Article
Editorial Note
References
POINT OF CONTACT FOR THIS
DOCUMENT:
Figures
Rate of injury associated with use of curved suture needles ...
Infections
with bloodborne pathogens resulting from exposures to blood through
percutaneous injuries (PIs) (e.g., needlestick injuries and cuts with sharp
objects) are an occupational hazard for health-care workers (HCWs) (1). PIs
have been reported during 1%-15% of surgical procedures, mostly associated with
suturing (1,2). Most suturing is done using curved suture needles, although
straight needles are used by some surgeons for suturing skin. Blunt suture needles
(curved suture needles that have a relatively blunt tip) may be less likely to
cause PIs because they do not easily penetrate skin. Based on small studies and
anecdotal experience, blunt suture needles appear able to replace conventional
curved suture needles for suturing many tissues, although they may require more
pressure to penetrate the tissues (3-6). This report summarizes results of a
study in which CDC collaborated with three teaching hospitals in New York City
during 1993-1994 to evaluate a safety device (a blunt suture needle) in
gynecologic surgery. The findings indicate that use of blunt needles was
associated with statistically significant reductions in PI rates, minimal
clinically apparent adverse effects on patient care, and general acceptance by
gynecologic surgeons in these hospitals. *
Blunt suture needles
(Ethiguard{trademark}, Ethicon, Inc., Somerville, New Jersey) ** were evaluated
as a potential replacement for conventional curved needles in gynecologic
surgery, a specialty in which high PI rates have been reported (2). From March
1993 through June 1994, trained nurse observers at the three hospitals
systematically recorded information about the nature and frequency of all PIs
and the number and type of suture needles used during gynecologic surgical
procedures (laparoscopy and dilation and curettage procedures were excluded
from the study). PIs observed or reported during surgery were confirmed by
inspection of HCWs' hands before they left the operating room. Beginning in
February 1994, hospital investigators replaced conventional curved suture
needles with blunt needles on all gynecologic surgical instrument trays;
however, surgeons retained the option of requesting conventional needles.
During March 1993-June
1994, a total of 1464 gynecologic surgery procedures were observed; of these,
1062 (73%) were performed using only conventional curved needles, 55 (4%) using
only blunt needles, and 347 (24%) using both. Straight needles were used in
addition to curved needles in 104 procedures. Overall, 87 PIs occurred during
84 (6%) of the 1464 procedures; of these, 61 (70%) involved suture needles, and
26 (30%) involved other surgical devices. Of the 61 injuries involving suture
needles, 56 (92%) were associated with conventional curved needles, none with
blunt needles, and five (8%) with straight needles.
The mean number of curved
suture needles used per procedure (24 needles) was constant throughout the
study period. The percentage of blunt needles used during a calendar quarter
increased, from less than 1% to 55% during the study; during April-June 1994,
at least one blunt suture needle was used in 243 (81%) of 299 procedures. The
increase in use of blunt suture needles was temporally associated with a
decrease in PIs from curved suture needles, from 5.9 PIs per 100 procedures (49
PIs among 835 procedures) in 1993 to 1.1 PIs per 100 procedures (seven PIs
among 629 procedures) in 1994 (p less than 0.01) (Figure 1). Rates of PIs with
devices other than curved suture needles remained constant (2.1 PIs per 100
procedures). The rates of PIs associated with use of curved suture needles were
1.9 per 1000 conventional curved suture needles used (56 PIs among 28,880
conventional curved suture needles used) and zero per 1000 blunt suture needles
used (0 PIs among 6139 blunt suture needles used) (p less than 0.01; relative
risk=0.0; 95% confidence interval {CI}=0-0.03). For straight suture needles,
the PI rate was 14.2 PIs per 1000 needles used (five PIs among 351 needles
used).
A logistic regression model
was developed to identify and control for potential risk factors for PI during
a procedure, including type and duration of the procedure, selected aspects of
surgical technique (e.g., using fingers to hold tissue being sutured),
estimated patient blood loss, number and type of curved suture needles used,
status of the primary surgeon (attending or resident), and whether the primary
surgeon had participated in a training program on PI prevention. The model
indicated that the use of blunt needles was protective: for each percentage
point increase in blunt needles used during a procedure, the adjusted odds
ratio for risk of curved suture needle injury was 0.96 (95% CI=0.92-0.98; p
less than 0.01). For example, if the percentage of blunt needles used increased
from 30% to 40%, the odds of a PI with a curved suture needle were reduced by
34% (i.e., 100 X {1-0.9610}). According to the model, the estimated odds of a
PI with a curved suture needle were reduced by 87% when 50% of the suture
needles used during a procedure were blunt.
In 25 (6%) of the 402
procedures during which blunt needles were used, surgeons reported technical
difficulties with the blunt needles, including problems penetrating tissue
(18), tearing of tissue (three), needle slippage (three), and bleeding when the
needle entered the tissue (one). However, none of these were reported to be
clinically important; for procedures performed with and without blunt needles,
mean blood loss was similar (328 cc and 351 cc, respectively; p=0.29), and mean
operative time was similar (102 min and 106 min, respectively; p=0.24). Long-term
complications (e.g., surgical site infections) were not assessed.
Reported by: M Mendelson,
MD, R Sperling, MD, M Brodman, MD, P Dottino, MD, J Morrow, MD, J Solomon, MPH,
Mt. Sinai Medical Center; B Raucher, MD, J Stein, MD, N Roche, MD, A Jacobs,
MD, Beth Israel Medical Center; P Nicholas, MD, I Karmin, MD, B Brown, MD,
Elmhurst Hospital, New York, New York. Hospital Infections Program, National
Center for Infectious Diseases, CDC.
Editorial
Note: The findings in this investigation indicate that in the three
participating hospitals, use of blunt suture needles effectively reduced
suture-related PIs during gynecologic surgical procedures. Smaller studies in
other surgical specialities also concluded that use of blunt suture needles was
not associated with PIs (3-6). Although some tissues cannot tolerate the
increased force required to use a blunt needle, a blunt needle probably could
be substituted for a conventional curved needle in a variety of procedures
(3-6). Blunt suture needles may be particularly useful in preventing PIs during
suturing in a poorly visualized anatomic space -- a situation associated with
increased risks for PI for surgeons and with transmission of hepatitis B virus
from surgeons to patients (7). Blunt needles recently have become available in
a variety of sizes and suture materials; the effectiveness of blunt needles in
reducing PIs suggests that they should be considered for more widespread use in
surgical procedures.
In this study, the PI rate
for straight suture needles was more than seven times the rate associated with
conventional curved needles. Straight needles are used by some surgeons to
close the skin; however, because safer alternatives (e.g., staplers,
conventional curved needles, and possibly blunt needles {6}) are available,
indications and techniques for using straight suture needles should be
reevaluated.
Safety devices designed to
reduce the risk for PI to HCWs should not adversely affect patients. In this
study, no clinically important patient-care complications attributable to blunt
needles were reported by surgeons or suggested based on objective clinical
parameters. One limitation of this assessment was the lack of systematic
long-term follow-up of patients to assess possible delayed complications of
surgery (e.g., surgical-site infections); however, a previously published
report on a small number of patients did not document infections in association
with use of blunt needles (6).
Safety devices must be
acceptable to the HCWs who use them. In this and previous reports, blunt
needles were acceptable to surgeons as replacement for some or all conventional
curved needles in a variety of procedures (3-5). Although specific uses and
limitations of blunt needles require further delineation, the findings of this
report support the use of blunt needles as an effective component of a
PI-prevention program in gynecologic surgery and possibly for other surgical
specialties. The Public Health Service is continuing to evaluate the
implications of these findings, data from a companion report on safety devices
for phlebotomy (8), and other information to assess the need for further
guidance on selection, implementation, and evaluation of safety devices in
health-care settings.
References
To request
a copy of this document or for questions concerning this document, please
contact the person or office listed below. If requesting a document, please
specify the complete name of the document as well as the address to which you
would like it mailed. Note that if a name is listed with the address below, you
may wish to contact this person via CDC WONDER/PC e-mail.
For single issue purchase 800-843-6356
HOSPITAL INFECTIONS PROGRAM
State/Fed Gov: For free copies
write to: CDC, MMWR MS(C-08)
Atlanta, GA 30333