Safety in Office-Based Dermatologic Surgery

Personal protective equipment (PPE) for biological hazards – such as, gloves, gowns, aprons, masks, or protective eyewear (face shields, goggles or glasses) - reduce the risk of exposure to potentially infective materials. This book highlights the risks inherent in dermatological surgery and the various tools used in its practice. The authors provide detailed guidance on best practice to remove or reduce risk and thus this book is an essential reference for anyone involved from dermatologic and cosmetic surgeons through nursing staff and on to clinic administrators. The book is lavishly illustrated to show some of the practical aspects of the subject and is packed with tips and tricks to assist the practitioner reduce risk wherever possible.

• Language: English
• Publisher: Springer
• Release date: Feb 5, 2015
• ISBN: 9783319133478

Book preview

© Springer International Publishing Switzerland 2015

Jacob O. Levitt and Joseph F. Sobanko (eds.)Safety in Office-Based Dermatologic Surgery10.1007/978-3-319-13347-8_1

1. Occupational Exposures: Epidemiology and Protocols

Joseph F. Sobanko¹  

(1)

Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

Joseph F. Sobanko

Email: [e-mail]

Keywords

Occupational exposureNeedle sticksHIVViral loadPost-exposure prophylaxisPEPHealthcare workersHepatitis BHepatitis CPercutaneous injuriesTransmissionContaminatedBloodSplashMucous membraneHollow-bore

Why Is This Information Important?

Up to 800,000 needle sticks occur to healthcare workers in the United States each year [1].

The healthcare workers most susceptible to blood exposure injuries are physicians-intraining (residents), nurses, and medical students [2].

Lack of training, fatigue and the sense of being rushed are frequently reported explanations by physician trainees for being stuck while suturing [3].

One of every ten US health care workers has a needle stick exposure each year [4].

HIV, Hepatitis B and C are the pathogens most likely to be transmitted via an occupational exposure.

Percutaneous injury is the most efficient mechanism of transmission of occupational blood-borne infections (HIV, HCV, HBV).

A person receiving a needle stick with known-HIV contaminated blood has a 0.3–5 % of acquiring the virus [5]. The risk of acquiring HIV through unprotected sexual intercourse is 0.3–3.0 % [5].

The risks of acquiring HBV or HCV through a needle stick are 5–35 and 3–10 %, respectively [6].

40–50 % of suture needle sticks occur while suturing [7, 8].

2/3 of suture needle sticks are self-inflicted [8].

Outpatient procedures most prone to result in an exposure are injection, suturing, and excision [9, 10].

Can Exposures Be Avoided Completely?

Despite the best attempts at prevention, occupational exposures in the form of needle sticks and splashes do occur.

It is essential to be familiar with your office/institution’s individual protocol for reporting such incidents. If you are unfamiliar with the protocol, you must immediately report the incident to your supervisor in the event of an exposure.

Most occupational exposures go unreported – PLEASE REPORT YOUR INJURY.

The action taken after an occupational exposure will often depend on the exposure risk (Table 1.1).

Table 1.1

Features of a high-risk occupational exposure [11]

What Do I Do in the Event of an Occupational Exposure (Fig. 1.1)?

Any employee who receives a stick during a surgical procedure should step out of the field and avoid further contact with the patient to prevent potential transfer of blood-borne pathogen from healthcare worker to patient.

Dispose of the instrument that has punctured the skin (i.e., suture needle, syringe) rather than reintroducing it to the patient.

Those with a needle stick should wash the affected area thoroughly with soap and water as quickly as possible after the exposure [13].

It is not necessary to use alcohol or other caustic agents such as bleach to clean the affected area.

The practice to milk out more blood is controversial and not recommended by the Centers for Disease Control (CDC).

Irrigate splashes to the eyes or mouth with water or saline as quickly as possible after the exposure. Do not use caustic agents such as antiseptics or disinfectants.

Report the exposure immediately [12].

A319561_1_En_1_Fig1_HTML.gif

Fig. 1.1

Four simple steps to follow in the event of an occupational exposure [12]

How Do I Report the Incident (Table 1.2)?

If the source patient is known then the patient should be tested for HIV/HBV/HCV (pending informed consent).

The CDC recommends that if the source patient cannot be tested then the medical diagnoses, clinical symptoms, and history of risky behaviors should contribute to the decision regarding post-exposure prophylaxis (PEP) [12].

When the source patient is not known then the likelihood of high risk exposure must be evaluated and used to guide further action (i.e., community infection rate, demographics of patients seen at site, etc.).

It is not recommended to test the discarded needles for bloodborne pathogens since the reliability of testing is unknown.

Baseline testing of healthcare practitioners should be performed for all occupational exposures.

Those exposed to HIV should receive repeat HIV-antibody testing at 6, 12, and 24 weeks following exposure [14].

Those exposed to HCV should have repeat tests for anti-HCV IgG and liver enzyme (ALT) at least 4–6 months after exposure.

Table 1.2

Necessary information when reporting an occupational exposure

Should I Take Post-Exposure Prophylaxis (PEP)?

HIV

The recommendation to initiate antiretroviral prophylaxis is determined by the factors noted above, in addition to balancing the risk of HIV with the known risks of PEP medications [15].

PEP rapidly loses its effectiveness if delayed. The goal should be to swallow the first pill within the first 24–36 h after exposure. Some reports note that if it is started more than 72 h after exposure then it is not effective [16].

PEP regimens continued for less than 4 weeks are also considered less effective [5].

The specific medication regimen will vary according to each institution. Two-drug regimens appear appropriate for low-risk exposures while three-drug regimens may be recommended for higher-risk exposures. These regimens change as new medications become available and as local resistance patterns change. Keep abreast of what the current recommendations are from Infection Control departments in the health care settings in which you work.

Baseline laboratory studies should be performed (e.g., CBC, CMP, HIV test, Hep C ELISA, Hep B sAg, Hep B sAb) if PEP is initiated.

Nausea and fatigue are the most commonly reported side effects of PEP medications. These symptoms may be relieved with promethazine and loperamide.

If the source patient’s HIV test is determined to be negative then PEP may be discontinued. Although HIV testing can be negative while a person is in the window period between infection and the presence of detectable antibodies against HIV, no case of transmission involving an exposure source during the window period has been reported in the United States.

If a source is known or subsequently determined to be HIV-positive, it is not necessary to perform medication-resistance testing to guide the PEP medication regimen. The most important means of ensuring effective PEP is rapid initiation of the medications.

HBV

Most US healthcare workers have been immunized with the hepatitis B vaccine and, based on vaccine efficacy data, almost all are protected [17].

HCV

Currently, there are no standard recommendations for HCV PEP.

The CDC recommends that exposed healthcare professionals receive appropriate counseling, testing, and follow up.

For seroconverters, pegylated interferon may be effective if started soon after HCV seroconversion or detection of an HCV viral load [18].

Consultation with a hepatologist and infectious disease specialist is advised.

Where Can I Receive Additional Counseling?

Those exposed to blood-borne pathogens should communicate feelings of stress and anxiety to the appropriate supervisors. The regulatory body that administers advice regarding post-exposure management should also be able to provide healthcare workers mental counseling.

Additional resources (as of 2014) regarding post-exposure management and counseling are listed below:

Centers for Disease Control and Prevention (CDC): 1-800-893-0485

National Clinicians’ Postexposure Prophylaxis Hotline (PEPline): 1-888-448-4911 or www.​ucsf.​edu/​hivcntr/​Hotlines/​PEPline.​html

Needlestick!: www.​needlestick.​mednet.​ucla.​edu

Hepatitis Hotline: [phone] or www.​cdc.​gov/​hepatitis

National HIV Telephone Consultation Service: 1-800-933-3413

Immediate Steps If Exposed

Dispose of instrument

Wash site with soap and water // irrigate with saline

Report incident

Test source patient (with informed consent)

Counseling with expert if source patient is unknown

Baseline testing of exposed person

First HIV PEP within 36 h (if applicable)

References

1.

National Institute for Occupational Safety and Health. Preventing Needlestick Injuries in Health Care Settings. (Publication no. 2000-108). 1999. http://​www.​cdc.​gov/​niosh/​docs/​2000-108/​.

2.

Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, Izard D, Triebel J, Khan M, Berger DH. Epidemiology of exposure to blood borne pathogens on a surgical service. Am J Surg. 2006;192:e18–21.PubMedCrossRef

3.

Makary MA, Al-Attar A, Holzmueller CG, et al. Needlestick injuries among surgeons in training. N Engl J Med. 2007;356(26):2693–9.PubMedCrossRef

4.

Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Cardo DM, NaSH Surveillance Group; EPINet Data Sharing Network. Estimate of the annual number of percutaneous injuries among hospital-based healthcare workers in the United States, 1997-1998. Infect Control Hosp Epidemiol. 2004;25(7):556–62.PubMedCrossRef

5.

Tolle MA, Schwarzwald HL. Postexposure prophylaxis against human immunodeficiency virus. Am Fam Physician. 2010;82(2):161–6.PubMed

6.

Doebbeling BN. Percutaneous injury: risks and management. In: Schlossberg D, editor. Current therapy of infectious disease. St. Louis: Mosby-Year Book; 2000. p. 402–7.

7.

Premier, Prevent Needlestick injuries. https://​legacy.​premierinc.​com/​quality-safety/​tools-services/​safety/​topics/​needlestick/​non-acute-care.​jsp. Accessed 20 Dec 2014.

8.

Jagger J, Balon M. Suture needle and scalpel blade injuries. Adv Expo Prev. 1995;1(3):6–9.

9.

Donnelly AF, Chang YH, Nemeth-Ochoa SA. Sharps injuries and reporting practices of U.S. dermatologists. Dermatol Surg. 2013;39(12):1813–21.PubMedCrossRef

10.

Goulart JM, Oliveria SA, Levitt J. Safety during dermatologic procedures and surgeries: a survey of resident injuries and prevention strategies. J Am Acad Dermatol. 2011;65(3):648–50.PubMedCrossRef

11.

Cardo DM, Culver DH, Ciesielski CA. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337(21):1485–90.PubMedCrossRef

12.

CDC. Updated CDC recommendations for the management of hepatitis B virus-infected health-care providers and students. MMWR Recomm Rep. 2012;61(RR-3):1–12.

13.

Henderson DK. Management of needlestick injuries: a house office who has a needlestick. JAMA. 2012;307(1):75–84.PubMedCrossRef

14.

CDC. Introduction to Travel Health & the Yellow Book. Website. http://​wwwnc.​cdc.​gov/​travel/​yellowbook/​2012/​chapter-2-the-pre-travel-consultation/​occupational-exposure-to-hiv.​htm. Accessed 24 Nov 2012.

15.

Henderson DK. HIV in the healthcare setting. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. New York: Elsevier Churchill Livingstone; 2009. p. 3753–70.

16.

CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54(RR09):1–17.

17.

Beekmann SE, Henderson DK. Health care workers and hepatitis: risk for infection and management of exposures. Infect Dis Clin Pract. 1992;1(6):424–8.

18.

Jaeckel E, Cornberg M, Wedemeyer H, et al.; German Acute Hepatitis C Therapy Group. Treatment of acute hepatitis C with interferon alfa-2b. N Engl J Med. 2001;345(20):1452–7.

© Springer International Publishing Switzerland 2015

Jacob O. Levitt and Joseph F. Sobanko (eds.)Safety in Office-Based Dermatologic Surgery10.1007/978-3-319-13347-8_2

2. The Surgical Tray

Joseph F. Sobanko¹  

(1)

Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

Joseph F. Sobanko

Email: [e-mail]

Keywords

Surgical traySharpsNeedlesInjuryNeutral zoneSterileSpongeMagnetSuture boxForcepsClean-upSharps disposal containerPunch biopsyExcisionShave removalSurgical instrumentsSterilitySkin hookNeedle stickSharpGauzeHitchhikeNeedle driverSpongeSuture needle counter boxSafetyScalpelSafety deviceBladeLacerationHemostatRecappingSharps container

Common Safety Pitfalls When Setting Up a Tray

Accidents Happen When

Unstable or inappropriate trays are used, such as those with a broken leg or an improperly secured tray.

Solution

Test the stability of the surgical tray prior to its use.

Accidents Happen When

The wrong equipment is placed on the tray. The surgeon may be tempted to use instruments that are not appropriate for a procedure.

Solution 1

Place the correct instruments on the tray. Assistants should know which instruments go with each procedure. Photo examples may be placed in locations where trays are assembled (Fig. 2.1).

A319561_1_En_2_Fig1a_HTML.jpgA319561_1_En_2_Fig1b_HTML.jpg

Fig. 2.1

Photos of tray setups for common office-based procedures. (Stock bottle and punch trephine wrapper are shown for clarity but should not actually be on the tray). (a) Shave removal. (b) Punch biopsy. (c) Excision

Solution 2

Anticipate special needs of the surgery that call for instruments not routinely placed on the tray (e.g., chalazion clamp for a lip procedure). Have these available on the tray before starting the procedure.

Solution 3

Have pre-arranged packages that contain all of the instruments necessary to perform a particular procedure (i.e., ‘punch biopsy bag’). An identifying label can be placed on the outside of this package to assist with accuracy.

Solution 4

If a surgeon only performs a limited range of procedures, having one generic tray will help with consistency and avoid the confusion of setting up several specialized trays.

Solution 5

Instruments should be catalogued properly