Christopher Rizk, MD; Holly Monroe, MD; Ida Orengo, MD; Theodore Rosen, MD Department of Dermatology, Baylor College of Medicine, Houston, Texas
Disclosure: The authors report no relevant conflicts of interest
Background: Needlestick and sharps injuries are the leading causes of morbidity in the dermatologic field. Among medical specialties, surgeons and dermatologists have the highest rates of needlestick and sharps injuries. The high rates of needlestick and sharps injuries in dermatology not only apply to physicians, but also to nurses, physician assistants, and technicians in the dermatologic field. Needlestick and sharps injuries are of great concern due to the monetary, opportunity, social, and emotional costs associated with their occurrence. Objective: A review of preventative techniques and post-exposure protocols for the major types of sharps injuries encountered in dermatologic practice. Design: The terms “needle-stick injury,” “sharps injury,” “dermatologic surgery,” “post-exposure prophylaxis,” and “health-care associated injury” were used in combinations to search the PubMed database. Relevant studies were reviewed for validity and included. Results: The authors discuss the major types of sharps injuries that occur in the dermatologic surgery setting and summarize preventative techniques with respect to each type of sharps injury. The authors also summarize and discuss relevant post-exposure protocols in the event of a sharps injury. Conclusion: The adoption of the discussed methods, techniques, practices, and attire can result in the elimination of the vast majority of dermatologic sharps injuries. J Clin Aesthet Dermatol. 2016;9(10):41–49
Needlestick and sharps injuries are the leading causes of morbidity in the dermatologic field. Among all medical specialties, surgeons and dermatologists have the highest rates of needlestick and sharps injuries (NSIs). A recent study showed that up to 65 percent of Mohs surgeons had experienced a NSI within the past year, with five percent of Mohs surgeons having a confirmed exposure to human immunodeficiency virus (HIV), hepatitis C virus (HCV), or hepatitis B virus (HBV). The high rates of NSIs in dermatology not only apply to physicians, but also to nurses, physician assistants, and technicians in the dermatologic field. NSIs are of great concern due to the monetary, opportunity, social, and emotional costs associated with their occurrence. The basic work-up following a NSI can cost upwards of $3000 and can cost exponentially more should transmission of an infectious agent actually occur.
Prior to the enactment of the Needlestick Prevention and Safety Act (NPSA), passed into law on November 6, 2000, the rate of NSIs in the United States was notably high and had been steadily increasing. Among other things, the NPSA required that special safety devices (e.g., safety syringes) be made available to certain healthcare professionals. Some studies show an almost 40-percent reduction in NSIs in 2001, followed by a steady decline in the rate of NSIs since then. However, according to a study by Jagger et al, the passage of the NPSA has only had a significant effect in the nonsurgical setting. Jagger et al showed that although the rate of NSIs in the nonsurgical setting has been reduced by more than 30 percent since 2000, the rate of NSIs in the surgical setting has actually increased by 6.5 percent since the passage of the NPSA. The difference between the two settings was attributed to the diligent adoption of safety devices in the nonsurgical setting and notable lack thereof in the surgical setting.
Although governmental efforts have been made to reduce NSIs in the medical setting, NSIs still remain a chief area of occupational morbidity in the dermatologic field. A recent study reported that the majority of NSIs in the dermatologic setting occur during skin surgery. In the surgical setting, the physician is usually injured while using the sharp object, whereas the nurse or technician is usually injured during passage or disassembly of the sharp. The most common NSIs were caused by suture needles, scalpel blades, and syringes, respectively. This article discusses the main types of needlestick and sharps injuries that occur in the dermatologic surgery setting and will focus on prevention and post-exposure protocols for each type of injury. A summary of strategies to prevent needlestick injuries can be found in Table 1 .
Prevention of Needlestick and Sharps Injuries Preventing suture needle injuries.
Suture needles are the most common cause of NSIs in the surgical setting and most commonly occur to the surgeon while the suture is being used., A study polling dermatologists found that more than 90 percent of NSIs occurring to dermatologists were deemed to be “self-inflicted,” the majority due to “awkward position,” or a “sense of being rushed”. However, a notable percentage of suture needle injuries also occur during passage of the needle driver and in between suture use.
Adopting several basic techniques can reduce or eliminate the majority of self-inflicted suture needle injures. Since “awkward position” was reported as a major cause of NSIs, surgeons should ensure that the surgical table is at an appropriate height and that the surgical tray/instruments are located in a convenient and easily accessible location, thus avoiding unnecessary bending or straining that might lead to a NSI. Many suture needle injuries occur during loading or adjustment of the needle in the needle driver. These injuries can be avoided by employing the “No Touch” technique. As the name implies, the authors recommend that the surgeon not touch the suture needle tip or the scalpel blade with their hands. The surgeon may utilize forceps to load or adjust the needle into the needle driver, thus reducing the need to touch the suture needle., This technique should also be utilized with assembling and disassembling scalpel blades (Figure 1). During suturing, the surgeon’s hands may avoid contacting the patient’s skin; forceps may be used to maneuver the wound margin and surrounding tissue.10 While the suture needle (or any other sharp) is in the surgical field, the assistant should refrain from blotting or cleaning the wound with gauze alone. If the sharp is in the surgical field, the assistant may blot utilizing cotton swabs or gauze grasped by a hemostat. Alternatively, the needle or other sharp may be removed from the surgical field until the assistant is finished blotting or cleaning the wound.
After suturing, if the surgeon does not plan to reuse the suture, the surgeon may either immediately dispose of the suture needle into the sharps disposal container or utilize a suture counter box. Along with preventing needlesticks from loose sutures, suture counter boxes facilitate tracking the number of used sutures and help avoid the need to dispose of each individual suture after use. If immediate disposal of the suture is preferred, the sharps disposal container should be located within arms reach of the surgeon. Large bore, floor-pedal-driven sharps disposal units are available; this avoids the temptation to “push” items into the disposal unit or clear a blocked opening with the hand.
If the surgeon intends on reusing the suture, the authors recommend that the surgeon “disarm” the needle driver and place the needle driver in the neutral zone. The needle driver should be disarmed by using forceps to rotate the needle until the sharp end of the needle faces the junction of the needle driver and is in contact with the side of the needle driver. Caution should be used to avoid grasping the needle tip within the jaws of the needle driver; this may damage the needle driver and lead to blunting of the needle tip (Figure 2). After the needle driver is disarmed, it should be placed in a neutral zone, as hand-to-hand passage of sharp objects should always be avoided.[12–14]
During dermatologic surgery, it is common to end up with several partially used sutures on the surgical tray. The small suture needles commonly used in cutaneous surgery can easily become lost or hidden on cluttered surgical trays. Chrastil et al describe suture “hitch-hiker” injuries that occur when sutures get caught on other instruments or surgical material. These suture “hitch-hiker” injuries can be avoided by utilizing autoclaved magnets or foam blocks to retain the sutures on the tray., Although magnets work well, they may magnetize instruments. Chrastil et al suggest using autoclaved 3cm red foam cubes to contain suture needles and scalpel blades. The foam blocks are small, lightweight, and inexpensive, and thus can be disposed of after a single use.
Preventing syringe needle and scalpel blade injuries.
In contrast to the suture needle, syringe needles and scalpel blades more frequently injure nurses and technicians than surgeons, and most injuries occur during passage of the sharp object. Safety syringes and scalpels are the most effective way to reduce syringe and scalpel NSIs. The adoption of new “safety engineered” syringes and scalpels are responsible for the significant decline in NSIs after the passage of the NPSA., Safety syringes contain two main safety features, the auto-disable feature and the needlestick prevention feature. The auto-disable feature prevents the re-use of syringes by blocking the barrel or cracking the syringe once the plunger is fully depressed. Needlestick prevention mechanisms can be either a protective sheath or a retractable needle. The protective sheaths can be partially engaged to transiently cover the needle for later use or fully engaged, which locks sheath in place if the syringe is ready for disposal. Safety syringes can also have spring-loaded or manually retractable needles that allow the needle to retract once the plunger is fully depressed. Safety scalpels allow the retraction of the scalpel blade into the handle of the scalpel. A study by Wicker et al showed that around one-third of dermatologic NSIs could be avoided by utilizing safety devices alone. The major barrier to implementation of safety devices is the associated cost. However, since the basic work-up for a NSI can cost upwards of $3000, the additional costs of safety devices may be easily justifiable.,
Aside from safety devices, certain precautions can also be taken to reduce the number of NSIs from syringes and scalpels. When utilizing a scalpel or syringe, the surgeon’s or assistant’s hand should not be located in the direction of the applied force. Just as with sutures, if the surgeon is finished using the syringe or scalpel blade, the sharp should be immediately disposed of. If the surgeon plans to reuse the sharp, it should be placed in a neutral zone, avoiding hand-to-hand passage of sharps.[12–14] If a syringe is going to be reused, the surgeon should not recap the needle unless the syringe is being “recapped” with a safety sheath. Although it is preferable to immediately dispose of used syringes and scalpel blades, if it is necessary to reuse them, one may utilize a surgical cup to contain and dispose of uncovered needles and scalpels (reducing NSIs from uncovered needles and blades on the surgical tray) (Figure 3).
A consistent and methodical approach is invaluable in the prevention of NSIs. Even when using surgical cups, foam cubes, or magnets, surgical trays should always be organized in a consistent and logical manner. Uncovered sharps strewn across a tray are a definite way to ensure an eventual NSI (Figure 3). The maintenance of an organized tray and proper sharp passing techniques depend on a well-trained and educated surgical assistant. LoPicollo et al2 showed that there is almost four times the risk of a NSI during Mohs Surgery when the surgical assistant is untrained or has no medical background. Surgeons and their assistants should also wear correctly sized gloves. Oversized gloves can more easily catch sutures or other sharps leading to NSIs. Although several types of puncture-resistant gloves are available, there are concerns over both the added cost and the possible impairment of the surgeons’ dexterity. Although controversial due to potential loss of dexterity, using two sets of gloves (“Double Gloving”) has been shown to significantly reduce NSIs., In situations where constant traction or blotting is needed, cotton-tip applicators (rather than fingers) can be utilized to apply counter-traction or blot the surgical field.
Although transmission rates via mucous membranes (e.g., eyes) are lower than percutaneous injury, surgeons and their assistants should always wear masks and eye protection during dermatologic surgery. Proper foot protection is also essential since NSIs may occur from dropped scalpel blades or loose suture needles. Barr et al  performed a study analyzing the ability of various shoe materials to withstand penetration from dropped scalpel blades during dermatologic surgery. Their study revealed that rubber shoes, shoes with “inner linings,” and boots (steel toe, work, or cowboy) provided the highest levels of protection.
With regards to patients with blood-borne illnesses, it should be noted that increased caution should be employed at all times due to the fact that many infected individuals are asymptomatic and unaware of their infection., However, one may consider the following precautions for patients with known disease. Such patients may be scheduled at select times, such as the last operative intervention of the day, so that the surgeon does not feel rushed to finish the procedure and move on to other waiting patients. Although some practices may consider the routine use of safety devices cost prohibitive, safety devices, such as skin adhesives, should be strongly considered in patients with confirmed blood-borne disease.
Post-Exposure Protocols for Dermatologic NSIs
It should be noted that with every NSI, exposure to blood-borne infections, such as HIV, HBV, and HCV, are of serious concern. In the event of a NSI or any exposure to infectious fluid, it is essential that all healthcare workers report the injury, obtain samples for source testing, and seek proper prophylaxis. Although the high rates of dermatologic NSIs are troubling, of equal concern are the extremely low levels of reporting NSIs among dermatologists. A recent study by Donnelly et al found that around 65 percent of dermatologists indicated having an unreported NSI. Believing that the “patient presented a low risk for a hematologically spread infectious disease” and that the reporting process would take “too much time” were the two most commonly cited reasons for not reporting. This is concerning due to the fact that a significant percentage of individuals infected with HIV or HCV are asymptomatic and unaware of their infection., The lack of reporting not only puts the surgeon at risk of contracting a blood-borne disease (BBD), but also puts the surgeon’s future patients at risk if the surgeon does contract a BBD. Along with immediately reporting the NSI, it is imperative that the source of the NSI be tested for blood-borne diseases in order to guide post-exposure prophylaxis. Samples from the source of the NSI should undergo rapid HIV testing and should be screened for Anti-HCV Ab, and HBsAg (if the healthcare worker does not have confirmed immunity to HBV).
Physicians and other healthcare professionals are at risk of contracting a BBD if an infectious fluid is involved in a percutaneous NSI or if an infectious fluid contacts an open wound or mucous membrane. Although there are many pathogens that can be transmitted via NSIs, those that are of greatest concern are HIV, HCV, and HBV. HIV transmission rates from percutanous injury are around 0.3 percent, while transmission rates from mucous membrane exposure are considerably lower at 0.09 percent.,, HIV transmission rates can increase from 5 to 16 fold in the event of deep injuries, or if the injury follows exposure to an instrument contaminated with visible amounts of blood. Hepatitis transmission rates from percutaneous injury range from 6 to 63 percent and from 0.5 to 10 percent for HBV and HCV, respectively.[27–31] Higher hepatitis or HIV viral loads are associated with 5 to 6 fold higher transmission rates., Transmission rates of HIV, HCV, and HBV also increase with deeper NSIs and when injured with hollow bore needles (versus suture needles).,
In dermatology, the main infectious fluids of concern are blood or blood-contaminated fluids. However, seminal, vaginal, amniotic, cerebrospinal, synovial, pericardial, pleural, and peritoneal fluids may also transmit infectious diseases. Fluids such as saliva, sweat, tears, urine, feces, vomitus, and sputum are generally considered noninfectious (unless they are contaminated with blood). Note that NSI involving desiccated blood on previously used sharps retain an infectious potential. Although the infectivity of HIV and HCV declines within hours, HBV can retain infectivity for several days on sharps contaminated with desiccated blood. Thus a NSI from a sharp of unknown origin (e.g., needle in a trash bag) should be treated as an HIV and hepatitis exposure until proven otherwise.
A summary of post-exposure protocols with regard to HIV, HBV, and HCV can be found in Table 2. Following a NSI, the injured healthcare worker should immediately scrub out of the surgery and wash the injured area with soap and water. Delaying irrigation of the wound and initiation of post-exposure prophylaxis has been associated with higher viral transmission rates. Trying to express blood or fluid from the site of injury or washing the area with stronger antiseptic substances has not been shown to reduce transmission of BBD., Immediately after washing the site with soap and water, the injured healthcare worker should contact either the occupational health office or designated personnel, depending on the occupational setting, in order to obtain source testing and initiate post-exposure protocol. If the NSI occurs after hours, the healthcare worker should report to an emergency room. Mental health services should also be made available to injured personnel, as healthcare workers suffering from NSIs can suffer from anxiety and depression.
If HIV transmission is of concern, a rapid HIV test should be run on a sample from the source of the NSI (results usually available within 30 minutes). If the rapid HIV test is positive or if the source is untestable, the injured healthcare worker should immediately begin post-exposure prophylaxis (PEP).36 Delaying initiation of PEP can increase risk of transmission via reducing the efficacy of the prophylaxis.[37–39] Pregnant healthcare workers should be especially cautious about NSIs since HIV PEP may lead to adverse events during pregnancy., If the risk of HIV transmission cannot be ruled out, the updated 2013 US Public Health Service Guidelines recommend a three-drug PEP regimen consisting of raltegravir 400mg twice a day, tenofovir 300mg, and emtricitabine 200mg. The three-drug PEP should be continued for four weeks, unless risk of HIV transmission has been ruled out. HIV PEP may be associated with severe side effects, leading many healthcare workers to discontinue PEP prior to completion at four weeks. However, it is worth noting that this particular three-drug regimen was selected as the optimal one based on minimization of side effects, drug-drug interactions, and adverse outcomes in pregnancy. When HIV PEP is initiated, renal and hepatic function will be assessed at baseline and again at two weeks. The injured healthcare worker will also be tested for HIV at baseline, six weeks, 12 weeks, and six months post-injury. US Public Health Service guidelines indicate that if combination HIV p24 antigen-HIV antibody tests are utilized, the injured healthcare worker only has to be tested at baseline, six weeks, and at four months. Until HIV transmission has been ruled out, the injured healthcare worker should be advised to avoid pregnancy, breast-feeding, and blood or tissue donation.
If HCV transmission is of concern, the source should be screened for Anti-HCV Ab. Even though HCV prophylaxis is not available, the injured healthcare worker should have a baseline anti-HCV Ab and alanine aminotransferase (ALT) measured. Baseline HCV serologies and liver function tests are obtained to monitor for the current or future development of hepatitis C.,, The injured healthcare worker should then have a repeat anti-HCV Ab and ALT in 4 to 6 months or a HCV RNA in 4 to 6 weeks if earlier diagnosis is desired. In the event of an HCV infection, the healthcare worker should be referred to hepatology and infectious disease for treatment options. Fortunately, there are currently a myriad of highly effective oral regimens for the treatment and cure of most HCV genotypes.
If HBV transmission is of concern, the course of action is dependent on the healthcare worker’s vaccination and protection status. It is recommended that all healthcare workers receive the three-dose HBV vaccination series, followed by post-vaccination serology to confirm a positive response (defined as levels of anti-HBs ?10mIU/mL). If the healthcare worker is vaccinated and has a confirmed positive response, then no further action is required with respect to HBV transmission. If the healthcare worker does not have proof of a positive response or has not been vaccinated, he/she will receive some combination of the HBV vaccine series and the HBV immune globulin, depending on his/her exact situation. In contrast to HIV exposure, sexual and lactation practices should not be altered in the case of exposures to HBV or HCV.
The elimination of NSIs begins with the documentation of how and why NSIs are occurring in each individual dermatologic setting. Once the main types of NSIs have been identified, a focused approach can be taken to eradicate their incidence. Given the frequency and considerable morbidity associated with NSIs, every effort should be made to minimize their occurrence. The adoption of the aforementioned methods, techniques, practices, and attire can result in the elimination of the vast majority of dermatologic NSIs. For additional information regarding preventative techniques, post-exposure algorithms, and the comprehensive evaluation of occupational exposures, one may reference Safety in Office-Based Dermatologic Surgery by Levitt and Sobanko.
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