By Tadge Kanjo, M.D.
For three decades now the healthcare industry has made a sustained effort to reduce the occupational health risk that sharp injuries pose to all healthcare workers. After the passage of the Needlestick Safety and Prevention Act in 2000, new “safety” devices flooded the market.
The rate of needlestick injuries dropped dramatically by 31% while the rate of scalpel injuries increased by 6.5%.1 Currently, scalpels are the second leading cause of sharps injuries (17% of all operating room injuries). There are several safety-engineered devices available on the market, yet they are only employed in 15% of operating rooms.1
The decrease in needlestick injuries is directly related to the adoption of safety-engineered needles as well as the fact that the end user does not have the ability to refuse to use such devices. As a result, adoption of safety-engineered needles is widespread and effective.
In contrast, physicians have the authority to determine that a safety-engineered scalpel is unsuitable for use in an operating room. Previous models have raised such levels of dissatisfaction among surgeons that there is an almost visceral reaction to the term “safety scalpel.” The mechanism used to provide protection with a scalpel is either a protective sheath or sliding blade, both of which must be manually activated to expose and cover the blade. As a general surgeon, I recall the negative reaction I had after being handed a flimsy plastic “protected” scalpel. Sliding the plastic sheath back and forth over the blade required constantly changing my grip which felt dangerous and awkward. The idea that I needed a safety device to protect myself and the perioperative staff was offensive. My dissatisfaction was even greater with the scalpels that were included with various packs such as central line trays and drainage kits.
Despite the level of resistance to adopting safety-engineered scalpels, health care facilities have a mandate to employ safety devices and/or safety protocols to mitigate the occupational risk to healthcare workers.2 In the absence of satisfactory safety-engineered devices, safety protocols need to be instituted and reviewed on an annual basis. The Hands-Free Technique (HFT) was developed and instituted as a result. The HFT is intended to minimize the risk when passing sharps from one person to another. While there has been a reduction in injuries noted when the HFT is employed, the overall rate of scalpel injuries has not decreased. While the HFT does reduce injuries during passing, injuries occur at different points in the use of scalpels. More importantly, the HFT technique is not commonly implemented in operating rooms.3
If hospitals can meet the OSHA mandate to review safety policies every year by checking a box on their safety protocol, and surgeons are not the healthcare workers most commonly injured (<25%)1, what is the incentive to adopt safety devices?
The scalpel is an iconic symbol for a surgeon. It has a familiar weight and feel, with significant flexibility regarding blade sizes and lengths. In comparison, previous safety scalpels have been made with inexpensive plastic, poor quality blades, and are cumbersome to use. Without a perceived risk to themselves, surgeons are understandably reluctant to change.
The fact remains, however, that scalpel injuries pose a significant risk to healthcare workers. Over 30,000 scalpel injuries occur each year in the United States.4 Each injury costs an average of $5,689 including diagnostic testing, prophylactic treatment, and lost labor time.5,6 The World Health Organization estimates 435 HCWs will contract HIV, HBV, or HCV each year in the United States as a result sharps injury at a cost of $1.1 million.7,8 These figures do not account for the morbidity, psychological effects, and career loss that are associated with these injuries.
The American College of Surgeons released a statement October 1, 2016, recommending “the use of ESIP [engineered sharps injury prevention] devices as an adjunctive safety measure to reduce sharps injuries during surgery except in situations where it may compromise the safe conduct of the operation or safety of the patient.”9 Many surgeons cite the latter part of this statement as why they cannot use safety scalpels. This is more of an excuse to avoid change than it is factual and is not dissimilar to the significant resistance to laparoscopic surgery in the 80’s and 90’s. After an initial period of frustration, I adapted to the use of safety scalpels without any compromise to patient safety or quality of care.
In the operating room, surgeons need to be leaders in safety for the entire staff. In the majority of cases, scalpels are used at the start of the case to incise skin and are not used again. In the case of minimally invasive surgery, the skin incision amounts to mere centimeters. Up to five passes of a scalpel occur with the risk of injury increasing with every blade exposure. During the period of adoption of safety needles, healthcare workers endured a period of adjustment resulting in a safer workplace. When it comes to the use of safety scalpels, the risk of injury to the surgeon may be small but the cost is equally as small. With the scalpel fading from the forefront of surgical instruments, safer options need to be adopted. A period of adjustment for the surgeon is well worth the reward of a safer workplace for all healthcare workers as well as improved morale that results when the perioperative staff recognizes their safety is paramount in the surgeon’s mind. The previous poor rate of adoption of safety scalpels is in a large part due to the poor quality and design of the initial products on the market. New safety scalpels address prior complaints by surgeons and early indicators demonstrate markedly improved levels of satisfaction. Healthcare facilities should review the current products on the market with the cooperation and willingness of surgeons to identify and implement a safety-engineered scalpel.
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References
- Jagger, J. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg. 2010 Apr;210(4):496-502. doi: 10.1016/j.jamcollsurg.2009.12.018
- Centers for Disease Control publication, Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program
- Y.G. Kim et al. Sharps injury prevention guidance among healthcare professionals: A comparison between self-reported and observed compliance.American Journal of Infection Control 43 (2015) 977-82.
- http://www.cdc.gov/nhsn/PDFs/NaSH/NaSH-Report-6-2011.pdf
- Bernard, David. 2013. Where do you stand with safety scalpels? Outpatient Surgery Magazine 14, no. 5 (May). http://www.outpatientsurgery.net/issues/2013/05/where-do-you-stand-with-safety-scalpels (accessed June 11, 2013)
- Panlilio, AL. Costs of management of occupational exposures to blood and body fluids. Infect Control Hosp Epidemiol. 2007 Jul;28(7):774-82. Epub 2007 May 25
- World Health Organization. 2003. Sharps Injuries: Global Burden of Disease from Sharps Injuries to Health Care Workers.
- Davis, M. The Economic Argument for Using Safety Scalpels. The Surgical Technologist, Vol. 47, No. 9, September 2015.
- American College of Surgeons. October 1, 2016. Revised Statement on Sharps Safety. https://www.facs.org.about-acs/statements/94-sharps-safety
- Ford, Donna. Implementing AORN Recommended Practices for Sharps Safety. AORN Journal January 2014, Vol. 99, No 1