Continued Non-Compliance with the American College of Surgeons Recommendations To Decrease Infectious Exposure in the Operating Room: Why?

Materials and Methods

This study was performed at a tertiary-care medical center after approval by the Institutional Review Board. The Department of Surgery compromises the Divisions of General Surgery, Surgical Oncology, Urology, Vascular, Trauma/Emergency General Surgery/Surgical Critical Care, Plastic, and Transplant Surgery. In addition, there are departments of neurosurgery, otolaryngology, orthopedics, and cardiovascular surgery. From September through December 2010, an anonymous, voluntary survey (Appendix) was distributed to a convenience sample of surgical staff in the operating room (OR) as well as at multiple surgical conferences in an effort to capture the majority of faculty and residents in all of the subspecialties. The survey collected data on level of training and surgical subspecialty and evaluated the three components of the ACS guidelines individually for awareness of the recommendations, compliance with the recommendations, and reasons for non-compliance. From the 324 surgical staff, 107 surveys were completed, for a response rate of 33%. Of the respondents, 69 (64%) were residents, and 31 (29%) were attending surgeons. The remaining participants were three OR nurses (7%), two fellows (6%), and two others (6%); given the small numbers, these surveys were excluded. The χ² test was used for statistical analysis with SAS version 9.2 (SAS Institute Inc., Cary, NC).

Results

Table 1 summarizes the responses to the questions related to DG. As shown, more attending faculty were aware of the DG recommendation, yet more residents agreed strongly that it decreased the risk of needlestick injury and complied with the recommendation. The majority of both groups strongly agreed that decreased tactile sensation was a significant impediment to DG. None of the differences in the responses of the two groups was a statistically significant difference.

The responses to the HFZ questions are shown in Table 2. Sixty-one percent of all respondents were aware of the recommendations. Although more than one-half of both residents and attending faculty agreed that the use of HFZ reduces needlestick injuries, fewer than 10% of both groups used HFZ more than 75% of the time. Both groups demonstrated some concern that the measure distracts them or breaks concentration and that the OR staff was not trained in HFZ. More residents than faculty believed compliance with the recommendation was encouraged by surgical leadership, although none of the responses concerning HFZ differed statistically between groups.

Table 3 reflects the responses to the BTSN queries. Approximately one-half of the residents and faculty were familiar with the guidelines, with fewer than one-half of both groups agreeing that they reduced percutaneous injuries. Ten percent or fewer of the surgeons used BTSN in 75% or more of their cases. Lack of availability of needles and less-effective closure were listed as reasons for non-compliance.

Discussion

Needlestick injury is a workplace hazard for healthcare providers, particularly surgeons. Doebbling et al. in 2003 surveyed 5,365 healthcare workers (20% of them physicians) regarding blood and body fluid (BBF) exposures [4]. The survey found that 72% of physician BBF exposures were percutaneous. Furthermore, a study that utilized trained circulating nurses to record exposures revealed that 55% of exposures, both percutaneous and mucocutaneous, occurred in surgeons [5,6].

Although these numbers seem high, they more than likely misrepresent the actual experience. Doebbling et al. [4] reported that 62% of physicians underreported blood exposure injuries. The reasons are unclear. Reporting may be seen as an inconvenience or unnecessary. Percutaneous injuries may be seen as “part of the job.” However, the risk of infection with a blood-borne pathogen, along with the potential for long-term disability, is not insignificant. The risk of infection after a percutaneous injury with a hollow needlestick injury is 30% for HBV, 1.5% to 3% for HBC, and 0.3% for HIV [2,3].

Given the risk of infection, risk-reduction measures have been formulated. Beurger and Heller noted that the use of double gloves reduced the risk of blood exposure by 85% when the outer glove was punctured, and that the volume of blood present on a suture was decreased by 95% if it had to pass through both gloves instead of only one [8]. Stringer et al. demonstrated that if HFZ was used >75% of the time, the risk of incidents decreased by 59% [9]. Additionally, during abdominal operations, the use of BTSN resulted in zero injuries per 1,000 needles versus 14.2 for straight needles and 1.9 for curved needles without blunt tips [8].

Despite promotion of evidence-based interventions such as DG, HFZ, and BTSN by the ACS, compliance by surgeons remains poor. Our study suggests that resident and attending surgeons had similar perspectives with respect to the guidelines. Both groups were more familiar with the ACS guidelines for DG and HFZ; however, the self-reported awareness of BTSN was only 50%. Moreover, compliance with the guidelines was poor, with a <30% DG rate and a <10% rate for HFZ and BTSN. Barriers to full implementation of the guidelines were knowledge and training gaps, lack of promotion by surgical leadership, and concerns about decreased tactile sensation with the use of DG. Of note, lack of availability was listed as a reason for non-compliance only with BTSN. This finding is despite the fact that 25% of the rooms at our institution are stocked with blunt-tip needles and the others have a central supply accessible. Improvement of protective supply availability is a simple solution to improve compliance; hence, our institution keeps several types of eye cover and gloves in the ORs to meet the needs of all healthcare providers.

A recent study by Fry et al. addressed the concerns about decreased dexterity and tactile sensation with DG. Fifty-three volunteer surgeons and surgeons-in-training were studied at the Clinical Congress of the ACS using the Purdue Pegboard test and a standard two-point discrimination test to compare no gloves, a single pair of gloves, and double gloves for manual dexterity and tactile sensitivity [10]. Glove status did not affect dexterity performance scores (p=0.57), even after accounting for the influence of age on score variation (p<0.001). In addition, when comparing the ulnar and radial surfaces of the index finger for two-point discrimination, no difference was detected between trials (p=0.66), nor was an interaction effect detected with glove status (p=0.40) [10]. This study provides empiric data to address concerns about compromised dexterity with the adoption of DG. Although this information should improve compliance, changing long-standing practice patterns can be challenging.

The perception of risk by a healthcare worker, particularly the risk of an infectious disease, is a known motivator for compliance with personal protective equipment recommendations [11]. Although exposure to blood-borne pathogens poses a danger to worker safety, the risk of HBV, HCV, or HIV seroconversion remains low. As such, the lack of perceived risk may negatively impact uptake of safety practices in the OR. A recent report on the failure of HIV post-exposure prophylaxis, with resultant seroconversion, should be taken seriously and is a notable reminder of the inherent danger posed by exposure to blood-borne pathogens [12].

Last, hospital culture can affect the uptake of safety practices [13]. A culture in which physician and surgeon practice is unchallenged in favor of healthcare worker autonomy over that of a team focus may stymie safety efforts. In such environments, efforts to change practice, including safety enhancements in an OR, are destined to fail unless the hospital culture is changed.

Although our study is limited by the small number of respondents and performance at a single center, the anonymous voluntary questionnaire minimized bias in survey completion and had an acceptable response rate. Therefore, the findings have value in raising concern about attitudes toward the ACS guidelines and the barriers to implementation. We believe a multimodal approach will be necessary to enhance and promote a culture of healthcare provider safety in the OR.

We suggest that successful implementation will require “buy-in” for and promotion by surgical and hospital leadership, safety education as part of training and certification, and promotion of relevant literature to address concerns related to decreased tactile sensation with DG. To achieve this, educational presentations on surgical safety must be provided to surgical trainees, surgical department chairs, and OR and hospital leadership. Preoperative checklists have been successful in improving patient outcomes [14]. We propose that enhanced preoperative checklists be employed as adjuncts to safety in the OR. These checklists would include reference to DG, HFZ, and BTSN use in all surgical procedures. In this fashion, surgeons would be required to opt out of surgical safety measures, likely improving adherence. Additionally, elective operations could be stopped if surgical team members felt unsafe because of the lack of utilization of these guidelines. Last, institutional policy changes may be required, mandating the adoption of these policies in all ORs. For maximal compliance, hospitals will need to provide suitable and preferable materials (gloves, blunt suture needles) so that surgeons will be more willing to comply with safe practices guidelines.