Hospices challenged by infection control

Needlesticks are only the tip of the iceberg

In June, Hospice Management Advisor reported on accidental needlesticks, which happen to health care workers more than 800,000 times a year and can cause deadly bloodborne illnesses such as hepatitis and AIDS. (See HMA, June 1998, pp. 75-77.)

The national debate over safer needle technology is growing in the health care system, in the media, and even in Congress, although it has been slow to reach hospice and home care.

Hospice managers and association representatives contacted for the June article, mentioned above, expressed unfamiliarity with the national controversy and lack of clarity on whether their agencies used the safest technology. Moreover, they suggested it was the responsibility of the individual health professional to be more careful in using intravenous devices, rather than the system's responsibility to engineer protocols to eliminate human error.

However, comments on home care and hospice listservs operated by American Health Consultants, HMA's publisher, suggest that field nurses are more acutely aware of the dangers posed by needles, blood draws, butterfly syringes, and other intravenous devices. Several respondents reported suffering needlesticks, and others questioned how home care professionals can be "more careful" in an environment where mandated productivity increases push them to hurry, cut corners, and sometimes get sloppy.

But needlesticks are only one facet of the range of infection control challenges facing hospices today, although this one issue hints at the need for increased awareness by hospice managers of infection control issues generally and on opportunities to make improvements.

"The subject of infection control on the job is very big," with volumes of material issued by the federal Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA), among others, says Deborah Lage, RN, MS, COHN-S, CHSP, director of occupational health risks for the National Hospice Organization Insurance Agency (NHOIA) in St. Helena, CA. "At NHOIA, our focus is on protecting hospice employees. Basically, we support the CDC guidelines, and we really support the use of safety needles," she relates.

"The bottom line: Your employees are your most precious resource. Following CDC guidelines and looking for safety engineering controls go a long way to show that you care about the health and safety of your employees. In a practical sense, if you can prevent infections, you can avoid the costs," such as for the triple-drug therapies now recommended for health care workers who become exposed to HIV, or the workers' compen sation and other costs incurred when an employee contracts an illness on the job, Lage says.

Few hospices have their own infection control staff, although a greater number could gain access to such resources through an affiliated or collaborating hospital. In the acute care setting, infection control is a way of life, not just an occupational health issue. A few of the most forward-looking hospices have even established their own safety committees to make the institutional commitment to worker safety a routine part of the life of the agency.

JCAHO demands safety compliance

Peggy Pettit, RN, vice president of patient and family services for Miami-based Vitas Healthcare Corporation, recommends that hospices take advantage of resources and policies that already exist, rather than creating their own.

"I don't think many hospices today have a carefully thought-out infection control plan. But those seeking accreditation from JCAHO [the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL] will be required to take a more thorough approach." JCAHO accreditation requires that the hospice put in place a safety program that follows all applicable laws and regulations related to health and safety. JCAHO also is in a three-year partnership with OSHA to develop cross-referenced materials.

"The idea is to design out hazard to the greatest extent possible, acknowledging that you're working in an uncontrollable environment in the patient's home," explains Elise Handleman, RN, COHN-S, MEd, director of OSHA's Office of Occupational Health Nursing.

"Whatever the employer can control to enhance safety and engineer out risk, that serves everybody," Handleman says.

Meanwhile, voluntary guidelines promulgated by CDC and others increasingly are being accompanied by mandated standards from OSHA and other government sources. Last fall OSHA published draft standards on occupational exposure to tuberculosis, which would have added teeth to existing CDC tuberculosis control guidelines.

Outcry from professionals in the health care industry - particularly from those working in home care - claimed that the standards would be more onerous and costly than OSHA had projected, without necessarily protecting workers. As a result, implementation was delayed, and a series of public hearings on the proposed standards were held through June to gather more input from the field.

Government getting involved

Other levels of government are also getting involved. Last fall Rep. Pete Stark (D-CA) introduced the Health Care Worker Protection Act, which would require hospitals and hospital-owned facilities to use safe and approved needle devices as a condition of participation in Medicare. A similar bill has been introduced in the Senate this spring, and Stark already has garnered 73 House co-sponsors, as well as the support of the American Nurses Association, two leading unions representing health care workers, and a number of health care specialty associations.

In late June, California's state Occupational Health and Safety Administration issued a draft of tough new compliance regulations requiring the use of safety needles to prevent needlesticks. That proposal could spark nationwide action on needle safety, observers say.

A new federal plan on needle safety also is under development, spurred by a hard-hitting series of articles on needlesticks published in the San Francisco Chronicle in April, while the San Francisco Board of Supervisors is considering a needlestick prevention measure.