Since the revised bloodborne pathogens standard (BPS) took effect in July 2001, the largest number of OSHA citations to healthcare facilities have been for, you guessed it, violations of the BPS.

The standard now directs healthcare facilities to use safety-engineered sharp devices whenever possible to lower employees' risk of needlestick injuries and blood exposures. Between April 2001 and May 2002, OSHA issued 132 citations for failure to use engineering and work practice controls - four times the number issued for this specific violation in the previous 10 years.

Framing sharps safety
In addition to propelling conversion to safety-engineered sharp devices in healthcare, the BPS and the federal Needlestick Safety and Prevention Act (2000) spell out three additional requirements:

• Frontline healthcare workers are to be included in evaluating safety devices.
• Facilities must document safety-device evaluation and implementation in their exposure-control plans.
• Facilities must maintain sharps injury logs with information such as type and brand of device causing injury, department where the injury occurred and an explanation of how it occurred.

Measuring sharps safety
So how are ORs faring in terms of compliance? The leading cause of sharps injuries in surgical settings is suture needles: they are responsible for 41 percent of injuries, far more than any other device.1 (Scalpels are next with 18 percent.) For all hospital settings, suture needles rank second, after disposable syringes, as a source of sharps injuries.

A recent study comparing 1993 and 2001 injury rates for a variety of sharp devices found only one device category - suture needles - whose injury rate hadn't dramatically declined.2 While the suture-needle injury rate decreased by 5 percent, the injury rate for phlebotomy needles decreased by 70 percent from 1993 to 2001; for lancets by 87 percent; and for IV catheters by 55 percent.

Another analysis of EPINet data, for 2001 only, looked at percutaneous injuries (PIs) from safety devices separately from PIs caused by conventional devices to determine any difference in injury patterns. The findings: A relatively small proportion of injuries (7.4 percent) was caused by safety devices in ORs, even though, overall, 28.8 percent of sharps injuries in hospital settings occur in ORs. (Note: The fact that injuries still occur with safety devices doesn't mean they aren't "working." Safety device injuries can occur during use, or after use if the worker fails to activate the safety feature. And overall, safety devices cause far fewer injuries than conventional devices.) What accounts for this discrepancy? Most likely that relatively fewer safety devices are used in ORs compared to other clinical areas.

Such data could be a red flag for OSHA inspectors that ORs lag behind other healthcare settings in BPS compliance and require more stringent enforcement efforts.

Ensuring BPS compliance
In addition to heeding OSHA's advice (see "Help in Avoiding OSHA's Costly Citations"), here are other steps you can take to improve sharps safety and OSHA compliance in the OR:

• Collect injury data. This is not only required by OSHA, it is crucial for effectively targeting your safety efforts. Consider tracking sharps injury data with a program specifically designed for the OR, such as Access EPINet/OR (for more information, go to www.med.virginia. edu/epinet/subpage2.html).
• Regularly post OR injury data where OR staff can see it to reinforce that sharps injuries are a problem and to gain staff support in efforts to reduce injuries.
• Evaluate (or re-evaluate) blunt suture needles. Since sharp-tip suture needles are the No. 1 cause of sharps injuries in ORs, you should make every effort to find safer alternatives. Blunt suture needles are sharp enough to pierce internal tissue, but not sharp enough, in most cases, to pierce skin. A 1997 study conducted by the Centers for Disease Control and Prevention found blunt suture needles significantly reduced PI rates, had minimal adverse effects on patient care and were well accepted by the surgeons using them.4 For skin closures, evaluate alternatives to suturing, such as tissue adhesives, adhesive strips or staples.
• Eliminate unnecessary sharp devices or equipment whenever possible. For example, you can easily substitute blunt towel clips for sharp ones. Use needleless instead of needle-based IV connectors.
• Include a variety of OR staff involved with direct patient care in the evaluations. OSHA requires that surgeons, nurses and OR techs are part of the process.
• Build a team of OR-safety advocates. It's especially important to get buy-in from your facility's leaders, such as the chief of surgery, OR manager and director of surgical services.

Safety inspections
Since 2000, OSHA has included healthcare among the high-hazard industries that it targets for unannounced, comprehensive safety and health inspections. From July 2003 to June 2004, as many 170 hospitals with high overall injury rates - more than eight lost-time injuries per 100 full-time employees - could be subject to "wall-to-wall" inspections. All areas of hospitals and healthcare facilities, including surgical settings, will be scrutinized for compliance with the BPS and, in particular, with the requirement to use safety devices.

References
1. EPINet Sharps Injury Database, 1993-2001. International Healthcare Worker Safety Center, University of Virginia Health System.
2. Jagger J, Perry J. Comparison of EPINet data for 1993 and 2001 shows marked decline in needlestick injury rates. Advances in Exposure Prevention 2003;6(3):25-27.
3. Perry J, Parker G, Jagger J. EPINet report: 2001 percutaneous injury rates. Advances in Exposure Prevention 2003;6(3):32-36.
4. Centers for Disease Control and Prevention. Evaluation of Blunt Suture Needles in Preventing Percutaneous Injuries Among Health-Care Workers During Gynecologic Surgical Procedures - New York City, March 1993-June 1994. MMWR 1997 (1/17/97)46(2):25-29.