Needle-stick injuries; coronary artery bypass; dressings; retained objects – Evidence For Practice
George Allen
Predictors of needle-stick injuries in nurses
American Journal of Infection Control, June 2002
Despite passage of the Needle-stick Safety and Prevention Act, needle-stick injuries continue to be a topic of profound concern in health care settings. This study examined nurse characteristics, specific types of protective equipment, staffing, and organizational climate in relation to the risk for needle-stick injuries and near misses. (1)
Questionnaires with pre-stamped return envelopes were distributed to 4,085 RNs in 22 hospitals. Questions elicited information on compliance with universal precautions and perception of risk of transmitting bloodborne pathogens. Nurse characteristics, nature of work, perceived risk factors, protective equipment, nurse staffing, and organizational climate (ie, administrative support for nurses, average nurse experience) were assessed. Descriptive methods were used to analyze self-reported compliance with universal precautions, perceptions about bloodborne pathogens, exposure risk, and injury experience. Logistic regression modeling was used to estimate the odds of needle-stick injuries and near misses associated with various factors.
Findings. The majority (85.2%) of nurses reported complying with universal precautions and always wearing gloves in situations in which contact with body fluids was possible. Rushing (48%), uncooperative patients (40%), and carelessness of physicians (26%) were reported as factors that most frequently pose a risk of injury. A large majority (94%) of nurses reported that their hospitals had done a good job of providing education, safety supplies, and equipment. Almost half (48%) reported having sustained a needle-stick injury at least once in their career, and 23.2% reported a near miss in the past month. The likelihood of nurses reporting that they never had sustained an injury varied inversely with years of experience; however, the risk of injury in the recent past was low. Nurses with more experience were less likely to have sustained an injury in the previous year ([X.sup.2.sub.3], = 7.75, P = .05).
Clinical implications. This study provides evidence that safety equipment may help reduce the occurrence of needle-stick injuries; however, it points out that staffing levels and working climate are significant factors in nurses’ risk of sustaining sharps injuries. Perioperative managers should assess staffing levels periodically in regard to their relationship to exposure incidents.
Competing on- and off-pump coronary artery bypass surgery
The New England Journal of Medicine, Jan 30, 2003
Coronary artery bypass grafting (CABG) is a surgical procedure that restores blood flow to the heart beyond a blocked coronary artery, and it substantially improves symptoms in most patients. An on-pump procedure with a nonbeating heart provides a surgical field free of motion and allows for safe anastomoses. The on-pump procedure employs cardiac stabilizers and only immobilizes targeted areas of the beating heart.
This randomized, multicenter study compared the cardiac outcome and cost effectiveness of on-and off-pump CABG one year after the procedure. (2) Two hundred eighty-one patients from three centers were randomized into groups, with 139 patients in the on-pump group and 142 in the off-pump group. Cardiac outcome, including death, stroke, myocardial infarction, and repeated revascularization, was determined one year after the procedure. The cost: effectiveness ratio was calculated and evaluated using the bootstrap method.
Findings, Off-pump surgery was found to be more effective. At one year, the total direct costs for on-pump surgery were 14.1% higher than for off-pump surgery. No statistically significant difference in death, myocardial infarction, and coronary revascularization rates was found between the two groups (P = .48).
Clinical implications. Perioperative nursing managers and staff members must be prepared to effectively participate in the health care and management of patients, regardless of which surgical procedure is used. Educating personnel in both on- and off-pump procedures is paramount.
Occlusive wrap dressings reduce infection rate
Annals of Thoracic Surgery, January 2003
The prevention of surgical site infection (SSI) is a high priority because of the high cost associated with it. Surgical site infection after harvest of saphenous veins for CABG is a significant problem. The purpose of this randomized study was to determine whether an occlusive wrap dressing was more effective in reducing SSI than a standard longitudinal dressing. (3) One hundred fifty-two patients were assigned randomly to either an occlusive wrap dressing group (ie, 72 patients) or a standard dressing group (ie, 78 patients). The researchers did not account for two patients; thus, data on 150 patients were analyzed. Development of SSI was assessed up to six weeks postoperatively. Multivariate analysis techniques were used to elicit predictors of infection.
Findings. The study showed that occlusive wrap dressings were superior. The infection rate for patients in the occlusive wrap group was 14% compared to 35% for patients in the standard group (P = .006). Analysis revealed that the use of occlusive wrap dressings was the only significant independent negative predictor of infection (odds ratio = 0.19; P = .001).
Clinical implications. This appears to be a simple intervention that potentially can affect saphenous vein harvest SSI rates positively. It also potentially can affect which dressings are used for radial artery harvest sites. Perioperative staff members should be prepared to evaluate the type of dressing used at their institutions.
Retained instruments and sponges
The New England Journal of Medicine, Jan 16, 2003
Leaving instruments and sponges in patients after surgery, although uncommon, is a serious medical error. A retrospective, case-control study was conducted to identify risk factors for this type of error. (4) Malpractice claims and incident reports involving retained instruments and sponges were reviewed to identify cases. Cases from 10 hospitals were matched with controls (ie, patients who had undergone the same type of procedure during the same six-month period). Every case was matched with approximately four randomly selected controls. Univariate and multivariate conditional regression modeling procedures were used to analyze the data.
Findings. Sixty-one retained foreign bodies were identified. Sixty-nine percent were sponges, and 31% were instruments. Sixty-nine percent of patients in whom a foreign body was left required reoperation, and 22% had small bowel fistulae, obstructions, or visceral perforations. Significant risk factors identified were emergency procedures (risk ratio 8.8, 95% confidence interval, 2.4 to 31.9), unexpected changes in surgical procedure (risk ratio 4.1, 95% confidence interval, 1.4 to 12.4), and obesity determined by body mass index (risk ratio for each one-unit increment 1.1, 95% confidence interval, 1.0 to 1.2).
Clinical implications. Retention of a foreign body was nine times more likely to occur during emergency surgery and four times more likely to occur when surgery involved an unplanned change in procedure, which suggests that perioperative managers should focus on these areas. As recommended by the researchers, consideration should be given to radiographic screening in these situations. Additionally, procedures must be evaluated to facilitate compliance with existing standards of counting sponges and instruments in every procedure involving an open cavity.
NOTES
(1.) S P Clarke et al, “Organizational climate, staffing, and safety equipment as predictors of needlestick injuries and near-misses in hospital nurses,” American Journal of Infection Control 30 (June 2002) 207-216.
(2.) H M Nathoe et al, “A comparison of on-pump and off-pump coronary bypass surgery in low-risk patients,” The New England Journal of Medicine 348 (Jan 30, 2003) 394-402.
(3.) F L Rosenfeldt et al, “Occlusive wrap dressing reduces infection rate in saphenous vein harvest site,” Annals of Thoracic Surgery 75 (January 2003) 101-105.
(4.) A A Gawande et al, “Risk factors for retained instruments and sponges after surgery,” The New England Journal of Medicine 348 (Jan 16, 2003) 229-235.
This information is intended for general use only. The clinical implications ore specific to the abstracted article only. Those intending to put these findings into practice ore strongly encouraged to review the original article to determine its applicability to their setting.
COPYRIGHT 2003 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group
