Clean up your act!
October 1, 1996 9 minutes read
Clean up your act!
Misplaced sharps expose laundry workers, housekeepers to HIV, HBV
While attempting to dislodge intravenous tubing that had become entangled in a bed frame, a housekeeper sustains a deep puncture wound to her foot from an exposed needle that had been left on the IV line.
A laundry worker is injured by an improperly disposed needle, and routinely comes across a frightening array of objects including hazardous waste, beer cans, and body parts all while sorting through dirty linen.
While these scenarios may sound extreme, they are routine at some hospitals.
Housekeepers and laundry workers may be the most overlooked categories of health care workers who are contracting hepatitis or HIV, and eventually dying of AIDS, as a result of occupational exposures that could have been prevented by safer needle devices and improved employee education.
Information currently provided by the federal Centers for Disease Control and Prevention (CDC) in Atlanta reveals a total of eight workers in the housekeeper category (which includes laundry workers) with documented or possible occupationally acquired HIV/AIDS. (See related story in Hospital Employee Health, May 1996, p. 54.) One seroconversion resulted from a documented occupational exposure, while seven others are included in the "possible" list, meaning that those workers had no identified risk factors for infection except for occupational exposures to blood or body fluids, says Russ Metler, RN, MSPH, a nurse epidemiologist in the CDC’s division of HIV/AIDS prevention.
Six of those eight employees have died from AIDS, Metler notes.
The CDC’s figures are based on a voluntary reporting system. Agency officials and others in the occupational health community are aware that the CDC figures are only minimal estimates and that actual numbers of infected HCWs, although unknown, are much higher.
Under-reporting applies not only to HIV seroconversions but also to the exposures that caused them. And although under-reporting applies to all HCW categories, "the housekeeping and laundry worker category is the most under-reported category of any of those," says Katherine Cox, health and safety specialist with the American Federation of State, County, and Municipal Employees (AFSCME). The Washington, DC-based labor union represents about 360,000 HCWs.
"Those folks are the least likely to come forward unless it’s a really serious injury that they think requires medical attention," Cox states. "The problem is, even if you tell people about reporting injuries, there are some very subtle disincentives to reporting out there. You’re often blamed for being careless or not paying attention, so people are afraid to report. The hierarchy in hospitals is pretty intimidating if you’re at the bottom of it."
The federal bloodborne pathogens standard mandates hospital employee education related to transmission and exposure prevention,1 but Cox says programs often are not geared to the education levels of housekeepers and laundry workers, who might lack literacy or fluency in English. In some hospitals, training is aimed more at professional worker categories and not at service workers or the job tasks they perform.
Officials of another union representing hospital laundry workers and housekeepers also are critical of the training many of those employees receive. Health care professionals who use needles and other sharps in their work usually receive the first priority for federally mandated bloodborne pathogens training, they say.
"The kind of training provided to those who work down in the bowels of the hospital often is inadequate," says Jamie Cohen, assistant director for occupational health and safety with the Service Employees International Union (SEIU) in Washington, DC, which represents about 500,000 HCWs.
"The bloodborne pathogens standard clearly states that you’re supposed to provide training geared toward the workers’ literacy level and language, so everyone can understand the information. They shouldn’t just be shown a 15-minute videotape, which I think is what a lot of people are getting, if they are getting any training at all," Cohen states.
Hospital downsizing affects laundry workers and housekeepers as much as it does nurses and other health care professionals, she adds. Fewer people doing more work can lead to more accidents.
"It’s some of the dirtiest work in the hospital, and it’s a downstream problem," Cohen says. "If safer needle devices were used, these injuries wouldn’t be happening. If you’re not dealing with the problem upstream in a hospital, downstream workers are going to be affected by it."
While nurses sustain sharps injuries most often in their hands, housekeepers’ injuries usually are to the calves. Those injuries result from used needles improperly discarded in trash containers. When the workers remove the full trash liners and carry them at their sides, the contaminated needles pierce the plastic liners, grazing the housekeepers’ calves, Cox explains. Housekeepers also have been stuck when removing linens from patient beds and cleaning rooms between patients.
"Sometimes when someone is giving multiple injections at the bedside, instead of putting [used] syringes down on a tray, they’ll stick them into the mattress. Theoretically, they’ll go back and dispose of them properly. Think about what happens at the bedside if there’s not a needle box right there and you have to do multiple injections. Do you give all the injections, or do you give one, go over to a needle box that’s on the other wall, put the needle in, come back, give the next injection, go over to the needle box again? Many times these things are done in a hurry. That’s how needles get lost in the bed linen," she says.
That type of improper disposal is responsible for laundry workers’ sharps injuries, as well. Those injuries occur as workers sort dirty linen in which exposed contaminated needles and other sharps have been improperly discarded.
"These injuries are the least excusable," Cox states. "Most could be prevented if hospitals purchase safer needle devices and make sure that disposal containers are accessible and not overly full. People are not improperly disposing of needles maliciously. They’re rushed, the needle boxes are not accessible or easy to use, or they’re not trained on the importance of proper disposal."
Although the CDC will not release information on how the eight housekeepers/laundry workers with occupational HIV/AIDS were exposed due to confidentiality considerations, according to Metler, one recent study by other researchers provides insights into disposal-related sharps injuries.
Data gathered by the Exposure Prevention Information Network (EPINet), an international computerized system based at the University of Virginia in Charlottesville, show that disposal-related injuries occur in significant numbers.2
Information from nine hospitals reveals that of 3,666 percutaneous injuries reported by HCWS since September 1992, 1,335 (36.4%) were classified as disposal-related. That classification included injuries occurring: after use but before disposal of sharps; from devices left on or near disposal containers; from introducing a sharp into a disposal container; from a device protruding from a disposal container opening; from a sharp piercing the side of a disposal container; and from a sharp placed in an inappropriate trash container.
Analysis of the data shows that housekeepers and laundry workers constitute the second-largest group of workers sustaining disposal-related sharps injuries, with 10.3% of cases. Nurses are the largest group, with about 50% of cases. While injuries to nurses occur primarily after use and before disposal of sharps, as well as during the act of disposal, housekeepers’ and laundry workers’ injuries occur mainly after device disposal.
"This comparison suggests that the actions of one group affect the risk of injury for other groups," the EPINet report states.
Nevertheless, Janine Jagger, MPH, PhD, director of the International Health Care Worker Safety Research and Resource Center, which operates EPINet, says focusing on being more careful about sharps disposal is not the whole answer.
"[Housekeepers and laundry workers] frequently are the victims of other people’s carelessness; however, if safety devices were more systematically used and if protective features were on devices, it would be less likely that housekeepers would get stuck by them," Jagger tells Hospital Employee Health. "Although the cause may be in part related to carelessness, there are other solutions than just getting people to be less careless."
The fact that workers who do not use needles and sharps in the course of their work are being injured by those devices prompted one hospital infection control practitioner to investigate further.
Connie J. Steed, RN, CIC, nurse epidemiologist at the Greenville (SC) Hospital System (GHS), launched a study of the prevalence of hepatitis B and occurrence of sharps injuries among 49 laundry workers in 1990 and conducted mail surveys in 1990 and 1992 (post-OSHA bloodborne pathogens standard) of 21 hospital laundries in 14 Southeastern states.3,4
Although demographic data show the worker population in a socioeconomic class at risk for HBV infection, the results of Steed’s probe led to concerns about occupational exposure risks.
During efforts to establish a more efficient employee exposure protocol, Steed examined incident reports and discovered that two laundry workers who had incurred needlesticks were HBsAg-positive after baseline testing.
"I scheduled an environmental assessment of the laundry and found some very interesting things," Steed tells HEH. "Laundry workers were dealing with sharps in the dirty linen. They had a needle box sitting in the area where they sort the linen."
Workers were asked to set aside all sharps and other objects found in dirty linen for one week. What Steed saw when she examined the collection was "unbelievably surprising." Not only were there hundreds of sharps (needles, syringes, scalpels), but a partial list of objects found at her facility as well as at the 21 other hospitals surveyed includes: a whole needle disposal box; a box of hazardous waste; IV bags, bottles, tubing, and poles; a blood-pressure cuff; a stethoscope; a heart monitor; a life-support system; a fetal monitor; respirators; oxygen regulator, cylinder, and tank stand; complete surgical instrument trays; endoscope with camera attached; a bone drill; a whole sink; a butcher knife; beer and soda cans; and body parts such as fingers and placentas.4
Steed also distributed a confidential questionnaire to laundry workers, and conducted interviews. Questionnaire information included demographic data, health care employment history, potential non-occupational HBV exposure, medical history, and HBV vaccination status.
A hepatitis B seroprevalence survey was done by screening for core antibody, with subsequent testing for surface antigen in those who were core-antibody-positive.
Of the 49 participating laundry workers, 85% were black, and 65% were female. Eleven were HBsAg-positive. None had definable non-occupational risk factors for HBV. None had received hepatitis B vaccination.
The 1990 survey of 21 hospital laundries found a monthly average of 66 sharps in dirty laundry and a yearly average of three sharps injuries to laundry workers. The 1992 survey had 31 respondents reporting a monthly average of 35 sharps in dirty laundry and an average of 2.7 injuries per year.
Interventions for GHS laundry workers as a result of Steed’s investigation included HBV vaccination, one-on-one educational programs tailored to the workers’ jobs and education levels, and the use of personal protective equipment such as utility gloves, face shields, and barrier gowns for sorting laundry.
Photos convince administrators
Educational programs were conducted for all HCWs to emphasize proper disposal techniques and the potential consequences of improper disposal. A needleless intravenous system was implemented in 1991 and a resheathing IV catheter in 1992 to reduce the number of sharp objects that could injure workers downstream. The laundry department manager continues to monitor and report objects found in dirty linen.
But Steed says that perhaps the most effective intervention of all was taking pictures of objects found in the laundry and of sharps lying in trash and in other inappropriate locations. She gave administrators a slide show they would not soon forget.
"I knew I was taking a risk, but it was a way to open their eyes to the problem," she says. "I was able to get their support for educating staff about sharps disposal."
Steed also recommends showing the pictures to managers of units where sharps injury hazards are found.
"If you get a picture of the hazard, and then you take that picture with a follow-up form to the area where the hazard was, such as a nursing unit, it makes a bigger impact. That is the most effective method of education I have found to date. Show the picture to the nurse manager or other supervisors and ask them to educate staff and take corrective action. Put the responsibility with the manager," she states.
Employee health and infection control departments need to do immediate follow-up, she adds.
"Don’t forget about laundry workers and housekeepers; they get stuck, and they don’t even use these things. But just seeing numbers on a piece of paper is not effective," says Steed. "Go out on the nursing units and look in rooms; talk to the workers. They can tell you a lot. Do environmental rounds to help identify problems such as overfilled needle containers before they can cause injuries. Follow-up of incidents that are preventable with each area makes a big difference."
References
1. U.S. Department of Labor, Occupational Safety and Health Administration. 29 CFR Part 1920.1030, Occupational exposure to bloodborne pathogens, final rule. Fed Reg Dec. 6, 1991; 56:64,004-64,182.
2. Jagger J, Bentley MB. EPINet report: Disposal-related sharp-object injuries. Advances in Exposure Prevention 1995; 1:1-2, 6-7, 11.
3. Steed, CJ, Lettau LA, Sexton F. Hepatitis B (HB) infection and sharps injury in laundry workers (Abstract No. S95-01-031). Presented at Frontline Healthcare Workers: National Conference on Prevention of Sharps Injuries and Bloodborne Exposures. Atlanta; August 1995.
4. Steed C, Lettau L. Hepatitis B infection and sharp object injuries in hospital laundry workers: Amazing discoveries in hospital laundries. Advances in Exposure Prevention 1995; 1:8-9.
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