zone, such as a mat, tray or surgical drape, where staff can place and pick up instruments.3
• Finally, scalpels with shielded or retractable blades that you can place in a protected position during passing and after use can prevent up to two-thirds of scalpel injuries if used consistently and correctly. n

References
1. EPINet multihospital sharps injury database at the International Healthcare Worker Safety Center, University of Virginia.
2. Ippolito G, Puro V, Heptonstall J, Jagger J, et al. Occupational human immunodeficiency virus infection in health care workers: Worldwide cases through September 1997. Clinical Infectious Diseases, 1999; 28:365-383.
3. Diaz-Buxo, JA. Cut resistant glove liner for medical use. Surgery, Gynecology and Obstetrics, 1991;172:312-314.
4. Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theatre injuries. Occupational & Environmental Medicine, 2002; 59(10):703-707.