The following statement was revised by the American College of Surgeons (ACS) Committee on Perioperative Care and was reviewed and approved by the ACS Board of Regents at its June 2016 meeting.
Sharps injuries and surgical glove tears continue to expose surgeons and operating room (OR) personnel to the risk of infection. Patients’ blood makes contact with the skin or mucous membranes of OR personnel in as many as 50 percent of operations, with cuts or needlesticks occurring in as many as 15 percent of operations. Surgeons and first assistants are at highest risk for injury, sustaining up to 59 percent of the injuries in the OR. Scrub personnel have the second highest frequency of injuries in the OR (19 percent), followed by anesthesiologists (6 percent), and circulating nurses (6 percent). Of the estimated 384,000 needlestick injuries that occur in hospitals each year, 23 percent occur in surgical settings.
Published literature indicates that while needlestick injury rates have been decreasing among nonsurgical health care providers, they have not declined among health care professionals who work in surgical settings. According to a 2010 article published in the Journal of the American College of Surgeons and citing data from a 1998 study, more than half of needlestick injuries involving suture needles occur during the suturing of fascia or muscle. For surgeons, suture needles are the most frequent source of sharps injuries.
The ACS supports work practices that are designed to eliminate, protect, or standardize the use of sharp instruments in the OR. The ACS also recommends the use of structured evaluations and user-based criteria that include performance standards, task analysis, simulation, and training programs for devices intended to reduce sharps injuries in the OR.
A team approach is critical to reduce the risk of blood-borne infections resulting from sharps injuries in the OR. Hospitals and health care facilities should make sharps injury reduction techniques and instruments available to surgeons and OR personnel.
OR work practices
Glove barrier failure is common, with reported perforation rates as high as 61 percent for surgeons and 40 percent for scrub personnel. Double gloving reduces the risk of exposure to patient blood by as much as 87 percent when the outer glove is punctured. However, double gloving has certain disadvantages, such as decreased tactile sensation. In certain types of operations (such as neurosurgery procedures), where delicate manipulation of instruments and tissues is required, double gloving may impair the surgeon’s ability to optimally perform the procedures. Despite a large body of data documenting the benefits of double gloving, this technique has not received wide acceptance among surgeons. In many cases, a period of adaptation and “retraining” appears to be necessary before practitioners feel comfortable with the technique. Specially designed undergloves are available to make the process of double gloving more acceptable to surgeons.
Therefore the ACS recommends:
- The universal adoption of the double glove (or underglove) technique to reduce exposure to body fluids resulting from glove tears and sharps injuries. In certain delicate operations, and in situations where it may compromise the safe conduct of the operation or safety of the patient, the surgeon may decide to forgo this safety measure.
Blunt-tip suture needles
Suture needle injuries pose the greatest risk of sharps injury to the surgeon and scrub personnel. The effectiveness of the use of blunt-tip suture needles in reducing sharps injuries is supported by a number of randomized studies and case series that demonstrate a decrease in the rate of glove puncture from 38 percent down to 6 percent—and down to zero in some cases—following the adoption of blunt-tip suture needles. Recently published studies show that using blunt-tip suture needles reduces the risk of needlestick injuries from suture needles by 69 percent. Although blunt-tip suture needles cost approximately 70 cents more than their standard suture needle counterparts, the benefits of reducing the risk of serious and potentially fatal blood-borne infections for health care personnel support their use when clinically appropriate.
A 2007 report suggests that the slight difference in costs of blunt- and sharp-tip suture needles is balanced by the economic savings associated with needlestick injury prevention. This report, which assessed the costs of managing occupational exposures to blood and body fluids, concluded that the cost of managing a needlestick injury can range from $376 to $2,456 per reported incident. In addition, personnel who receive needlestick injuries may experience anxiety and a loss of productivity as they await the results of blood tests.
The use of blunt-tip suture needles does not require the surgeon to change their work practices. In fact, a new generation of blunt-tip suture needles is now on the market with a slightly more tapered tip profile that may provide for easier suturing compared with the earlier needles used in the referenced studies. The College recognizes that specific procedures may preclude the use of blunt-tip suture needles.
Therefore the ACS recommends:
- The universal adoption of blunt-tip suture needles for the closure of fascia and muscle in order to reduce needlestick injuries in surgeons and OR personnel.
The neutral zone
The hands-free technique (HFT) requires the surgical team to designate a sharps neutral zone (for example, a towel, Mayo stand, magnetic pad) for the pickup and release of surgical sharps such as needle-holders, scalpels, and syringes with needles. With this technique, there is no direct handing of instruments from scrub person to surgeon and back. If the surgeon must not break eye contact with the surgical field during critical parts of the operation where patient safety or workflow might be compromised, a partial HFT may be used whereby sharps are directly handed from the scrub person to the surgeon but then returned to the scrub person via a neutral zone.
The use of the neutral zone to transfer sharps is supported by the Occupational Safety and Health Administration and the Association of periOperative Registered Nurses as a method to reduce health care workers’ risk of sharps injury during surgery. The data supporting the use of HFT are inconclusive at present, with one large study reporting lower needlestick rates more than 75 percent of the time when the HFT technique was used, and another, smaller randomized controlled trial reporting no difference in needlestick rates with HFT use.
Therefore the ACS recommends:
- The use of HFT as an adjunctive safety measure to reduce sharps injuries during a surgical procedure except in situations where it may compromise the safe conduct of the operation, in which case a partial HFT may be used.
Engineered sharps injury prevention devices
Engineered sharps injury prevention (ESIP) mechanical devices may provide varying degrees of mechanical protection from sharps injuries involving suture needles and scalpel blades. Manufacturers of ESIP devices approved by the U.S. Food and Drug Administration have been permitted to claim prevention of sharps injury as a feature of their use. No study published to date demonstrates the clinical effectiveness of ESIP devices. The design and quality of these devices has been variable and their acceptance among surgeons limited. Nevertheless, these devices may contribute to minimizing sharps injuries in the OR.
Therefore the ACS recommends:
- The use of ESIP 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.
The ACS offers this statement for consideration by surgeons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not constitute a standard of care and is not intended to replace the professional judgment of the surgeon or health care administrator. This statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care organization, and requirements of other allied and health care organizations.
Aarnio P, Laine T. Glove perforation rate in vascular surgery—A comparison between single and double gloving. Vasa. 2001;30(2):122-124.
Berguer R, Heller PJ. Strategies for preventing sharps injuries in the operating room. Surg Clin North Am. 2005;85(6):1288-305.
Eggleston MK Jr, Wax JR., Philput C, et al. Use of surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997;6(4):245-247.
Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J. 1998;67(5):979-981, 983-974, 986-977.
Jagger J, Berguer R, Phillips EK, Parker G, Gomaa AE. Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation. J Am Coll Surg. 2010;210(4):496-502.
Jensen SL. Double gloving—Electrical resistance and surgeons’ resistance. Lancet. 2000;355(9203):514-515.
Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system. Am J Surg. 2001;181(6):564-566.
Naver LP, Gottrup F. Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: A prospective, randomised controlled study. Eur J Surg. 2000;166(4):293-295.
O’Malley EM, Scott RDII, Gayle J, et al. Costs of management of occupational exposures to blood and body fluids. Infect Control Hosp Epidemiol. 2007;28(7):774-782.
Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systemic Reviews. 2011; Issue 11, Art. No.: CD009170. DOI: 10. 1002/14651858.CD009170.pub2.
Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theatre injuries. Occup Environ Med. 2002;59(10):703-707.