Home health workforce, sharps injuries grow

As the nation's population ages, a growing number of registered nurses, certified nursing assistants, and nurses' aides will be working in patients' homes rather than in hospitals. But many of them will be working without the basic safety devices that most nurses now take for granted, safety experts say.

"Home health is the fastest growing sector in health care, yet they're not having the benefit of the changing landscape in safety needles. That's not fair," says Robyn Gershon, DrPH, professor of socio-medical sciences and associate dean for research resources at the Mailman School of Public Health at Columbia University in New York City.

A study of occupational hazards among home health nurses in New York state found that safety equipment was lacking. Only 14% were provided with sharps containers, 9% had safety needles and syringes, and only about one in four had safety butterfly needles (23%) or safety lancets (26%).1

The primary reason, says Gershon, is economic. "It's really about the finances," she says. In some cases, the home health agency is not providing the proper safety devices because they are more expensive, she says. In other cases, the home health nurse uses the devices that patients have in their home, and those do not have to have safety features. In fact, the safety versions might not be fully reimbursed by insurers, Gershon notes.

Not surprisingly, fewer safety devices mean more sharps injuries. A study of home health nurses in North Carolina found that almost one in 10 (8.9%) had a blood exposure in the past year. The exposure rates were highest among nurses who had worked in home health for less than five years and for contract nurses or those who worked part-time.2

Researchers also found that nurses often didn't use personal protective equipment (PPE) that would prevent blood exposures, and the primary reason was because the equipment wasn't provided by employers. Jack K. Leiss, PhD, head of the Epidemiology Research Program at the Cedar Grove Institute for Sustainable Communities, a non-profit research organization in Mebane, NC, says, "There's a national policy to protect health care workers. The policy is to provide them with safety medical devices and PPE. It's not working."

Granted, it's more difficult to enforce the bloodborne pathogen standard in a home care environment. "OSHA [the U.S. Occupational Safety and Health Administration] doesn't regulate the home environment," says Gershon. "Yet there are workers in that home environment, and they're unprotected in multiple ways."

In fiscal year 2009, for example, OSHA conducted just three inspections of home health agencies that included bloodborne pathogens concerns and issued 12 citations. Dionne Williams, MPH, a senior industrial hygienist with OSHA, says, "Home health is very unique. It's very distinct from the hospital setting. It's a lot more challenging."

Employers still are responsible for providing safety equipment and training, she says. But they do not have control over the work environment, the patient's home, so they aren't responsible for making sure employees use the equipment, she says. In some cases, the employer isn't even responsible for the devices. "Employees may have to administer the meds but use the devices that the patients supply," Williams says. In that instance, employers still would be responsible for providing sharps containers.

Sharps safety in home health care mighty be a growing issue as the nation ages and the nature of health care delivery changes. According to the U.S. Bureau of Labor Statistics, the employment of registered nurses will rise twice as fast in home health as in hospitals through 2018.

An increased emphasis on worker safety in health care overall would benefit home health nurses, says Gershon.


1. Gershon RRM, Canton AN, Raveis VH, et al. Household-related hazardous conditions with implications for patient safety in the home health care sector. J Patient Saf 2008;4:227-234.

2. Leiss JK, Lyden JT, Mathews R, et al. Blood exposure incidence rates from the North Carolina study of home care and hospice nurses. Am J Ind Med 2009;52:99-104.