Newspaper report decries needlestick epidemic
Why aren't hospices more attuned to the dangers?
"Deadly Needles," a hard-hitting three-part series of front-page articles that ran in the San Francisco Chronicle in April, detailed the dangers that health care workers face every day from needlestick injuries that could be prevented with the use of existing technology. Yet a number of calls to hospice nurse managers about this issue uncovered a lack of awareness - and, sometimes, a lack of belief - that this is a serious safety issue deserving of industry attention.
Among the sobering statistics marshalled by reporters Reynolds Holding and William Carlsen, based on six months of research: Nearly one million needlestick injuries occur each year in this country. Between 50,000 and 60,000 health care workers have contracted serious infectious diseases from needlesticks in the past decade, including Hepatitis B and C and HIV - which now occurs at a rate of one new health care worker infected per week. Medical workers are four times more likely to die from a job-related injury than police officers.
The report asserts that syringes with simple safety features, costing pennies more to make, have been available for more than a decade. However, "a chilling pattern of indifference and neglect within the nation's medical industry," pushed by an unholy alliance of cost-conscious hospital buying groups, marketing practices by the leading manufacturer, and lax enforcement by the government, has effectively closed over 90% of the market to syringes with the recommended safety features. Instead, health care organizations urge their workers to be more careful.
Although intravenous injection products are less widely utilized in hospice than in other health care settings, their use is growing as more high-technology medicine makes its way into the home. At least three cases of occupationally acquired HIV have occurred in home care or hospice settings, according to the federal Centers for Disease Control and Prevention (CDC). However, it is not known how many hospice workers have suffered needlesticks or contracted serious illnesses from this kind of exposure, which may be at the root of the lack of awareness of this issue.
Hospice professional association representatives and nurse managers contacted for this article say they are not aware that a safety problem exists in this area, but they often do not know whether or not their agencies use the safest technology available. In several cases, they fell back on the conventional arguments of cost and the need for staff to be more careful.
"There truly is an unawareness of the scope of what's happening out there," says Deborah Lage, RN, MS, COHN-S, CHSP, director of occupational health risks for the National Hospice Organization Insurance Agency (NHOIA). "The focus has always been on the nurse's behavior, instead of engineering controls. That has to shift. In any other industry, engineering controls are the No. 1 approach to safety. In health care, they say, 'If you'd just be more careful.' And in the home setting, there are so many uncontrollable factors," Lage says.
"Every time I go out and preach on this issue to hospice managers, they get this deer-in-the-headlights look on their faces. Clinical staff know the risk; it's the upper management that doesn't," she relates. If agencies were to take a closer look at their OSHA report logs, they might get a sense of the magnitude of the problem, but even that won't reflect the number of incidents that go unreported.
Lage relates two recent incidents of needlesticks of nurses employed by NHOIA client hospices in cases where the patient was known to be HIV-positive. Both nurses were started on the CDC's recommended antiviral protocol for exposed health care workers. "Both incidents could have been prevented. One was a clinical practice issue, and the other didn't have a proper sharps container. The bottom line is that there are systems they could have used," she says.
Which costs more - treatment or prevention?
Hospice managers often tell Lage they can't afford equipment with state-of-the-art safety features. "When you think of how much it will cost to treat these individuals, you could buy boxes and boxes of needles," Lage points out. "So it never really makes sense."
NHOIA is now amassing data on needlesticks and obtaining samples of safer syringes from manufacturers (see resource box on p. 77). At least 20 employees of NHOIA hospices have had occupational exposure to blood since the agency began tracking these data, Lage says. Hospices seeking accreditation are likely to face a growing focus on safety issues in this area, as well. "If they are using needles in hospice to inject, to draw blood, or for IV solutions, there are safety devices available to give a high degree of confidence. And the cost of protecting your employees is far outweighed by the cost of treating a long-term chronic disease"caused by occupational exposure, Lage says.
Janine Jagger, MPH, PhD, who was interviewed in the San Francisco Chronicle series, has single-mindedly pursued needle safety since she conducted the first epidemiological study connecting needlestick injuries to medical device design (published in 1988 in the New England Journal of Medicine). In 1992, Jagger founded the Interna tional Health Care Worker Safety Center at the University of Virginia in Charlottesville. The center has developed a computerized surveillance system for needlesticks and other bloodborne pathogen exposures for health care workers, called the Exposure Prevention Information Network (EPINet). EPINet collects and analyzes such data from 70 hospitals.
"A good deal of our work is promoting safer technology so that safety will come to constitute a major part of the marketplace," Jagger says. "One thing I can tell you is that home-based sites including hospice have not been at the forefront of this issue. They're not organized and there are little data - which is why there's less of a focus," she says.>
'Agencies just have to bite the bullet'
"The first thing you need to know is how these injuries are happening. In our data, the three biggest sources are drawing a venous blood sample, intramuscular injections, and finger sticks. We have excellent solutions for all of these," Jagger says. "The cost issues depend on which device we're talking about. When it comes to blood drawing in home care settings, it makes sense to look for the best buy in safety. But I don't think you can begin to justify not having the protective feature right on the device. This is one area where agencies just have to bite the bullet."
Other groups and individuals are also looking at the issues of worker safety and the prevention of needlesticks. The National Campaign for Healthcare Worker Safety in Norristown, PA, was founded by Linda Arnold, RN, BSN, who was infected with HIV by a needlestick in 1992 at the age of 23. This group's "Pledge to Safety" program aims to collect written commitments from every health facility in the country to implement safer blood drawing devices and IV catheters. The first hospital to sign the pledge was the hospital where Arnold worked at the time of her needlestick.
U.S. Rep. Pete Stark (D-CA) introduced H.R. 2754 into Congress last fall, a bill that would require hospitals to provide their employees with "approved and safe hollow bore needle products" or risk losing their eligibility to collect Medicare payments. This bill is supported by the American Nurses Association and the Service Employees International Union, although other observers question whether its definition might be too narrow to allow innovations in technology. In December, a Connecticut jury awarded $12.2 million to a physician who became infected with HIV from a 1988 needlestick injury as she was inserting an IV catheter into a patient with AIDS on an ICU.
"One thing I would encourage your readers to think about is the feasibility of instituting safer needle devices," says Elise M. Handleman, RN, COHN-S, MEd, director of OSHA's Office of Occupational Health Nursing. "There are myriad new technologies out there. The whole issue of needlesticks in home care is worthy of further research."
(Editor's note: Next month, Hospice Management Advisor covers other major infection control issues facing today's hospice workers, and discusses prudent and reasonable infection control policies to minimize these risks, satisfy mandated safety standards, and protect the field's precious human resources. Also, we'll present a round-up of some of the resources available to help hospices shape comprehensive infection control programs.)
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