HISTORY

During the early to mid-1980s, transmissible, potentially fatal diseases became of great concern to HCWs. In response the Occupational Safety and Health Administration (OSHA) developed standards addressing workplace safety and Bloodborne Pathogens (Cuming et al, 2008). In 1991 OSHA (2008) issued the Bloodborne Pathogens standard (29 CFR 1910.1030) to protect workers from this risk. Beginning in 1996, nursing organizations along with grassroots groups lobbied for legislation at the federal level to mandate safer needlestick devices and improve HCW education (Peterson, 1997). It was not until November 6, 2000, that President Clinton signed the Needlestick Safety and Prevention Act (Murphy, 2001). In 2001, as a response to the Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens standard.

OSHA requires that employers reduce and eliminate employee risk through the use of engineering and work practice controls. The revised standard clarifies the need for employers to select safer needle devices and to involve employees in identifying and choosing these devices, to annually review advances in technology to reduce risk or injury, and to maintain a log of injuries from contaminated sharps (OSHA, 2009).

PATHOGEN PREVALENCE

Bloodborne Pathogens are pathogenic microorganisms that are present in human blood, or blood components, that can cause disease in humans. There are more than 20 pathogens that can be transmitted with occupational exposure. The pathogens that are of greatest concern are HBV, HCV, and HIV. They are the most commonly transmitted pathogens during patient care (Centers for Disease Control and Prevention [CDC], 2008b) (Table 19-1). The operating room and perioperative services are areas of high risk for exposure, and the risk for becoming infected is a concern for all perioperative team members. Other bloodborne diseases that pose sporadic but infrequent occupational infection risks include syphilis, malaria, babesiosis, brucellosis, relapsing fever, human T-lymphotropic viruses, viral hemorrhagic fever agents, and arboviruses.

TABLE 19-1 Infections Transmitted via Sharps Injuries During Patient Care (PC) and/or Laboratory/Autopsy (L/A)

From Centers for Disease Control and Prevention: Workbook for designing, implementing, and evaluating a sharps injury prevention program, 2008, available at http://www.cdc.gov/sharpssafety/pdf/​sharpsworkbook_2008.pdf. Accessed September 6, 2009.

BLOODBORNE PATHOGEN TRANSMISSION

To develop strategies for reduction of occupational exposures to Bloodborne Pathogens it is important to examine the types of exposures: cutaneous contact, mucous membrane contact, percutaneous penetration, and aerosolization of blood.

The first means of transmission is through cutaneous contact, and the intact skin is the first line of defense for the body to help prevent contamination. Most cutaneous exposures are breaks in the skin and remain unnoticed by the HCW (Stringer et al, 2001). Many HCWs, especially OR personnel, develop these breaks in their skin. Breaks in the skin also are thought to be caused by repeated scrubbing, hand washing, and dermatitis linked to latex allergy (Stringer et al, 2001). The prevalence of latex sensitivity is reported to be 3% in hospital workers as a whole and 6% in OR personnel (Stringer et al, 2001).

The second means of transmission is through mucous membrane (i.e., the lining of the mouth, eyes, and nostrils), which are more vulnerable to disease organisms than intact skin. The risk for HIV transmission from mucous membrane contamination has been estimated to be 0.09% (Stringer et al, 2001). There have been at least four documented cases of U.S. workers who seroconverted after being exposed to HIV-infected blood through contact with mucous membranes (Stringer et al, 2001). There are many cases of both HBV and HCV that were transmitted via contaminated blood contact through the mucous membrane.

The third means of transmission is percutaneous contamination; it may also be referred to as transcutaneous or parenteral route. This type of transmission occurs when a sharp instrument such as a scalpel, bone hooks, needles, or bone penetrates the skin.

The fourth means of exposure is aerosol. As technology has advanced, high-speed cutting devices produce an aerosol that may be contaminated with pathogens from an infected or colonized patient (Taylor, 2006). This method of transmission has not been well studied and requires further research.

Prevention of blood exposure—by implementing the use of barriers in the operating room and modification of surgical techniques—is recommended to minimize risk for needlestick or sharps injury to prevent occupational infection from both known and unknown bloodborne viruses from the surgical patient.

INJURY PATTERN

To understand the mechanism of injury and implement best practices to prevent exposure to Bloodborne Pathogens, the perioperative nurse must be aware of the contributing factors for exposure. One recognized factor is related to the invasive nature of surgical procedures, which places the perioperative team in a highly vulnerable position for percutaneous exposure. Taylor (2006) identifies contributing factors related to occupational needlestick or sharps injury: (1) extended contact with open surgical sites, (2) manipulation of equipment and sharp instruments, and (3) exposure to large quantities of blood and body fluids and other types of tissue.

Wright et al (1991) investigated the mechanisms of glove tears and injuries resulting from sharp objects in the operating room. Each person who experienced a glove tear or sharps injury was interviewed immediately after the incident. During 2292 operations, 249 glove tears and 70 injuries from sharp objects were documented. In 63% of the glove tears, there was visible contact with the patient’s blood. The cause of the glove tear could be identified in only 81 incidents (33%). Ninety-two percent of the glove tears occurred when personnel were wearing one glove. These findings suggest that most glove tears are the result of unknown causes; however, changes in the number of gloves worn was suggested to reduce risk. Sixty-seven percent of the sharps injuries were caused by needlesticks, usually during suture placement. The majority of the sharps injuries (57%) occurred with the injured hand stationary or holding an object (16%), while the hand was retracting tissue (17%), and by instruments not in use (24%) (Wright et al, 1991).

Tanner and Parkinson (2006) conducted a systematic review to include 31 randomized controlled trials investigating various parameters, which included glove perforations, double-gloving practices, and effectiveness of indicator gloves. Tanner and Parkinson (2006) concluded that the practice of double gloving is effective in significantly decreasing exposure to Bloodborne Pathogens. The recommendation for double gloving has since become endorsed as a best practice by the Association of periOperative Registered Nurses (2009), American College of Surgeons (2007), and American Academy of Orthopedic Surgeons (2008).

Berguer and Heller (2004) state that needlestick injuries may occur in as many as 15% of operations. Scrub nurses and scrub technicians sustain the second-highest frequency of injuries in the OR at 19%; surgeons and first assistants are the highest at 59% (Berguer and Heller, 2004). Suture needles are the main source of needlesticks to OR personnel, causing 51% of all sharps injuries in surgical settings. Scalpel blades cause 12% of injuries (Jagger et al, 1998). The most common body part injured is the nondominant hand, usually suturing the fascia. Surgeons also fail to report as many as 70% of their injuries and do not participate in recommended postexposure strategies (Patterson et al, 1998). Knowing the mechanism of sharps injuries should lead to the development of effective preventive strategies aimed at protecting operating room personal from exposure to Bloodborne Pathogens.

The Exposure Information Network (EPINet) is a voluntary surveillance program to report needlestick and sharp-object injury and blood and body fluid exposure. The database is managed by the International Healthcare Worker Safety Center at the University of Virginia. Data are reported by hospitals voluntarily. Using EPINet data from 2007, there were 29 health care facilities that participated from the United States. The total cases of percutaneous injuries in 2007 were 951 (Perry et al, 2009). The majority of percutaneous injuries, 35.9% (341), occurred in the operating room. Suture needles were involved in 23.9% of all reported percutaneous injuries. Data were then pulled out as to when the injury occurred; 47.5% of the percutaneous injuries occurred during use of the device. Ninety-two percent of the sharps injuries were contaminated. If the injury that occurred was by needle, the data were then broken down by whether the needle was a “safety design.” Injuries continue at a high rate, but there is still a high rate of use of items that are not “safety devices.” It is not known if injury by an item occurred because no safety device has been developed or because the institution had not implemented available safety-engineered devices. Of the injuries that occurred with a safety needle, the safety mechanism was activated in only 11.9% of the cases. The data suggest that there needs to be more training and education on safety devices to determine that the devices are used correctly. Training and education should include information on the device’s intended use. The issues of why HCWs chose not to use safety devices when available also demands further research.