Use of safety scalpels and other safety practices to reduce sharps injury in the operating room: what is the evidence?

BACKGROUND: The occupational hazard associated with percutaneous injury in the operating room (OR) has encouraged harm reduction through behaviour change and the use of safety-engineered surgical sharps. Some Canadian regulatory agencies have mandated the use of "safety scalpels." Our primary objective was to determine whether safety scalpels reduce the risk of percutaneous injury in the OR, while a secondary objective was to evaluate risk reduction associated with other safety practices. METHODS: We used evidence review methods described by the International Liaison Committee on Resuscitation and conducted a systematic, English-language search of Ovid, MEDLINE and EMBASE using the following search terms: "safety-engineered scalpel," "mistake proofing device," "retractable/removable blade/scalpel," "pass tray," "hands free passing," "neutral zone," "sharpless surgery," "double/cutproof gloving" and "blunt suture needles." Included articles were scored according to level of evidence; quality; and whether they were supportive, opposed or neutral to the study question(s). RESULTS: Of 72 included citations, none was supportive of the use of safety scalpels. There was high-level/quality evidence (Cochrane reviews) in support of risk reduction through double-gloving and use of blunt suture needles, with additional evidence supporting a pass tray/neutral zone for sharps handling (4 of 5 articles supportive) and use of suturing adjuncts (1 article supportive). CONCLUSION: There is insufficient evidence to support regulated use of safety scalpels. Injury-reduction strategies should emphasize proven methods, including double-gloving, blunt suture needles and use of hands-free sharps transfer.

CONTEXTE: Les risques professionnels associés aux lésions percutanées subies à la salle d'opération ont favorisé la réduction des préjudices grâce à des changements de comportement et à l'utilisation d'aiguilles et de lames chirurgicales conçues en fonction de la sécurité. Certaines agences de réglementation du Canada ont imposé l'utilisation de « scalpels de sécurité ¼. Nous voulions déterminer principalement si les scalpels de sécurité réduisent le risque de lésions percutanées à la salle d'opération et, dans un deuxième temps, évaluer la réduction du risque associée à d'autres mesures de sécurité. MÉTHODES: Nous avons utilisé des méthodes d'examen des données probantes décrites par le Comité international de liaison sur la réanimation et procédé à une recherche systématique en anglais dans les bases de données Ovid, MEDLINE et EMBASE en utilisant les termes de recherche suivants : « safety-engineered scalpel ¼, « mistake proofing device ¼, « retractable/removable blade/scalpel ¼, « pass tray ¼, « hands free passing ¼, « neutral zone ¼, « sharpless surgery ¼, « double/cutproof gloving ¼ et « blunt suture needles ¼. Nous avons évalué les articles inclus en fonction du niveau de preuve, de la qualité et de la prise de position en faveur des questions à l'étude, contre celles ci ou neutre. RÉSULTANTS: Sur 72 citations incluses, aucune n'appuyait l'utilisation des scalpels de sécurité. Des éléments probants de haut niveau ou de grande qualité (examens Cochrane) appuyaient la réduction des risques par le port de doubles gants et l'utilisation d'aiguilles émoussées, et d'autres éléments de preuve appuyaient l'utilisation d'un plateau de transition ou d'une zone neutre pour la manipulation des aiguilles ou des lames (4 articles sur 5 en faveur) et l'utilisation de moyens auxiliaires de suture (1 article en faveur). CONCLUSIONS: Il n'y a pas suffisamment de preuves pour appuyer l'utilisation réglementée de scalpels de sécurité. Les stratégies de réduction des traumatismes devraient mettre l'accent sur les méthodes éprouvées, y compris le port de doubles gants, l'usage d'aiguilles émoussées et l'utilisation de moyens mains libres de transfert des aiguilles et des lames.

Capacity enhancement of hepatitis C virus treatment through integrated, community-based care.

BACKGROUND: An estimated 250,000 Canadians are infected with the hepatitis C virus (HCV). The present study describes a cohort of individuals with HCV referred to community-based, integrated prevention and care projects developed in British Columbia. Treatment outcomes are reported for a subset of individuals undergoing antiviral therapy at four project sites. METHODS: Four demonstration projects based on a public health nurse and physician partnership were established in rural and small urban centres in British Columbia. Comprehensive medical assessments determined whether individuals received treatment, or counselling and education. Outcomes of the treatment group were compared with published randomized controlled trials. Client demographics were mapped using geographical information systems applications. RESULTS: A total of 1795 individuals were referred to the clinics for medical assessment between September 2001 and December 2005. After assessment, 26% were eligible for therapy, while 74% received counselling and education. Wait times decreased annually, with one-half of all referrals assessed within 30 days. Combination antiviral therapy was initiated in 363 clients with interferon plus ribavirin (n=36) or pegylated interferon plus ribavirin (n=327). Treatment outcomes were available for 205 individuals. The overall rate of sustained virological response was 61% (126 of 205 individuals). The number of individuals assessed at each site represented, on average, 20% of the total cumulative reported HCV cases in the catchment areas. DISCUSSION: The study findings illustrate how a public health nurse and physician partnership can service a population with complex medical needs while simultaneously increasing local capacity. Treatment outcomes were comparable with published clinical trials.

Publicly funded pegylated interferon-alpha treatment in British Columbia: disparities in treatment patterns for people with hepatitis C.

BACKGROUND: An estimated 60,000 British Columbians are chronically infected with the hepatitis C virus (HCV); 10% to 20% will develop cirrhosis after 20 years and 5% to 10% of these will develop hepatocellular carcinoma. Although treatment may prevent cirrhosis and liver cancer, and improve quality of life, availability is limited. METHODS: Individuals with HCV genotypes 1, 4, 5 and 6 who underwent baseline HCV-RNA tests between January 1, 2003 and December 31, 2005, and were eligible for publicly funded treatment through PharmaCare were linked to British Columbia's reportable disease database. Patterns in treatment were examined, including age at treatment, sex, location, time to treatment from HCV diagnosis and seasonality of treatment. RESULTS: When corrected for HCV prevalence, men were more likely to receive treatment than women (RR 1.16, 95% CI 1.02 to 1.31). Patients aged 35 to 54 years and 55 years or older were 3.45 times (95% CI 2.80 to 4.26 times) and 4.49 times (95% CI 3.55 to 5.69 times), respectively, more likely to initiate treatment than 15- to 34-year-olds. Differences were noted between health authorities. Patients in rural health service delivery areas (HSDAs) were 1.25 times (95% CI 1.10 to 1.42 times) more likely to receive treatment than those in urban HSDAs. Patients had an average lapse of four years between HCV diagnosis and receiving treatment. The highest proportion of patients initiated therapy between January and March (36.5%), with the lowest between October and December (less than 14%). CONCLUSIONS: This data linkage enabled us to identify populations less likely to receive publicly funded treatment. Rural HSDAs have higher rates of therapy initiation; this pattern merits further research but may be a result of integrated prevention and care projects in rural areas. Policy changes to the current PharmaCare funding co-payment schedules could reduce seasonal variability of treatment initiations throughout the year.

Harm reduction product distribution in British Columbia.

OBJECTIVES: The British Columbia Centre for Disease Control (BCCDC) tracks the distribution of all harm reduction products subsidized by the BC government, including needles and syringes, sterile water vials, alcohol swabs, condoms, and lubricant. This study measures the distribution of harm reduction products in BC, identifies regional variation in distribution, and estimates the supply/demand ratio for needle and syringe units. METHODS: Using three years of administrative data (2004-2006) from the BCCDC, the quantity of harm reduction products distributed was calculated by Health Service Delivery Area (HSDA). Regional hepatitis C virus (HCV) case report rates were calculated to reflect potential variation in IDU populations at the HSDA-level and the number of needle and syringe units distributed per reported case of HCV was calculated and ranked by HSDA. To compare the demand for sterile injecting equipment to the distribution, the number of illicit drug injections per year was approximated using established estimates of IDU populations in BC and Vancouver. RESULTS: Marked regional variation exists in the rates of harm reduction product distribution per 100,000 residents aged 15-64. The average number of needle and syringe units distributed annually in BC from 2004-2006 was 5,382,933. The estimated number of injections per year in BC is 24,951,144, suggesting the province distributed 21.5% of the units required to cover all illicit drug injections in the province. DISCUSSION: Harm reduction product distribution is not equitable between BC HSDAs. The current level of distribution of sterile injecting equipment is inadequate to provide a clean needle for every injection.