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Sharps Handling Practices Among Junior Surgical Residents – A Video Analysis David Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MD Division of Pediatric General Surgery, BC Children’s Hospital INTRODUCTION  A survey of surgical residents at over 17 medical centers found that 99% of surgeons in training had sustained a needlestick injury by their final year of training (2)  53% involved patients with a history of HIV, hepatitis B or C, or intravenous-drug use  In differentiating the mechanisms of injuries due to sharps, Bakaeen and colleagues found that  69% of OR injuries were inflicted by suture needles  9% from hollow-bore needles  34% from sharp instruments (3)  Specifically, injuries from sharps can occur when  Loading suture needle into driver/repositioning needle with fingers  During hand-to-hand passing of sharps  Suturing muscle and fascia when needle manipulated with fingers  Retraction of tissue with hands  Surgeon sews towards own hand or assistant's hand  Tying a suture while needle is attached  Suture is left unattended on operative field after use (4) REFERENCES (1) O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch.Intern.Med. 1992 Jul;152(7):1451-1456. (2) Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, et al. Needlestick injuries among surgeons in training. N.Engl.J.Med. 2007 Jun 28;356(26):2693-2699. (3) Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, et al. Epidemiology of exposure to blood borne pathogens on a surgical service. Am.J.Surg. 2006 Nov;192(5):e18-21. PURPOSE  To examine sharps handling practices of junior surgical residents performing an operation  Evaluate whether experience correlates with a decrease in unsafe sharps behavior Hypothesis: Safety performance is not expected to improve with operative experience in the absence of formal training on sharps practices Sharps TaskSafeUnsafe Personal Sharp Tasks Suture needleUsing forceps to load or reposition needle Using fingers to load or reposition needle Tying SuturesNeedle is on driver during tying, and is protected Needle is exposed while tying suture Tissue RetractionUsing instrument to retract wound edge when using sharps Using hand/fingers to retract wound edge, when suturing towards hand/fingers Injection Needle Handling Injecting away from hand/fingers, no 2- handed needle re- capping Injecting towards hand/fingers, 2 handed needle capping Sharps Placement on Operative Field Placing sharps back onto a neutral hands free zone while not in use Sharps left on operative field unattended Passing of Sharps Passing suture with needle in driver handle first, scalpel handle first, use of neutral hands free zone Passing of suture with needle exposed, blade first Verbal Notification Verbal notification when passing sharp instruments Clear verbal notification when passing sharps Unclear/No verbal notification when passing sharps Table 1: Definitions of safe and unsafe sharps tasks used to assess safety performance  Resident safety performance was assessed in three areas: 1.Personal sharps tasks  E.g. Suture needle handling 2.Passage of sharps  E.g. Scalpel, injection needle 3.Verbal notification when passing of sharps  E.g. “There’s a needle up.”  Second video was taken of the resident after the technical performance feedback session and safety performance was compared between the two procedures. Video reviewer blinded to resident level & video order Figure 2. Graph of mean percentage of safe tasks performed by surgical residents as seen in the initial and final videos (n=8) taken during an inguinal hernia repair. DescriptionSafety Initial video (mean) Standard Deviation Suture needle manipulation Safe4.32.7 Unsafe4.74.0 % Safe53.7%33.8% Tying sutures Safe3.51.5 Unsafe0.51.0 % Safe86.9%25.6% Tissue retraction Safe1.80.8 Unsafe0.50.8 % Safe83.3%28.3% Injection needle handling Safe0.40.5 Unsafe0.20.5 % Safe72.2%44.1% Overall Personal Sharps Tasks% Safe66.3%23.1% Table 2. Summary of safe and unsafe personal sharps tasks for all initial videos of surgical residents (n=19). RESULTS  19 surgical residents videoed  15 general surgery residents (PGY-2)  4 plastic surgery residents (PGY-1)  Initial videos (n=19):  Sharps tasks performed safely = 66.3%  Safe passing of sharps = 90.4%  Verbal notification when passing = 10.1%  Unsafe sharps practices mostly with handling of suture needle  4.7 unsafe actions per surgery  All residents demonstrated safe handling of the scalpel blade  No actual injuries to the surgical resident/ team   Second video follow-up (n=8)  No statistically significant differences between initial and final procedures with regards to Personal sharps tasks (p=0.17), Passing of sharps instruments (p=0.14) or Verbal notification (p=0.29)  4.4 missed opportunities to use of verbal cues to alert team members when passing sharp instruments (SD=1.2) DISCUSSION  Junior surgical residents consistently passed sharp instruments in a safe manner  Tasks relating to manipulation of sharps were less likely to be performed safely  Minority of residents verbally notified team members when passing sharp instruments  Review of technical performance of the surgical procedure did not significantly improve safe sharps handling practices Explicit instruction and feedback on sharps handling should become an integral part of surgical residency programs and surgical culture (4-7) Figure 1. Examples of safe and unsafe manipulation of the suture needle. 1) Unsafe handling of suture needle using fingers. 2) Safe handling of suture needle using forceps. METHODS  Junior surgical residents:  PGY-2 general surgery & PGY-1 plastic surgery residents  2 month rotation in pediatric general pediatric surgery at BC Children’s Hospital in Vancouver, British Columbia  Videotaped performing pediatric indirect inguinal hernia repairs:  Junior surgical residents as principle operator, attending surgeon assisting  Technical feedback was given by the attending surgeon on review of the videotape footage with resident  Residents were not given specific feedback on sharps handling technique  Safe/unsafe practices  Based on the Association of Perioperative Nurses and the American College of Surgeons guidelines (4,7).  Videos reviewed, each sharp episode judged “safe” or “unsafe” (4) Association of periOperative Registered Nurses. AORN guidance statement: sharps injury prevention in the perioperative setting. AORN J. 2005 Mar;81(3):662, 665-6, 669-71. (5) Camilleri AE, Murray S, Squair JL, Imrie CW. Epidemiology of sharps accidents in general surgery. J.R.Coll.Surg.Edinb. 1991 Oct;36(5):314-316. (6) Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and surgical residents: who is most at risk? J.Surg.Educ. 2007 Nov-Dec;64(6):395-398. (7) Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J.Am.Coll.Surg. 2004 Sep;199(3):462-467. RESULTS