safetyinsurgerybibliography.html

Bibliography with abstracts:

Needlesticks, Sharp-Object Injuries and Blood Exposures in Surgical Settings
Epidemiology/Risk/Prevention

Organized in reverse chronological order, by year (goes back to 1989); within each year, articles are in alphabetical order. 

2010

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. Journal of the American College of Surgeons 2010 Apr;210(4):496-502.
ABSTRACT - BACKGROUND: The operating room is a high-risk setting for occupational sharps injuries and bloodborne pathogen exposure. The requirement to provide safety-engineered devices, mandated by the Needlestick Safety and Prevention Act of 2000, has received scant attention in surgical settings. STUDY DESIGN: We analyzed percutaneous injury surveillance data from 87 hospitals in the United States from 1993 through 2006, comparing injury rates in surgical and nonsurgical settings before and after passage of the law. We identified devices and circumstances associated with injuries among surgical team members. RESULTS: Of 31,324 total sharps injuries, 7,186 were to surgical personnel. After the legislation, injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings. Most injuries were caused by suture needles (43.4%), scalpel blades (17%), and syringes (12%). Three-quarters of injuries occurred during use or passing of devices. Surgeons and residents were most often original users of the injury-causing devices; nurses and surgical technicians were typically injured by devices originally used by others. CONCLUSIONS: Despite legislation and advances in sharps safety technology, surgical injuries continued to increase during the period that nonsurgical injuries decreased significantly. Hospitals should comply with requirements for the adoption of safer surgical technologies, and promote policies and practices shown to substantially reduce blood exposures to surgeons, their coworkers, and patients. Although decisions affecting the safety of the surgical team lie primarily in the surgeon's hands, there are also roles for administrators, educators, and policy makers.

Mingoli A, Brachini G, Sgarzini G, Binda B, Sapienza P, Modini C. Blunt needles for patients' and surgeons' safety [letter]. Arch Surg. 2010 Feb;145(2):210-11.

Saver C. Blunting sharps injuries in the OR continues to be a work in progress. OR Manager 2010 (Jan.);26(1):1,7-11. [No abstract.]

Sinnott M, Shaban R. "Scalpel safety," not "safety scalpel": a new paradigm in staff safety. Perioperative Nursing Clinics 2010;5(1):59-67.
SUMMARY: Scalpel injuries account for between 7% and 12% of all sharps injuries. Efforts to increase the awareness of potential hazards of sharps injuries and related prevention efforts began in the early 1980s. Research shows convincingly that a single-handed scalpel blade remover combined with a hands-free passing technique (HFPT) is a safe alternative choice to the safety scalpel. The concept of "scalpel safety" is based on providing nurses the freedom of choice to select the best safety device for their individual needs on a case-by-case basis. Team members can now choose between a safety scalpel and a single-handed scalpel blade remover combined with a HFPT to achieve the correct balance between patient safety and staff safety.

Watt A, Patkin M, Sinnott M, Black R, Maddern G. Scalpel safety in the operative setting: A systematic review. Surgery 2010;147(1):98-106.
BACKGROUND: The complex environment of the operative setting provides multiple opportunities for health care workers to sustain scalpel injuries; scalpels are the second most frequent source of sharps injuries in this setting. Little evidence has been published detailing the effectiveness of proposed safety procedures and devices. Methods: A systematic search strategy was used to identify relevant studies. Studies were included based on the application of a predetermined protocol, an independent assessment by 2 reviewers, and a consensus decision. Nineteen articles formed the evidence base for this review. Results: Little high-level evidence was available. The results of studies reporting on 5 different devices/procedures were identified: the use of cut-resistant gloves/liners decreased the number of glove perforations in comparison with double latex gloves alone but lessened the wearer's dexterity and tactile sensation; the benefit derived from the use of the hands-free passing technique seemed equivocal; "sharpless surgery" was found to be feasible; a single-handed blade remover prevented at least as many injuries as a safety scalpel; and some shoe materials provided superior foot protection. Conclusion: The lack of available evidence highlights the need for the generation of a methodologically rigorous, clinically relevant, and statistically valid body of primary research in this area to support appropriate and effective safety interventions.

2009
Misteli H, Weber WP, Reck S, Rosenthal R, Zwahlen M, Fueglistaler P, Bolli MK, Oertli D, Widmer AF, Marti WR. Surgical glove perforation and the risk of surgical site infection. Arch Surg. 2009 Jun;144(6):553-8; discussion 558.
ABSTRACT: Clinically apparent surgical glove perforation increases the risk of surgical site infection (SSI). DESIGN: Prospective observational cohort study. SETTING: University Hospital Basel, with an average of 28,000 surgical interventions per year. PARTICIPANTS: Consecutive series of 4147 surgical procedures performed in the Visceral Surgery, Vascular Surgery, and Traumatology divisions of the Department of General Surgery. MAIN OUTCOME MEASURES: The outcome of interest was SSI occurrence as assessed pursuant to the Centers of Disease Control and Prevention standards. The primary predictor variable was compromised asepsis due to glove perforation. RESULTS: The overall SSI rate was 4.5% (188 of 4147 procedures). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared with interventions with maintained asepsis (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4-2.8; P < .001). However, multivariate logistic regression analyses showed that the increase in SSI risk with perforated gloves was different for procedures with vs those without surgical antimicrobial prophylaxis (test for effect modification, P = .005). Without antimicrobial prophylaxis, glove perforation entailed significantly higher odds of SSI compared with the reference group with no breach of asepsis (adjusted OR, 4.2; 95% CI, 1.7-10.8; P = .003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted OR, 1.3; 95% CI, 0.9-1.9; P = .26). CONCLUSION: Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI.  

Nagao M, Iinuma Y, Igawa J, Matsumura Y, Shirano M, Matsushima A, Saito T, Takakura S, Ichiyama S. Accidental exposures to blood and body fluid in the operation room and the issue of underreporting. Am J Infect Control 2009 Apr 9 [Epub ahead of print].
ABSTRACT: A retrospective review of all exposure injuries affecting members of the operative care line at a single university hospital between January 2000 and December 2007 was performed. A questionnaire survey on current status of adherence to barrier precautions was also completed by 164 staff members. Of 136 exposure injuries, 87 (64.0%) were in surgeons, and 49 (36.0%) were in scrub nurses. Surgeons were most commonly injured during suturing (49, 56%), followed by "handing over sharps" (7, 8%), whereas scrub nurses were most commonly injured during "counting and sorting of sharps" (15, 41%), followed by "handing over sharps," and "splash." The questionnaire survey revealed that compliance with goggles, face shields, and double gloving was poor, and only 9% of respondents routinely used the hands-free technique. Only 22% of staff who had experienced exposure injuries reported every incident. Because circumstances of exposure injuries in operating rooms differ by profession, appropriate preventive measures should address individual situations. To reduce exposure injuries in the operating room, further efforts are required including education, mentoring, and competency training for operation personnel.

Stringer B, Haines T, Goldsmith CH, Blythe J, Berguer R, Andersen J, De Gara CJ. Hands-Free Technique in the Operating Room: Reduction in Body Fluid Exposure and the Value of a Training Video. Public Health Reports 2009;124 (S1):169-79.
Available at: http://www.publichealthreports.org/archives/issueopen.html?articleID=2258

OBJECTIVES: This study sought to determine if (1) using a hands-free technique (HFT)-whereby no two surgical team members touch the same sharp item simultaneously-$75% of the time reduced the rate of percutaneous injury, glove tear, and contamination (incidents); and (2) if a video-based intervention increased HFT use to $75%, immediately and over time. METHODS: During three and four periods, in three intervention and three control hospitals, respectively, nurses recorded incidents, percentage of HFT use, and other information in 10,596 surgeries. The video was shown in intervention hospitals between Periods 1 and 2, and in control hospitals between Periods 3 and 4. HFT, considered used when $75% passes were done hands-free, was practiced in 35% of all surgeries. We applied logistic regression to (1) estimate the rate reduction for incidents in surgeries when the HFT was used and not used, while adjusting for potential risk factors, and (2) estimate HFT use of about 75% and 100%, in intervention compared with control hospitals, in Period 2 compared with Period 1, and Period 3 compared with Period 2. RESULTS: A total of 202 incidents (49 injuries, 125 glove tears, and 28 contaminations) were reported. Adjusted for differences in surgical type, length, emergency status, blood loss, time of day, and number of personnel present for $75% of the surgery, the HFT-associated reduction in rate was 35%. An increase in use of HFT of $75% was significantly greater in intervention hospitals, during the first post-intervention period, and was sustained five months later. CONCLUSION: The use of HFT and the HFT video were both found to be effective.

Thomas WJ, Murray JR. The incidence and reporting rates of needle-stick injury amongst UK surgeons. Ann R Coll Surg Engl 2009;91(1):12-17.
INTRODUCTION: Needle-stick injuries are common. Such accidents are associated with a small, but significant, risk to our career, health, families and not least our patients. National guidelines steer institution-specific strategies to provide a consistent and safe method of dealing with such incidents. Surgeon-specific guidelines are not currently available. We have observed that hospital sharps policy is often considered cumbersome to the surgeon, resulting in on-the-spot decision making with potential long-term implications. By their essence, these decisions are inconsistent, not reproducible and, thus, we believe them to be unsafe. The under-reporting to occupational health departments is well documented. Current surgical practice has the potential to expose the surgeon to unnecessary risk. The aims of this study were to establish the true incidence of contaminations caused by needle-stick injury in our hospital and to assess how well current protocols are really implemented. SUBJECTS AND METHODS: We identified all surgeons of consultant, non-career staff grade (NCSG) and registrar grade working in a large 687-bed district general hospital serving a population of 550,000, in the UK. We designed a retrospective, anonymous 30-second survey. Surgeons' awareness and opinion of local policy was sought in a free-text section. RESULTS: Of the 98 surgeons in the hospital, 77% responded to the questionnaire and 44% anonymously admitted to having a needle-stick injury. Only 3 of the 33 (9%) who sustained an needle-stick injury said that they followed the agreed local policy. Twenty-three surgeons (70%) performed first aid type procedures such as informing scrub nurse, changing needle and gloves. Seven surgeons (21%) simply ignored the incident and continued. Forty-three surgeons commented on the policy's nature with only 9 who regarded it as 'user friendly'. CONCLUSIONS: Needle-stick injury is still a common problem, particularly in the surgical cohort and remains significantly under-reported. The disparity between hospital sharps policy and actual surgical practice is considered and an explanation for the difference sought. Without this awareness of 'real-life' surgical practice, the occupational health figures for sharps injury will always tell a rosy story under-estimating a real problem. We strongly advocate universal precautions in the operating theatre. However, we acknowledge that sharps injuries will occur. We should remain vigilant and act upon contaminations without surgical bravado but with mater-of-fact professionalism. This includes regular review of policy and, particularly, promotion of surgical awareness.

Vose JG, McAdara-Berowitz J. Reducing scalpel injuries in the operating room. AORN J 2009 (Dec.);90(6):867-72.
OBJECTIVE: Standard precautions, training and awareness for those at risk, the use of neutral passing zones, and safety-engineered devices have helped decrease the incidence of injury for specific categories of sharps. One new safety device is a hand piece that uses electrosurgical plasma induced with pulsed radio-frequency energy to cut tissue.

2008
Aisaka K, Itabashi K, Nagasaka K., Kuroda K, Arita S, Takane V. Influence of Novel Blunt Needles (Ethiguard) on Safety for Gynecologic Operations. Obstet Gynecol 2008;109(4[suppl]):25S.
OBJECTIVE: The present study was performed to evaluate the safety of the Ethiguard (a new type of blunt needle) by measurement of the resistance to puncture using a surgical rubber glove and chicken breast meat. METHODS: The resistance of a surgical glove and chicken breast meat (5 mm and 10 mm thick) to being punctured by three needles, a conventional round needle (J-765D), Ethiguard CTXB (circle taper extra large blunt), and a usual type of blunt needle (BP-1) was measured by the computer control system autograph (AGS-100B; Shimadzu Company, Tokyo, Japan). This procedure was repeated 10 times on each material. RESULTS: The values measured for the resistance of the surgical glove to being pierced by the three needles were 27.110.1, 17515.4, and 352.421.7 g, respectively (P.001). In contrast, the resistance of the 5-mm and 10-mm chicken breast meat test pieces to being pierced by the blunt needle was found to be significantly greater than their resistance to being pierced by the other two needles (5 mm: 13.82.7, 18.64.2, 45.95.5 g, P.001; 10 mm: 32.44.2, 37.85.8, 77.96.8 g, P.001). These results demonstrated that the Ethiguard was less likely than the conventional round needle to puncture a surgical glove, but it had the same capacity as the conventional round needle to penetrate tissue. CONCLUSION: The use of the Ethiguard is effective in preventing needle-stick accidents but still penetrates tissues satisfactorily, and also it is effective in protecting against such infections as human immunodeficiency virus (HIV) and hepatitis C virus (HCV).

Au E, Gossage JA, Bailey SR. The reporting of needlestick injuries sustained in theatre by surgeons: are we under-reporting? J Hosp Infect 2008;70(1):66-70.
ABSTRACT - Surgeons frequently sustain needlestick injuries when operating. The aim of this study was to evaluate the incidence and reporting rate of needlestick injuries at one institution. A questionnaire was distributed anonymously to 69 surgeons of all grades and specialties in a district general hospital in the UK. The questionnaire was returned by 42 surgeons (60.9%). There were 840 needlestick injuries over two years, of which 126 caused bleeding. Senior surgeons who spent more hours operating per week had a higher rate of needlestick injuries compared with junior surgeons (29.1 vs 6.59 injuries per surgeon over two years). Of the total number of injuries, 19 (2.26%) were reported to Occupational Health according to the surgeons questioned, but only six reported incidents were found in the Occupational Health records. Junior surgeons were significantly more likely to report needlestick injuries than senior surgeons (9.82% vs 1.10% of injuries reported, P=0.0000045). The main reasons for failure to report needlestick injuries were due to the lack of time and excessive paperwork. Seventy-three percent of surgeons did not routinely use double gloves when operating, mainly because of decreased hand sensation. The rate of needlestick injury reporting by surgeons at this institution is extremely low. Previous studies have shown a higher reporting rate suggesting that, despite awareness of blood-borne infections, surgeons are still not following recommended protocols.

Fuentes H, Collier J, Sinnott M, Whitby M. Scalpel safety: modeling the effectiveness of different safety devices' ability to reduce scalpel blade injuries. Int J Risk Saf Med 2008;20(1-2):83-9.
ABSTRACT - Background: The objective of this study was to analyse and compare the potential effectiveness of two safety strategies in reducing scalpel blade injuries. The two strategies examined were safety scalpel vs. a single-handed scalpel blade remover combined with a hands free passing technique (HFPT) (e.g. passing tray or neutral zone). Methods: This was a retrospective study involving review of a 550-bed adult metropolitan tertiary referral hospital's sharps injuries database, chart review, and hypothetical modelling of the data to determine potential preventable injuries. The modelling was done twice, firstly assuming 100% effectiveness of each safety device and secondly using previously published activation rates for "active" safety devices which were considered to be a more accurate reflection of real-life work practices. Results: A total of 141 scalpel injuries were reported between 1987 and 2003. Clinical charts were reviewed for 137 of these injuries. Just under 50% of injuries were sustained while the scalpel was in use and these were assumed to be not preventable. Assuming 100% effectiveness for each safety device resulted in 72 injuries being prevented by safety scalpels and 69 injuries being prevented by a combination of a single-handed scalpel blade remover and an HFPT. When injury prevention was calculated using published data on activation rates for "active" safety devices, the number fell to as low as 12 for safety scalpel and to 61 for the combination of a single-handed scalpel blade remover and an HFPT. Conclusion: Both safety strategies are potentially effective in reducing scalpel blade injuries. However the safety scalpels are active devices and as such are subject to widely variable activation rates. We recommend use of a single-handed scalpel blade remover in combination with an HFPT as this can potentially prevent 5 times as many injuries as safety scalpels.

Jagger J, Gomaa AE, Phillips EK. Safety of surgical personnel: a global concern [letter]. Lancet 2008;372(9644):1149. 

Lefebvre DR, Strande LF, Hewitt CW. An enzyme-mediated assay to quantify inoculation volume delivered by suture needlestick injury: two gloves are better than one. J Am Coll Surg 2008;206:113-22.
Link to full text at: http://www.ncbi.nlm.nih.gov/pubmed/18155576
BACKGROUND: Acquiring a blood-borne disease is a risk of performing operations. Most data about seroconversion are based on hollow-bore needlesticks. Some studies have examined the inoculation volumes of pure blood delivered by suture needles. There is a lack of data about the effect of double-gloving on contaminant transmission in less viscous fluids that are not prone to coagulation. STUDY DESIGN: We used enzymatic colorimetry to quantify the volume of inoculation delivered by a suture needle that was coated with an aqueous contaminant. Substrate color change was measured using a microplate reader. Both cutting and tapered suture needles were tested against five different glove types and differing numbers of glove layers (from zero to three). RESULTS: One glove layer removed 97% of contaminant from tapered needles and 65% from cutting needles, compared with the no-glove control data. Additional glove layers did not significantly improve contaminant removal from tapered needles (p > 0.05). For the cutting needle, 2 glove layers removed 91% of contaminant, which was significantly better than a single glove (p = 0.002). Three glove layers did not afford statistically significant additional protection (p = 0.122). There were no statistically significant differences between glove types (p = 0.41). CONCLUSIONS: With an aqueous needle contaminant, a single glove layer removes contaminant from tapered needles as effectively as multiple glove layers. For cutting needles, double-glove layering offers superior protection. There is no advantage to triple-glove layering. A surgeon should doubleglove for maximum safety. Additionally, a surgeon should take advantage of other riskreduction strategies, such as sharps safety, risk management, and use of sharpless instrumentation when possible.

Mornar SJ, Perlow JH. Blunt suture needle use in laceration and episiotomy repair at vaginal delivery. Am J Obstet Gynecol 2008;198:e14-5.
Available at: http://www.ajog.org/article/PIIS0002937807011957/fulltext OBJECTIVE: By surveying obstetricians regarding the use of blunt suture needles for laceration and episiotomy repair, the purpose of this study was to determine whether blunt suture needles represent a safe and effective alternative to sharp needles. STUDY DESIGN: Blunt suture needles were made available at our institution for repairs at vaginal delivery. Participating physicians indicated their personal history of needlestick injuries and rated the blunt suture needle after completing the repair. Categorical variables were analyzed using Fisher's exact test and a 2-tailed P < .05 was considered significant. RESULTS: Attending and resident physicians completed 80 surveys, and 83% reported previous needlestick injuries. Blunt suture needles were rated as excellent or good by 92.5% (95% confidence interval 84.6 to 96.5%). No needlestick injuries occurred. CONCLUSION: In an effort to reduce needlestick injuries, the use of blunt suture needles is safe and effective for repairs at vaginal delivery.

Sinnott M, Wall D. "Scalpel safety": how safe (or dangerous) are safety scalpels? [letter] Int J Surg 2008;6(2):176-7.

2007
Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and surgical residents: who is most at risk? J Surg Educ 2007; 64:395-8.
OBJECTIVE: Exposure to blood-borne diseases remains an occupational risk. Mandates have improved training in how to report exposures for all health-care workers. How exposure rates of surgical residents correlate with experience and mandatory training to reduce risk is not known. It was hypothesized that enhanced training would result in an increased reporting of exposures by surgical trainees and that risk would be greater in the first years of training. DESIGN: Retrospective review of occupational health records and operative case logs, prospective survey. METHODS: Occupational Health Services provides both initial and annual training to General Surgery house staff at the Medical College of Wisconsin. Initial training consists of a blood-borne pathogen review and a detailed explanation of exposure reporting. Mandatory annual training is provided during Surgical Grand Rounds. Training was enhanced beginning June 2005 using a videotape outlining surgical risks and specific countermeasures. The numbers of reported exposures per year before and after enhanced training were compared. Exposures were self-reported. As most exposures occurred in the operating room, rate of exposure was calculated for each year of training using the total number of cases done each year reported by the general surgical residents. RESULTS: Surgical residents reported 118 needlestick injuries over 6 years. Senior and chief residents demonstrated a significantly lower exposure rate than junior residents (nonparametric Mood's median test, p < 0.0001). No significant difference in the injury rate was found per 1000 cases after enhanced training. CONCLUSIONS: Increasing surgical experience lowered the needlestick injury rate. Assuming no change in self-reporting rates by year, enhanced training and reporting guidelines did not seem to change risk. More specific training for junior residents, as well as passive prevention solutions, may be necessary to positively impact their exposure risk.

Catanzarite V, Byrd K, McNamara M, Bombard A. Preventing needlestick injuries in obstetrics and gynecology: how can we improve the use of blunt tip needles in practice? Obstet Gynecol 2007;110:1399-1403.
ABSTRACT: Surgical needlestick injuries are common in obstetrics and gynecology and can cause transmission of viral diseases including hepatitis and acquired immunodeficiency syndrome (AIDS). Strategies to reduce the rate of needlestick injuries include using instruments rather than fingers to retract tissue and grasp needles, double gloving, using surgical staplers for skin closure, and substituting blunt tip surgical needles for sharp tip needles where applicable. Studies have shown the use of blunt tip surgical needles to be remarkably effective in reducing needlestick injuries. Despite recommendations by the American College of Surgeons that blunt tip surgical needles be used routinely, at least for fascial closure, and by the Occupational Safety and Health Administration and the National Institute for Occupational Health and Safety that these devices be used whenever medically appropriate, use in obstetrics and gynecology appears to be limited. Potential barriers to use include availability, the "feel" of the needle as it penetrates tissue, and habit. We suggest that blunt tip surgical needles have the potential to replace traditional needles for many obstetric and gynecologic applications. If their use is to become more widespread, we must focus on availability, evaluation for specific applications, and physician education.

Cunningham TR, Austin J. Using goal setting, task clarification, and feedback to increase the use of the hands-free technique by hospital operating room staff. J Appl Behav Anal 2007;40:673-7.
SUMMARY: We evaluated the effects of a behavioral treatment on the safe passing of sharp instruments using the hands-free technique among hospital operating room personnel during surgical procedures. Treatment consisted of participative goal setting, task clarification, and feedback. The average percentage of sharp instruments passed safely increased from 32% to 64% and 31% to 70% between baseline and treatment phases in the inpatient and outpatient surgery units, respectively. Five-month follow-up data suggested maintenance of treatment effects. These findings suggest the utility of organizational behavior management strategies in reducing risky behavior in hospital settings.

Dagi TF, Berguer R, Moore S, Reines HD. Preventable Errors in the Operating Room-Part 2: Retained Foreign Objects, Sharps Injuries, and Wrong Site Surgery [monograph]. Curr Probl Surg 2007;44:352-81.
SUMMARY: The concept of safe surgery has received significantly more attention since the publication of the Institute of Medicine report in 1999. Safety issues have always attracted surgeons' attention, but the details have frequently been left to nurses, and more recently to anesthesiologists. Surgeons have always assumed patient safety was a primary goal; however, recent findings and regulations from the Joint Commission for Accreditation of Hospitals (JCAHO) and the Occupational Safety and Health Administration (OSHA) have challenged this belief. Only recently has academic surgery addressed the issue of error prevention and causation. This monograph will address the specific safety issues of retained surgical items, wrong-site surgery, and injuries from sharp instruments, all of which affect the practicing surgeons in the operating room.

Fry DE. Occupational risks of blood exposure in the operating room. Am Surg 2007;73:637-46.
ABSTRACT: Bloodborne pathogens continue to be a source of occupational infection for healthcare workers, but particularly for surgeons. Over 1 per cent of the U.S. population has one or more chronic viral infections. Hepatitis B is the infection that has the longest known role as an occupational pathogen, but infection with this virus is largely preventable with the use of the effective hepatitis B vaccine. Hepatitis C affects the largest number of people in the United States, and there is no vaccine available for the prevention of this infection. HIV infection still has not been associated with a documented transmission in the operating room environment, but six cases of probable occupational transmission have been reported. A total of 57 healthcare workers have had documented occupational infection since the epidemic of HIV infection began. Infection of blood-borne pathogens to patients from infected surgeons remains a concern. Surgeons who are e-antigen-positive for hepatitis B have been well documented to be an infection risk to patients in the operating room. Only four surgeons have been documented to transmit hepatitis C, although other transmissions have occurred in the care of patients when practices of infection control have been violated. No surgical transmission of HIV to a patient has been identified at this time. Prevention of occupational infection requires use of protective barriers, avoidance of exposure risk by modification of techniques, and a constant awareness of sharp instruments in the operating room. Blood exposure in the operating room carries risk of infection and should be avoided. It is likely that other infectious agents will emerge as operating room threats. Surgeons must maintain vigilance in avoiding blood exposure and percutaneous injury.

Makary MA, Al-Attar A, Holzmueller CG et al. Needlestick injuries among surgeons in training. N Engl J Med 2007; 2007:2693-9.
Available at: http://content.nejm.org/cgi/reprint/356/26/2693.pdf BACKGROUND: Surgeons in training are at high risk for needlestick injuries. The reporting of such injuries is a critical step in initiating early prophylaxis or treatment. METHODS: We surveyed surgeons in training at 17 medical centers about previous needlestick injuries. Survey items inquired about whether the most recent injury was reported to an employee health service or involved a "high-risk" patient (i.e., one with a history of infection with human immunodeficiency virus, hepatitis B or hepatitis C, or injection-drug use); we also asked about the perceived cause of the injury and the surrounding circumstances. RESULTS: The overall response rate was 95%. Of 699 respondents, 582 (83%) had had a needlestick injury during training; the mean number of needlestick injuries during residency increased according to the postgraduate year (PGY): PGY-1, 1.5 injuries; PGY-2, 3.7; PGY-3, 4.1; PGY-4, 5.3; and PGY-5, 7.7. By their final year of training, 99% of residents had had a needlestick injury; for 53%, the injury had involved a high-risk patient. Of the most recent injuries, 297 of 578 (51%) were not reported to an employee health service, and 15 of 91 of those involving high-risk patients (16%) were not reported. Lack of time was the most common reason given for not reporting such injuries among 126 of 297 respondents (42%). If someone other than the respondent knew about an unreported injury, that person was most frequently the attending physician (51%) and least frequently a "significant other" (13%). CONCLUSIONS: Needlestick injuries are common among surgeons in training and are often not reported. Improved prevention and reporting strategies are needed to increase occupational safety for surgical providers.

Phillips EK, Owusu-Ofori A, Jagger J. Bloodborne pathogen exposure risk among surgeons in sub-Saharan Africa. Infect Control Hosp Epidemiol 2007;28:1334-6.
Available at: http://www.journals.uchicago.edu/doi/abs/10.1086/522681 ABSTRACT: To document the frequency and circumstances of bloodborne pathogen exposures among surgeons in sub-Saharan Africa, we surveyed surgeons attending the 2006 Pan-African Association of Surgeons conference. During the previous year, surgeons sustained a mean of 3.1 percutaneous injuries, which were typically caused by suture needles. They sustained a mean of 4.1 exposures to blood and body fluid, predominantly from blood splashes to the eyes. Fewer than half of the respondents reported completion of hepatitis B vaccination, and postexposure prophylaxis for human immunodeficiency virus was widely available. Surgeons reported using hands-free passing and blunt suture needles. Non-fluid-resistant cotton gowns and masks were the barrier garments worn most frequently.

2006
Makary M, Pronovost PJ, Weiss ES, Millman EA, Chang D, Baker SP, Cornwell EE, Syin D, Freischlag JA. Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice. World J Surg 2006;30:1224-9.
Available at: http://www.springerlink.com/content/y28268608068j232/fulltext.pdf
CONTEXT: Percutaneous injuries occur frequently during surgical procedures and represent a significant occupational hazard to operating room personnel. OBJECTIVES: To evaluate the feasibility of performing select general surgical procedures using a combination of non-sharp devices and techniques to replace the conventional use of scalpels and needles. DESIGN, SETTING, PARTICIPANTS: Candidate procedures for which sharpless techniques could replace conventional scalpels and suture needles were identified preoperatively in an urban, university-based general surgical practice over a 1-year period (June 2003-June 2004). Non-sharp techniques included monomeric 2-octyl cyanoacrylate adhesive, electrocautery, tissue stapler, and minimally invasive instrumentation. Conventional scalpels and suture needles were readily available and used whenever necessary. MAIN OUTCOME MEASURES: We rated the feasibility of performing specific procedures without sharps. We also documented the rate of overall reversion to sharps during operations on patients that had been identified preoperatively as candidates for sharpless surgery. RESULTS: Of 358 procedures performed in the general surgery university practice, 91 were identified preoperatively as appropriate for sharpless surgery. Of these, 86.8% (79/91) were completed without the use of sharps, including 13/22 (59.1%) open laparotomy procedures, 20/22 (90.9%) laparoscopic procedures, and 46/47 (97.8%) soft tissue procedures. Intraoperative reversion to sharps occurred in 12 cases when deemed necessary by the surgeon. CONCLUSIONS: Select common procedures can be performed entirely with sharpless techniques, eliminating the risk to surgical personnel associated with intraoperative percutaneous injuries.

Stringer B, Haines T. Hands-free technique: preventing occupational exposure during surgery. J Perioper Pract 2006 (Oct.);16:495-500.
Available at: http://www.highbeam.com/doc/1P3-1148839911.html ABSTRACT: Occupational exposure to blood borne pathogens has led to HBV, HCV and HIV infections among surgeons, nurses and other operating room (OR) personnel and, to a lesser degree, patients (Ross et al 2000, The incident investigation teams and others 1997). Of seven OR studies in which an observer or circulating nurse recorded exposures, there was a percuataneous injury in 1.7-15% of all surgeries, and a mucocutaneous contamination in 6.2-50% of all surgeries. (Gerberding et al 1990, Panlilio et al 1991, Popejoy & Fry 1991, Quebbeman et al 1991, Tokars et al 1992, Lynch & White 1993, Stringer, Infante-Rivard & Hanley 2002). Surgeons and residents usually sustained the greatest number of percutaneous and other exposures during surgery.

Stringer B, Haines T, Goldsmith CH, Blythe J, Harris KA. Perioperative use of the hands-free technique: a semistructured interview study. AORN J 2006;84(2):233-5, 238-48.
SUMMARY: Occupationally contracted bloodborne infections are preventable, but the use of many protective measures remains limited. There is growing evidence that the use of the hands-free technique (HFT) to pass sharp items during surgical procedures is effective in protecting against sharps injury and bloody contamination. Researchers conducted in-depth telephone interviews to explore 20 health care providers' knowledge and use of the HFT. Most of the interviewees did not regularly use the HFT, and some were resistant to its use.

2005
Berguer R, Heller PJ. Strategies for preventing sharps injuries in the operating room. Surg Clin N Am 2005;85:1299-1305.
SUMMARY: With the discovery of AIDS and HIV, the medical community began to widely recognize the dangers of serious illnesses spreading through contact with contaminated blood and body fluids. In response, the Centers for Disease Control and other groups have developed guidelines for the operating room to prevent the spread of infection from, for example, accidental needle sticks. Unfortunately, those guidelines are not always strictly followed. This article reviews studies that have examined precautionary practices, including such practices as double gloving, the use of blunt suture needles, and the use of neutral zones for passing sharps. The article also provides related sources for further information.

Fry DE. Occupational blood-borne diseases in surgery. Am J Surg 2005; 190:249-54.
BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C (HCV) infections are transmitted by blood exposure. Surgeons have been concerned about the risks of blood exposure in the operating room as a potential source of occupational infections from these viruses. The actual risk and frequency of operating room transmission remains poorly understood by many surgeons. METHODS: The pertinent recent literature on the pathophysiology, diagnosis, prevention, and treatment of HIV, HBV and HCV were reviewed to address the current understanding of these viruses as occupational risks to surgeons. RESULTS: HIV transmission to surgeons has not been documented in the United States by the Centers for Disease Control. HIV transmission from a surgeon to a patient in the environment of the operating room, as well as transmission from an HIV-infected surgeon to a patient, has not been documented. HBV infection of surgeons has declined with the general acceptance of the HBV vaccine. HCV infection remains a real risk for transmission in the operating room, given that no vaccine is currently available and that the overall number of chronically infected patients remains quite high. CONCLUSION: The risk of occupational infection from known viral pathogens for surgeons is low, but it is not zero. Effective barriers, modified patterns of behavior, and prompt responses to blood exposure events are the best methods for prevention.

Perry J, Jagger J. Slash sharps risk for surgical personnel. Nurs Manage 2005 (Nov);Suppl:28-9.

Weiss ES, Makary MA, Wang T, Syin D, Pronovost PJ, Chang D, et al. Prevalence of blood-borne pathogens in an urban, university-based general surgical practice. Ann Surg 2005;241:803-7.
Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1357135
OBJECTIVE: To measure the current prevalence of blood-borne pathogens in an urban, university-based, general surgical practice. BACKGROUND: Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C represent significant occupational hazards to the surgeon. While the incidence of these blood-borne pathogens is increasing in the general population, little is known about the current prevalence of these exposures among patients presenting for surgery. METHODS: We studied 709 consecutive operative cases (July 2003 to June 2004) in a university practice that provides all inpatient, emergency department, and outpatient consultative general surgical services. Trauma cases and bedside procedures were excluded. Data collected included HIV, hepatitis B and C test results, type of operation, age, sex, and history of intravenous drug use. RESULTS: Testing for blood-borne pathogens was performed in 53% (N = 373) of 709 patients based on abnormal liver function tests, neutropenia, history of IV drug use, or patient request. Thirty-eight percent of all operations (142/373) were found to involve a blood-borne pathogen when tested: HIV (26%), hepatitis B (4%), hepatitis C (35%), and coinfection with HIV and hepatitis C (17%). Forty-seven percent of men tested positive for at least 1 blood-borne pathogen. Seventy-three different types of operations were performed, ranging from Whipple procedures to amputations. Soft-tissue abscess procedures 48% (34/71) and lymph node biopsies 67% (10/15) (P < 0.01) were most often associated with blood-borne pathogens. Infections were more common among men (P < 0.01), patients 41 to 50 years of age (P < 0.01), and patients with a history of intravenous drug use (P < 0.01). CONCLUSIONS: HIV and hepatitis C infections are common in an urban university general surgical practice, while hepatitis B is less common. In addition, certain operations are associated with significantly increased exposure rates. Given the high incidence of these infections, strategies such as sharpless surgical techniques should be evaluated and implemented to protect surgeons from blood-borne pathogens.

2004
Arribas Llorente JL, Hernández Navarrete MJ, Campins Martí M, Martín Sánchez JI, Solano Bernad VM; Grupo EPINETAC. [Risk injuries at operating and delivery rooms. EPINETAC Project 1996-2000][in Spanish] Medicina Clinica 2004;122:773-8.
BACKGROUND AND OBJECTIVE: Surgical areas have long been considered risky with regard to occupational exposures to blood-borne pathogens. The objective of study was to describe and evaluate the risk of occupational exposure to blood-borne pathogens at operating and delivery rooms, from reports of injuries in health care workers. SUBJECTS AND METHOD: Transversal study of percutaneous injuries occurring in operating and delivery rooms which were registered in the Spanish surveillance system EPINETAC (Exposure Prevention Information Network Accidents) between 1996 and 2000. We recorded data from the exposed health care worker, from the accident itself and from the exposure source. The risk of exposition was calculated by logistic regression. The dependent variable was the exposition in operating/delivery rooms. We calculated the rate of exposure, total and by occupational categories, per 10,000 surgical procedures in 3 surgical specialties. RESULTS: There were 3,625 percutaneous injuries reported. The exposure risk was higher in midwives [OR 36.6 (CI 95% 19.61-68.52)] than in staff [OR 12.6 (CI 95% 10.21-15.71)] or training doctors [OR 12.8 (CI 95% 10.34-15.98)]. The highest risk turned up during use of material [OR 1.37 (CI 95% 1.05-1.79)] and during preparation of material for reuse [OR 1.81 (CI 95% 1.27-2.59)]. The exposure rate, in gynecologic procedures, was 34.36 injuries per 10,000, in digestive surgery it was 24.61 per 10,000, and in trauma surgery it was 18.92 per 10,000 surgical procedures. CONCLUSIONS: The risk of occupational exposure to blood-borne pathogens in staff and training doctors was higher in operating and delivery rooms than in others areas. Obstetric and gynecologic procedures exhibited the highest risk of exposure.

Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll Surg 2004;199:462-7.
Available at: http://www.facs.org/about/committees/cpc/preventingsharpsinjuries.pdf [no abstract]

2003
Adesunkanmi AK, Badmus TA, Ogunlusi JO. Accidental injuries and cutaneous contaminations during general surgical operations in a Nigerian teaching hospital. East Afr Med J 2003;80:227-34.
OBJECTIVE: To determine the prevalence of accidental injuries and body contaminations among the operating personnel during general surgical operation, those involved, the circumstances surrounding the injuries or body contaminations and the factors affecting the prevalence in a unit of a teaching hospital in Nigeria. DESIGN: Patients operated for general surgical conditions in a unit of a Teaching Hospital Complex during a period of two years (1997-1998) were studied. A proforma was designed to enter personal biodata, preoperative and intra-postoperative clinical information of all the patients. SETTING: Wesley Guild Hospital a unit of teaching hospital complex serving the large agrarian rural and semi-urban Nigerians. PATIENTS: Five hundred and eighty nine consecutive general surgical patients. All types of general surgical operations were included, emergency or elective, major or minor, carried out during the day or at night. INTERVENTION: All the patients were operated and operating personnel observed for sharp injuries and body contamination. MAIN OUTCOME MEASURES: Incidence of sharp injuries and cutaneous contamination and personnel at risk determined. RESULTS: Operating personnel sustained 62 sharp injuries (10.5%), these were caused by suture needle in 57 cases (92.0%), towel clips in three (4.8%), knife cut in two (3.2%). Operating physicians sustained 56 cases of sharp injuries (90.3%) and Scrub Nurses in six (9.7 %). Self-inflicted sharp injuries in 49 (79 %) and in 12 cases (21%) injuries were inflicted by the surgeons or their assistants. Left hand was injured in 39 cases (63%) and right in 23 (37%). Cutaneous or mucosa membrane contamination with blood or body fluid occurred in 232 cases (39.4 %). These were made up of wet gown contamination in 124(53.5 %), glove failure in 72(31%) and splashing of blood or fluids into the face or eyes in 36 cases (15.5 %). Contamination occurred in more than one operating personnel in more than half of the cases. Operating surgeons were affected in 211 cases (91%). The risks of accidental injuries and blood and body fluid contamination were significant, if the duration of the operation was more than one hour, among the operating surgeons and if the operation was major (p<0.05). CONCLUSION: This study has demonstrated that cutaneous, percutaneous, and mucous membrane exposure to patients blood and body fluids are common events during general surgical operations. Most accidental injuries were due to solid suture needle-sticks, mostly injured personnel were the primary operating surgeons, injuries occurred predominantly on the left hand. This may poses a significant risk of infection with blood borne pathogens when operating on infected patients.

Daley J. Bloodborne pathogen exposures and prevention in the perioperative environment. Can Oper Room Nurs J 2003;21:7-8,31-3,36.
ABSTRACT: The fear of exposure to bloodborne pathogens and disease transmission from patients to health care professionals or health care professional to patients is real. Perioperative nurses and other surgical personnel should be aware of the dangers and risks of exposure to these viruses. Patients may be infected with one of the currently recognized bloodborne viruses including Hepatitis B (HBV), Hepatitis C (HCV) and the Human Immunodeficiency Virus (HIV). It is imperative that accidental exposure during surgical procedures be avoided. The most common means of exposure are percutaneous and mucous membrane routes. The persistence of HBV, HCV and HIV infections, long incubation periods, and the likelihood of frequent asymptomatic carrier states remain continuing threats to the surgical team and makes it difficult to rely on a diagnosis. Infection prevention and control strategies to reduce the risk of exposures and prevent transmission are based on a number of approaches including engineering, administrative and works practice controls and the proper selection and use of personal protective equipment.

Edlich RF, Wind TC, Hill LG, Thacker JG, McGregor W. Reducing accidental injuries during surgery. J Long Term Eff Med Implants. 2003;13:1-10.
ABSTRACT: Extensive clinical investigations have demonstrated that double-gloves and blunt-tipped surgical needles dramatically reduced the risk of accidental injuries during surgery. During the last decade, double-glove hole puncture indication systems have been developed that reduce the clinical risk of accidental needlestick injuries as well as detect the presence of glove hole puncture in the presence of fluids. When the outer glove is punctured, the colored underglove becomes apparent through the translucent outer glove, necessitating glove removal, hand washing, and donning of another double-glove hole puncture Indicator system. This article presents the first biomechanical performance study that documents the puncture resistance of blunt surgical needles in latex and nonlatex single gloves and double-glove hole puncture indication systems. The technique for measuring glove puncture resistance simulates the standard test for material resistance to puncture outlined by the American Society for Testing and Materials. The maximum puncture resistance force was measured by the compression load cell and recorded in grams with a strip chart recorder. Ten puncture resistance measurements for the taper point needle, blunt taper point needle, and blunt needle were taken from five samples of the Biogel Indicator underglove, Biogel Super-Sensitive glove, Biogel glove, Biogel Skinsense N Universal underglove, and Biogel Skinsense Polyisoprene glove; and the Biogel, Biogel Super-Sensitive, and Biogel Skinsense Polyisoprene double-glove hole puncture indication systems. The magnitude of puncture resistance forces recorded was influenced by several factors: glove material, number of glove layers, and type of surgical needle. For each type of curved surgical needle,the resistance to needle penetration by the nonlatex gloves was significantly greater than those encountered by the latex glove materials. The resistance to needle puncture of all three double-glove systems was significantly greater than that of either the nonlatex or latex underglove or outer glove. The taper point needle encountered the lowest puncture resistance forces in the five single gloves and the three double-glove systems. Blunting the sharp end of the taper point needle markedly increased its resistance to glove puncture in the five single gloves and five double-glove systems. The blunt-point surgical needle elicited the greatest needle penetration force in all of the single and double-glove systems.

2002
Perry J, Jagger J. Lessons from an HCV-infected surgeon. Bull Am Coll Surg 2002l;87(3):9-13.
Available at: http://www.facs.org/fellows_info/bulletin/perry0302.pdf

Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theatre injuries. Occup Environ Med 2002;59:703-7.
Available at: http://oem.bmj.com/cgi/reprint/59/10/703
BACKGROUND: Operating theatre personnel are at increased risk for transmission of blood borne pathogens when passing sharp instruments. The hands-free technique, whereby a tray or other means are used to eliminate simultaneous handling of sharp instruments, has been recommended. AIMS: To prospectively evaluate the effectiveness of the hands-free technique in reducing the incidence of percutaneous injuries, contaminations, and glove tears arising from handling sharp instruments. METHODS: For each of 3765 operations carried out in main and surgical day care operating theatres in a large urban hospital, over six months, circulating nurses recorded the proportion of use of the hands-free technique during each operation, as well as other features of the operation. The hands-free technique, considered to be used when 75% or more of the passes in an operation were done in this way, was used in 42% of operations. The relative rate of incidents (percutaneous injuries, contaminations, and glove tears) in operations where the hands-free technique was used and not used, with adjustment via multiple logistic regression for the different risk profiles of the two sets of operations, was calculated. RESULTS: A total of 143 incidents (40 percutaneous injuries, 51 contaminations, and 52 glove tears) were reported. In operations with greater than 100 ml blood loss, the incident rate was 4% (18/486) when the hands-free technique was used and 10% (90/880) when it was not, approximately 60% less. When adjusted for differences in type and duration of surgery, emergency status, noisiness, time of day, and number present for 75% of the operation, the reduction in the rate was 59% (95% CI 23% to 72%). In operations with less than 100 ml blood loss, the corresponding rates were 1.4% (15/1051) when the hands-free technique was used and 1.5% (19/1259) when it was not used. Adjustment for differences in risk factors did not alter the difference. CONCLUSIONS: Although not effective in all operations, use of the hands-free technique was effective in operations with more substantial blood loss.

2001
Davis, M. Advanced Precautions for Today's OR: The Operating Room Professional's Handbook for the Prevention of Sharps Injuries and Bloodborne Exposures (2nd edition). Atlanta, GA: Sweinbinder Publications LLC, 2001.

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):564-6.
BACKGROUND: In surgery, intact gloves protect the surgeon from bloodborne pathogens and the surgical wound from microorganisms on the skin of the surgeon. However, glove perforation is very common, and puncture rates as high as 61% are published in the literature. One objective of this study was to compare puncture rates between a unique double-gloving puncture indication system and single-use gloves, and another was to determine the extent to which glove perforations remain undetected during surgery. METHODS: The study material comprised all gloves used in surgical operations at our hospital for a period of 2 months. The analysis was made by the glove type in a prospective and randomized manner. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method for 2 minutes to detect any holes. The gloves used in this study were either a double-gloving puncture indication system or the standard glove used at our hospital. RESULTS: In 885 operations altogether, 2,462 gloves were tested; 1,020 single gloves, 1,148 double-glove systems, and 294 combination gloves were studied. The overall perforation rate was 192 out of 2,462 gloves (7.80%), and 162 out of 885 operations (18.3%). The detection of perforation during surgery was 28 out of 76 (36.84%) with single gloves, 77 out of 89 with the double-gloving system (86.52%), and 9 out of 27 with combination gloves (33.33%; P <0.001). The inner glove of the double-gloving system was punctured in 6 out of 88 outer glove perforations (6.82%). CONCLUSIONS: In view of the critical importance of safety at work by having a sterile barrier between surgeon and patient, it is very important to use a double-gloving puncture indication system, at least in operations where there is a high risk of glove perforation.

Puro V, De Carli G, Scognamiglio P, Porcasi R, Ippolito G. (Studio Italiano Rischio Occupazionale HIV) Risk of HIV and Other Blood-Borne Infections in the Cardiac Setting: Patient-to-Provider and Provider-to-Patient Transmission. Ann NY Acad Sci 2001;946:291-309.
ABSTRACT: Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.

Stringer B, Infante-Rivard C, Hanley J. Quantifying and reducing the risk of bloodborne pathogen exposure. AORN J 2001;73:1135-40.
Available at: http://findarticles.com/p/articles/mi_m0FSL/is_6_73/ai_75562155
ABSTRACT: The risk of becoming infected with bloodborne pathogens (e.g., hepatitis B, hepatitis C, HIV) during surgery is real. The degree of risk for perioperative personnel is related to factors that include participating in large numbers of surgical procedures each year; the nature of perioperative work (e.g., use of different types of sharp instruments): exposure to large amounts of blood and body fluids; the prevalence of bloodborne pathogens in the surgical population; the variation in different organisms' ability to be transmitted; the existence of vaccines and the level of vaccination; the availability of postexposure treatment; and the consequences of acquiring the disease. Controlling risks to perioperative personnel can be accomplished by using the Occupational Safety and Health Administration's three methods of control--redesigning surgical equipment and procedures, changing work practices, and enhancing the personal protection equipment of perioperative personnel.

Thomas S, Agarwal M, Mehta G. Intraoperative glove perforation--single versus double gloving in protection against skin contamination. Postgrad Med J 2001;77(909):458-60.
ABSTRACT: Surgeons have the highest risk of contact with patients' blood and body fluids, and breaches in gloving material may expose operating room staff to risk of infections. This prospective randomised study was done to assess the effectiveness of the practice of double gloving compared with single gloving in decreasing finger contamination during surgery. In 66 consecutive surgical procedures studied, preoperative skin abrasions were detected on the hands of 17.4% of the surgeons. In the double gloving pattern, 32 glove perforations were observed, of which 22 were in the outer glove and 10 in the inner glove. Only four outer glove perforations had matching inner glove perforations, thus indicating that in 82% of cases when the outer glove is perforated the inner glove will protect the surgeon's hand from contamination. The presence of visible skin contamination was also higher in perforation with the single gloving pattern (42.1%) than with the double gloving pattern (22.7%). An overwhelming majority of glove perforations (83.3%) went unnoticed. Double gloving was accepted by the majority of surgeons, especially with repeated use. It is recommended that double gloves are used routinely in all surgical procedures in view of the significantly higher protection it provides.

2000
Folin A, Nyberg B, Nordström G. Reducing blood exposures during orthopedic surgical procedures. AORN J 2000;71(3):573-6, 579, 581-2.
SUMMARY: Surgical team members constantly are exposed to blood during procedures. Inadvertent injuries (e.g., needle sticks, cuts) and contaminations expose team members and patients to the risk of transmission of bloodborne pathogens. Injuries and contaminations can be decreased significantly for scrub people and first assistants, however, by introducing new working methods (i.e., no-touch instrument passing technique, instrument neutral zone).

1998
C one LA, Curry N, Wuestoff MA, O'Connell SJ, Feller JF. Septic synovitis and arthritis due to Corynebacterium striatum following an accidental scalpel injury. Clin Infect Dis. 1998;27(6):1532-3.

Greene ES, Berry AJ, Jagger J, Hanley E, Arnold WP, Bailey MK, et al. Multicenter study of contaminated percutaneous injuries in anesthesia personnel. Anesthesiol 1998;89:1362-72.
BACKGROUND: Anesthesia personnel are at risk for occupational infection with bloodborne pathogens from contaminated percutaneous injuries (CPIs). Additional information is needed to formulate methods to reduce risk. METHODS: The authors analyzed CPIs collected during a 2-yr period at 11 hospitals, assessed CPI underreporting, and estimated risks of infection with human immunodeficiency virus and hepatitis C virus. RESULTS: Data regarding 138 CPIs were collected: 74% were associated with blood-contaminated hollow-bore needles, 74% were potentially preventable, 30% were considered high-risk injuries from devices used for intravascular catheter insertion or obtaining blood, and 45% were reported to hospital health services. Corrected for injury underreporting, the CPI rate was 0.27 CPIs per yr per person; per full-time equivalent worker, there were 0.42 CPIs/yr. The estimated average 30-yr risks of human immunodeficiency virus or hepatitis C virus infection per full-time equivalent are 0.049% and 0.45%, respectively. Projecting these findings to all anesthesia personnel in the United States, the authors estimate that there will be 17 human immunodeficiency virus infections and 155 hepatitis C virus infections in 30 yr. CONCLUSIONS: Performance of anesthesia tasks is associated with CPIs from blood-contaminated hollow-bore needles. Thirty percent of all CPIs would have been high-risk for bloodborne pathogen transmission if the source patients were infected. Most CPIs were potentially preventable, and fewer than half were reported to hospital health services. The results identify devices and mechanisms responsible for CPIs, provide estimates of risk levels, and permit formulation of strategies to reduce risks.

Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J 1998;67:979-4, 986.
Available at: http://findarticles.com/p/articles/mi_m0FSL/is_n5_v67/ai_20601098
ABSTRACT: The authors conducted a surveillance study of occupational blood exposures in the ORs at six hospitals to identify risk patterns and prevention strategies. For 15 months, trained circulating nurses recorded OR staff members' exposures during all surgical procedures using a modified version of the Exposure Prevention Information Network surveillance system. It was discovered that a high proportion of percutaneous injuries were potentially preventable if safer devices had been used, and the authors estimate that use of blunt suture needles alone could reduce injuries by 30%. Increased use of barrier precautions is indicated to prevent mucocutaneous blood exposures. Health care workers' eyes were identified in the study as being the most vulnerable location for serious blood exposures

Stafford MK, Pitman MC, Nanthakumaran N, Smith JR. Blunt-tipped versus  sharp-tipped needles: wound morbidity. J Obstet Gynaecol 1998;18:18-19.
ABSTRACT: Blunt-tipped needles have previously been shown to reduce needle-stick injury but the issue of morbidity had not been addressed. As awareness of the need for universal precautions heightens, concerns have been raised about any possible morbidity brought about by their use. We present the results of a randomised, controlled study which investigated wound morbidity following caesarean section. Of the 204 women randomised to closure with sharp or blunt-tipped needles, none developed anything other than superficial infection and there were no significant differences between the two groups. We conclude that the use of blunt-tipped needles does not cause an increase in wound morbidity.

1997
Centers for Disease Control and Prevention. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures--New York City, March 1993-June 1994. JAMA 1997;277:451-2.
ABSTRACT: Infections with bloodborne pathogens resulting from exposures to blood through percutaneous injuries (PIs) (e.g., needlestick injuries and cuts with sharp objects) are an occupational hazard for health-care workers (HCWs). PIs have been reported during 1% - 15% of surgical procedures, mostly associated with suturing. Most suturing is done using curved suture needles, although straight needles are used by some surgeons for suturing skin. Blunt suture needles (curved suture needles that have a relatively blunt tip) may be less likely to cause PIs because they do not easily penetrate skin. Based on small studies and anecdotal experience, blunt suture needles appear able to replace conventional curved suture needles for suturing many tissues, although they may require more pressure to penetrate the tissues. This report summarizes results of a study in which CDC collaborated with three teaching hospitals in New York City during 1993-1994 to evaluate a safety device (a blunt suture needle) in gynecologic surgery. The findings indicate that use of blunt needles was associated with statistically significant reductions in PI rates, minimal clinically apparent adverse effects on patient care, and general acceptance by gynecologic surgeons in these hospitals.

Same study:
Centers for Disease Control and Prevention. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures--New York City, March 1993-June 1994. MMWR Morb Mortal Wkly Rep 1997;46:25-29.

Folin AC, Nordstrom GM. Accidental blood contact during orthopedic surgical procedures. Infect Control Hosp Epidemiol 1997;18:244-6.
ABSTRACT: A questionnaire study was carried out of all orthopedic surgical procedures in the operating rooms of a teaching hospital over an 8-week period to describe the frequency and circumstances of accidental blood contact. Blood exposure occurred in 11% of the procedures. Contamination of intact skin was the most common incident (79%); percutaneous injury occurred in 13%. The majority of the incidents were believed to be preventable

Pietrabissa A, Merigliano S, Montorsi M, Poggioli G, Stella M, Borzomati D et al. Reducing the occupational risk of infections for the surgeon: multicentric national survey on more than 15,000 surgical procedures. World J Surg 1997;21:573-8.
ABSTRACT: The objective of this study was to find the incidence of accidental exposures to blood and body fluids among surgeons during operations and to describe their dynamics. A probabilistic model was also used to predict the cumulative 30-year risk to the surgeon of contracting hepatitis B and C viruses (HBV, HCV) or human immunodeficiency virus (HIV) infection and estimate the effect of preventive strategies in reducing this risk. A multicentric prospective survey, based on self- administered questionnaires, was conducted during a period of 6 months in 39 Italian hospitals. As accidental exposure to blood or body fluids occurred in 9.2% of 15,375 operations. In about 2% of procedures a parenteral-type injury, such as actual skin puncture or eye contamination, was suffered by the operating surgeon. A needle-stick injury was the commonest accident, and its occurrence was found to vary with the phase of the procedure and its length. The current lifetime risk of acquiring HBV, HCV, and HIV infection in our regions was estimated to be as high as 42.7%, 34.8%, and 0.54%, respectively. The adoption of preventive strategies is expected to reduce this risk to 21% for HBV, 16.6% for HCV, and 0.23% for HIV infection. Active immunization of surgeons against HBV is strongly recommended. The case is also made for the use of a face-shield combined with a permanent change in our surgical practice capable of reducing the current high rate of parenteral injuries.

1996
Esteban JI, Gómez J, Martell M, Cabot B, Quer J, Camps J, González A, Otero T, Moya A, Esteban R, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334(9):555-60.
Available at: http://content.nejm.org/cgi/reprint/334/9/555.pdf BACKGROUND. In the course of a study conducted in 1992 through 1994 of the efficacy of screening blood donors for antibodies to hepatitis C virus (HCV), we found that two patients had acquired hepatitis C after cardiac surgery, with the transmission apparently unrelated to blood transfusions. Because their surgeon had chronic hepatitis C, we sought to determine whether he was transmitting the virus to his patients. METHODS. Of 222 of the surgeon's patients who participated in studies of post-transfusion hepatitis between 1988 and 1994, 6 contracted postoperative hepatitis C, despite the use of only seronegative blood for transfusions. All six patients had undergone valve-replacement surgery. Analyses were performed to compare nucleotide sequences encompassing the hypervariable region at the junction between the coding regions for envelope glycoproteins E1 and E2 in the surgeon, the patients, and 10 controls infected with the same HCV genotype. RESULTS. The surgeon and five of the six patients with hepatitis C unrelated to transfusion were infected with HCV genotype 3; the sixth patient had genotype 1 and was considered to have been infected from another source. Thirteen other patients of the surgeon had transfusion-associated hepatitis C and were also infected with genotype 1. The average net genetic distance between the sequences from the five patients with HCV genotype 3 and those from the surgeon was 2.1 percent (range, 1.1 to 2.5 percent; P < 0.001), as compared with an average distance of 7.6 percent (range, 6.1 to 8.3 percent) between the sequences from the patients and those from the controls. The results of phylogenetic-tree analysis indicated a common epidemiologic origin of the viruses from the surgeon and the five patients. CONCLUSIONS. Our findings provide evidence that a cardiac surgeon with chronic hepatitis C may have transmitted HCV to five of his patients during open-heart surgery.

Greene ES, Berry AJ, Arnold WP, Jagger J. Percutaneous injuries in anesthesia personnel. Anesth Analg 1996;83:273-8.
Available at: http://www.anesthesia-analgesia.org/cgi/reprint/83/2/273 BACKGROUND: Anesthesia personnel are at risk for occupationally acquired blood-borne infections from human immunodeficiency virus, hepatitis viruses, and others after percutaneous exposures to infected blood or body fluids. The risk is greater after an infected, blood-contaminated, percutaneous injury, especially from a hollow-bore blood-filled needle, than from other types of exposures. Few data are available on the specific occupational hazards to anesthesia personnel from needles and other sharp devices. METHODS: Fifty-eight percutaneous injuries (PIs) from anesthesia personnel in nine hospitals were analyzed. RESULTS: Thirty-nine of 58 PIs were from contaminated devices (all needles), and 19 were from uncontaminated devices or of unknown contamination status. Forty-three percent of contaminated percutaneous injuries (CPI) were classified as moderate (some bleeding) or severe (deep injury with profuse bleeding), and most were to health-care workers' hands. Fifty-nine percent of CPI were potentially preventable. Eighty-seven percent of CPI were from hollow-bore needles, and 68% of these were potentially preventable. The largest categories of devices causing CPI were needle on syringe, intravenous (i.v.) or arterial catheter needle-stylet, suture needle, and standard hollow-bore needle for secondary i.v. infusion. Most CPI occurred between steps of a multistep procedure (8%), were recapping related (13%), or occurred at other times after use (41%). No CPI were reported from use of needlestick-prevention safety devices. CONCLUSION: The devices and mechanisms of injury identified in this study provide specific data that may lead to prevention strategies to reduce the risk of PI.

Harpaz R, Von Seidlein L, Averhoff FM, Tormey MP, Sinha SD, Kotsopoulou K, Lambert SB, Robertson BH, Cherry JD, Shapiro CN. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med. 1996 29;334(9):549-54.
Available at: http://content.nejm.org/cgi/reprint/334/9/549.pdf
BACKGROUND. Although about 1 percent of surgeons are infected with hepatitis B virus (HBV), transmission from surgeons to patients is thought to be uncommon. In July 1992, a 47-year-old woman became ill with acute hepatitis B after undergoing a thymectomy in which a thoracic-surgery resident who had had acute hepatitis B six months earlier assisted. METHODS. To determine whether the surgeon transmitted HBV to this patient and others, we conducted chart reviews, interviews, and serologic testing of thoracic-surgery patients at the two hospitals where the surgeon worked from July 1991 to July 1992. Hepatitis B surface antigen (HBsAg) subtypes and DNA sequences from the surgeon and from infected patients were determined. RESULTS. Of 144 susceptible patients in whose surgery the infected surgeon participated, 19 had evidence of recent HBV infection (13 percent). One of the hospitals was selected for additional study, and none of the 124 susceptible patients of the other thoracic surgeons at this hospital had evidence of recent HBV infection (relative risk, infinity; 95 percent confidence interval, 4.7 to infinity). No evidence was found for any common source of HBV other than the infected surgeon. The HBsAg subtype and the partial HBV DNA sequences from the surgeon were identical to those in the infected patients. Transmission of the infection was associated with cardiac transplantation (relative risk, 4.9; 95 percent confidence interval, 1.5 to 15.5) but not with other surgical procedures. The surgeon was positive for hepatitis B e antigen and had a high serum HBV DNA concentration (15 ng per milliliter). Our investigations identified no deficiencies in the surgeon's infection-control practices. CONCLUSIONS. In this outbreak there was surgeon-to-patient HBV transmission despite apparent compliance with recommended infection-control practices. We could not identify any specific events that led to transmission.

Hartley JE, Ahmed S, Milkins R, Naylor G, Monson JR, Lee PW. Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen. Br J Surg 1996;83:1156-7.
Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/112181706/PDFSTART
SUMMARY: Eighty-five consecutive patients were randomized to undergo mass closure of the abdomen with no. 1 polydioxanone mounted on either a blunt-tipped (n = 46) or cutting (n = 39) needle. Gloves were changed before closure and tested for perforation afterwards using standard air or water techniques. Fourteen pairs of gloves were punctured when using a cutting needle, and three pairs when a blunt-tipped needle was used. The majority of punctures were to the non-dominant glove. The surgeon was aware of the puncture in eight of the 14 instances involving a sharp needle and in one of the three involving a blunt-tipped needle. Blunt-tipped needles, while not eliminating the risk, significantly reduced the incidence of surgical glove puncture (P < 0.001, Fisher's exact test). The use of cutting needles for abdominal closure should be abandoned.

Mingoli A, Sapienza P, Sgarzini G, Luciani G, De Angelis G, Modini C, et al. Influence of blunt needles on surgical glove perforation and safety for the surgeon. Am J Surg 1996;172:512-6.
BACKGROUND: Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS: Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS: Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P <0.00004 and P <0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P <0.0006). CONCLUSION: The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Rice JJ, McCabe J P, McManus F. Needlestick injuries: reducing the risk. Int Orthop 1996;20:132-3.
ABSTRACT: The incidence of penetrating skin wounds and needle penetration of gloves during operation was studied in orthopaedic surgeons. Significant hand wounds were found in 11% of surgeons before operations. Glove penetration during closure of the deep tissues occurred in 16% of outer gloves and 6% of inner gloves when standard needle points were used. The surgeon sustained a needle-stick injury in 6% of this group. When a needle with a protective point was used, there were no glove perforations. This simple precaution reduces the risk of transmission of blood-borne disease during operation.

1995
Chamberland ME, Ciesielski CA, Howard RJ, Fry DE, Bell DM. Occupational risk of infection with human immunodeficiency virus. Surg Clin North Am 1995; 75:1057-70.
ABSTRACT: The risk of HIV infection in surgical settings is a composite of overlapping risks related to the local prevalence of HIV, the route of exposure to HIV-infected blood, and the susceptibility of the worker. Studies continue to suggest that the risk of blood contact, including percutaneous injuries, remains appreciable. Prevention of such exposures in the operating and delivery room by adoption of safer instruments, work practices, and techniques and by the consistent use of appropriate personnel protective equipment must be viewed as a priority.

Consten EC, van Lanschot JJ, Henny PC, Tinnemans JG, van der Meer JT. A prospective study on the risk of exposure to HIV during surgery in Zambia. AIDS 1995;9:585-8.
OBJECTIVE: To investigate the relative risk of occupational HIV transmission for surgeons practising in tropical Africa compared with their western colleagues. DESIGN AND SETTING: From June to November 1993, a prospective study was performed at St Francis' Hospital, Katete, Zambia (350-bed hospital which serves a community of 300,000 people). METHODS: The HIV seroprevalence among consecutive surgical patients and the incidence of occupational parenteral exposures to blood during surgery were prospectively studied in a Zambian district hospital. HIV seroprevalence was determined by taking blood from the surgical patients on admission into the operating theatre. Serum was stored at -20 degrees C and transported to the Academic Medical Centre of the University of Amsterdam, where the presence of HIV antibodies was tested by enzyme immunoassay and seropositive samples confirmed by Western blot. Number of parenteral exposures during the study period was scored by interviewing the seven surgeons and their personnel after each surgical procedure about accidental parenteral exposures to blood. The total number of parenteral exposures per surgeon per year was obtained by extrapolation. The cumulated risk of seroconversion due to parenteral blood exposure can be calculated as: 1-(1-fp)ny, where f is the population seroprevalence, p the chance of transmission per incident (estimated to be 0.46%), n the number of parenteral exposures per year and y the years of practice. RESULTS: HIV seroprevalence in the surgical patient group was 22.3%. Twelve parenteral exposures to blood (surgeons, n = 8; other personnel, n = 4) took place in 1161 operations. Number of parenteral exposures per surgeon was extrapolated to three per year. The non-dominant index finger was exposed in 10 out of the 12 parenteral exposures. Based on these data, the risk of contracting HIV infection for a surgeon practising in Zambia for 5 years is 1.5%. The risk for a surgeon working in a western hospital when f = 0.23%, n = 20 per year (5.6% of 350 operations) and y = 5 is estimated at 0.1%. CONCLUSIONS: Although occupational exposure rate was relatively low, the HIV seroprevalence was so high that the relative cumulated seroconversion risk for surgeons in tropical Africa is estimated to be 15 times higher than in western countries. This implies that health-care organizations should bear in mind that each year one out of 300 employees working in tropical Africa may become occupationally infected with HIV.

Lewis FR, Jr., Short LJ, Howard RJ, Jacobs AJ, Roche NE. Epidemiology of injuries by needles and other sharp instruments. Minimizing sharp injuries in gynecologic and obstetric operations. Surg Clin North Am 1995;75:1105-21.
ABSTRACT: Surgical and obstetric HCWs and epidemiologists will benefit from working together to describe the frequency and circumstances of percutaneous injuries in operating and delivery rooms. Rates of percutaneous injury vary among institutions, and attending and resident surgeons are among those at greatest risk for injury. Gynecologic surgery appears to have one of the highest rates of injury of the surgical specialties, and rates of injury vary by procedure within a given specialty. Suture needles cause the majority of injuries. Certain actions such as holding tissue while suturing or cutting are associated with a higher risk of injury. Many percutaneous injuries appear to be preventable. Epidemiologic data can be used to develop strategies based on the industrial hygiene model to reduce the incidence of percutaneous injury and to collect and disseminate data on the efficacy of new preventive measures. Potentially safer instruments and suture needles, technique modification strategies, and personal protective equipment such as cut-resistant gloves and finger protective strips are now available. Scientific assessment is needed of these and other new measures to determine whether they will decrease the risk of percutaneous injury, be acceptable to users, be cost effective, and avoid adverse consequences to patients or HCWs.

Tokars JI, Culver DH, Mendelson MH, Sloan EP, Farber BF, Fligner DJ et al. Skin and mucous membrane contacts with blood during surgical procedures: risk and prevention. Infect Control Hosp Epidemiol 1995;16:703-11.
OBJECTIVE: To study the epidemiology and preventability of blood contact with skin and mucous membranes during surgical procedures. DESIGN: Observers present at 1,382 surgical procedures recorded information about the procedure, the personnel present, and the contacts that occurred. SETTING: Four US teaching hospitals during 1990. PARTICIPANTS: Operating room personnel in five surgical specialties. MAIN OUTCOME MEASURES: Numbers and circumstances of contact between the patient's blood (or other infective fluids) and surgical personnel's mucous membranes (mucous membrane contacts) or skin (skin contacts, excluding percutaneous injuries). RESULTS: A total of 1,069 skin (including 620 hand, 258 body, and 172 face) and 32 mucous membrane (all affecting eyes) contacts were observed. Surgeons sustained most contacts (19% had > or = 1 skin contact and 0.5% had > or = 1 mucous membrane-eye contact). Hand contacts were 72% lower among surgeons who double gloved, and face contacts were prevented reliably by face shields. Mucous membrane-eye contacts were significantly less frequent in surgeons wearing eyeglasses and were absent in surgeons wearing goggles or face shields. Among surgeons, risk factors for skin contact depended on the area of contact: hand contacts were associated most closely with procedure duration (adjusted odds ratio [OR], 9.4; > or = 4 versus < 1 hour); body contacts (arms, legs, and torso) with estimated blood losses (adjusted OR, 8.4; > or = 1,000 versus < 100 mL); and face contacts, with orthopedic service (adjusted OR, 7.5 compared with general surgery). CONCLUSION: Skin and mucous membrane contacts are preventable by appropriate barrier precautions, yet occur commonly during surgery. Surgeons who perform procedures similar to those included in this study should strongly consider double gloving, changing gloves routinely during surgery, or both.

Wright JG, Young NL, Stephens D. Reported use of strategies by surgeons to prevent transmission of bloodborne diseases. Can Med Assn J 1995;152:1089-95.
Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1337656
OBJECTIVE: To determine how often surgeons use strategies to prevent the transmission of bloodborne diseases and what factors are associated with the use of these strategies. DESIGN: Cross-sectional mail survey. SETTING: Secondary and tertiary care teaching hospitals affiliated with the University of Toronto. PARTICIPANTS: Of 539 active surgical staff and residents who were eligible, 503 (93.3%) responded. OUTCOME MEASURES: Current preventive practices, attitudes toward transmission of bloodborne diseases, perceived risk of infection and willingness to adopt preventive strategies. RESULTS: On average, surgeons reported using double- or triple-gloving in 32.2% of procedures, facial protection (including regular corrective eyewear) in 74.2% and goggles or face shields in 19.4%. Use of strategies to prevent sharp injuries, in addition to barrier precautions, was reported by 259 (51.5%) of the respondents. Factors associated with greater use of preventive strategies included resident position, subspecialty, greater number of years in surgical practice and a high perceived risk. Most of the respondents thought that patients should be routinely screened for HIV antibodies before surgery (68.2% [343/503]), that there was too little research into ways to reduce the risk of transmission of bloodborne diseases (55.3% [278/503]) and that there was too little effort on the part of organizations to reduce the risk of transmission (58.8% [296/503]). The perceived lifetime risk was reported to be moderate or high by 191 (38.0%) of the respondents and low or insignificant by 308 (61.2%). In all, 463 (92.0%) indicated a willingness to change the way they performed surgery to prevent transmission of bloodborne diseases. CONCLUSION: Surgeons expressed varying degrees of concern about the transmission of bloodborne diseases and reported infrequent use of preventive strategies. Efforts to reduce the risk of transmission between patients and surgeons will need to include informing surgeons of their personal risk and the availability of preventive strategies, improving the comfort of barrier precautions and minimizing how preventive strategies interfere with surgery.

1994
Bennett NT, Howard RJ. Quantity of blood inoculated in a needlestick injury from suture needles. J Am Coll Surg 1994;178:107-10.
BACKGROUND: We wanted to quantify the amount of blood inoculum present on several commonly used surgical and phlebotomy needles and to determine the effect of single or double gloving, the depth of needle penetration and needle size on inoculum volume. METHODS: Nineteen, 22 gauge and 25 gauge phlebotomy needles, as well as the tapered suture needles from zero, 3-0 and 5-0 sutures and a cutting needle from a 4-0 suture were assessed. The needles were dipped into blood labeled with 125I-epidermal growth factor and then embedded 2 or 5 millimeters into an agarose gel. The volume of blood inoculum ranged from 133 to 683 nanoliters for the phlebotomy needles and from 35 to 366 nanoliters for the suture needles. Needles were then passed through none, one or two layers of surgical glove material before embedding the needles 5 millimeters into agarose gel. RESULTS: The use of one layer of surgical glove resulted in a significant (p < 0.001) decrease in inoculum from tapered suture needles, but not from the cutting needles. Two gloves were even more efficient (p < 0.001) than one glove at removing blood from all suture needles, including the cutting needle. However, surgical glove material did not significantly reduce the volume of blood inoculum transferred by the phlebotomy needles. CONCLUSION: The size of the needle and depth of penetration were found to have a significant influence on inoculum.

Dauleh MI, Irving AD, Townell NH. Needle prick injury to the surgeon-do we need sharp needles? J R Coll Surg Edinb 1994;39:310-11.
ABSTRACT: Needle prick injury is a well known hazard for surgeons and their assistants. This carries a risk of transmitting HIV and hepatitis infection. In this study the high incidence of sharp needle injury was confirmed (18.9%), with more than one third (8.7%) resulting in skin puncture. The highest incidence of injury occurred during hernia repair (27%) and abdominal wound closure (52%), where injury was sustained to the left index and middle finger as would be expected in right-handed surgeons. Blunt-tipped needles were used in 78 different procedures with technically satisfactory outcome particularly in abdominal wall wound closure and hernia repair, and even in colonic anastomosis, only two glove injuries were reported, with no skin injury. We concluded that the used of blunt-tipped needles is a practical option in eliminating needle prick injury to surgeon's hands.

1993
Gerberding JL. Procedure-specific infection control for preventing intraoperative blood exposures. Am J Infect Control 1993;21:364-7.
ABSTRACT: Contemporary intraoperative infection control must address the risk of infection transmission to both patients and their providers. The patient must be protected from intraoperative wound contamination and exposure to blood-borne pathogens during procedures. Providers must be protected from injuries and mucocutaneous exposure to the patient's blood. Procedure-specific infection control precautions, or similar strategies that address this bidirectional potential for infection transmission, may prove successful in accomplishing improved safety for all.

Lynch P, White MC. Perioperative blood contact and exposures: a comparison of incident reports and focused studies. Am J Infect Control 1993;21:357-63.
BACKGROUND: Occupational blood exposures among operating room personnel have been substantially underreported in incident reports. Recent research has indicated several common factors influencing exposure rates: surgical service (thoracic, neurosurgery, orthopedic), length of operation, and emergency status. METHODS: This report examines further data from a study of 8502 surgical cases in nine hospitals, in which a site coordinator and circulating nurses reported consecutive case information, including blood contacts that occurred during the procedures. For three of the participating hospitals, incident reports of blood exposures among operating room personnel that occurred during a 12-month period before the study were also tabulated. RESULTS: Incident reports underreported parenteral exposures (punctures, mucous membrane and nonintact skin contact with patient blood) by as much as a factor of 25. Individual hospital rates of occupational surgical blood exposure varied considerably. CONCLUSIONS: To ensure that resources to prevent occupational blood exposure are allocated appropriately, on the basis of actual risk, among all personnel, hospitals must actively monitor blood exposures in their operating rooms.

Mast ST, Woolwine JD, Gerberding JL. Efficacy of gloves in reducing blood volumes transferred during simulated needlestick injury. J Infect Dis 1993;168:1589-92.
ABSTRACT: This study was designed to evaluate factors that affect blood volumes transferred to skin during simulated needlestick injuries in an in vitro paper prefilter model and an ex vivo porcine tissue model. The effect of needle type and size, penetration depth, and glove use on the volume of radiolabeled blood transferred was determined in each model. Blood volumes ranged from 0.47 +/- 0.26 microL (30-gauge needle, 0.5-cm depth, in vitro model) to 5.88 +/- 1.45 microL (18-gauge needle, 2.0-cm depth, in vitro model). Needle size and penetration depth were significantly associated with transfer volume. Glove material reduced the transferred blood volume by 46%-86% in both models. Transfer volumes were within the same order of magnitude for all conditions. Hence, virus titer in the source blood may be a better predictor of needlestick infectivity than is exposure volume. Regardless, gloves may exert some protective effect and should be worn whenever needles are handled.

Short LJ, Bell DM. Risk of occupational infection with blood-borne pathogens in operating and delivery room settings. Am J Infect Control 1993;21:343-50.
ABSTRACT: Surveillance data and case reports substantiate that health care workers are at risk for occupationally acquired infection with blood- borne pathogens. The risk of transmission of blood-borne pathogens to a health care worker depends on the prevalence of blood-borne pathogen infection among patients, the likelihood of transmission of infection per blood contact, and the nature and frequency of occupational blood contacts. In surgical and obstetrical settings, blood contact varies with occupation, specialty, procedures performed, and precautions used. Many contacts appear to be preventable by changes in technique or instrument design and by use of protective barriers. Studies are needed to assess the impact of such interventions.

Telford GL, Quebbeman EJ. Assessing the risk of blood exposure in the operating room. Am J Infect Control 1993;21:351-6.
ABSTRACT: During the past 3 years, a great deal of new information has been published on the risk of blood exposure and injury in the operating room. In addition, detailed information about the effectiveness of barrier materials, operating room garments, and gloves has also become available. On the basis of this information, it has become possible to recommend strategies, barrier materials, and garments that should reduce the risk of contracting a blood-borne infection in the operating room. Further attempts to decrease the risk of blood exposure and injury require thorough evaluation of all risk-reduction strategies and careful selection of protective apparel and barriers on the basis of well-designed studies performed in the operating room environment.

Vergilio JA, Roberts RB, Davis JM. The risk of exposure of third-year surgical clerks to human immunodeficiency virus in the operating room. Arch Surg 1993;128:36-8.
ABSTRACT: The exposure of third-year medical students to blood and blood products in the operating room was assessed with a questionnaire distributed at the end of their clerkship in surgery. Sixty-six (68%) of ninety-seven students reported having been exposed to blood in the operating room during their 3-month rotation in surgery. During the year there was a decrease in the exposure rate that correlated with the students' knowledge of universal precautions (r = .96). Consistent with this observation was a significant decrease in the exposure rate from the first quarter of the year to the last quarter (88% vs 56% of the students). Of the 32 students stuck or cut in the operating room, 21 (66%) were injured by the surgeon. These data underscore the risk to medical students during their clerkships and the important role that universal precautions had in their protection.

White MC, Lynch P. Blood contact and exposures among operating room personnel: a multicenter study. Am J Infect Control 1993;21:243-8.
ABSTRACT: Blood exposures are increasingly recognized as a risk for health care workers in the operating room. Trained circulating nurses supervised by site coordinators queried surgical team members about blood contact and collected data on 8502 surgical procedures from seven community and two university hospitals in 1992. Blood contact occurred during 864 cases (10.2% case-contact rate) in 1054 health care workers (12.4% person- contact rate). The parenteral exposure (punctures or cuts, mucous membranes, nonintact skin) rate was 2.2% and the cutaneous exposure (intact skin) rate was 10.2%. Blood contacts were twice as likely to be parenteral among surgeons as among other operating room personnel (odds ratio, 2.0; 95% confidence interval, 1.4 to 2.9). Of cutaneous exposures, 46.9% were from unknown sources or were surprise spatters. Logistic regression analyses indicated that risk factors associated with any blood contact (parenteral or cutaneous) were length of procedure (odds ratio, 1.51; 95% confidence interval, 1.46 to 1.56), emergency versus scheduled status (odds ratio, 1.44; 95% confidence interval, 1.21 to 1.66), selected surgical services, and the hospital. Logistic regression analyses of parenteral exposures, as compared with cases in which no contact occurred, indicated that risk factors were length (odds ratio, 1.39; 95% confidence interval, 1.31 to 1.47), thoracic surgery (odds ratio, 2.79; 95% confidence interval, 2.18 to 3.40), and university hospital versus community (odds ratio, 2.26; 95% confidence interval, 1.89 to 2.63). Parenteral exposures are clear risks to health care workers; however, it is also important to study all contact with blood in the operating room to appreciate potential risks and develop appropriate intervention strategies.

Wright JG, McGeer AJ, Chyatte D, Ransohoff DF. Exposure rates to patients' blood for surgical personnel Surgery 1993;114:897-901.
BACKGROUND. Surgical personnel are at risk of contracting blood-borne diseases through exposure to patients' blood. Exposure rates for each surgical subspecialty have not been previously reported. The purpose of this study was to determine the rates of exposure to patients' blood for operating room personnel. METHODS. The study was conducted at Yale- New Haven Hospital, a level I trauma center and tertiary care hospital. During a 3-month period, exposed personnel were interviewed by a study nurse immediately after a cutaneous exposure to blood or after a sharp injury. RESULTS. During 2292 surgical procedures, 70 sharp injuries and 168 cutaneous exposures to blood were reported. The combined exposure rate (skin contact and sharp injury) was 10.4 per 100 procedures (95% confidence interval, 9.1 to 11.6) and ranged from 21.2 for general surgery to 3.3 for pediatric surgery (goodness-of-fit chi-squared, p < 0.001). The combined exposure rates were also significantly different among types of surgery and ranged from 18 for laparotomies to 4.3 for craniotomies (chi-squared, p < 0.001). The overall sharp injury rate was 3.1 per 100 procedures (95% confidence interval, 2.3 to 3.8) and ranged from 4.3 for general surgery to 1.3 for vascular surgery. CONCLUSIONS. The rate of exposure to blood for operating room personnel, which differ from prior studies, was 10.4 per 100 procedures and was highest for general surgical procedures. The differences in rates among studies might be attributable to different surgical technique, dissimilar case-mix, or different research methods relating to definition or ascertainment of exposure.

Wright KU, Moran CG, Briggs PJ. Glove perforation during hip arthroplasty: a randomized prospective study of a new taper-point needle. J Bone Joint Surg Br 1993;75:918-20.
Available at: http://www.jbjs.org.uk/cgi/content/abstract/75-B/6/918 ABSTRACT: Exposure to blood is a hazard for all surgeons. We assessed the incidence of glove perforation and needlestick injury from a new blunt taperpoint needle designed to penetrate tissues other than skin with the minimum of force. We performed a prospective, randomised trial comparing the incidence of perforations of surgical gloves with the new needle and a standard cutting needle during wound closure after hip arthroplasties. There was at least one glove perforation in 46 of 69 such procedures (67%). The use of the taperpoint needle produced a significant decrease in perforations (p = 0.049).

1992
Jackson MM, McPherson DC. Blood exposure and puncture risks for OR personnel. Todays OR Nurse 1992;14:5-10.
ABSTRACT: 1. Although all health-care workers are at risk for exposure to bloodborne organisms, OR personnel are the most intensively exposed to blood. Exposures to blood were noted in up to half of the procedures observed. 2. Risk-reduction strategies include using two pairs of puncture-resistant gloves and face protection for all procedures; wearing impermeable gowns during procedures with heavy blood loss; using surgical instruments and techniques that reduce the chance of percutaneous contacts; and adopting protocols for handling sharps, counting sponges, and cleaning the operating room. 3. Better and more comfortable personal protective equipment is needed. Manufacturers should develop risk-protective and cost-effective barriers that reduce risks for patients of surgical wound infections while reducing the risks for health-care workers of exposures to blood and bloodborne pathogens.

O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch Intern Med 1992;152:1451-6.
PROBLEM: Occupational exposure to human immunodeficiency virus (HIV) disease is a problem of concern to all health care workers, especially those in large urban teaching hospitals with large numbers of HIV- positive patients. METHOD: The self-reported incidence of needlesticks and other exposures to patients' blood and body fluids in 550 medical students and residents at the Los Angeles County-University of Southern California Medical Center during the 1989 through 1990 training year was studied by means of an anonymous survey. RESULTS: Seventy-one percent of respondents reported one or more needlesticks or other exposures during the training year. Surgical residents had a sixfold greater rate of occupational exposure compared with medicine residents and were significantly more likely to experience suture needlesticks, cuts, open wound contamination, and mucous membrane exposure. Medical students generally were at somewhat lower risk compared with residents, but had greater rates of hollow-needle puncture accidents. No trend was found for accidental exposure by level of residency training. The known HIV-positive exposure rate for students and residents was 9.5% per person per year. Only 9% of exposures were actually reported to the health center. CONCLUSIONS: Based on the rate of exposures reported, numbers of known and estimated HIV-positive patients, and previously published HIV seroconversion rates, we would expect an annual rate of HIV seroconversion rates, we would expect an annual rate of HIV seroconversion as a result of occupational exposures of between 27 and 46 per 100,000. This rate is similar to the leading cause of death in this age group--motor vehicle accidents--and is equivalent to one student or resident in this medical center seroconverting every 2 to 3 years. Although only a portion of accidental exposures are regarded as preventable, these data emphasize the importance of increased efforts toward improved education, prevention, and accessibility of protective equipment

Tokars JI, Bell DM, Culver DH, Marcus R, Mendelson MH, Sloan EP et al. Percutaneous injuries during surgical procedures. JAMA 1992;267:2899-2904.
OBJECTIVE: To study the numbers and circumstances of percutaneous injuries (eg, needle sticks, cuts) that occur during surgical procedures. Surgical personnel risk infection with blood-borne pathogens from percutaneous injuries; some injuries might also place patients at risk by exposing them to a health care worker's blood. DESIGN: Observers present at 1382 surgical procedures recorded information about the procedure, the personnel present, and percutaneous injuries that occurred. SETTING: Four US teaching hospitals during 1990. PARTICIPANTS: Operating room personnel in five surgical specialties. MAIN OUTCOME MEASURES: Numbers and circumstances of percutaneous injuries among surgical personnel and instances in which surgical instruments that had injured a worker recontacted the patient's surgical wound. RESULTS: Ninety-nine injuries occurred during 95 (6.9%) of the 1382 procedures. Seventy-six injuries (77%) were caused by suture needles and affected the nondominant hand (62 injuries [63%]), especially the distal forefinger. The risk of injury adjusted for confounding variables by logistic regression was higher during vaginal hysterectomy (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.5) and lower during certain orthopedic procedures (OR, 0.2; CI, 0.1 to 0.7) than during 11 other types of procedures (reference group; OR, 1.0). Use of fingers rather than an instrument to hold the tissue being sutured was associated with 35 injuries (35%). Eighty-eight injuries (89%) were sustained by resident or attending surgeons; in 28 (32%) of the 88 injuries in surgeons, the sharp object that caused the injury recontacted the patient. CONCLUSION: Percutaneous injuries occur regularly during surgery, placing surgical personnel and, to a lesser extent, patients at risk for infection with blood-borne pathogens. Many such injuries may be preventable with changes in devices, techniques, or protective equipment; all such measures require careful evaluation to determine their efficacy in reducing injury and their effect on patient care.

Tokars JI, Chamberland ME, Schable CA, Culver DH, Jones M, McKibben PS et al. A survey of occupational blood contact and HIV infection among orthopedic surgeons. The American Academy of Orthopaedic Surgeons Serosurvey Study Committee. JAMA 1992;268:489-94.
OBJECTIVE: To study the seroprevalence of human immunodeficiency virus (HIV) among orthopedic surgeons, and correlate the results with occupational and nonoccupational risk factors. Orthopedic surgeons are one of several groups of health care workers at risk for occupationally acquired HIV infection; however, few HIV seroprevalence studies in health care workers, and none in surgeons, have been performed to assist in estimating the extent of occupational risk. DESIGN: A voluntary, anonymous HIV serosurvey at an annual meeting. To assess the representativeness of participants, a mail survey of orthopedic surgeons was conducted 5 months prior to the annual meeting. SETTING: The 1991 annual meeting of the American Academy of Orthopaedic Surgeons held in Anaheim, Calif. PARTICIPANTS: United States or Canadian orthopedic surgeons in training, in practice, or retired from practice who attended the annual meeting. MAIN OUTCOME MEASURES: Participants' HIV serostatus and reporting of occupational and nonoccupational risk factors for HIV infection. RESULTS: Of 7147 eligible orthopedists at the annual meeting, 3420 (47.9%) participated. Compared with the 10,411 orthopedic surgeons responding to the mail survey, serosurvey participants had at least as many opportunities for occupational contact with blood and with HIV-infected patients. Among participants, 87.4% reported a blood-skin contact and 39.2% reported a percutaneous blood contact in the previous month. Among 3267 participants without reported nonoccupational risk factors for HIV infection, none was positive for HIV antibody (0%; upper limit of the 95% confidence interval [CI] = 0.09%); among 108 participants with reported nonoccupational HIV risk factors, two were positive for HIV antibody (1.9%; upper limit of the 95% CI = 5.7%). CONCLUSION: Although these findings may not be generalizable to all orthopedic surgeons, we found no evidence of HIV infection among serosurvey participants without nonoccupational risk factors. The high rates of self-reported blood contact underscore the importance of compliance with infection control precautions and of development of new techniques and equipment to minimize the risk of exposures to blood during surgical procedures.

1991
Montz FJ, Fowler JM, Farias-Eisner R, Nash TJ. Blunt needles in fascial closure. Surg Gynecol Obstet 1991;173:147-8.
SUMMARY: Blunt needles have been developed that are easily used in fascial closures while limiting penetrating cutaneous injury to the surgeon and the operating staff. These needles offer the surgeon further protection from inadvertent exposure to blood borne pathogens.

Panlilio AL, Foy DR, Edwards JR, Bell DM, Welch BA, Parrish CM et al. Blood contacts during surgical procedures. JAMA 1991;265:1533-7.
ABSTRACT: Operating room personnel are at risk for infection with blood-borne pathogens through blood contact. To describe the nature and frequency of blood contact and its risk factors, trained observers monitored a sample of operations performed by six surgical services at Grady Memorial Hospital, Atlanta, Ga, for 6 months. In 62 (30.1%) of 206 operations, at least one blood contact was observed. Of 1828 operating room person-procedures observed, 96 (5.3%) had 147 blood contacts (133 skin contacts [90%], 10 percutaneous injuries [7%], and four eye splashes [3%]). The mean number of blood contacts per 100 person- procedures was highest for surgeons (18.6). The frequency of percutaneous injury was similar among surgeons and scrub staff (mean, 1.2 per 100 worker-procedures for each group). Risk factors for surgeons' blood contacts were (1) performing a trauma, burn, or orthopedic emergency procedure (odds ratio [OR], 4.1; 95% confidence interval [CI], 2.0 to 8.7); (2) patient blood loss exceeding 250mL (OR, 2.1; 95% CI, 1.2 to 3.7); and (3) being in the operating room longer than 1 hour (OR, 3.3; 95% CI, 1.6 to 7.1). Of 110 blood contacts among surgeons, 81 (74%) were potentially preventable by additional barrier precautions, such as face shields and fluid-resistant gowns. Twenty-one (84%) of 25 blood contacts among surgeons in procedures in which all three risk factors were present were potentially preventable by additional barriers. Of 29 blood contacts among anesthesia and circulating personnel, 20 (69%) would have been prevented by glove use. For surgical procedures in which operating room personnel are at increased risk of blood contact, reevaluation of surgical technique, use of appropriate barrier precautions, and development of puncture- resistant glove materials are indicated.

Popejoy SL, Fry DE. Blood contact and exposure in the operating room. Surg Gynecol Obstet 1991;172:480-3.
ABSTRACT: We prospectively studied 684 operations from all surgical specialties to describe the frequency and character of blood contact and exposure during the procedures. Blood contact was defined as percutaneous, mucous membrane, nonintact skin or intact skin contact of patient blood with any member of the operative team. Blood exposure was defined as contact in any of the preceding categories excluding intact skin. Over- all, 28 per cent of the patients had one or more blood contact events that involved 293 operating room personnel. Risk of blood contact was significantly greater for cardiothoracic (p less than 0.001), trauma (p less than 0.003) and obstetric cesarean section (p less than 0.021) procedures when compared with all other procedures. Three services (Ophthalmology, Transplant and Oral Surgery) had no contact events. The remaining nine had rates ranging from 17 to 33 per cent. Eight per cent of the procedures (n = 54) resulted in blood exposure to 63 individuals. Percutaneous exposure occurred in 3 per cent of all procedures. Blood contact events increased with increasing operative time. Blood contact most commonly occurred among circulating nurses (n = 79), anesthesia personnel (n = 65), surgeons (n = 59) and first assistants (n = 49). Despite increased concerns over the risk of occupationally acquired viral diseases, blood contact and exposure continue to be frequent events. Surgeons must assume that all patients are potentially infected and should adopt universally applied standards of behavior to minimize contact with blood.

Quebbeman EJ, Telford GL, Hubbard S, Wadsworth K, Hardman B, Goodman H et al. Risk of blood contamination and injury to operating room personnel. Ann Surg 1991;214:614-20.
Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1358618
ABSTRACT: The potential for transmission of deadly viral diseases to health care workers exists when contaminated blood is inoculated through injury or when blood comes in contact with nonintact skin. Operating room personnel are at particularly high risk for injury and blood contamination, but data on the specifics of which personnel are at greater risk and which practices change risk in this environment are almost nonexistent. To define these risk factors, experienced operating room nurses were employed solely to observe and record the injuries and blood contaminations that occurred during 234 operations involving 1763 personnel. Overall 118 of the operations (50%) resulted in at least one person becoming contaminated with blood. Cuts or needlestick injuries occurred in 15% of the operations. Several factors were found to significantly alter the risk of blood contamination or injury: surgical specialty, role of each person, duration of the procedure, amount of blood loss, number of needles used, and volume of irrigation fluid used. Risk calculations that use average values to include all personnel in the operating room or all operations performed substantially underestimate risk for surgeons and first assistants, who accounted for 81% of all body contamination and 65% of the injuries. The area of the body contaminated also changed with the surgical specialty. These data should help define more appropriate protection for individuals in the operating room and should allow refinements of practices and techniques to decrease injury.

Wright JG, McGeer AJ, Chyatte D, Ransohoff DF. Mechanisms of glove tears and sharp injuries among surgical personnel. JAMA 1991;266:1668-71.
OBJECTIVE: The development of strategies to prevent exposure to blood for operating room personnel has been hampered by a lack of knowledge about the specific mechanisms of exposure. The purpose of this study was to classify the mechanisms of glove tears and sharp injuries in the operating room. DESIGN: During a 3-month period, a nurse interviewed operating room personnel immediately after a glove tear or sharp injury had occurred. SETTING: Yale-New Haven (Conn) Hospital is a tertiary care teaching hospital. RESULTS: There were 249 glove tears and 70 sharp injuries. Visible skin contact with the patient's blood occurred in 156 glove tears (63%). The mechanism causing the tear could be identified in only 81 (33%). For 230 glove tears (92%), personnel were wearing single gloves. Of 70 sharp injuries, 47 (67%) were caused by needles and usually occurred during suturing. The following three mechanisms accounted for 40 sharp injuries (57%): (1) hands injured while stationary and holding an instrument, 11 (16%)-a position of risk not previously identified; (2) hands injured while retracting tissue, 12 (17%); and (3) injuries caused by sharp instruments not being used, 17 (24%). Instrument passage caused only four sharp injuries (6%). CONCLUSIONS: The majority of glove tears have an unknown mechanism, and alteration in the manufacture or number of gloves worn may be helpful in reducing cutaneous blood exposures. The identification of specific mechanisms of sharp injuries should lead to effective strategies to prevent exposure to the human immunodeficiency virus and other blood-borne pathogens in the operating room.

1990
Gerberding JL, Littell C, Tarkington A, Brown A, Schecter WP. Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital. N Engl J Med 1990;322:1788-93.
BACKGROUND: We undertook an observational study of 1307 consecutive surgical procedures at San Francisco General Hospital to record descriptions of intraoperative exposures to blood and other body fluids, determine the factors predictive of these exposures, and identify interventions that might reduce their frequency. METHODS: During a two-month period, circulating nurses took note of parenteral and cutaneous exposures to blood and recorded information about all procedures. In a follow-up validation study, 50 additional procedures were observed by the study investigators to determine the accuracy of the data collected by the nurses. A total of 960 gloves used by surgical personnel during the validation study were examined to determine the perforation rate. RESULTS: Accidental exposure to blood (parenteral or cutaneous) occurred during 84 procedures (6.4 percent; 95 percent confidence interval, 5.1 to 7.8 percent). Parenteral exposure occurred in 1.7 percent. The risk of exposure was highest when the procedures lasted more than three hours, when blood loss exceeded 300 ml, and when major vascular and intraabdominal gynecologic surgery was involved. Neither knowledge of diagnosed human immunodeficiency virus (HIV) infection nor awareness of a patient's high-risk status for such infection influenced the rate of exposure. Double gloving prevented perforations of the inner glove and cutaneous exposures of the hand. CONCLUSIONS: We conclude that all surgical personnel are at risk for intraoperative exposure to blood. Our data support the practice of double gloving and the increased use of water- proof garments and face shields to prevent mucocutaneous exposures to blood. No evidence was found to suggest that preoperative testing for HIV infection would reduce the frequency of accidental exposures to blood.

Gompertz S. Needle-stick injuries in medical students. J Soc Occup Med 1990; 40:19-20.
SUMMARY: A standard questionnaire was used to assess the experience of needle- stick injury in 151 undergraduate medical students, during the previous 10 months. Eighty-two injuries were reported in the 95 questionnaires which were returned. Fifty-one of these took place during venipuncture; of these 26 whilst resheathing a needle. Seventy-two per cent of students resheathed used hypodermic needles, but their rate of injury did not differ significantly from the rate in those who did not resheath. The remaining 31 injuries occurred during surgical procedures. There was a significantly lower rate of injury in those who had earlier been advised to have hepatitis B immunization.

Heald AE, Ransohoff DF. Needlestick injuries among resident physicians. J Gen Intern Med 1990;5:389-93.
OBJECTIVE: To assess the frequency and causes of needlestick injuries in medical and surgical housestaff. DESIGN: A retrospective survey. SETTING: Urban university teaching hospital. PARTICIPANTS: 386 housestaff; 221 responded. INTERVENTION: Survey questionnaire. RESULTS: (1) Frequency of needlestick: Of 221 respondents, 57 (26%) reported never having had a needlestick, while 164 (74%) reported at least one needlestick injury with a suture or hollow-bore needle. The average frequencies were 0.63 per resident-year among 149 non-surgical residents and 3.8 per resident-year among 72 surgical residents. Among residents in internal medicine, 12 of 78 needlestick injuries (15%) sustained were from patients documented to be HIV-positive. (2) Causes of needlestick: The causes of injury were assessed in detail in a sample of the 157 most recent needlestick injuries. Suturing was the cause in 35 of 61 (57%) surgical residents, while recapping needles was the cause in 36 of 96 (38%) non-surgical residents. Inexperience was not the cause of injury; in 94% of cases the residents felt comfortable performing the procedure, and in 74% of cases the residents had performed the procedure more than 50 times before. (3) Reporting of injury: Only 30 (19%) of 157 injuries were reported to the personnel health service, thus compromising documentation for potential workmen's compensation. CONCLUSIONS: Needlestick injuries are common among medical and surgical housestaff. Efforts should be made to prevent needlestick injuries and to report those that occur.

McGeer A, Simor AE, Low DE. Epidemiology of needlestick injuries in house officers. J Infect Dis 1990;162:961-4.
ABSTRACT: Eighty-eight medical students, interns, and residents were surveyed to study the epidemiology of their percutaneous exposures to blood. Respondents described 159 injuries in 221 person-years (py) of exposure in hospital wards and 213 injuries in 166 py of exposure in operating rooms. Nearly all injuries (greater than 98%) were needlesticks; less than 5% were reported to occupational health services. Rates of ward- related injury were highest for students (0.97/py) and decreased during training. Most injuries were due to recapping of used needles. In contrast to ward-related injury, rates of operating room-related injury were relatively low for nonsurgical students and interns (0.3/py), higher for surgical students (1.36/py), and stable over surgical residency training (mean, 5.4/py). Virtually all surgical injuries occurred during suturing. Further research into mechanisms of needlestick injuries and product design for their prevention are needed

1989
Lowenfels AB, Wormser GP, Jain R. Frequency of puncture injuries in surgeons and estimated risk of HIV infection. Arch Surg 1989;124:1284-6.
ABSTRACT: To evaluate the occupational risk of human immunodeficiency virus (HIV) infection, we surveyed 202 surgeons working in the New York City metropolitan area. One hundred seventy-three (86%) surgeons reported at least one puncture injury in the preceding year (median number, 2 per year; interquartile range, 1 to 4 per year). Seventy-six percent of the injuries occurred during surgery, and the median injury rate was 4.2 per 1000 operating room hours. Twenty-five percent of the surgeons sustained yearly injury rates of 9 or more per 1000 operating room hours, and these high rates were independent of sex, age, type of practice, operative work load, or hospital location. Fifty-three percent of all injuries involved the index finger of the nondominant hand. If the prevalence of HIV infection in surgical patients is 5%, then the estimated 30-year risk of HIV seroconversion is less than 1% for 50% of the group, 1% to 2% for 25% of the group, 2% to 6% for 15% of the surgeons, and greater than 6% for 10% of the surgeons.

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