DENVER – Of all the procedures and behaviors that place dermatologists at risk for occupational exposure, needlestick injuries rank at the top.

According to 1999 data from the National Institute for Occupational Safety and Health, one in five health care workers sustains a needlestick injury each year, putting them at risk for acquiring pathogens such as HIV and hepatitis B and C viruses. "Conjunctival transmission of blood-borne pathogens can occur, and there are at least two cases of documented transmission of HIV via splashes," Dr. Joseph F. Sobanko said at the annual meeting of the American Academy of Dermatology. "Operating with exposed, nonintact skin also poses a risk of transmission of bloodborne pathogens."

Dr. Sobanko, a Mohs and reconstructive surgeon and director of dermatologic surgery education at the Hospital of the University of Pennsylvania, Philadelphia, emphasized that all health care employees are at risk of sharps injury. "Those physicians with the least experience are the most likely to receive an occupational exposure," he said. "When trainees and students receive injury, it is a risk factor for receiving future injuries, perhaps because of improper training early on."

A pilot study of sharps-related injuries in California health care facilities found that 49% occurred among nurses, followed by physicians (10%), phlebotomists (8%), and housekeeping and laundry personnel (7%), while the remainder occurred among a variety of other health care workers (Infect. Control Hosp. Epidemiol. 2003;24:113-21).

A separate survey study of needlestick injuries among 699 recent medical school graduates enrolled in a surgery residency at one of 17 medical centers in the United States found that 59% had a stick as a student, most commonly from suturing (42%), passing the needle (17%), and loading the needle (12%) (Academic Med. 2009;84:1815-21).

"Other studies have found that needlestick injuries commonly occur during device use and after device use during disposal," Dr. Sobanko noted.

Most occupational exposures are self-inflicted, and most sharps injuries tend to affect the left hand and digits, he continued. "When suturing, the injury that is self inflicted often happens on the nondominant hand," he said. "However, when not suturing but passing instruments (which shouldn’t be done), health care professionals are more likely to be injured on the dominant hand, because they accept the instrument with this hand. This is why ‘surgical neutral zones’ should be created to transfer instruments and eliminate this particular form of injury."

Occupational exposure is especially high in dermatology. One survey of 452 dermatologists queried in November of 2009 found a 90% injury rate (J. Am. Acad. Dermatol. 2011;65:648-50), while a separate, more recent survey of 336 dermatologists found an 85% injury rate 40% of the injuries had occurred within the year before the survey (Dermatol. Surg. 2013;39:1813-21). More than two-thirds of those same respondents (64%) reported having ever had a sharps injury that went unreported.

Procedures and behaviors that place dermatologists at highest risk for occupational exposure include drawing up solution, setting up a tray, injection, excision, biopsy, obtaining hemostasis, suturing, and disposal of sharps.

"Shortcuts, lack of focus, and improper training lead to avoidable accidents," Dr. Sobanko said. "Fostering a culture of safety can help reduce the risk of future injuries."

His recommended technique for uncapping a needle, for example, involves anchoring the top hand to the bottom hand, as in a golfer’s grip. Gentle extension releases the cap. His recommended technique for drawing solution involves resting the syringe on the hypothenar eminence of the left hand while holding the barrel with the thumb and index finger. This allows for safe placement of the bottle onto the needle. "This technique eliminates the risk of recoil injury if a cap is simply just pulled off a syringe at chest level, analogous to stretching a rubber band," he explained.

To avoid injuries while injecting, Dr. Sobanko advises ensuring that the hand or finger stabilizing the skin stays behind the path of the needle.

Dermatologists can keep themselves safe during office procedures by using protective sharps, eye protection, and gloves and by transferring instruments by implementing a neutral zone on the surgical tray. One review of seven studies of needle protective devices demonstrated an average 71% reduction in needlestick injuries (J. Hosp. Infect. 2003;53:237-42).

Dr. Sobanko described a safe needle device as one that is "easy to use and requires minimal effort to activate by the user. If activation is required, it must be a single-handed technique. The safety feature should click or be clear that it has activated, and the safety feature should remain protective throughout disposal."

Mental preparedness and motor repetition also play a role in protecting yourself. Dr. Sobanko’s five strategies for mental preparedness involve not rushing, knowing the pertinent anatomy for each case, having a proper tray set-up, having a proper preoperative plan, and not operating until an assistant is available.

Dr. Sobanko disclosed that he is a coeditor with Dr. Jacob Levitt of the forthcoming Springer book, "Atlas of Safe Practices in Office-Based Surgery."

dbrunk@frontlinemedcom.com

‘Culture of Safety’ Best Defense Against Sharps Injury