Sharps Safety

Each year over 100 000 sharps injuries are recorded in the NHS (Trim and Elliott 2003) with attendant risks of the transmission of bloodborne infection to the injured party. Despite information on these risks being widely disseminated, the number of injuries that go unreported is substantial, with one study looking at surgeon reporting of sharps injury noting that over 50% of surgeons questioned had experienced an injury but had not reported it (Kerr et al. 2009). Worryingly, this study also found that only 15% of ­surgeons were consistently adopting all of the three principles of sharps safety and ­prevention of percutaneous contamination: double gloving, face shields and a hands-free technique.

The hands-free technique, in which sharps are passed in a neutral zone (often a designated tray), has been demonstrated to reduce sharps injuries and associated percutaneous contamination by 60% (Stringer et al. 2002), yet these authors found that this technique was only used in 42% of operations.

All organisations will have detailed policies and procedures that are intended to ­protect staff from sharps injury, yet these polices are not adhered to. One study showed that seniority seemed to be a factor in adherence to policy, with 93% of consultants, 67% of junior medical staff and 13% of other perioperative practitioners not complying with local protocols (Adams et al. 2010). The two main reasons cited for the lack of compliance were given as the length of time it takes to do so (48%) and a low perception of risk of infection from the patient (78%). Local procedures should take these factors into account in order to increase compliance with policies that are intended to protect the health of staff and all perioperative practitioners should familiarise themselves with local procedures.

Patient Preparation

The purpose of patient preparation prior to an operative procedure is to reduce the risk of endogenous skin flora contaminating the surgical field with infection as a consequence. Prior to any surgical procedure it is good practice to wash the skin with soap and water (preferably in the form of a shower), as the effects of the soap are to remove dirt and break down skin oils before an antiseptic solution is applied. There is also a growing body of literature that suggests that there are benefits to showering with an antiseptic soap preparation with iodine (Finkelstein et al. 2005) or chlorhexidine gluconate (Milstone et al. 2008) in the immediate preoperative period and even the period prior to admission, as chlorhexidine has been demonstrated to have a cumulative and persistent effect on the skin (Edmiston et al. 2008). The optimal duration and frequency of preoperative showering is as yet unknown (Jakobsson et al. 2011).

Organism-specific risk assessment and patient preparation

Although many patients are now screened for specific organisms such as MRSA (­methicillin-resistant Staphylococcus aureus), it should be remembered that these tests are for screening purposes and are not 100% specific or sensitive. All patients undergoing surgery should be risk-assessed for the potential for carriage of certain organisms. For example, a risk assessment for MRSA should include: number of healthcare contacts (for example, frequent admissions to hospital), nursing/care home residency, presence of chronic wounds and other long-term indwelling medical devices (for example, urinary catheters). If emergency surgery is required, the results of the screening test may not be available. The risk assessment should ensure that appropriate and effective antibiotic prophylaxis is given and that specific transmission-based measures, for example contact precautions, are implemented throughout the patient’s journey through the perioperative area.

Antiseptic preparations for the skin

Although the skin can never be sterilised, immediately before the surgery commences, the skin is normally cleansed with an antiseptic solution. Lister’s pioneering work with antiseptics in this area (Lister 1867) enabled complex and time-consuming surgery to be undertaken with a greatly reduced risk of infection as a postoperative complication (which at the time normally resulted in the death of the patient as no treatments were available).

The purpose of the antiseptic solutions used to prepare the skin surface is to eradicate organisms in skin fissures and crevices that would not easily be removed by using soap and water. Both iodine and chlorhexidine have been found to be effective in reducing skin flora to a level that minimises the risk of infection and each of these antiseptics has historically had its champion groups of users. Iodine has the advantage of tinting the skin, enabling the person applying the solution to check that all areas have been covered, but chlorhexidine has the considerable advantage of having a demonstrably persistent effect, prolonging the effectiveness of the solution. Both are available in either aqueous or alcoholic preparations, although alcohol-based solutions have been the subject of hazard reports when excessive amounts of the solution have been used and allowed to pool underneath the patient, presenting a fire hazard when diathermy is used.

Until relatively recently there has been a lack of robust studies that have looked at the comparative efficacies of iodine and chlorhexidine in reducing infection rates. Dairouiche and colleagues (2010) performed a study of the effectiveness of alcoholic chlorhexidine when compared with aqueous povidone–iodine, reporting findings that demonstrated a significant reduction in the infection rate when the chlorhexidine solution was used. Although this study would have been improved by comparing alcohol-based solutions of both antiseptics, the authors took a pragmatic approach to the study by comparing the most widely used skin preparations in order to improve acceptance of the findings. The study has been considered of sufficient merit to have been included in a number of surgical guidelines, including those produced by the English Department of Health’s ‘Saving Lives’ care bundle programme (Department of Health 1999).

Skin preparation procedures

The area to be covered by the skin preparation should always cover the area of the incision and a significant area around this, ensuring that all of the skin areas exposed when the drapes are applied have been covered. Care should be taken to ensure that any additional or anticipated incisions or sites that may be used for wound drainage are also treated. Solutions should not be allowed to pool or to contaminate other items of equipment, for example tourniquet cuffs, diathermy electrodes or other patient-monitoring equipment.

If the skin is intact, the actual incision site should be prepped first, moving outwards to the other areas. The most contaminated areas should be prepared last. The chosen solution should be in contact with the skin surface for the time period recommended by the manufacturer, as any antiseptic is effective when the correct dilution is used for the correct contact time. All prepped areas should reach the contact time before any drapes are applied.

Preoperative hair removal

Hair removal is occasionally necessary in order to be able to gain unhindered access to the operative field, although it is recognised that sometimes hair is removed because of a perception that it presents an increased risk of infection. Shaving has until recently been the traditional method of hair removal, however this procedure can damage the skin and such injury may cause increased risk of infection by producing microscopic infected abrasions to the skin surface that can become colonised by organisms not ­normally found at the site by the time the operative procedure takes place.

The relative effects of different methods of hair removal have long been described; for example, a seminal study in the 1970s reported an infection rate of 2.3% in shaved patients and a lower rate (1.7%) in patients who had their hair clipped (Cruse and Foord 1973). Patients who were not clipped or shaved had the lowest infection rate of all of the groups under study (0.9%). Prior to that study, others had also reported an infection rate of 5.6% in shaved patients, whereas in unshaved patients or where depilation was used the rate was 0.6% (Seropian and Reynolds 1971).

The timing of hair removal is also significant (Alexander et al. 1983). A lower infection rate has been reported in patients who had hair removal by clipping on the morning of surgery as opposed to the night before both at discharge and 30 days follow-up.

These methods have been subject to a systematic review of the published studies, which concluded that should hair removal be absolutely necessary, clippers are the preferred method (Tanner et al. 2006). Interestingly, even though most guidelines now recommend using chemical hair removal, followed by clipping with a single-use device or clipper head as close to the operation as possible, the NICE Guideline Group (National Collaborating Centre for Women’s and Children’s Health 2008) reported that opportunities for research still remain, as they found no studies that compared clipping with no hair removal or compared clipping with chemical hair removal.

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