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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 11-15

Sharp injuries in the operative room among residents in surgical specialties: A cross-sectional study


Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication27-Feb-2018

Correspondence Address:
Dr. Murad M Aljiffry
Department of Surgery, Faculty of Medicine, King Abdulaziz University, P. O. Box 80215, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_43_17

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  Abstract 

Background and Objective: Surgical residents are at high risk of sustaining sharp injuries. Our aim is to identify predisposing factors of sustaining sharp injuries in operating rooms among surgical residents and their attitudes and behaviors in dealing with sharp injuries.
Methods: In this cross-sectional study, a random sampling technique was adopted to recruit a representative sample of surgical residents who were involved in operative procedures in King Abdulaziz University Hospital. Data were collected between September and December 2016 by completing a self-administered questionnaire on attitude toward the most recent sharp injuries, predisposing factors for sharp injuries, and practice of universal precautions during the surgical procedures.
Results: Among the 78 recruited residents, 46 (58.9%) had sharp injuries during surgical procedures. Most of the injuries (60%) were self-induced, and (72.9%) of the injuries took place while suturing. Twenty (43.5%) of those who had injuries did not report any injury, 15 (32.6%) reported some, and 11 (23.9%) claim that they reported all their sharp injuries. 44.9% of the participants are fully aware of sharp injuries local policy and procedures in the hospital. Most of the injured participants during surgeries did not follow each step of the local sharp injury policy. The perceived causes of sharp injuries among the participants were due to rushed (61.1%), fatigue (43%), lack of skills (19.4%), lack of assistance (15.3%), lack of sleep (13.9%) and (16.7%) though it is not preventable. 55.1% of all participants have never participated in any sharp-related safety training. 10.2% practiced all three universal precautions of double-gloving, face shields, and hands-free technique.
Conclusions: Sharp injuries are common among the surgical residents but are not reported by most of them. Target training about sharp injuries during residency may improve their attitude and behavior toward prevention of sharp injuries in the operative room.

Keywords: Needle stick, operating room hazard, reporting injuries, resident education, sharp injury


How to cite this article:
Alghamdi MS, Abbas MM, Shafei MO, Alali AM, Alshareef MA, Aljabri FA, Zaidi NH, Aljiffry MM. Sharp injuries in the operative room among residents in surgical specialties: A cross-sectional study. Saudi Surg J 2018;6:11-5

How to cite this URL:
Alghamdi MS, Abbas MM, Shafei MO, Alali AM, Alshareef MA, Aljabri FA, Zaidi NH, Aljiffry MM. Sharp injuries in the operative room among residents in surgical specialties: A cross-sectional study. Saudi Surg J [serial online] 2018 [cited 2018 Aug 20];6:11-5. Available from: http://www.saudisurgj.org/text.asp?2018/6/1/11/226229


  Introduction Top


Exposure to sharp-related injuries is considered as a cause of transmission of blood-borne pathogens to healthcare providers, as well as to patients. There is a risk of transmission of some potentially life-threatening organisms, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. According to the CDC, “a sharp injury is a penetrating stab wound from a needle, scalpel, or other sharp object that may result in exposure to blood or other body fluids.” Nearly 600,000–800,000 percutaneous injuries are reported annually among healthcare workers.[1] Surgeons and surgical staff are at high risk of sustaining sharp injuries due to the nature of their job where they are exposed to handling sharp instruments.[2],[3] The number of sustained injuries among surgical residents increases dramatically during training, reaching up to 99% by the 5th postgraduation year (PGY).[3] Although there is a fair extent of knowledge among surgical trainees of the general precautions of reducing sharp injuries in the intraoperative setting, yet there is poor adherence to safe surgical practices.[4] Notifying the concerned authorities and following the local policies are of great importance. However, in literature, there is significant under-reporting of injuries among surgical personnel.[5],[6] The aim of this study is to investigate the different aspects of sharp injuries such as frequency, circumstances, attitude, and adherence to universal precautions and policies in operating room among the residents in the various surgical specialties.


  Methods Top


Data collection

This is a cross-sectional analytical study. The population included was the residents in different surgical specialties (general surgery, orthopedics, neurosurgery, urology, pediatric surgery, plastic surgery, vascular surgery, cardiac surgery, ENT, and obstetrics and gynecology). There were no exclusion criteria. A total of 97 residents were available for inclusion in the study during the designated time interval (September to December 2016). A questionnaire was sent using E-mail, text messages, or contacting the residents directly in hospital. The research tool used to collect the data was a modified questionnaire made up from previous similar studies.[3],[5],[7] The first part was about the demographic data including gender, nationality, specialty, and residency level. The questionnaire then addressed whether the participant had experienced any sharp-related injuries in the last year, the number of sustained injuries, if they ever had experienced injuries involving a high-risk patient, plus five questions evaluating the attitude, behavior toward the injuries, action taken to report it, and awareness and adherence to local safety policies. Four questions then followed about investigating the surrounding circumstances, most probable cause, instrument involved, and the task taken when injury took place. Finally, three yes/no items for evaluating the awareness about the universal precautions (double-gloving, eye protection, and no-touch technique) in addition to asking the participants if they ever participated in any sharp-related safety training.

Statistical analysis

SPSS version 21 software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used. Continuous variables were presented as mean and standard deviation. Categorical variables were presented as frequency and percentage.

Ethics

The Medical Research Ethical Committee at King Abdulaziz University approval was obtained before the conduction of the research. The questionnaire included a brief introduction about the aim and importance of the research and clarification to the participant that their confidentiality will be protected. Informed consents were obtained from the participants.


  Results Top


A total of 97 questionnaires were distributed. Seventy-eight residents participated by filling out the questionnaire. The number of the residents experienced at least one injury in the last 12 months was 46 (58.9%), and 13% of them had experienced, in their career, at least one injury involving a high-risk patient. High-risk patient was defined as a patient with a history of HBV, HCV, or HIV. The prevalence of injuries was directly proportional to the PGY level. While 33.3% of the PGY-1 residents sustained injury in the last 12 months, all the participants in PGY-5 and PGY-6 had experienced at least one injury in the last 12 months [Figure 1]. Among the participants who had experienced injuries, the percentage of residents who admitted not reporting any of their injuries was (20 [43.5%]). 15 (32.6%) reported some, and only 11 (23.9%) claim that they reported all injuries [Figure 2]. Of the participants, 44.9% are fully aware of the sharp injuries local policy and procedures. However, only 11 (23.9%) of the participants who experienced injuries in the last year followed each step of local policy after their last injury. Replacing gloves and needle was overwhelmingly the most adopted action after sustaining the injury 20 (43.5%) [Table 1]. 42.9% thought that applying the policies and procedures was a difficult task to follow through 31.4% thought that it was user-friendly. Among the participants 31.9% justified nonreporting by thinking that the patient was at low risk of transmission [Table 2]. Most of the injuries (60%) were self-induced. A solid-bore needle was the involved in 78.8% of the injuries. 72.9% of the injuries took place while suturing. 61.1% of the participants attributed the cause of their injuries to “being rushed” [Table 3]. Only 10.2% practiced all three universal precautions of double-gloving, face shields, and hands-free technique [Table 4].
Figure 1: Prevalence of sharp injuries according to postgraduate years

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Figure 2: Reporting of sharp injuries

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Table 1: Behavior toward sharp injuries

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Table 2: Reason for nonreporting of most recent sharp injuries

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Table 3: Characteristics of sharp injuries

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Table 4: Precautions taken in surgical procedures

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  Discussion Top


Sustaining injuries in the medical field is a serious health issue. It had been stated that needle stick injuries are the most common cause behind HIV infection in healthcare workers.[8] Although this problem is highly preventable in most instances, suffering an injury once in a while is inevitable, especially in operating rooms, so it makes sense to see the highest number of injuries scored by surgeons. In this study, our results demonstrate that more than half (58.9%) of surgical residents were exposed to injuries in the operating room during the last year, in which 13% of them were exposed to injuries involving high-risk patients. Residents in 1st year of training were significantly less exposed to injuries (33.3%) due to less tasks and shorter period of training. The incidence increases dramatically with each year reaching up to 100% in the PGY-5 and PGY-6 residents. Similarly, another study conducted in the United States included 78 PGY-5 residents, 77 of whom have had needle injuries.[4] In most instances, surgeons tend to take their action right after the injury. Changing gloves and needles is overwhelmingly the action of choice in most cases.[7],[9] Although changing gloves and needles in our study was not as high as shown in literature, yet it is still the most commonly adopted action. Reporting injuries is a critical step in the context of sharp injuries. Early reporting may allow injured victims to get benefit from postexposure prophylactic measures. Antiretroviral therapy had been associated with a significant reduction in HIV infection when administered early after exposure.[10] The percentage of the awareness of the local policies and not reporting injuries in this study were, surprisingly enough, close to each other (44.9% and 43.5%, respectively). However, under-reporting remains to be a problem in different places around the world. A study by Thomas and Murry (2009) showed that only 9% of the surgeons report their injuries.[7] Another study conducted in Iran revealed similarly low results.[9] The belief that the patient is at low risk seems to have a great impact on the attitude of doctors toward injuries. Of the participants, 31.9% justified not reporting their injuries by stating that the patient is not at high risk. Furthermore, the residency years in the different surgical specialties are full of tasks. Having no time to report had been proposed as a cause for under-reporting.[4] This might contribute to the problem of ignoring the policies and the reporting of injuries as reflected by the other questionnaire items. “Could not spare time” was identified as the second most common cause identified by residents not to report their injuries. Most of the participants described the policies as “able to follow but with difficulty.” Although the questionnaire does not address “time-consuming” as the cause behind this discretion, yet it is still to be considered. Anyways, further evaluation of reasons of not reporting in future studies might be needed. The responses to the questionnaire items investigating the characteristics of the last injury revealed substantially high prevalence of a common cause which is consistent with the literature. Suturing was shown to be the task with the highest risk of sustaining injuries.[4],[11] In our study, 72.9% of the injuries happened while suturing. Furthermore, this study showed that solid-bore needle was involved in 78.8% of the occasions, and 60% of the injuries were self-induced, which goes along with previously conducted studies as well.[4],[12] Finally, 61.1% of the responders thought that being “rushed” is the cause behind their injury [Table 3].[12] Identification of this consistent pattern of injuries is of importance and may help set goals and add more to the existing regulatory measures to prevent such problems. Some of the regulatory requirements tackled the problem from some aspects and had revealed a noticeable success in terms of reducing the incidence of injuries.[13] As suturing is associated with highest risk of sustaining injuries, the use of blunt-tip suture needles was presented as a safety measure as it showed substantial decrease in the incidence of injuries when used instead of standard needles[14] as recommended by the Food and Drug Administration, National Institute for Occupational Safety and Health, and Occupational Safety and Health Administration safety communication.[15] Following safety precautions has a significant effect on reducing the incidence of injuries.[13],[16] Precautions, such as double-gloving, can help protect surgeons against blood contaminations.[17] By comparison, most of the residents participated in the study tend to go with the no-touch technique other than other safety measures. Eye protection seems to be the less popular kind of protective measures among the residents.


  Conclusions Top


The high prevalence of sharp injuries and their reporting does not seem to correlate. It is recommended to promote awareness about the importance and the impact of sharp injuries among doctors in training. Further, thorough investigation of each injury might provide better understanding of causes and risk factors associated with sharp related injuries in both.

Acknowledgments

We would like to acknowledge the efforts of the following medical interns at King Abdulaziz University for participating in the data collection of this paper: Ahmed Mohammad Abdulrazzg, Moataz Saeed M. Hantoush, Yazeed Abdulhameed Alharbi, Mohammad Fat'hy Saeedi, Mohammed Saad Ahmed Alghamdi, Abdalrahman Abdallah Aljameely, Mohammed Saleh Alzahrani, Naif Mohammed Alharbi, Mohammad Abdulghani Alqasimi, and Abdulaziz Owaimer AlSulami.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
National Institute for Occupation Safety and Health, NIOSH. Alert: Preventing Needle-Stick Injuries in Healthcare Setting. DHHS (NIOSH) Publication No. 2000-108. Cincinnati: National Institute for Occupation Safety and Health; 1999.  Back to cited text no. 1
    
2.
Tokars JI, Bell DM, Culver DH, Marcus R, Mendelson MH, Sloan EP, et al. Percutaneous injuries during surgical procedures. JAMA 1992;267:2899-904.  Back to cited text no. 2
[PUBMED]    
3.
Kennedy R, Kelly S, Gonsalves S, Mc Cann PA. Barriers to the reporting and management of needlestick injuries among surgeons. Ir J Med Sci 2009;178:297-9.  Back to cited text no. 3
    
4.
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;356:2693-9.  Back to cited text no. 4
    
5.
Welc CM, Nassiry A, Elam K, Sanogo K, Zuelzer W, Duane T, et al. Continued non-compliance with the American College of Surgeons recommendations to decrease infectious exposure in the operating room: Why? Surg Infect (Larchmt) 2013;14:288-92.  Back to cited text no. 5
    
6.
Kerr HL, Stewart N, Pace A, Elsayed S. Sharps injury reporting amongst surgeons. Ann R Coll Surg Engl 2009;91:430-2.  Back to cited text no. 6
    
7.
Thomas WJ, Murray JR. The incidence and reporting rates of needle-stick injury amongst UK surgeons. Ann R Coll Surg Engl 2009;91:12-7.  Back to cited text no. 7
    
8.
Rapparini C. Occupational HIV infection among health care workers exposed to blood and body fluids in Brazil. Am J Infect Control 2006;34:237-40.  Back to cited text no. 8
    
9.
Khatony A, Abdi A, Jafari F, Vafaei K. Prevalence and reporting of needle stick injuries: A survey of surgery team members in Kermanshah University of Medical Sciences in 2012. Glob J Health Sci 2015;8:245-51.  Back to cited text no. 9
    
10.
Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al. Acase-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337:1485-90.  Back to cited text no. 10
    
11.
Nagao M, Iinuma Y, Igawa J, Matsumura Y, Shirano M, Matsushima A, et al. Accidental exposures to blood and body fluid in the operation room and the issue of underreporting. Am J Infect Control 2009;37:541-4.  Back to cited text no. 11
    
12.
Wada K, Yoshikawa T, Lee JJ, Mitsuda T, Kidouchi K, Kurosu H, et al. Sharp injuries in Japanese operating theaters of HIV/AIDS referral hospitals 2009-2011. Ind Health 2016;54:224-9.  Back to cited text no. 12
    
13.
Jagger J, Perry J, Gomaa A, Phillips EK. The impact of U.S. policies to protect healthcare workers from bloodborne pathogens: The critical role of safety-engineered devices. J Infect Public Health 2008;1:62-71.  Back to cited text no. 13
    
14.
Saarto A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systematic Reviews 2011. Art. No.: CD009170. DOI: 10.1002/14651858.CD009170.pub2.  Back to cited text no. 14
    
15.
FDA, NIOSH, OSHA Joint Safety Communication: Blunt Tip Surgical Suture Needles Reduce Needlestick Injuries and the Risk of Subsequent Bloodborne Pathogen Transmission to Surgical Personnel; 30 May, 2012. US Food and Drug Administration; 2013. Available from: http://www. AlertsandNotices/ucm305757.htm. [Last accessed on 2016 Dec 18].  Back to cited text no. 15
    
16.
Holodnick CL, Barkauskas V. Reducing percutaneous injuries in the OR by educational methods. AORN J 2000;72:461-4, 468-72, 475-6.  Back to cited text no. 16
    
17.
Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database of Systematic Reviews 2006. Art. No.: CD003087. DOI: 10.1002/14651858.CD003087.pub2.  Back to cited text no. 17
    


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