While most junior surgical residents performing an open indirect inguinal hernia repair in the present study consistently passed sharp instruments in a safe manner (e.g., needle protected), an HFT was used in only 3 operations. The HFT is recommended by several professional organizations.2,5
Conflicting data regarding its efficacy in decreasing events exist.16,17
Supporting the use of an HFT, an uncontrolled prospective analysis demonstrated a decrease in the number of incidents of injuries and glove tears by 59% when an HFT was used.16
In contrast, a prospective randomized controlled trial of 156 operations did not demonstrate a difference in glove perforations when an HFT was used compared with cases where no HFT was used.17
It could be argued that our definition of safe passage of sharp instruments was too loose, as we only considered passage hand to hand, sharp end first and unprotected, to be unsafe. Studies indicate that 6%–16% of sharps injuries in the OR occur during hand-to-hand passing, even with protected sharps.7,18–20
When tasks relating to the manipulation of sharps were evaluated, residents only met safety standards 69.2% of the time. Most unsafe personal task events occurred when residents manipulated the suture needle with their fingers. This result is especially concerning given that studies have shown that suture needles pose the single greatest risk to OR staff, accounting for the vast majority of percutaneous injures in the OR, particularly when suturing muscle and fascia during wound closure.7,19
Traditionally, much of the focus for safety awareness campaigns has been on hollow bore needle stick injury prevention; however, increased emphasis should be placed on suture needle manipulation. Training surgeons should be instructed to manipulate suture needles with an instrument if possible to target the riskiest behaviour causing these injuries.
Clear communication between surgical team members when sharps are being moved is a consistent recommendation of many organizations, including the American College of Surgeons, the American Operating Room Nurses Association and the Center for Disease Control.2,4,5
Despite the emphasis on this factor, literature measuring this facet of OR sharps culture is lacking. In the present study, a minority of residents verbally notified team members when passing sharp instruments. The underutilization of verbal notification was observed among all surgical team members, and in 8 of the 18 procedures assessed no notification was given by any team member when sharps were passed.
Two universal recommendations by the American College of Surgeons in preventing unsafe sharps-handling practices include double gloving and the use of blunt suture needles.21
However, in our study, we were not able to accurately assess whether double gloving was used, and our institution did not have blunt suture needles available during the study period.
Throughout surgical training decreased rates of sharps exposure have been documented, with a much lower incidence of percutanoeus injury among senior surgical residents than among more junior trainees.8
In a study of surgical residents by Makary and colleagues,6
59% of respondents indicated that they experienced a sharps injury during medical school. It appears that early in the academic year, residents are more at risk. In a study at a teaching institution, most sharps injuries occurred in the first 3 months of the academic year.22
Education about safe sharps behaviour and injury prevention is most effective early on to ensure durable practices.23
In addition, given that most injuries occur at the beginning of the academic year, safe sharps education should be timed accordingly. Though we found PGY-2 residents do have improved suture needle manipulation technique compared with PGY-1 residents, other parameters were not significantly different between the groups. Our study emphasizes the importance of education and prevention strategies for sharps injuries among surgical trainees, especially early and ongoing in their training.
The literature on decreasing sharps exposure and improving reporting among surgical residents is sparse. Brasel and colleagues8
sought to determine whether mandatory safety training influenced self-reporting of sharps injuries in the OR. They retrospectively reviewed occupational health records of percutaneous OR exposures, intervened with enhanced training, including instructional rounds supplemented by a videotape. Injury reports were then prospectively surveyed, and no difference was noted in between the preintervention and the enhanced training groups.8
Over our study period, no such education or interventions occurred either in the context of resident education or OR policy.
There are several limitations to our study. First, data was gathered by retrospective review of videotaped procedures to assess technical performance and not safety performance. It is also possible that a Hawthorne effect altered the behaviour of residents and staff such that the results do not truly represent their typical sharps-handling techniques. The residents were especially aware that they were being videotaped, and that awareness may have changed their behaviour. In addition, because of limited view, there were occasions during the surgeries in which we were not able to evaluate the sharps-handling behaviour. We assumed there would be evenly distributed safe and unsafe missed events for the purposes of data evaluation, although this is probably unlikely given the data generated. We attempted to minimize the bias of a single reviewer by duplicate review of the videos to record the sharps events and by rereview of each identified event by a second reviewer to determine if the event was, first, sharps-related and, second, safe or unsafe. It is possible that there were sharps-related tasks not identified by the first review and, as a result, were not evaluated by the second reviewer. However, given the standard approach (and the typical timing of scalpel use, suture and injection sharps) to pediatric inguinal hernia repairs, we felt that the likelihood of missing a substantial number of sharps events would be low. When comparing the performance between PGY-2 general surgery residents and PGY-1 plastic surgery residents, the difference in safe suture needle manipulation could be related to resident experience, specialty training or other factors.