HIV+ nurse launches national campaign for safer needle devices
RN petitions hospitals to help stop occupational infections
A nurse whose career ended only months after it had begun due to occupational HIV infection from a needlestick injury is spearheading a national campaign that she hopes will accomplish what many federal agencies have not: the adoption of safer needle devices by hospitals to protect health care workers.
Lynda Marie Arnold, RN, now 26, had graduated from nursing school barely four months prior to sustaining a needlestick in the intensive care unit of Community Hospital of Lancaster (PA) in September 1992 while installing an intravenous line on a terminal AIDS patient. The accident occurred as she withdrew the catheter from the patient's vein. He suddenly moved his arm, knocking hers. The movement forced the needle that she held in her right hand into her left palm. (See related article, p. 40.)
"It was a moment I will never forget," says Arnold. "I began testing for HIV immediately and was negative each time until my six-month test. On April 7, 1993, I was told I had tested positive for HIV."
Arnold has not developed AIDS, but is no longer working due to complications from medication. She receives workers' compensation and recently settled a product liability lawsuit for an undisclosed sum against Becton Dickinson of Franklin Lakes, NJ, the manufacturer of the IV catheter implicated in the needlestick accident. (For a story on the same or similar device being involved in another accident that resulted in an HCW becoming infected with HIV, see Hospital Employee Health, November 1995, pp. 137-140.)
For three years, Arnold has been an HIV/AIDS educator in her community, but "now that the suit is settled, I'm free to discuss this publicly and try to make a bigger difference, especially on the issue of safer needle devices," she says. "There will always be risks on the job, but that doesn't mean the risks can't be reduced."
Arnold launched her appeal to the nation's hospitals with a press conference in Philadelphia. Over the next 18 months, she intends to reach thousands of hospitals through mass mailings, personal visits, phone contacts, and media articles, bringing her message and petition (see Arnold's petition, inserted in this issue) to administrators, employee health professionals, safety officers, risk managers, infection control practitioners, and purchasing directors, as well as needle manufacturers.
She plans to target intravenous catheters and blood-drawing devices because data on occupational HIV transmission to HCWs show that those needles most often are implicated in seroconversions.1 (See Literature Review in this issue, p. 47.)
Arnold's petition gives hospitals the opportunity to sign a pledge that they will begin to institute the use of safer catheters or blood-drawing devices, depending upon which devices cause most of the facility's needlesticks, within one year of signing.
"From my story comes the need for hospitals to sit up, take notice, and decide that they want to put their employees' safety above other considerations. It comes down to a matter of economic choice," says Arnold. "I'm not asking hospitals to make a complete switch to needleless systems, just that they look where the [injury] risks are. It may involve a smaller subset of devices, which would be less costly [to replace]."
Arnold's hospital switched to a safer catheter device in March 1993, and although she is aware that her injury would not have occurred if the switch had occurred about six months earlier, she praises the hospital for its commitment to safety.
"It's impressive to me that a small, private community hospital that is financially challenged could make the switch. If they could do it, then I don't see why any other hospital wouldn't be able to," she says.
Switching worth the cost
The economic impact of a seroconversion makes replacing unsafe devices a practical matter. A hospital can end up paying "hundreds of thousands of dollars" through the workers' compensation system if just one employee contracts HIV from a needlestick injury, she points out.
Jim Kelly, vice president of finance at Community Hospital of Lancaster, says financial considerations were a significant factor in the decision to purchase safer catheters three years ago. The hospital was in the process of becoming self-insured for workers' compensation, and administrators were seeking ways to reduce compensable injuries and their associated costs. This process already was under way before Arnold's accident, he adds.
Although the first in-house trial of the new catheter technology had negative results, Kelly says the device trial was expanded later, with more favorable outcomes. At that time, the decision was made to switch to the new device, which cost almost twice as much as the old one.
Has it been worth the additional cost? "There is no question in my mind that we have been better off and that it was a good investment," he says. "We're pleased, and our workers' compensation costs indicate it was the right thing to do."
Kelly openly acknowledges two main reasons why many hospitals find it difficult to switch to safer needle devices. First, reimbursements for hospitals from third-party payers are not keeping pace with the rate of inflation, "so the reimbursement we're getting today is not going to keep pace with the increase in the expenses that we have to provide that service," he explains. "From a strict cost perspective, to change to a more expensive catheter is only going to decrease reimbursements even further."
Second, hospitals often tend to wait until they are mandated to take action, either by the U.S. Occupational Safety and Health Administration or by another regulatory agency.
"We are not in that scenario here," he notes. "OSHA does not specify what catheters you need to use, or if you have to use protective catheters. Sometimes you kind of fall into that trap of, 'If it isn't necessary, we won't do it right now. We'll just do better on educating our employees,' and you can rationalize it very easily that way."
No federal agency support?
Kelly's explanation confirms the arguments put forth by health care worker labor unions that the best way to ensure the use of safer needle devices in hospitals is federal regulation. So far, that hasn't happened, nor is it likely to. The Service Employees International Union (SEIU) in Washington, DC, which represents some 500,000 HCWs, has filed a petition with the U.S. Food and Drug Administration (FDA) in Rockville, MD, to outlaw what union officials describe as "hazardous" needle devices.
At a national conference last summer on protecting HCWs from bloodborne exposures, FDA officials said banning conventional needle devices would be "difficult" based on the agency's regulatory framework. (See related story in HEH, October 1995, pp. 121-125.)
The SEIU supports Arnold's campaign to protect HCWs from contracting HIV, as well as hepatitis infections, from needlesticks. William K. Borwegen, MPH, the union's health and safety director, calls upon device manufacturers and federal agencies to "pull older, inherently dangerous needles off the market" and urges hospitals to purchase only the newer, safer ones.
"If a corporation can have a conscience, on behalf of Lynda Marie Arnold and the millions of other health care workers who conscientiously use and are needlessly exposed to tens of millions of inherently dangerous needles every day, I implore needle manufacturers to make the right moral and ethical decision to sell only their safer product lines," Borwegen says.
Another federal agency is withholding support of Arnold's campaign, at least initially. Attorneys for the Centers for Disease Control and Prevention in Atlanta, the sponsor of last summer's conference on preventing bloodborne exposures, are "uncomfortable" with Arnold's recent litigation against device manufacturer Becton Dickinson, says David M. Bell, MD, chief of the HIV infections branch in the CDC's hospital infections program.
"We had considered sending a letter of support, but our attorneys were uncomfortable with our becoming a party at this time. It's not to say that we don't support the development and use of safer medical devices," Bell says. "We've said that for years, and we've done studies evaluating these devices and have testified before Congress supporting the development of newer devices."
Bell does not rule out future involvement in the campaign. "Over time I don't doubt that we'll have more contact with Lynda Arnold, but right at the moment we're not able to get directly involved," he says.
Nurses 'leading the way'
In addition to the SEIU, many organizations have been receptive to the campaign, Arnold points out. In any case, she is undaunted by the CDC's decision.
"I'm an individual, and I'm going to do my best. If anyone wants to help me, that's fine. I have the support of many organizations, and at this point it looks like the nurses are leading the way."
Both the American Nurses Association (ANA) in Washington, DC, and the Association of Operating Room Nurses (AORN) in Denver have signed on to the campaign, as have a number of other nursing specialty groups and AIDS service organizations.
The ANA will connect Arnold's campaign with state nurses' associations, says Susan Wilburn, RN, ANA occupational safety and health specialist.
Nurses on the state level will take petitions to their hospitals "and better yet, negotiate language in contracts that says [hospitals] will use needleless and protected systems," Wilburn says. "Nurses and other health care workers in hospitals don't deserve to have an injury that can be prevented."
Wilburn adds that once the public learns of needlestick hazards in hospitals through media reports, their "outcry" will help bring about change.
The replacement of unsafe devices is "critically important," Wilburn maintains.
"Since the OSHA bloodborne pathogen standard, we have moved away from blaming nurses for causing needlestick injuries by being careless or not minding the right way to dispose of a needle, when in fact there are engineering controls that can be used to prevent an injury from happening," she says. "Any person working in a setting where there are needles is exposed to needlestick injuries."
In a position statement on Arnold's campaign, the AORN affirms its support of the "use and continued development of improved procedures and devices that will lessen the chance of occupational exposure to HIV through skin puncture."
It goes on to say that the "AORN expects health care institutions to provide adequate protective supplies and devices to minimize the risk of occupational exposure to bloodborne diseases to patients and health care workers alike."
The statement also points out that "shielded protective devices for intravenous catheters have been shown to reduce the incidence of needlesticks."
Also supporting the project is the National Phlebotomy Association (NPA) in Hyattsville, MD. Data uncovered in recent years show that phlebotomists and nurses rank first among HIV-infected HCWs.2 Phlebotomy was the procedure most frequently associated with HIV exposures.3 Most needlestick injuries sustained by phlebotomists could be prevented with safer devices, according to the author of a 1994 study on needlestick injuries published in Advances in Exposure Prevention.4 (See related story in HEH, March 1995, pp. 32-34.)
"We always support the effort when it comes to safer devices," says Diane Crawford, MT, CPT (NPA), chief executive officer of the NPA. "We're the health professionals most apt to get needlesticks. We're going to have a voice whenever anybody gets a needlestick injury because we want it stopped. The manufacturers are making safer devices as well as the traditional sharp instruments, and hospitals are still purchasing the unsafe ones. This has to stop, too."
EPINet provides data
Many of the data on IV catheters and phlebotomy devices were derived from the Exposure Prevention Information Network (EPINet), a national computerized data collection and analysis system that provides specific identification of injury-causing needle and sharps devices, allowing hospitals to target high-risk devices and evaluate the efficacy of new devices designed to prevent injuries. In 1993, data from the network showed a statistically significant reduction in IV catheter-related needlestick injuries with the Protectiv catheter, manufactured by Critikon in Tampa, FL. (See related story in HEH, August 1993, pp. 105-108.)
Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Research and Resource Center at the University of Virginia in Charlottesville, developed and maintains the EPINet system. She provided Arnold with accurate data on needlestick rates and causes, and bloodborne pathogens transmission risks.
Jagger, a well-known expert on needle safety and the epidemiology of needlestick injuries, says that although many hospitals already are using safety devices for drawing blood and IV access, "it's been difficult to get the attention of hospitals on a large scale."
Arnold will bring "a new opportunity to this area that I'm hoping will help accelerate the use of safer devices by hospitals," Jagger says. "She will make it more difficult for hospitals to ignore the simple measures that they can undertake to substantially reduce risk for their employees. Her initiative will generate a great deal of discussion and debate in hospitals and draw attention to an issue that has been too easy to ignore in the past."
Arnold was working in a small community hospital with around 200 beds, in a location where there was not a high prevalence of HIV. This represents the typical U.S. hospital, says Jagger.
"The fact that this could happen to her in a place like that will draw the attention of people all over the country. It's difficult for health care workers who have contracted the worst bloodborne pathogen to become visible advocates for these prevention measures because most of them are dealing with the devastating personal consequences that they have to endure, and many want to remain anonymous," Jagger notes.
Despite the difficulties, Arnold plans to continue the campaign.
"I don't want this to happen to anyone else," she says, "so I'm dedicating myself to doing this. I want my son to know that his mother tried to make something good come out of something bad, that she tried to make a difference."
References
1. Centers for Disease Control and Prevention. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood -- France, United Kingdom, and United States, January 1988-August 1994. JAMA 1996; 275:274-275.
2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 1994; 5:19.
3. Metler R, Ciesielski C, Marcus R, et al. Exposure circumstances of workers with occupationally acquired HIV infection. Presented at Frontline Healthcare Workers: A National Conference on Prevention of Device-Mediated Bloodborne Infections. Washington, DC; Aug. 18, 1992.
4. Jagger J. Risky procedures, risky devices, risky jobs. Advances in Exposure Prevention 1994; 1:4-7, 9. *
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