The personal side to needlestick prevention: One nurse’s story
New law requiring agencies to change will save lives
Once every 39 seconds, a nurse in this country sustains a needlestick injury. While most needlestick injuries result in nothing more than a good scare, far too many of them result in serious, life-altering (and in some cases, life-ending) diseases.
Most nurses accept accidental needlesticks as part and parcel of the job. Others are optimistic that it won’t ever happen to them. Lisa Black, RN, a nurse living in Reno, NV, once thought the same thing. Then, it happened to her.
Today, Black can no longer practice bedside nursing, a job which she loved and still misses. She has spent countless hours and days in the hospital and is on a strict regimen of medications. And her young children may one day find themselves without her. That kind of accident, as she is quick to remind people, is not a situation that affects one person. It affects entire families; and while she admits that hers is an extreme example, the fact that it happens at all is one family too many that is affected.
"Most cases might be low-risk, but that doesn’t negate the fact that [affected nurses] have families that are then frightened," she says. "The psychological impact is still huge."
A mission of education
Black, who contracted HIV and hepatitis C three years ago when she was accidentally stuck, has a warning for other health care professionals. "Nurses need to realize that needlesticks can happen to them and that they do happen to nurses every day. The statistics are unbelievable. When I started looking at the issue, all I could think was, This is unreal. How can it be happening this much in this country?’ The reality is that it does happen, and people need to realize that it is preventable and it is not an acceptable risk."
Black is on a mission to educate others: "When you figure that as an industry, nurses and other health care workers sustain in the area of 800,000 needlestick injuries every year — and not because people aren’t careful, but because it just happens — ethically and morally if you know it’s within your power to prevent something like what happened to me from happening, then how do you justify not doing it?"
Strong arm of the law
Preventing accidental needlesticks from happening was the impetus behind HR 5178, the Needlestick Safety and Prevention Act, which was enacted into law late last year. With the legislative portion of the battle to enact needlestick safety programs behind them, activists for the issue now face the tough road of regulation.
"This is where the true meat of the matter comes in," says Black. "The legislation sets forth guidelines, but how they will be implemented will be done on the state level. States that already have an individual OSHA [Occupational Safety and Health Administration] program will need to amend their bloodborne pathogen standards to be at least as restrictive as federal OSHA.
"This process is only going to be really successful if nurses and other health care workers get involved. My message to them is that if they want to see legislation that is most beneficial to them, then they need to take it upon themselves to see that it gets done."
As part of HR 5178, she explains, in cases where a health care facility has a choice between traditional devices and safety devices, the safety device must replace the traditional unless you can show that it is either not in the best interest of the patient or that it poses an additional hazard to the user.
Federal legislation also has emphasized that not only must the safety devices be used whenever possible, but bedside nurses should be included in the decision and selection process.
"It’s important that the decisions on what devices to use aren’t being made in a vacuum by administrators with a rubber arm who are looking only at the bottom line," Black asserts. "The fact that nurses have a say in this process is a very important component."
In addition to selecting safety devices, the new federal law mandates that health care facilities adopt a record-keeping program that will allow them to track the incidences of needlesticks among their employees. Employers will be required to maintain a sharps injury log, which must cover, at the bare minimum, the type and brand of device involved in the incident; the department or work area where the exposure incident occurred; and an explanation of how the incident occurred.
The information will be recorded and maintained in a way that will protect the confidentiality of the injured employees, and the log will be an important source of data for researchers to determine the relative effectiveness and safety of devices now on the market and those that may be developed in the future.
Black notes that 17 states have already independently enacted needlestick prevention safety regulations, but the federal law will take them to a new level.
"With the status quo, you can look at the numbers of accidental needlesticks, but reporting is sketchy at best," she explains. This legislation requires that every exposure that occurs be recorded in one place and logged by exposure, the type and brand of device that was used, how it was used, if it has a safety feature, and if not, why. Many states already have taken this to a higher level and included a statement from the employee as to whether there’s a device that could have prevented this from occurring."
While the government has made certain that needlestick prevention programs will be in place in every health care facility, it can’t mandate that health care professionals follow those instructions.
"People hate change," Black points out. "You can’t just put out the new devices and leave it at that. You need to get buy-in from your employees, otherwise you’ll have people saying, Well, I did it this way before, and it worked fine. Why do I need to change?’ So giving people new devices is only half the battle; you want to get them to use them, and that might take teaching them slightly new techniques."
At Home Health Care Management in Wyomissing, PA, Romayne Keener, RN, has seen that change in action. Her agency has been using a needleless injection device for flu vaccinations for eight years now, and they’re beginning to test other devices for use with other injections. She agrees that people sometimes react initially with negative attitudes.
"Change is difficult for everyone," she notes. "It’s a very different feel to use the new device than to use a needle, and hard-core nurses like myself, who have been doing this for a long time, pride themselves on their technique. These new things can rob you a little bit of that in the beginning. But you can have good technique with these devices, and you will if you keep plugging away."
Needlestick prevention is like the age of computers, Keener explains. "Technology is coming whether you want it to or not." And unlike the computer revolution, jumping on the needle safety bandwagon is not optional.
Since all health care facilities also are mandated by law to provide employees with annual training on preventing bloodborne pathogens, Black suggests merging the two subjects and providing employees with training on how to use the new devices (such as syringes with retractable needles), and how to use them most effectively.
While the need to enact needlestick prevention legislation is rooted in the moral and ethical issues of "if a tragedy can be prevented, why not do it?" there is, of course, another side of the equation — money.
"Cost is the argument against it," Black explains. "The argument goes that it just costs too much money to enact such a program on the off-chance that a worker may sustain an injury that may or may not cause them to become infected. And it does cost more money, but when you look at the cost of follow-up health care, it pales."
For a needlestick injury that doesn’t lead to infection, the cost of treatment is somewhere in the neighborhood of $3,000. "That covers lab work, follow-up prophylactic medications, and if it was a high-risk stick, that person will be taking some very costly medication that may or may not work," Black points out. And, she adds, when you extrapolate that to every high-risk needlestick, "you’re talking about a lot of money."
Take that one step further to someone who does become infected, and you’re talking about a huge monthly sum for medications and Medicare disability payments. Black, for example, says her HIV medication costs between $2,000 and $3,000 a month, while her hepatitis C medication is another $2,000 a month. Add to that several thousand dollars in disability, and it costs about $7,500 a month to keep her alive . . . and that’s provided she remains "healthy." She recently suffered from a severe infection that put her in intensive care. The cost: $80,000 for one week.
"When you look at that, the cost of one conversion [infection] in a 30-year-old health care worker is fully estimated to exceed $1 million from time of conversion to the end of that person’s life. So I see not implementing a needlestick prevention program as a game of Russian roulette," she states.
The cost of human suffering
Keener agrees. "It’s like my daddy used to tell me: If you want something, and you really need it, go buy it. And buy top of the line." Instead of only considering the cost of the device and the cost of implementing it, she stresses, "look at the cost of what it is for just one needlestick injury," especially in a company like hers, which is a conglomeration of five different health care organizations. The risk far outweighs the cost of change.
Regardless of whether an institution wants to implement a needlestick prevention program, they now must. Black encourages health care facilities not to reinvent the wheel and to do some research into other similar agencies in states where needlestick prevention regulations have already been in effect and then see if they can’t share information.
But even the best-laid plans can go astray, especially when there is no one watching to see that they don’t. Black points out that OSHA currently has enough funding to spontaneously inspect every health care facility in the country once every 75 years.
"OSHA doesn’t plan on stepping up its enforcement efforts," she notes, "so the odds of being caught if you don’t have a strong program in place are slim. If a facility is not in compliance, it’s up to the employees to call and report it and ask for an investigation. If that’s done, OSHA is obligated to comply, and the facility can be cited."
Citations have a greater effect than a slap on the hand, she notes, pointing out that in California "some substantial fines were levied on some facilities and after that, statewide compliance shot way up."
By and large, facilities are going to comply, she says, but to get true compliance and the highest level of protection, "people need to understand that they have the power to anonymously report these offenders to OSHA.
"My own bias is that I think it’s sad that we’ve had to legislate this issue. Ideally and ethically those in administrative positions would recognize this threat. They see the numbers; they know it’s preventable; and in an ideal world, people would take precautions to protect their people and take whatever steps they needed to protect them.
"They think if it happens to one person, those risks don’t matter. But when it happens to you, it’s 100%, and it matters," Black adds.
[For more information, contact:
• Romayne Keener, RN, Community Health Educator, Home Health Care Management, 1170 Berkshire Blvd., Wyomissing, PA 19610. Telephone: (610) 378-0481.]