Taking safety into your own hands

by Linda McNeilly

The operating room (OR) is a unique practice environment that, by its nature, places staff members at higher risk for certain exposure incidents and injuries. To eliminate the risk of both, healthcare workers must take safety into their own hands.

It’s imperative for surgical staff to understand the risk factors associated with incidents and injuries and to maintain compliance with correlating regulations and safety guidelines. And so the first step toward safety is a review of workplace safety standards and regulations.

DARE to Discuss Safety Standards

In the perioperative environment, the surgical staff is responsible for providing a safe environment of care for surgical patients and a safe workplace for one another. While compliance may not be a comfortable topic for discussion, it is necessary if the OR is to operate at an acceptable state of safety.

Employee compliance with applicable standards and recommended practices is a key factor in maintaining a safe workplace environment. By discussing safety standards, healthcare workers can encourage compliance with regulations, hold each other accountable and promote workplace safety. The following basic considerations can help surgical teams avoid non-compliance.

• Double-glove during all invasive procedures;
• Always wear the correct AAMI level gown;
• Remember mask or goggles during surgery;
• Establish a neutral zone when passing sharps, instruments and needles in surgery.

OSHA Impact

Aside from the quicklist of OR safety considerations, surgical staff should also be able to discuss the role of the Occupational Safety and Health Administration (OSHA) in the development of workplace safety standards.

OSHA was created to set and enforce workplace safety and health standards. These standards are legally mandated; apply to all employers in the United Sates; and are enforced by means of inspection.

President Richard M. Nixon signed The Occupational Safety and Health Act into law in 1970 in response to a public outcry against rising injury and death rates on the job. The Act established three permanent agencies: OSHA, National Institute for Occupational Safety and Health (NIOSH) and Occupational Safety and Health Review Commission (OSHRC).

Through the years, OSHA has focused its resources where it can have the greatest impact in reducing injuries, illnesses and deaths in the workplace. ¹ Specific to healthcare, these standards address exposure to bloodborne pathogens and musculoskeletal injuries.

Exposure to Bloodborne Pathogens 

In 1991, OSHA issued its bloodborne pathogens standard with the intent to help protect workers from occupational exposure to blood and other potentially infectious material. To protect against exposure to bloodborne pathogens and infectious diseases, surgical staff should be vaccinated as a preventative measure. In the OR, they should always wear appropriate personal protective equipment, and they should be sure to double glove during all invasive procedures. Beyond that, staff should safely use and dispose of sharps and needles and always report exposures to or injuries with needle sticks and sharps.

Sharps Injury

Even after implementation of the original OSHA Bloodborne Pathogens Standard, occupational exposure to bloodborne pathogens from accidental sharps injuries continued to be a serious problem. ² In 2000, President Bill Clinton signed into law the Needlestick Safety and Prevention Act (NSPA), requiring that OSHA make specific changes in the Bloodborne Pathogens Standard.

 Personnel in the OR are at higher risk for exposure to bloodborne pathogens from percutaneous injuries. Both OSHA and NIOSH strongly encourage the use of blunt-tip suture needles, whenever feasible and appropriate, to reduce percutaneous injuries to perioperative personnel. While employees and employers share the responsibility to reduce the risk of injuries from sharp devices used routinely in the OR, perioperative nurse managers should collaborate with the facility’s safety officer or risk manager to identify the types of sharp devices and how they are used in the perioperative setting.³

Employers must write an effective sharps injury and bloodborne pathogen exposure control plan and communicate it to all workers in the perioperative setting. And perioperative leadership needs to uniformly support and enforce that plan.

Fire

Because fire is an inherent risk in the OR environment, the entire surgical team must be involved in taking appropriate measures to ensure a safe workplace environment. Safety measures must be aimed at keeping the elements of the fire triangle—oxidizer, fuel and igniter—separate. Education and training in the fire risk reduction strategies for all members of the perioperative team is crucial in order to promote and maintain a fire-safe perioperative practice environment. Some key safety measures include participation in fire drills; the use of firefighting equipment, rescue methods and evacuation procedures; specific protocols to contact the local fire department; and know-how to initiate a “code red” or fire alarm within the facility.

Ergonomics

Ergonomics involves designing equipment and work tasks to conform to the capability of the worker. It provides a means for adjusting the work environment and procedures to prevent injuries. Contributing factors that can lead to injury include the duration, frequency and magnitude of ergonomic stressors. Examples of ergonomic stressors encountered during patient handling tasks in the perioperative practice setting include forceful tasks such as pushing a stretcher and patient up a ramp; repetitive motion such as passing instruments or opening suture packets; awkward posture such as that when holding retractors during a surgical procedure or lifting or holding patient extremities; static posture or standing for long periods of time in one position; moving or lifting patients; moving, carrying or lifting equipment; and overexertion.

In its Position Statement on Ergonomically Healthy Workplace Practices, the Association of periOperative Registered Nurses (AORN) outlines risk-reduction strategies relative to administrative, engineering and behavioral controls. AORN’s suggested controls for an ergonomically healthy perioperative workplace include administrative controls such as staff education and training in the use of patient handling devices and ergonomically designed work stations; engineering controls such as adequate room lighting; and behavioral controls such as the use of nonskid footwear, elimination of clutter, the use of lift teams to handle patients and immediate clean-up of spills or debris.⁴

Waste Anesthetic Gases and Hazardous Chemicals

As with surgical smoke, exposure to waste anesthetic gases and other hazardous chemicals used in the OR is a potential health hazard. AORN also provides <I>Recommended Practices for Safe Environment of Care<$> and outlines measures to limit the amount of waste anesthetic gases, including suggestions to:⁵

• Establish a waste anesthetic gas management program that minimizes healthcare workers’ exposure;
• Use a scavenging system, to remove all waste anesthetic gases;.
• Ensure that anesthesia delivery systems are in proper working order and maintain them on a regularly scheduled basis. 

Measures to reduce the risk of injury associated with chemicals used in the OR include the availability and accessibility of material safety data sheets (MSDS) for every potentially hazardous chemical as well as proper storage and handling of chemicals.

Laser

Lasers are a unique safety hazard to perioperative personnel, with the most common cause of laser-induced tissue damage being thermal in nature. The human body is vulnerable to the output of certain lasers and exposure can result in damage to the eye or skin. The AORN Recommended Practices for Laser Safety in Practice Settings outlines a number of safety measures related to lasers, including suggestions to use signage to inform all personnel where lasers are being used; provide protection from unintentional laser beam exposure; ensure that all people in the nominal hazard zone wear appropriate eyewear and ensure that all people are protected from flammability hazards associated with laser use. ⁶

Latex Allergy

There are many products used on a daily basis in the perioperative practice setting today that contain latex, and repeated exposure to latex proteins increases the risk of developing allergic symptoms. Reactions to latex range from irritant contact dermatitis (the most common), allergic contact dermatitis and latex allergy (the most serious). To reduce the risk of contact dermatitis and latex allergy, healthcare workers need to perform and promote good hand hygiene. Naturally, they should also avoid latex when and where possible, especially if they have a sensitivity or allergic reaction to natural rubber latex. Staff should also consider new technologies like emollient impregnated surgical gloves.

Surgical Smoke

It is estimated that half a million healthcare workers are exposed to electrosurgical or laser smoke annually. ⁷ Surgical smoke has been found to contain toxic gases and vapors, as well as bioaerosols and viruses. In high concentrations, it can cause adverse health conditions.

While there are no mandatory regulations in the United States requiring that surgical smoke be evacuated, there are control measures designed to reduce the inhalation of aerosols released into the air from surgical smoke. Among those measures is the use of a high filtration surgical mask. Other possible solutions include the use of portable smoke evacuators and room suction systems with inline filters, the availability of a smoke evacuator in every operating room where plume is generated, and the evacuation of all smoke—no matter how much is generated.

Radiological Exposure

The use of radiation in the OR presents environmental safety concerns, because ionizing radiation can damage living tissues and may produce long-term effects. Perioperative personnel should protect themselves from unsafe levels of radiation by following proper safety precautions such as the following recommended by AORN’s Recommended Practices for Reducing Radiological Exposure in the Perioperative Practice Setting: ⁸

• Post warning signs to alert personnel to potential radiation hazards.
• Limit the amount of time spent in close proximity to a radiation source.
• Use shielding whenever possible.
• Wear radiation monitors or dosimeters.

Transmissible Infections

Perioperative nurse managers and educators continue to focus efforts on protecting staff members from the transmission of potentially infectious agents, especially when challenged by both newly recognized pathogens as well as well-known pathogens that have become resistant to current treatment modalities. Among other measures, the AORN Recommended Practices for Prevention of Transmissible Infections in the Perioperative Practice Setting recommends that surgical staff perform hand hygiene before and after each patient contacts, use protective barriers to reduce the risk of skin and mucous membrane exposure to potentially infectious materials, double glove during invasive procedures and take precautions to prevent sharps injuries. ⁹ In the same document, AORN recommends that healthcare workers be immunized against epidemiologically significant agents according to recommendations from the Centers for Disease Control and Prevention (CDC).

To ensure safety in the OR, perioperative staff should regularly review workplace safety standards, identify the standards and guidelines applicable to employee safety in the OR, discuss the most potentially serious risks and describe risk reduction strategies. Staff should have a working knowledge of standards and regulations so they are able to critique workplace scenarios and strategies. In doing so, surgical teams can help elevate employee safety to the same level as patient safety, motivate healthcare professionals to embrace safety and become safety role models for others.

For information on presenting the Taking Safety Into Your Own Hands continuing education activity to your perioperative team, request the activity via the Cardinal Health Continuing Education Opportunities webpage at http://161.244.186.129/education/ce/ or contact your local Cardinal Health representative. The intended audience is perioperative registered nurse directors, managers and educators as well as clinicians and surgical technologists responsible for implementation of the OSHA standards and maintaining compliance with all worker safety regulations. 

Nurses, clinicians and surgical technologists can earn 2.0 contact hours or CE credits through Pfiedler Enterprises for watching an educational video, reading the accompanying study guide and then completing the required test and forms. Via its grant funds, Cardinal Health has pre-paid the cost of the contact hours or credits.

If you have questions related to the contact hours, contact Pfiedler Enterprises at 720.748.6144.

References

1. OSHA. OSHA’s 30th anniversary. OSHA at 30: three decades of progress in occupational safety and health. Available at: http://www.osha.gov/as/opa/osha-at-30.html. Accessed September 14, 2009.
2. US Department of Labor. OSHA. Frequently asked questions. What is the Needlestick Safety and Prevention Act? Available at: http://www.osha.gov/needlesticks/needlefaq.html. Accessed September 15, 2009.
3. AORN. AORN guidance statement: sharps injury prevention in the perioperative setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2009; 275-280.
4. AORN. AORN position statement on ergonomically healthy workplace practices. Available at http://www.aorn.org/PracticeResources/AORNPositionStatements/Position_Ergonomicas/. Accessed September 16, 2009.
5. AORN. Recommended practices for a safe environment of care. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2009:415-437.
6. AORN. Recommended practices for laser safety in practice settings. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.; 2009: 367-372.
7. US Department of Labor. OSHA. Safety and health topics: laser/electrosurgery plume. Available at http://www.osha.gov/SLTC/laserelectrosurgeryplume/.Accessed September 15, 2009.
8. AORN. Recommended practices for reducing radiological exposure in the perioperative practice setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.: 2009: 367-372.
9. AORN. Recommended practices for prevention of transmissible infections in the perioperative practice setting. Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.: 2009: 475-485.

Linda McNeilly is director of marketing for Surgical Products at Cardinal Health.