Special Report: Frontline HCWs
Advocates hail 'political momentum' in renewing calls for needle safety
HIV-infected worker: 'I needed to have a different device in my hands'
Buoyed by increasing interest in needle safety devices on the part of legislators, regulatory agencies, and accrediting bodies, health care safety advocates say it's time to end the "moral outrage" of preventable needlestick infections felling front-line workers.
Such calls for action - given an emotional edge by firsthand accounts of workers occupationally infected with bloodborne pathogens - became the prevailing theme at the recent Frontline Healthcare Workers conference in Washington, DC.
"Seize the day," said Mary Foley, RN, MS, vice president of the American Nurses Association. "Now is our time. There is attention to our issues. It has gone public. It is not just us talking to each other."
The sense of urgency was echoed by Betty Bednarczyk, secretary-treasurer of the Service Employees International Union, which represents some 600,000 health care workers.
"We must act - each of us today - to put an end to this moral outrage," she told conference attendees.
The remarks were made in light of a growing number of state and federal initiatives to mandate needle safety devices designed to protect health care workers by blunting or shielding used needles. Occupational Safety and Health Administration Secretary Charles Jeffress opened the two-day conference Aug. 10 with an announcement that the agency will reopen the needle safety question by soliciting information that could lead to new regulatory action or additional requirements under the 1991 bloodborne pathogen standard. (See Hospital Infection Control, September 1998, pp. 130-133.) As this issue of HIC went to press, OSHA officials were hopeful that a "Request for Information" notice would be published in the Federal Register sometime in September.
In another development discussed at the conference, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has formed an "educational partnership" with OSHA to place a greater emphasis on worker safety issues, says Carole Patterson, RN, MN, associate director of standards at the Joint Commission.
"We came down on the side of this being an educational initiative because the Joint Commission cannot survey for OSHA," she told conference attendees. "They cannot give away that congressional authority. But we certainly can educate the field and educate our surveyors."
In addition, the Joint Commission's Committee on Healthcare Safety has identified needlestick prevention as an issue that needs to be addressed somewhere in the accreditation standards, possibly under the infection control component, said Patterson. However, any recommendation by that committee for increased emphasis on needle safety equipment, for example, still would have to go before the commission's professional and technical advisory committees, she explained.
Mandates shouldn't override judgment
While welcoming the "political momentum" building around the issue, Foley said the push for needle safety should not result in regulatory authorities making medical decisions that must be made by clinicians.
"I do not want legislatures mandating which device I use," she said. "I don't want a legislator or a regulator mandating exactly how I would use it. But I do want them - within their authority - to mandate that a safer device be used."
In that regard, OSHA did not specifically require replacing conventional sharps with needle safety devices in its bloodborne pathogen standard, though it did list "self-sheathing needles" as an example of an engineering control. OSHA distributed a needlestick pamphlet at the meeting essentially clarifying that it did not currently require the devices but encouraged their use. (See related story, p. 148.) The new OSHA initiative to seek more information on the issue could result in "a higher standard of what is possible" under the agency's bloodborne pathogen standard if all interested parties work together on the issue, Foley said.
"The unions have to work with the professional organizations," she said. "The infection control experts need to work with the workers and realize we are all in this together. We have been asked our input. We need to provide that."
Health care workers intuitively try to protect others, Foley said, adding that she has seen nursing students even try to recap needles with protective designs if they think someone else may be at risk of being injured.
"It does teach us that the goal really needs to be as passive a device as possible," she said, "one that will activate as quickly as possible and will take the least amount of worker thought and worker involvement."
Indeed, there is sufficient clinical evidence to require some of the safety devices currently on the market, argued Bednarczyk.
"The technology is not some dream of the future," she said. "Life-saving safer needles exist today. But we have big corporations that make needles that won't aggressively market their safer products or develop the best designs, hospitals that won't buy or even evaluate them, and regulatory agencies that - to be blunt - basically look the other way. Therefore, we have health care workers who die. . . . The solution is simple: Except in cases where the old needles are medically necessary, the manufacturers must stop producing needles that kill. Hospitals must stop buying them and the government must ban them."
Though empathetic to the point of sharing his own needlestick story, former U.S. Surgeon General C. Everett Koop underscored the complex nature of the problem in a keynote address delivered via video.
"While it seems that protecting health care workers from bloodborne diseases should be a cause that everyone can embrace, it is not that easy," he said. "The right strategy must be matched with the specific risk, procedure, device, and health care setting in order to be effective. . . . Safety devices must be made available to all that need them, [but] not all needlestick injuries are equally hazardous. The CDC and others have struggled to define relative risk and focus on prevention of the sharps injuries that pose the highest risk."
Urging the disparate forces - frontline workers, manufacturers, and hospital officials - to seek "common ground" on the issue, Koop described a firsthand experience with sharps injury that occurred during a surgical procedure in his clinical practice.
"I well remember the day I had difficulty getting a large curved needle through the sternum as I was closing the chest after a thoracic procedure," he said. "Suddenly the needle did penetrate the bone - as it should - but it also went right through the palm of my hand as well. Six weeks later I was jaundiced and had hepatitis."
While warning of the complex nature of the problem, Koop conceded that data from various studies indicate that as many as 90% of all sharp object injuries are preventable with the procedures, technologies, and safety devices that exist in the health care workplace today.
"Think about this comparison: A vaccine intervention 90% effective in preventing disease transmission would be considered highly effective," he said. "But the key to a successful immunization program is access and implementation - getting the vaccine to the folks who need it most. The same is true for percutaneous injury prevention. How do we improve the implementation of procedures and technologies that we already know will be highly effective in preventing occupational bloodborne pathogen exposures?"
'Something needs to happen'
Much of the logjam surrounding this issue could be broken up if hospital administrators were convinced of the need for the devices, said Janine Jagger, PhD, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville, VA.
"If the hospital administrators decided today that they wanted their institutions to have the best protective technology, tomorrow we would have a massive improvement in this situation," she said.
In that regard, Lynda Arnold, RN, founder and president of the National Campaign for Health Care Worker Safety, reported that some 600 hospital administration officials have signed her pledge to implement needle safety-designed intravenous catheters and blood-drawing devices. Approximately 1,000 other hospitals view the campaign in a favorable light but have not signed the pledge on advice from legal counsel, she told conference attendees.
Arnold began the campaign after contracting HIV from a needlestick in 1992 when she was an intensive care unit nurse in a small community hospital in rural Pennsylvania. The accident occurred when she was starting an IV line on an emergency patient, who moved suddenly as she was retracting the needle, forcing it directly into her left palm. The hospital switched about six months later - shortly before she seroconverted for HIV - to an IV safety catheter design that could have prevented her injury, Arnold explained.
"There was nothing individually I could have done differently that day," she said. "I needed to have a different type of device in my hands."
Cautiously optimistic about her health, Arnold cited the effectiveness of a "protease inhibitor combination cocktail" that involves taking 24 pills a day and 10 injections a month. Still, drug regimens can fail and people with chronic illnesses don't always beat the odds, she conceded.
"Something needs to happen at this conference," she said. ". . . I know the awareness is there. It is up to all of you to make the difference. My injury did not have to happen."
Because Arnold had a well-documented injury from a known source case and seroconverted six months after testing baseline negative, she is likely among the 54 health care workers listed in CDC statistics as a confirmed case of occupational HIV infection, though the CDC does not identify such confidential cases. In addition to those 54 cases, the CDC lists another 132 health care workers as possible occupational HIV infections due to less clinical documentation.
"We know that the number of health care workers with occupationally acquired HIV infection is probably higher," Denise Cardo, MD, chief of the HIV infections branch in the CDC hospital infections program, told conference attendees.
Not all workers are evaluated for HIV infection following occupational exposures, and not all HIV cases are reported to health departments, she noted, adding that data from all available sources suggest the count of HIV-infected workers is not off by a wide margin. All the while, however, the occupational threat of hepatitis C virus appears to be growing, as some four million people in the United States are now estimated to be infected and there is 10-fold greater risk of transmission per exposure than with HIV. (See related story, p. 150.)
On the other hand, the incidence of hepatitis B virus (HBV) has fallen dramatically among heath care workers. According to the CDC, 1991 estimates of 5,100 new HBV infections among health care workers dropped to 1,012 new infections annually in 1994 and fell again to 800 in 1996. The finding is being widely attributed to the emphasis on HBV immunization in the 1991 OSHA bloodborne standard, a trend that health care worker advocates will certainly underscore as the calls for needle safety mandates continue.
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