OSHA directive aims to reduce high numbers of needlestick injuries

Agencies must include safety devices in their exposure control plans

Another new occupational safety development has hit the home health industry: federal and state initiatives requiring all health care providers to switch to devices that reduce the risk of needlestick accidents.

The Occupational Safety and Health Administration issued a directive to its inspectors in November regarding the bloodborne pathogen exposure control plans that health care providers must create for their operations.

The directive requires that the plans include the use of "engineering controls" such as sharps injury protection or needle-free devices to reduce employee exposure to bloodborne diseases such as human immunodeficiency virus (HIV), hepatitis B, and hepatitis C.

For agencies in a number of states, the push for safer needles began even earlier. In California, for example, a similar directive signed into law in 1998 set a July 1, 1999 deadline for making the changes. At least six other states have similar legislation pending.

High incidence of accidents

The regulators’ goal is to reduce the estimated 600,000 to 800,000 needlestick injuries occurring among health care workers each year. It’s hard to determine how many of those occur in home health, but consultant Lori Douglass, RN, MS, CFNP, COHN-S, owner of OccuHealth Consultants in Modesto, CA, says she believes the number is extremely small.

She says the home health industry once again has been caught up in regulations designed to solve problems in hospitals and other health care settings.

"As far as home health, it was a very unwelcome development," she says. "The risk is so minimal in home health. You want to cut the risk down as much as possible, but you can only take it down so far."

Mary St. Pierre, RN, BSN, director of regulatory affairs for the National Association for Home Care (NAHC), says agencies are required to keep up with the latest directives, and know what safety devices are available for the procedures they perform. "I know that agencies are desperately trying to get the best equipment in there because it is very costly when they have somebody who has a needlestick injury — both emotionally and financially costly."

St. Pierre says some advances that agencies may see as too expensive could end up saving money in the long run. "[Agencies] need to be certain that they weigh the cost-benefit analysis. It may save them tremendously, if they avoid the emotional trauma and the financial costs of having their staff have to go through the follow-up of having a needlestick, the reports and physician visits and testing."

Special risks in home health

The very nature of home health — bringing care to patient homes, transporting supplies from place to place in personal vehicles — leads to particular needle safety risks, says Donna Haiduven, RN, PhD, CIC, infection control supervisor for Santa Clara Valley Medical Center in San Jose, CA.

Haiduven conducted focus groups with home health nurses to study the barriers to needle safety in home care.

"There’s no standardized work surface, so a nurse has to put her equipment down wherever she can find a place," she says. "Poor lighting makes it hard to see what you’re doing."

Body mechanics can play a part if a patient is in a chair or other position that requires a nurse to bend at an uncomfortable angle. In addition, she says, the nurse never knows what other factors may hinder a procedure, including children and pets getting in the way.

Scott D. Alcott, RN, BSN, PhRN, works on a relief basis for Abington (PA) Memorial Hospital Home Care, and performs a lot of venipuncture and IV access procedures. He says that one of the most difficult issues he deals with is disposal of the sharps afterward, particularly if a patient doesn’t have a sharps container in the home.

"You now have to be prepared to deal with sharps waste disposal, which for me means I carry a red box in my car," Alcott says. "So now I’m driving around with contaminated sharps — with biohazard waste — in my personal vehicle."

Needlesticks can occur when a sharps container falls open in the trunk, Haiduven says. If a container isn’t available, and the nurse leaves a recapped needle in the supply bag, another person could end up being injured later.

When a home health worker is injured by a needlestick, the cost of treating it can vary dramatically based on various risk factors, including the status of the patient and the type of wound inflicted.

Douglass says that in California, proponents of the new needle safety legislation pointed to treatment costs of $8,000 per needlestick. But she contends that costs only apply to a small number of cases. "Most needlesticks, including the large majority of what you see in home health care, are going to be low or maybe moderate risk. Then, you’re really looking at the cost of doing four blood tests over a six-month period — less than $500."

There may be added costs for giving a worker a hepatitis B shot if needed.

However, if the needlestick is deemed high-risk — from a clearly infected patient and involving a deep stick or large amount of blood — the nurse may have to embark on a 28-day drug regimen that is extremely expensive and can result in lost work time. In addition, some workers need counseling to deal with their fears about the injury.

And in the case of a hepatitis C exposure, where there is no vaccine and patients often progress to the point of needing a liver transplant, the costs are astronomical.

"You’re looking at up to a million dollars for a liver transplant," Douglass says.

Alcott, who himself suffered a nonseroconverting needlestick five years ago, estimates the cost of his prophylactic medications, lab work, doctor’s visits, and counseling at more than $3,500. And that didn’t take into account emotional stress or lost work time. "You have to start putting that into the price," he says.

Safer needle alternatives are improving

As interest has increased in safer alternatives to the standard needle equipment, technology has begun to provide new devices.

Most involve some means of moving the needle to a position where the sharp end isn’t sticking out of the device after a procedure is completed.

For example, Bio-Plexus Inc., of Vernon, CT, produces a blood collection needle that is "blunted" after use. A blunted needle sits inside another hollow-bore needle with a beveled edge. When the nurse or phlebotomist pushes a button, the blunted end slides outside the sharp edge, and the needle is removed.

"Sixty-one percent of needlestick injuries happen in the two seconds between the time the needle is removed from the patient and disposed of," says Carol Coburn, director of investor relations for Bio-Plexus. "What our product does is eliminate that two-second exposure time."

Another type of device causes a spring-loaded needle to retract into the syringe after it is completely depressed. Still others allow operators to slide or flip a plastic sheath over the exposed needle.

Bioject Inc. of Portland, OR, goes even further — its injector doesn’t use a needle at all, instead using compressed CO2 gas to fire medication directly through the skin.

Alcott, who in addition to his home health duties serves as northeast sales representative for Bioject, says his clients have seen a welcome side effect to the device: reduction in the need for sharps containers and red-bagged trash since the procedure rarely draws blood and the device has no sharp end.

New products aren’t perfect

All of those products have their limitations and drawbacks. Some require two-handed use, or that nurses change how they perform a procedure. If a safety device isn’t activated automatically, a nurse may forget to activate it.

The retractable devices may not be used for drugs given in incremental doses. Alcott says the Biojector shouldn’t be used for drugs intended to last a long time, such as the contraceptive Depo-Provera. It also isn’t calibrated to inject insulin, although the company makes a home-based insulin injector that a patient can use.

All of these options have one thing in common — they’re significantly more expensive than the standard needle and syringe. Douglass says facilities such as hospitals can justify the expense by pointing to a noticeable decrease in needlesticks. But her home health clients, many of whom had very few needlesticks to begin with, see less return on that expenditure.

"They can’t even equate it into reducing needlesticks, if they’re only having one every five years," she says. "It’s solely money out of their pockets."

Alcott points out that some of his clients have been able to go to their insurance companies and argue for lower premiums based on the lessened risk to employees.

Conversion process slow

Despite the regulatory move to safer needle devices, home health workers may be dealing with unprotected needles for years to come. One reason is that occupational safety guidelines don’t apply to individual patients, such as diabetics who self-inject. Home health nurses will continue to instruct those patients in how to use the needles.

In addition, because of the natural lag time as agencies and DMEs regroup and retool, "the standard syringe and needle are out there for a while to come, I would think," says Mike Brown, RN, CRNI, clinical director for Phoebe Care Connection in Allentown, PA.

But Alcott says change is coming. "You’re seeing more and more manufacturers developing safer systems. They know that the old 3- and 5-cents needle and syringe is a thing of the past. In most of the states that have passed legislation, the only way you’re allowed to use a needle is if you cannot do the procedure any other way. That’s pretty strict."