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Perioperative use of the hands-free technique: a semistructured interview study

AORN Journal, August, 2006 by Bernadette Stringer, Ted Haines, C.H. Goldsmith, Jennifer Blythe, Kenneth A. Harris

Perioperative personnel who are involved in surgical procedures are exposed to a significant amount of blood and bloody fluids, which may be infected with hepatitis C, hepatitis B, or HIV. Surgical procedures require the use of many sharp instruments, (1) so OR personnel are at an increased risk of sustaining percutaneous injuries, glove tears, and skin and mucous membrane contamination. (2-8)

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Many surgical practices and barriers have been proposed to lessen surgical risk of bloodborne pathogen transmission, but little evidence for their effectiveness exists because most have not been properly evaluated. There is good evidence, however, that using redesigned syringes with retractable needles, (9,10) using blunt-tipped suture needles to close tissue layers below the skin, (11,12) and wearing two pairs of gloves during surgery (13,14) can reduce the risk of percutaneous injury. There is also limited evidence that the hands-free technique (HFT) reduces a health care provider's risk of sharps injury and exposure to bloody fluids. (2)

When the HFT is used, instead of sharp items being passed directly between surgeons, residents, nurses, and other OR personnel, they are laid down in a designated "neutral" or "safe" zone and then retrieved as required (Table 1). This applies to passing scalpels and suture needles, other routinely identified sharp items, and items such as trocars, wires, and sharp bone fragments. Safe or neutral zones can consist of a section of the surgical field, a Mayo stand, a table, or a basin, depending on the size, type, and number of sharp items required during a surgical procedure.

Surgeons and nurses in the United States are gaining experience in implementing the HFT under the Occupational Safety and Health Administration's (OSHA's) standard titled Occupational Exposure to Bloodborne Pathogens; Needlestick and Other Sharps Injuries, which has been in place since 1991 and was further strengthened in 2001.15 Implementing the HFT may reduce the risk of transmission of bloodborne pathogens, so OSHA has begun inspecting hospitals to assess whether the HFT is used routinely to pass sharp items during surgery." The ability to implement the HFT in sections of the surgical field or potentially to use receptacles already present during surgery is a feature that makes use of the HFT particularly attractive. (17)

The primary purpose of the study reported below (ie, one phase of a three-phase study) was to explore the attitudes of Canadian and US surgeons, perioperative nurses, and surgical technologists regarding their use of the HFT. The research approach was qualitative; telephone interviews were conducted with perioperative personnel. During this phase, data also were collected regarding factors that prevent use of the HFT and suggestions were solicited on how to encourage use of the technique during surgical procedures.

LITERATURE REVIEW

The HFT, which is endorsed by many professional and occupational health organizations, (18-22) was shown to be effective in a prospective study of 3,765 surgical procedures that took place in an inner city hospital in the United States. (2) In that study, surgical procedures in which the HFT was used 75% to 100% of the time were compared to surgical procedures in which the HFT was used 50% of the time or less. Data were adjusted for differences in type of surgery, duration, emergency status, and other factors during the comparison. During procedures in which blood loss was 100 mL or more, use of the HFT 75% to 100% of the time resulted in 59% fewer injuries, glove tears, and contaminations (95% confidence interval; range 28% to 77%) when compared to procedures in which the HFT was used 50% of the time or less. (2)

In another randomized, controlled trial evaluating the HFT, use of the HFT did not result in a decrease in glove tears during cesarean sections, (23) but that study had several limitations that included

* randomizing at the level of the surgery,

* not randomizing 14% of eligible cases,

* not confirming compliance with the HFT,

* not providing information on the ability to fit sharp items in the trays allocated for use of the HFT,

* not providing information on the potential underreporting of injuries and contaminations, and

* missing data from 5% of cases.

Randomizing individual surgeries as well as implementing the HFT by using pass trays in intervention surgeries on a procedure-by-procedure basis was not the best method to evaluate the HFT's potential benefits. The study should have used cluster randomization to allocate HFT use to intervention hospitals.

METHODS

Our previous findings of the effectiveness of the HFT provided the impetus for a three-phase, ongoing research project designed to assess whether use of the HFT would reduce the risk of exposure to bloodborne pathogens. The study proposal was approved by the University of Western Ontario, London, Ontario, ethics committee.

PARTICIPANT SELECTION

Using purposeful sampling, we selected 20 health care providers for the study. Those chosen included 11 US and Canadian surgeons, eight perioperative nurses who circulated and scrubbed, and one surgical technologist. These participants represented a broad range of ages, specialties, and views on the use of the HFT. Recruitment was accomplished by e-mail using addresses obtained from the 2003 Canadian Medical Directory and the American College of Surgeons' Committee on Perioperative Care, as well as in person and through OR postings. One surgeon in the group of selected surgeons had previously contracted hepatitis C through an occupational exposure and no longer performed surgical procedures.

Health Care Industry

Perioperative use of the hands-free technique: a semistructured interview study

AORN Journal, August, 2006 by Bernadette Stringer, Ted Haines, C.H. Goldsmith, Jennifer Blythe, Kenneth A. Harris

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