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Unformatted text preview: SEVEN SAFE PRACTICES IN THE OPERATING ROOM
KEY CONCEPTS you will learn in this chapter include:
Why the operating room is so risky for patients and staff
Which instruments cause most injuries in the operating room and why
How to avoid injuries from sharps
How to manage exposure to blood and potentially contaminated body
“The operating room is clearly one of the most hazardous
environments in the healthcare delivery system. By
definition, surgery is invasive. Instruments that are designed
to penetrate patients’ tissue can just as easily injure the
provider. Blood is everywhere. Speed is essential.
Emergencies can occur at any time and interrupt routines.
Preventing injuries and exposures [to infectious agents]
under these circumstances is indeed challenging!”
—Julie Louise Gerberding, MD, MPH
Advanced Precautions for Today’s OR (Davis 2001a)
In the past decade, awareness of the risk of exposure to blood and body
fluids containing HIV, HBV and most recently HCV have created a new
era in surgical infection prevention practices. Just as patients must be
protected from wound contamination and infections, so must providers be
protected from intraoperative injuries and exposure to patients’ blood and
other body fluids.
Preventing infections following an operation is a complex process that
begins in the operating room by preparing and maintaining a safe
environment for performing the surgery. Surgical aseptic techniques are
designed to create such an environment by controlling the four main
sources of infectious organisms: the patient, surgical staff, equipment and
the operating room environment. Although the patient is often the source
of surgical infections, the other three sources are important and should not
be overlooked (see Chapter 6).
The science of safety in the surgical unit, whether it is located in a large
specialty hospital or freestanding primary healthcare clinic, has not kept
pace with the urgent need for prevention strategies. Although some of the
Infection Prevention Guidelines 7-1 Safe Practices in the Operating Room specific recommendations presented in this chapter have not been
evaluated in clinical trials, they have been found over time to be
worthwhile and merit further consideration. Fortunately, the effectiveness
of many of these recommendations—HBV immunization, use of
appropriate personal protective equipment when indicated (see Chapter
5), double gloving, sharps management and the use of blunt needles for
suturing—is well-supported by data.
Specific techniques required to establish and maintain surgical asepsis and
make the surgical environment safer include the following:
Patient considerations: skin cleaning pre-operatively, skin antisepsis
and wound covering (Chapters 6 and 23)
Surgical staff considerations: hand hygiene (handwashing and/or
handrub and handrubbing with waterless, alcohol-based antiseptic
agents); use and removal of gloves and gowns (Chapters 3 and 5)
Equipment and room preparation considerations: traffic flow and
activity patterns as well as housekeeping practices (Chapters 15 and
16) and decontamination, cleaning and either sterilization or high-level
disinfection of instruments, gloves and other items (Chapters 10–12)
Environmental considerations: maintaining an aseptic operating field
and using safer operating practices and techniques (Chapter 7 and 15)
Because traffic flow, equipment processing and room preparation
requirements are discussed in other chapters, the focus of this chapter will
be on improving the surgical environment (operating room), especially the
practices and techniques that make surgery safer for both the patient and
Antisepsis. Process of reducing the number of microorganisms on
skin, mucous membranes or other body tissue by applying an
antimicrobial (antiseptic) agent.
Asepsis and aseptic technique: Combination of efforts made to
prevent entry of microorganisms into any area of the body where they
are likely to cause infection. The goal of asepsis is to reduce to a safe
level or eliminate the number of microorganisms on both animate
(living) surfaces (skin and tissue) and inanimate objects (surgical
instruments and other items).
Surgical asepsis. Preparation and maintenance of a reduced (safe)
level of microorganisms during an operation by controlling four main
sources of infectious organisms: the patient, personnel, equipment and
the environment. 7-2 Infection Prevention Guidelines Safe Practices in the Operating Room THE SURGICAL ENVIRONMENT
The operating room has special characteristics that increase the chance of
accidents. For example, staff often use and pass sharp instruments without
looking or letting the other person know what they are doing. The
workspace is confined and the ability to see what is going on in the
operative field for some members of the team (scrub nurse or assistant)
may be poor. There is, moreover, the need for speed and the added stress
of anxiety, fatigue, frustration and occasionally even anger. Finally, there
is the fact that exposure to blood often occurs without the person’s
knowledge, usually not until the gloves are removed at the end of the
procedure, which prolongs the duration of exposure. The fact that fingers
are frequently the site of minor scratches and cuts further increases the risk
of infection with bloodborne pathogens.
Cause Injuries The vast majority of sharps injuries in hospitals occur in the operating
room, and most are due to scalpel and suture-needle injuries, which is not
surprising given that these are the two most frequently used sharps during
operations. Many other items can also cause sharps injuries and glove
tears resulting in exposure to blood. Some of the most important are:
Laparoscopy and surgical drain trocars
Orthopedic drill bits, screws, pins, wires and saws
Needle point cautery tips
Skin hooks and towel clips
Sharp-pointed scissors and sharp-tipped mosquito forceps
Sharp-toothed tenaculi When Do Injuries
Occur Scalpel injuries most often occur when:
Putting on and taking off the disposable blade
Passing the scalpel hand to hand between team members
Cutting (e.g., in using fingers to hold or spread tissue or cutting toward
the fingers of the surgeon or assistant)
Before and after using the scalpel: leaving it on the operative field,
dropping it on your own or the assistant’s foot, and reaching for
scalpels sliding off the drapes
Placing the scalpel in an over-filled sharps container or a poorly
located container Infection Prevention Guidelines 7-3 Safe Practices in the Operating Room Suture needle injuries most often occur when:
Loading or repositioning it in the needle holder
Passing the needle hand to hand between team members
Suturing: using fingers to hold tissue or to guide the needle, sewing
toward the surgeon or assistant and holding back other tissues by the
surgeon or assistant
Tying with the needle still attached or left on the operative field
Before and after using the needle: leaving it on the operative field,
dropping it on your own or the assistant’s foot, and reaching for suture
needles or needles loaded in the needle holder sliding off the drapes
Placing needles in an over-filled sharps container or a poorly located
Not surprisingly, almost all of these injuries can be easily avoided and
with little expense. For example:
Use a small Mayo forceps (not fingers) when holding the scalpel
blade, when putting it on or taking it off or loading the suture needle.
(Alternatively, use disposable scalpels with a permanent blade that
cannot be removed.)
Always use tissue forceps, not fingers, to hold tissue when using a
scalpel or suturing.
Use a “hands-free” technique to pass or transfer sharps (scalpel,
needles and sharp-tipped scissors) by establishing a Safe or Neutral
Zone in the operative field (see below).
Always remove sharps from the field immediately after use.
Make sure that sharps containers are replaced when they are only
three-quarters full and place containers as close to where sharps are
being used as conveniently possible (i.e., within arm’s reach).
Technique for Passing
Surgical Instruments A safer method of passing sharp instruments (scalpels, suture needles and
sharp scissors) during surgery, called the “hands-free” technique, has
recently been recommended. This technique for sharps is inexpensive,
simple to use, and ensures that the surgeon, assistant or scrub nurse never
touches the same instrument at the same time (Bessinger 1988; Fox 1992).
Instruments passed with the hands-free technique (besides those listed
above) include anything sharp enough to puncture a glove (e.g., trocars,
sharp-tipped mosquito forceps and loaded needle holders). Using the
hands-free technique, the assistant or scrub nurse places a sterile or highlevel disinfected kidney basin, or other suitable small container, on the
operative field between her/himself and the surgeon. The container is
designated as the Safe or Neutral Zone in which sharps are placed before 7-4 Infection Prevention Guidelines Safe Practices in the Operating Room Note: To avoid dulling
scalpel blades, use a plastic
container or place a sterile
cloth in a metal container. and immediately after use.1 For example, the assistant or scrub nurse alerts
the surgeon that a sharp instrument has been placed in or on the Safe
Zone, with the handle pointing toward the surgeon, by saying “scalpel” or
“sharp” while placing it there. The surgeon then picks up the instrument
and returns it to the container after use, this time with the handle pointing
away from her/him.
Another way to do this is to have the assistant or scrub nurse place the
instrument in a container and pass it to the surgeon. The surgeon lifts the
instrument out of the container, which is left on the field until the surgeon
returns the instrument to it. The assistant or scrub nurse then picks up the
container and returns it to the Mayo stand. DESIGNING SAFER OPERATIONS
Using the least dangerous instrument or device that will effectively
accomplish the task, while at the same time minimizing risks to the patient
and surgical team, should be a goal of any operation. Simple things, such
as a brief pre-op discussion of how sharps will be handled by the surgeon,
assistant or scrub nurse, can be very helpful. Better still is for the surgical
team to review how to make each step in the operation safer, from
securing the towel drapes around the proposed incision with
nonperforating towel clips to using blunt-tipped needles for closure of all
layers except the skin (CDC 1997; Dauleh et al. 1994). Other examples of
instruments or devices that protect the surgical team without sacrificing
patient safety or staff performance are shown in Table 7-1.
In addition, the use of hand-held straight suture needles to close skin
incisions is especially dangerous, with a reported injury rate of 17%, much
higher than with curved needles carried in a needle holder (Davis 2001b).
Anesthesiologists, radiologists and others who close small incisions after
placement of vascular catheters or cut-downs should be made aware of
The risk associated with assisting or being the scrub nurse in surgery may
be reduced by anticipating (preferably knowing) the needs of the surgeon
for each step of the operation in advance. Where procedures are short (30
minutes or less) and/or the surgical steps are straightforward such as a
D&C or cesarean section, this can be accomplished by developing
checklists that lay out each step (or task) in the operation or procedure in
the sequence in which they usually will be performed (i.e., from skin
incision to closure). Reviewing the checklist with the surgical team just
before starting the case and pointing out where deviations may be
necessary will make the planned surgery go more smoothly and with less 1 Various items, such as basins, mats or trays, including part of a sterile instrument stand or a designated area on the
operative field, have been used as the Safe Zone.
Infection Prevention Guidelines 7-5 Safe Practices in the Operating Room risk of injury. An additional advantage of this review is that it can help
protect patients from injury or increased blood loss.
Table 7-1. Reducing the Risk of Exposure
FUNCTION SAFER LESS SAFE LEAST SAFE1 Skin incision cautery disposable scalpel scalpel with
removable blade Cutting scissors, blunt tip
or cautery probe scissors, sharp tip scalpel Hemostasis blunt suture needles
or cautery sharp suture
needles wire sutures Sponging with
gauze while using
a scalpel surgeon does
retracts assistant sponges
but only by request assistant sponges
communication) Retraction blunt retractor sharp retractor fingers or hands Sharps transfer Neutral Zone hand-to-hand
(communication) hand to hand (no
communication) Surgical gloves double gloving single pair of
gloves or double
reprocessed gloves single pair of
reprocessed gloves, Closing
2–3 cm incision) do not close purse-string closure
using tissue forceps
to grasp needle purse-string closure
using fingers to
grasp needle 1 Blunt Needles for
Suturing Should be avoided if at all possible. The range of “bluntness” in commercially available blunt-tipped needles
varies from minimal (no extra effort needed to use them) to very blunt
(does not penetrate tissue such as fascia and requires conscious effort).
Minimally blunt needles can be used for closure of all layers from fascia
to skin. Intermediate blunt needles require some additional conscious
effort to close fascia, but are safer to use. Very blunt needles are seldom
used except when operating deep in the pelvis where the needle absolutely
must be retrieved with fingers. The technique for using blunt needles is as
STEP 1: Use a strong needle holder and lock it fully.
STEP 2: Position the needle in the mid-curve, rather than three-quarters of
the way back to prevent slippage or bending the needle. (This usually is
not necessary when using minimally blunt needles.)
STEP 3: Grasp and hold the tissue to be sutured with a tissue forceps to
make it easier for the needle to go through the tissue being sutured. 7-6 Infection Prevention Guidelines Safe Practices in the Operating Room In general, the blunter the tip, the more important it is to follow these three
Double Gloving The transmission of HBV and HCV from surgeon to patient and vice versa
has occurred in the absence of breaks in technique and with apparently
intact gloves (Davis 2001c). Even the best quality, new latex rubber
surgical gloves may leak up to 4% of the time.2 Moreover, latex gloves,
especially when exposed to fat in wounds, gradually become weaker and
lose their integrity.
Although double gloving is of little benefit in preventing blood exposure if
needlesticks or other injuries occur, it may decrease the risk of blood-hand
contact. For example, one recent study showed that surgeons wearing
single gloves had a blood-hand contact rate of 14% while surgeons
wearing double gloves had only a rate of 5% (Tokars et al 1995; Tokars et
al 1992). Based on this study, the following are reasonable guidelines for
when to double glove:
The procedure involves coming in contact with large amounts of blood
or other body fluids (e.g., vaginal deliveries and cesarean sections).
Orthopedic procedures in which sharp bone fragments, wire sutures
and other sharps are likely to be encountered.
Surgical gloves are reused. (The possibility of inapparent holes or
perforations in any type of reprocessed glove is higher than with new
In general, for surgical procedures that are short (30 minutes or less) and
involve minimal exposure to blood or mucous secretions (e.g.,
laparoscopy or minilaparotomy), double gloving is probably not
necessary. Whether or not the surgeon, assistant or nurse should double
glove should be considered carefully, especially where gloves are reused
and in areas where the risk of contracting bloodborne pathogens, such as
HIV, is high (>5% prevalence). Elbow-length Gloves for
Obstetrical Procedures 2 Blood contact with the skin and mucous membranes of providers occurs in
25% of vaginal deliveries and 35% of cesarean sections (Davis 2001d). In
addition, large volumes of amniotic fluid contaminated with blood are
routine in obstetrics. For skilled birth attendants doing home deliveries,
wearing clean examination gloves and avoiding contact with the vaginal
area as much as possible is recommended, especially after the membranes
have ruptured. Also, changing gloves and washing hands if gloved hands
become heavily contaminated with blood or amniotic fluid can minimize
the risk of exposure. The “acceptable” leak rate for new surgical and examination gloves designated by regulatory agencies is up to 4% (Davis 2001c). Infection Prevention Guidelines 7-7 Safe Practices in the Operating Room Where the hand and forearm need to be inserted into the vagina (manual
removal of a retained placenta) or deep into the uterus to deliver the
infant’s head (cesarean section), elbow-length, so-called “gauntlet” gloves,
help protect the provider from significant blood and amniotic fluid
contamination. Moreover, by wearing gauntlet gloves, the mother will be
protected as well.
If gauntlet gloves are not available, an inexpensive, effective alternative
can be easily made from previously used surgical gloves that have been
decontaminated, cleaned and dried.3 The steps for making them are:
STEP 1: Cut the four fingers completely off each glove just below where
all the fingers join the glove (Figure 7-1).
STEP 2: Sterilize or high-level disinfect 2–3 pairs of cut-off (fingerless)
gloves according to the recommended process for each method (Appendix
C) and store the gloves after final processing in a sterile or high-level
disinfected container until needed.
Figure 7-1. Creating Gauntlet Gloves from Previously Used Surgical Gloves Note: If the need for
protection of the forearm(s)
occurs during a procedure
(e.g., removal of a retained
placenta), first remove the
surgical glove from one or
both hands using the
technique described in
Chapter 3. Next, put on a
fingerless sterile or highlevel disinfected glove(s)
and pull up onto the
forearm(s). Finally, put a
new sterile or high-level
disinfected surgical glove
on one or both hands. If it is anticipated that the forearms need to be protected before starting
the procedure (e.g., cesarean section with presenting part deep in the
pelvis), the steps are:
STEP 1: Perform surgical handscrub, including the forearms up to the
elbows, as detailed in Chapter 3 using an alcohol-based antiseptic agent.
STEP 2: Put fingerless sterile or high-level disinfected gloves on both
hands and pull up onto the forearm(s) (as shown in Figure 7-2a).
STEP 3: Put intact sterile or high-level disinfected surgical gloves on both
hands so that the distal (lower) end of the fingerless glove is completely
covered (Figure 7-2b). 3 Latex rubber surgical gloves are preferred over examination gloves or even nitrile surgical gloves because they have longer
cuffs, are more elastic, fit tighter on the forearm and are more durable. 7-8 Infection Prevention Guidelines Safe Practices in the Operating Room
Figure 7-2a and b. Putting on Fingerless and Surgical Gloves a b
SAFE HANDLING OF HYPODERMIC NEEDLES AND SYRINGES
In the operating room, scalpels and suture needles are the leading source
of penetrating injuries. Hypodermic (hollow bore) needles, however, cause
the most injuries to health workers at all levels. Consider:
Surgeons and assistants are most often stuck by hypodermic needles
Cleaning staff are most often stuck by needles when washing soiled
Housekeeping staff are most often stuck by needles when disposing of
infectious waste material.
Safety Tips for Using Hypodermic Needles and Syringes
Use each needle and syringe only once.4
Do not disassemble the needle and syringe after use.
Do not recap, bend or break needles prior to disposal.
Decontaminate the needle and syringe prior to disposal.
Dispose of the needle and syringe in a puncture-resistant container. 4 Several studies have documented that unsafe injection practices, such as using the same needle, syringe or both for more
than one injection or improperly processed syringes and needles, are responsible for transmitting HIV, HBV and HCV
(Drucker, Alcabes and Marx 200l; Simonsen et al 1999). Therefore, after each use, the assembled needle and syringe should
either be decontaminated and placed in a sharps container for disposal, or reprocessed using recommended infection
prevention practices (see Chapter 14 and Appendix E).
Infection Prevention Guidelines 7-9 Safe Practices in the Operating Room If the needle must be recapped, use the “one-handed” recap method:
First, place the needle cap on a firm, flat surface; then remove hand.
Next, with one hand holding the syringe, use the needle to “scoop” up
the cap (Figure 7-3a).
With the cap now covering the needle tip, turn the syringe upright
(vertical) so the needle and syringe are pointing toward the ceiling.
Finally, using the forefinger and thumb of your other hand, grasp the
cap just above its open end (Figure 7-3b) and push the cap firmly
down onto the hub (the place where the needle joins the syringe under
Figure 7-3a and b. One-Handed Recap Method a b Safety Tip for Using a Needle and Syringe for Multiple Injections in
the Operating Room
If a hypodermic needle must be used for multiple injections during a
surgical procedure, one option for preventing accidents between uses is
Roll a sterile towel into a tube shape.
Stick the needle into the towel between uses. 7 - 10 Infection Prevention Guidelines Safe Practices in the Operating Room How to Withdraw
Medication from a
Sterile Multidose Bottle
Note: Do not leave a
needle inserted in the
rubber stopper of a
multidose bottle. This
practice provides a direct
route for microorganisms,
including HIV, to enter the
bottle and contaminate the
fluid between each use. How to Withdraw
Medication Using an
Autodisable Syringe Wipe the top of the bottle with a cotton swab soaked in 60–90%
alcohol or other locally available disinfectant. Allow it to dry.
If using a new disposable needle and syringe, open the sterile pack.
If using a sterile or high-level disinfected syringe, remove it from the
covered container using dry, sterile or high-level disinfected forceps.
Attach the needle to the syringe.
Remove the needle cap and insert the needle tip until it touches the
bottom of the bottle.
After filling the syringe, withdraw both the needle and syringe from
In seeking to improve injection safety, several years ago WHO
recommended that all immunizations be given using autodisable syringes.
Since then they have been widely used in both campaign and routine
immunization settings. Although there are many types of autodisable
syringes, the key feature of all of them is that they only permit the syringe
to be filled and emptied once. In 2002, USAID began providing the
SoloShot FX autodisable syringe for use in giving the injectable
contraceptive DMPA (Depo Provera ).
The SoloShot FX syringe is a single-use, disposable syringe with a metal
clip that locks the plunger after a single use (i.e., it can not be pulled back
a second time). The syringe is packaged with a detachable needle, which
cannot be attached to any other type of syringes, in a sterile package.
Although autodisable syringes and needles are similar to conventional ones,
most health workers will require practice in learning to correctly fill them to
avoid wasting medication, syringes and needles (i.e., if air is drawn up into
the syringe instead of the prescribed amount of medication, the syringe
cannot be refilled). Moreover, it is anticipated that with time use of
autodisable syringes for giving other types of injections will increase;
therefore, clinicians need to be familiar with using autodisable syringes.
The following instructions are specific for the SoloShot FX syringe and
Open the sterile pack containing the needle and syringe and attach the
Remove the needle cap and insert the needle tip until it touches the
bottom of the bottle as shown in Figure 7-4a. (To avoid drawing air into
the syringe, be sure the needle tip stays below the fluid level in the bottle.) 5 Store opened multidose bottles in a separate, covered container to avoid contamination. Also, mark the date of the first
withdrawal. Discard if unused after 30 days or if contaminated at any time.
Infection Prevention Guidelines 7 - 11 Safe Practices in the Operating Room While holding the bottle with one hand, slowly pull back on the
plunger of the syringe and draw up fluid to just above the “fill line”
mark (Figure 7-4b).6
Figure 7-4a and b. Withdrawing Medication Using an Autodisable Syringe
(SoloShot FX ) a
Withdraw the needle and syringe from the bottle and hold the syringe
upright (needle pointing to the ceiling) to see if any air is in the
If there are air bubbles, slowly push the plunger in, but only until the
“fill line” mark is reached.
Check to be sure the fluid level in the syringe is at or slightly above
the “fill line” mark. If it is below the fill line mark, there may not be
enough medication to be effective and the injection should not be
administered. In this situation, either inject the medication back into
the single dose bottle and draw up the medication again using a new
autodisable syringe and needle, or discard the partially filled syringe
and use a new bottle and autodisable syringe and needle.
SHARPS CONTAINERS: DOs AND DON’Ts
Sharps containers are a key component in minimizing injuries from
disposable sharps—such as hypodermic needles, scalpels and suture
needles—that are used at all levels of the healthcare system. Other
operating room-specific sharps that require similar disposal include:
surgical drain trocars, needle point cautery tips, wire sutures, orthopedic
drill bits and a range of hollow injection needles used by radiologists and
6 For the SoloShot FX syringes used with DMPA, the “fill line” mark is at 1 mL. 7 - 12 Infection Prevention Guidelines Safe Practices in the Operating Room Note: Educating staff on
the safe handling of sharps
reduces the risk of injury
(Managan et al 2001). anesthesiologists for various medical invasive procedures. Disposal of
these items after their use requires careful planning and action on the part
of the healthcare team to avoid injury to the housekeeping and maintenance
staff that ultimately will be removing them.
In the US and other developed countries, a whole industry has grown up to
meet the increasing demand for sharps containers. Today, sharps containers
of all sizes and shapes are available, either disposable or reusable. Most
manufactured containers are designed to be wall mounted or attached to a
surface and come with special mounting brackets. A few, however, are still
designed to be freestanding (ECRI 1993). In most developing countries,
these manufactured items are a luxury. As a result, health workers
throughout the world have cleverly developed sharps containers from
readily available “throw away” items, such as metal food containers made
of aluminum, tin or heavy plastic (e.g., cooking oil bottles and cans), heavyduty cardboard boxes and even the used plastic drinking water bottles with
caps that litter the streets and countryside. Although some are safer than
others, they all provide a no-cost, sustainable source of disposable sharps
containers for use in small clinics, polyclinics and district-level hospitals
with limited budgets. Rather than discouraging practitioners from using
these items in favor of manufactured products, they should be given help in
developing better, safer containers from existing materials (e.g., advised on
which items are more appropriate to use).
When using sharps containers, either commercial or locally produced, here
are some DOs and DON’Ts to consider:
DO put sharps containers as close to the point of use as possible and
practical, ideally within arm’s reach. Also, they should be easy to see,
recognize and use.
DO attach containers to walls or other surfaces if at all possible.
DO mark them clearly so that people will not unknowingly use them as
a garbage container or for discarding cigarettes.
DO place them at a convenient height so staff can use and replace them
DO mark the fill line at the three quarters full level.
DON’T shake a container to settle its contents and make room for more
DON’T place containers in high traffic areas (corridors outside patient
rooms or procedure rooms) where people could bump into them or be
stuck by someone carrying sharps to be disposed of.
DON’T place containers on the floor or anywhere they could be
knocked over or easily reached by a child.
DON’T place containers near light switches, overhead fans or thermostat
controls where people might accidentally put their hand into them. Infection Prevention Guidelines 7 - 13 Safe Practices in the Operating Room MANAGING EXPOSURE TO BLOOD AND BODY FLUIDS
Healthcare professionals (physicians, nurses and midwives) who work in
high-risk areas such as surgical and obstetrical units should know what to
do in the event of a possible blood exposure to themselves or another
health worker. Preventing accidents (needlesticks) and other blood or body
fluid exposures are the primary means of preventing work-related
transmission of HIV or HCV. For HBV, however, an effective vaccine has
been available for nearly 20 years. Unfortunately, in many countries, even
health professionals have not been immunized against this serious
bloodborne disease. Although only about 5% of people who contract
hepatitis B die from the disease, a high percentage become chronic carriers
or are disabled and cannot work because of permanent damage to the liver
(cirrhosis). In addition, hepatitis B infection is a necessary precursor for
hepatitis D (HDV) and primary liver cancer.7 Being vaccinated protects not
only the individual, but also fellow workers, other patients and the
Hepatitis B Post Exposure Guidelines Several studies have demonstrated that, in susceptible persons (i.e., negative
hepatitis B surface antigen [HBsAG] test and no history of receiving
immune serum globulin), giving hepatitis B immune globulin (HBIG) is
better than conventional immune serum globulin (ISG) (or by inference
doing nothing) in preventing acute hepatitis B and seroconversion
(Desmyter et al 1975; Grady and Lee 1975). For example, in the study by
Seeff et al (1975), a randomized clinical trial comparing HBIG to ISG, only
1.4% compared to 5.9% of susceptible individuals developed acute
hepatitis, and only 5.6% compared to 20.7 % seroconverted. Both results
were statistically significant at the P <0.01 level, and the findings persisted
for up to 1 year. In this trial, the first dose of HBIG (5 mL intramuscularly)
was given within 7 days of exposure; with the second dose approximately 1
month later. Only brief and mild side effects were noted with either HBIG
(3%) or ISG (3.2%). Unfortunately, the availability of HBIG is limited in
many countries, but if accidental exposure is reported promptly, there may
be time to procure the HBIG and still give it within 7 days of exposure.
Whether ISG provides any protection is not known.
The suggested steps for managing an injury is as follows8:
STEP 1: Treat the exposure site if appropriate (e.g., an open wound or
STEP 2: If tetanus immunization or boosters are indicated (>10 years
since immunization), give it. 7 HDV is an incomplete virus that is unable to replicate (make more virus particles) in humans without binding to HBV
If exposure is limited to contact with blood or body fluids on intact skin (hands), wash affected areas with soap and water
as soon as possible. For contact with mucous membranes (eyes, nose or mouth), rinse with clean water at least two times. 7 - 14 Infection Prevention Guidelines Safe Practices in the Operating Room STEP 3: Assess the risk of HBV exposure and determine the immune
status of the patient (i.e., history of jaundice, hepatitis or previous
immunization with hepatitis B vaccine). If status is unknown, continue
STEP 4: Collect a specimen from the source person (i.e., the carrier or
person suspected of being infected) if possible and from the patient for
HBsAGg testing. If testing is not possible, base the HBV status of the
infected person on clinical history and clinical findings.
STEP 5: Give HBIG (5mL IM) as soon as possible and within 7 days of
exposure, and also give the first dose of hepatitis B vaccine, which should
be repeated at 1 and 6 months. If active immunization with hepatitis B
vaccine is not possible, a second dose of HBIG should be given 1 month
later (Chin 2000).
Prophylaxis Guidelines The plan for assessing the risk of accidental exposure to HIV is similar
to that for HBV. Because there is no vaccine for passive or active
immunization against HIV, post-exposure prophylaxis (PEP) is much
more complicated; therefore, the decision to recommend it needs to be
based on a careful assessment of the injury. For example, although the risk
of HIV seroconversion after all types of work-related percutaneous
(breaks the skin) exposure is only about 0.3% (Tokars et al 1993), the risk
for deep injuries (extends into the muscle), including deep needlesticks, is
15 times greater than for superficial injuries (CDC 1995; Cardo et al
If the assessment is positive for a high risk of HIV exposure (i.e., deep
injury or needlestick), consider giving treatment with antiretroviral agents
(zidovudine [ZDV] plus lamivudine [3TC] has been shown to prevent HIV
transmission) (CDC 2001).9 Determining whether or not PEP should be
initiated for a potentially HIV-exposed individual is more difficult than for
HBV for three reasons. First, treatment should be initiated as soon as
possible and at least within hours after exposure to HIV. Second, a
physician or other health professional with knowledge and experience in
managing patients with HIV should do the assessment of risk. And third,
treatment with antiretroviral agents has considerable side effects, even for
prophylaxis, and the long-term safety is not known. Whether or not health
workers with exposure to HIV are given PEP, they should receive
followup counseling, post-exposure testing and a medical evaluation. Hepatitis C PostExposure Guidelines 9 There is no post-exposure vaccine or drug prophylaxis for hepatitis C
(immune globulin is ineffective). Prevention of exposure, therefore, is the
only effective strategy for prevention of HCV. For the most recent information on post-exposure prophylaxis, go to http://www.cdc.gov/ncidod/hip/guide/phspep.htm. Infection Prevention Guidelines 7 - 15 Safe Practices in the Operating Room The CDC (1998) has recommended the following guidelines that
institutions should consider for followup of health workers exposed to
HCV-positive blood or other body fluids:
Baseline testing of the source patient (if available and a consent form
is signed) for anti-HCV antibody (if the test is available).
Baseline and 6-month followup testing of exposed health worker for
anti-HCV antibody and liver function screen.
If available, treatment of early HCV infection with pegylated
interferon alfa before significant liver damage has occurred.10
Where possible, all positive anti-HCV results should be confirmed by
supplemental, accurate anti-HCV antibody testing.
MAKING THE SURGICAL ENVIRONMENT SAFER
The responsibility for making today’s operating rooms safer extends
beyond concern for the well-being of the patient to all healthcare staff who
together form the surgical team. The approaches to making operations
safer outlined in this chapter are simple, practical and have been
documented over a 10-year period. The key to success is to apply the
principles and practices in an integrated and consistent manner, with daily
attention to detail and, above all, with support at all levels of the
Bessinger CD Jr. 1988. Preventing transmission of human immunodeficiency
virus during operations. Surg Gynecol Obstet 167(4): 287–289.
Cardo DM et al. 1997. A case-control study of HIV seroconversion in
healthcare workers after percutaneous exposure. N Engl J Med 337: 1485–
Centers for Disease Control and Prevention (CDC). 2001. Updated U.S.
public health service guidelines for the management of occupational
exposures to HBV, HCV, and HIV and recommendations for postexposure
prophylaxis. MMWR 50(No. RR-11): 26–27.
Centers for Disease Control and Prevention (CDC). 1998. Public health
service guidelines for the management of health-care worker exposures to
HIV and recommendations for post-exposure prophylaxis. MMWR 47(RR7): 1–33. 10 Adding polyethylene glycol (PEG) to the interferon molecule increases the half-life of the drug, allowing for less frequent
dosing (from three to once a week), but the cost of treatment per month is still nearly USD $2000 (Pharmacology Watch 2002). 7 - 16 Infection Prevention Guidelines Safe Practices in the Operating Room Centers for Disease Control and Prevention (CDC). 1997. Evaluation of
blunt suture needles in preventing percutaneous injuries among health-care
workers during gynecological surgical procedures. MMWR 46(2): 25–29.
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exposures to HIV-infected blood—France, United Kingdom and United
States, January 1988–August 1994. MMWR 44(50): 929–933.
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Washington, DC, pp 247–251.
Dauleh MI et al. 1994. Needle prick injury to the surgeon—do we need
sharp needles? J R Coll Surg Edinb 39(5): 310–311.
Davis MS. 2001a. Advanced Precautions for Today’s OR: The Operating
Room Professional's Handbook for the Prevention of Sharps Injuries and
Bloodborne Exposures, 2nd ed. Sweinbinder Publications LLC: Atlanta.
Davis MS. 2001b. Blunt alternatives to sharps, in Advanced Precautions
for Today’s OR: The Operating Room Professional's Handbook for the
Prevention of Sharps Injuries and Bloodborne Exposures, 2nd ed.
Sweinbinder Publications LLC: Atlanta, pp 53–63.
Davis MS. 2001c. Choices of effective personal protective equipment, in
Advanced Precautions for Today’s OR: The Operating Room
Professional's Handbook for the Prevention of Sharps Injuries and
Bloodborne Exposures, 2nd ed. Sweinbinder Publications LLC: Atlanta,
Davis MS. 2001d. Obstetrical procedures, in Advanced Precautions for
Today’s OR: The Operating Room Professional's Handbook for the
Prevention of Sharps Injuries and Bloodborne Exposures, 2nd ed.
Sweinbinder Publications LLC: Atlanta, pp 85–92.
Davis MS. 2001e. Bloodborne pathogens and occupational risk, in
Advanced Precautions for Today’s OR: The Operating Room
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Bloodborne Exposures, 2nd ed. Sweinbinder Publications LLC: Atlanta,
Desmyter J et al. 1975. Hepatitis-B immunoglobulin in prevention of HBS
antigenemia in hemodialysis patients. Lancet 2(7931): 376–379.
Drucker EM, PG Alcabes and PA Marx. 2001. The injection century:
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pathogens. Lancet 358: 1989–1992.
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containers, in Technology for Critical Care Nurses. Plymouth Meeting,
PA and from Nursing96 (February): 51.
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Infection Prevention Guidelines 7 - 17 Safe Practices in the Operating Room Grady GF and VA Lee. 1975. Hepatitis B immune globulin—prevention
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Organ 77(10): 789–800.
Tokars JI et al. 1995. Skin and mucous membrane contacts with blood
during surgical procedures: Risk and prevention. Infect Control Hosp
Epidemiol 16(12): 703–711.
Tokars JI et al. 1993. Surveillance of HIV infection and zidovudine use
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Tokars JI et al. 1992. Double gloving cuts blood contacts 70%. Ob/Gyn
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