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JACS CME-1 featured articles, volume 199, September 2004
CONTINUING MEDICAL EDUCATION PROGRAM JACS CME-1 FEATURED ARTICLES, VOLUME 199, SEPTEMBER 2004 Preventing sharps injuries in the operating room Berguer R, Heller PJ J Am Coll Surg 2004;199:462–467 Pedestrians injured by automobiles: Relationship of age to injury type and severity Demetriades D, Murray J, Martin M, et al J Am Coll Surg 2004;199:382–387
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are:
Earn 1 CME Credit by Fax
Earn 2 CME Credits Online
Based on 2 articles in this issue (see next page), complete information below and fax to 312/202-5027 (Fax only, no mail submissions)
Log on to JACS CME Web site:
Preventing sharps injuries in the operating room. Berguer R, Heller PJ Pedestrians injured by automobiles: Relationship of age to injury type and severity. Demetriades D, Murray J, Martin M, et al Frozen section analyses as predictors of lymphatic spread in patients with early stage uterine cancer. Frumovitz M, Slomovitz BM, Singh DK, et al Survival after lower extremity amputation. Sandnes DK, Sobel M, Flum DR
http://jacscme.facs.org
Name: ACS Fellow ID# Your fax number: ANSWERS: Article 1 Article 2 Question 1 Question 1 Question 2 Question 2
© 2004 by the American College of Surgeons Published by Elsevier Inc.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
520
ISSN 1072-7515/04/$30.00 doi:10.1016/j.amcollsurg.2004.06.012
Vol. 199, No. 3, September 2004
Preventing sharps injuries in the operating room R Berguer, Heller PJ J Am Coll Surg 2004;199:462–467 Learning Objectives: After study of this article, surgeons should understand how and when needle sticks occur in the operating room (OR), and the scientific basis for the three prevention strategies presented. Question 1 Needle sticks to OR personnel a) occur most commonly with curved suture needles during fascial closure. b) can always be prevented by the “neutral zone technique.” c) are frequently caused by hollow-bore needles. d) most often injure the scrub nurse. e) are less likely to occur with straight suture needles. Critique: The skin or mucous membranes of OR personnel may have contact with patient blood in as many as 50% of operations, and cuts or needle sticks may occur in as many as 15% of operations. The risk increases with longer, more invasive, higher blood loss procedures. Surgeons and first assistants are at highest risk for injury. Scrub nurses and scrub technicians sustain the second highest frequency of injuries in the OR, followed by anesthesiologists and circulating nurses. Suture needles are the most frequent source of injury. Interestingly, while the largest number of injuries occurs with curved suture needles, straight suture needle use has a significantly higher rate of injuries per number of needles used. Many suture needle injuries occur during wound closure. Up to 16% of injuries occur while passing sharp instruments hand to hand. Most injuries are selfinflicted but a significant number, perhaps as many as 24%, are inflicted by a coworker. The most common body part injured is the nondominant hand. Question 2 Prevention of needle sticks to operating room personnel a) can be achieved by the use of universal precautions. b) is significantly reduced by the use of blunt suture needles. c) can be entirely achieved by the use of the “neutral zone” or hands-free technique. d) is not important in long operations with higher blood loss. e) is unaffected by using double gloves.
Continuing Medical Education Program
521
Critique: Glove perforation rates as high as 61% for thoracic surgeons and 40% for scrub nurses have been reported. Intraoperative glove perforation is not detected by the surgeon in as many as 83% of cases. While puncture of the outer glove is common, corresponding punctures of both the inner and outer gloves are rare. Double gloving reduces the risk of exposure to patient blood by as much as 87% when the outer glove is punctured. Additionally, the volume of blood on a solid suture needle is reduced as much as 95% when passing through two glove layers, thereby reducing the viral load in the event of a contaminated percutaneous injury. The neutral zone is “a previously agreed upon location on the field where sharps are placed from which the surgeon or scrub can retrieve them. Therefore, hand-to-hand passing of sharps is limited.” The use of the neutral zone to transfer sharps, otherwise known as the hands-free technique (HFT), has been proposed to reduce healthcare workers’ exposure to blood during surgery. There are very limited data regarding the efficacy of the HFT in reducing sharps injuries in the operating room. The use of HFT is recommended by several leading professional organizations and by many hospitals as a safety measure to reduce sharps injuries during surgery. Despite this recommendation, its use is not widespread (42% in the Stringer study), and its effectiveness in reducing sharps injuries is unproven. As many as 59% of suture needle injuries occur during suturing of muscle and fascia with curved suture needles. The use of blunt suture needles has been proposed and studied in four prospective randomized trials and several case series. All studies support the safety and usability of blunt suture needles and provide compelling published evidence to support the routine use of blunt suture needles in order to eliminate needle stick injuries during the closure of fascia and muscle. Pedestrians injured by automobiles: Relationship of age to injury type and severity Demetriades D, Murray J, Martin M, et al J Am Coll Surg 2004;199:382–387 Learning Objectives: After study of this article the surgeon will understand the effect of age on the type, injury severity, and survival outcomes on pedestrians injured by automobiles. Question 1 After pedestrians are injured by autos: a) The incidence of severe head trauma is not affected by age.
522
Continuing Medical Education Program
b) Pediatric victims are more likely to suffer severe trauma than elderly victims. c) Pediatric victims are more likely to suffer severe chest trauma than elderly victims. d) The incidence of spinal trauma is not affected by age. e) Pediatric victims are more likely to suffer femur fractures than elderly patients. Critique Age has a major impact on the type and severity of injuries after pedestrians are injured by autos. Older victims are significantly more likely to suffer severe trauma (Injury Severity Score ⬎15) than are pediatric victims (ⱕ14 years). Older victims are significantly more likely to suffer severe head or chest or abdominal trauma (Abbreviated Injury Score ⬎ 3) trauma than are pediatric victims. Similarly, older people are significantly more likely to suffer spinal fractures. Children are significantly more likely to suffer fractures of the femur. Question 2 When pedestrians are injured by autos: a) the most common body area with severe injury is the abdomen.
J Am Coll Surg
b) severe head trauma occurs in about 10% of all victims and increases with age. c) epidural hematoma is the most common intracranial pathology. d) the thoracic spine is the most commonly injured part of the spine. e) aortic rupture occurs in about 10% of victims. Critique: The most common body area with severe trauma is the head (about 10% of all cases, increasing to about 25% in the age group ⬎65 years). Severe chest trauma occurs in about 3% and severe abdominal trauma in about 2% of all cases. Epidural hematoma is the least common type of intracranial hemorrhage and is diagnosed in only 1% of all cases. Subarachnoid hemorrhage is the most common bleed (overall incidence about 5%), followed by subdural hematomas (about 3% of patients). Spinal injuries were evenly distributed among the cervical, thoracic, and lumbar spine. Rupture of the thoracic aorta is rare and is diagnosed in 0.3% of patients reaching hospital care.
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in the JACS CME program should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. Objectives are stated at the beginning of each featured article; the questions follow with five response choices, and a critique discussing the objective. The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The JACS CME program fulfills the ACCME essentials. The American College of Surgeons designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/ she actually spent in the educational activity.
You can earn two CME credits using JACS CME Online, at http://jacscme.facs.org, or you can earn one CME credit if you submit this page by fax (see instructions in box below). JACS CME Online provides four articles from each issue for two credits per month. The articles this month on JACS CME Online are:
Earn 1 CME Credit by Fax
Earn 2 CME Credits Online
Based on 2 articles in this issue (see next page), complete information below and fax to 312/202-5027 (Fax only, no mail submissions)
Log on to JACS CME Web site:
Preventing sharps injuries in the operating room. Berguer R, Heller PJ Pedestrians injured by automobiles: Relationship of age to injury type and severity. Demetriades D, Murray J, Martin M, et al Frozen section analyses as predictors of lymphatic spread in patients with early stage uterine cancer. Frumovitz M, Slomovitz BM, Singh DK, et al Survival after lower extremity amputation. Sandnes DK, Sobel M, Flum DR
http://jacscme.facs.org
Name: ACS Fellow ID# Your fax number: ANSWERS: Article 1 Article 2 Question 1 Question 1 Question 2 Question 2
© 2004 by the American College of Surgeons Published by Elsevier Inc.
Questions: Wendy Cowles Husser, MA, MPA Executive Editor, JACS 633 N Saint Clair Street, Chicago, IL 60611 312-202-5306 (ph) 312-202-5027 (fax) [email protected]
520
ISSN 1072-7515/04/$30.00 doi:10.1016/j.amcollsurg.2004.06.012
Vol. 199, No. 3, September 2004
Preventing sharps injuries in the operating room R Berguer, Heller PJ J Am Coll Surg 2004;199:462–467 Learning Objectives: After study of this article, surgeons should understand how and when needle sticks occur in the operating room (OR), and the scientific basis for the three prevention strategies presented. Question 1 Needle sticks to OR personnel a) occur most commonly with curved suture needles during fascial closure. b) can always be prevented by the “neutral zone technique.” c) are frequently caused by hollow-bore needles. d) most often injure the scrub nurse. e) are less likely to occur with straight suture needles. Critique: The skin or mucous membranes of OR personnel may have contact with patient blood in as many as 50% of operations, and cuts or needle sticks may occur in as many as 15% of operations. The risk increases with longer, more invasive, higher blood loss procedures. Surgeons and first assistants are at highest risk for injury. Scrub nurses and scrub technicians sustain the second highest frequency of injuries in the OR, followed by anesthesiologists and circulating nurses. Suture needles are the most frequent source of injury. Interestingly, while the largest number of injuries occurs with curved suture needles, straight suture needle use has a significantly higher rate of injuries per number of needles used. Many suture needle injuries occur during wound closure. Up to 16% of injuries occur while passing sharp instruments hand to hand. Most injuries are selfinflicted but a significant number, perhaps as many as 24%, are inflicted by a coworker. The most common body part injured is the nondominant hand. Question 2 Prevention of needle sticks to operating room personnel a) can be achieved by the use of universal precautions. b) is significantly reduced by the use of blunt suture needles. c) can be entirely achieved by the use of the “neutral zone” or hands-free technique. d) is not important in long operations with higher blood loss. e) is unaffected by using double gloves.
Continuing Medical Education Program
521
Critique: Glove perforation rates as high as 61% for thoracic surgeons and 40% for scrub nurses have been reported. Intraoperative glove perforation is not detected by the surgeon in as many as 83% of cases. While puncture of the outer glove is common, corresponding punctures of both the inner and outer gloves are rare. Double gloving reduces the risk of exposure to patient blood by as much as 87% when the outer glove is punctured. Additionally, the volume of blood on a solid suture needle is reduced as much as 95% when passing through two glove layers, thereby reducing the viral load in the event of a contaminated percutaneous injury. The neutral zone is “a previously agreed upon location on the field where sharps are placed from which the surgeon or scrub can retrieve them. Therefore, hand-to-hand passing of sharps is limited.” The use of the neutral zone to transfer sharps, otherwise known as the hands-free technique (HFT), has been proposed to reduce healthcare workers’ exposure to blood during surgery. There are very limited data regarding the efficacy of the HFT in reducing sharps injuries in the operating room. The use of HFT is recommended by several leading professional organizations and by many hospitals as a safety measure to reduce sharps injuries during surgery. Despite this recommendation, its use is not widespread (42% in the Stringer study), and its effectiveness in reducing sharps injuries is unproven. As many as 59% of suture needle injuries occur during suturing of muscle and fascia with curved suture needles. The use of blunt suture needles has been proposed and studied in four prospective randomized trials and several case series. All studies support the safety and usability of blunt suture needles and provide compelling published evidence to support the routine use of blunt suture needles in order to eliminate needle stick injuries during the closure of fascia and muscle. Pedestrians injured by automobiles: Relationship of age to injury type and severity Demetriades D, Murray J, Martin M, et al J Am Coll Surg 2004;199:382–387 Learning Objectives: After study of this article the surgeon will understand the effect of age on the type, injury severity, and survival outcomes on pedestrians injured by automobiles. Question 1 After pedestrians are injured by autos: a) The incidence of severe head trauma is not affected by age.
522
Continuing Medical Education Program
b) Pediatric victims are more likely to suffer severe trauma than elderly victims. c) Pediatric victims are more likely to suffer severe chest trauma than elderly victims. d) The incidence of spinal trauma is not affected by age. e) Pediatric victims are more likely to suffer femur fractures than elderly patients. Critique Age has a major impact on the type and severity of injuries after pedestrians are injured by autos. Older victims are significantly more likely to suffer severe trauma (Injury Severity Score ⬎15) than are pediatric victims (ⱕ14 years). Older victims are significantly more likely to suffer severe head or chest or abdominal trauma (Abbreviated Injury Score ⬎ 3) trauma than are pediatric victims. Similarly, older people are significantly more likely to suffer spinal fractures. Children are significantly more likely to suffer fractures of the femur. Question 2 When pedestrians are injured by autos: a) the most common body area with severe injury is the abdomen.
J Am Coll Surg
b) severe head trauma occurs in about 10% of all victims and increases with age. c) epidural hematoma is the most common intracranial pathology. d) the thoracic spine is the most commonly injured part of the spine. e) aortic rupture occurs in about 10% of victims. Critique: The most common body area with severe trauma is the head (about 10% of all cases, increasing to about 25% in the age group ⬎65 years). Severe chest trauma occurs in about 3% and severe abdominal trauma in about 2% of all cases. Epidural hematoma is the least common type of intracranial hemorrhage and is diagnosed in only 1% of all cases. Subarachnoid hemorrhage is the most common bleed (overall incidence about 5%), followed by subdural hematomas (about 3% of patients). Spinal injuries were evenly distributed among the cervical, thoracic, and lumbar spine. Rupture of the thoracic aorta is rare and is diagnosed in 0.3% of patients reaching hospital care.