HIV-positive nurse’s challenge to hospitals

IV catheters, other devices targeted in campaign

A nurse infected with HIV after a needlestick is issuing a ’moral challenge” to hospital administrations, asking them to pledge to protect health care workers by implementing needle safety devices designed to prevent some of the most dangerous of the estimated 800,000 sharps injuries that occur annually.

’I am living proof that needlesticks happen and that the consequences can be deadly,” says Lynda Arnold, RN, founder of the Campaign for Health Care Worker Safety in Lancaster, PA.

Working as an intensive care nurse at a hospital in Lancaster on Sept 9, 1992, Arnold was stuck by an intravenous catheter needle she had just removed from an AIDS patient. The patient suddenly jerked his arm, forcing the needle into her left palm, she recalls. Emphasizing that she was following universal (now called standard) precautions, Arnold says she saw the bloody wound upon removing her gloves moments later. Six months later she seroconverted for HIV, adding to a toll that is currently estimated by the Centers for Disease Control and Prevention in Atlanta (CDC) at 151 health care workers occupationally infected with the AIDS virus.

Infections through needlesticks

That total includes 49 workers with documented occupationally acquired HIV/AIDS infections and 102 more who may have acquired HIV/AIDS through occupational transmission, according to the most recent estimates by the CDC. Of the 49 documented cases, 42 had needlesticks, five had mucocutaneous exposures, one had both percutaneous and mucocutaneous exposures, and one had an unknown route of exposure. Forty-four exposures were to HIV-infected blood, three to concentrated virus in a laboratory, one to visibly bloody fluid, and one to unspecified fluid.

The CDC concedes the reported numbers of infected workers are low because they are largely based on passive surveillance that relies heavily on voluntary reporting of seroconversions by health care workers through state health departments. A more formal surveillance system for a wide variety of health care worker exposures and infections is being piloted by the CDC, which also recently began encouraging hospitals to follow up workers for hepatitis C virus exposures. (See Hospital Infection Control, September 1994, pp. 117-120; May 1996, pp. 57-61.)

Though there is currently no surveillance system for workers infected with hepatitis, Arnold says she has heard from many since publicly disclosing her infection earlier this year.

’I have already heard from 100 health care workers who have been infected with bloodborne pathogen diseases on the job,” she tells HIC. ’I have had people calling and saying, ‘we are proud of you and glad you are doing what you are doing.’”

Raising consciousness

She is now conducting a national mailing to hospitals and health care facilities, trying to raise consciousness on the issue and get administration officials to sign a pledge to implement safer devices within one year. (See pledge, above.)

’It is kind of like a moral challenge to do the right thing,” Arnold says. ’It may not be at this point a regulatory issue, but it is simply an effort to protect our workers and to really understand where the risks are coming from and to revisit this issue.”

Indeed, Arnold reports being advised by some that she is picking up the weathered banner of an ’old” issue, as many hospitals have already purchased some of the increasing array of needle designs currently on the market.

’There has been a lot of progress made, primarily in the development of different types of devices and fine-tuning those types of devices in trying to get what hospitals want,” she says. ’However, in the overall picture there is still a lot of work to be done.

Needle safety efforts should concentrate on those types of equipment, which are available in self-sheathing and blunting designs to protect workers, she says. According to the CDC, many of the documented occupational transmissions of HIV were associated with starting or manipulating IV lines and collecting blood in vacuum tubes. In addition, needlesticks involving such equipment may be more likely to result in transmission, thus warranting immediate post-exposure prophylaxis.

The CDC recently defined the highest risk occupational exposures as those having both a larger volume of blood (i.e., deep injury with a larger diameter hollow needle previously in source patient’s vein or artery) and blood containing a high titer of HIV (i.e. source patient with end-stage AIDS.) ’Increased risk” exposures are those involving either exposure to larger volume of blood or blood with a higher viral titer of HIV, the CDC noted.1

’All the recent data and all the statistics point to the need for the prevention of certain types of injuries with the use of certain types of devices — those that are placed directly into the vein or artery and those with hollow-bore needles,” Arnold says. ’There is a need to push for these particular devices. Because they may not [cause] the greatest number of needlesticks, but they are clearly the most dangerous.”

By the same token, Arnold argues that focusing her campaign on getting facilities to adopt safer IV catheter and blood-drawing devices is the most cost-effective approach for budget-crunched hospitals.

’When everyone talks about safety, they assume they need to be completely needleless and get rid of everything,” she says. ’It is not cost-effective — it’s not practical. What I’m talking about is that there are specific devices that are more risky, and that’s what we need to look at. That is what I am hoping that hospitals will implement.”

Safety features on needle devices could potentially prevent some 85% of needlesticks, according to the International Health Care Worker Safety Research and Resource Center in Charlottesville, VA. Janine Jagger, PhD, director of the center and an associate professor of neurosurgery at the University of Virginia, has been at the forefront of the needle safety issue for many years and founded the Exposure Prevention Information Network.

Recent data from 58 hospitals participating in the surveillance network reveals an annual average rate of 33 needlesticks per 100 occupied beds. Likewise, a 1994 survey by the National Phlebotomists Association in Hyattsville, MD, found that during the previous 12 months, 25% of health care workers who drew blood were stuck by a needle.

’It is important for hospitals to understand that these particular devices are more important than good worker’s compensation, more important than good insurance,” Jagger says.

Still, Arnold acknowledges some mixed feelings in going public with her story, particularly because it may fan AIDS fears among the public and young nursing students.

’I want to make sure that my story or my campaign does not create a level of fear and panic — definitely not in the young nursing community that is just out there and starting,” she says. ’But I don’t think we are adequately protected. I really don’t. Because if we were adequately protected, you wouldn’t have stories like mine.”

[Editor’s note: For more information on the effort, call the Campaign for Health Care Worker Safety at (717) 299-0228.]

Reference

1. Centers for Disease Control and Prevention. Update: Provisional public health service recommendations for chemoprophylaxis after occupation exposure to HIV. MMWR 1996; 45:468-472.