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Delving into unmapped territory, researchers have embarked on a three-year study to determine rates and risk factors for occupational exposures and bloodborne infections in health care workers beyond the hospital setting.
"From what we have seen so far these are pockets of risk that are hidden," says Robyn Gershon, MSH, DrPH, principal investigator for the project at the Mailman School of Public Health at Columbia University in New York City. "It doesn’t mean they have the same kind of risk as hospital [workers]. In many cases of course it is less, but in other ways it could be more."
Though the focus on hospital workers and needlesticks has intensified in recent years, millions of workers along the health care continuum remain something of an unknown in terms of blood exposures and risk.
While hospitals employ some 5 million workers, Gershon estimates that some 3 million to 5 million health care workers are currently employed in nonhospital settings. For example, 1.7 million workers are in nursing and personal care facilities; 672,000 work in home health care, and another 200,000 work in medical and dental labs. (See "Diverse settings, specific aims," in this issue.) In particular, early findings of the study suggest that settings that are not affiliated with a hospital are less likely to have adequate infection control personnel and policies.
"If they are not affiliated they really have potentially greater risk because they don’t have the infrastructure," she says. "They are not big enough to have to have an involved safety committee let alone an infection control committee. They may not have their own in-house, trained infection control officer. They might have a nurse who picks up that responsibility, but they may not be trained and certified. I think that makes a tremendous difference," Gershon continues.
Though not wanting to detail observations about specific settings yet, she described initial findings of concern in many areas. "It is almost like they are doing a do-it-yourself kind of infection control program," she says. "They didn’t have expertise, they aren’t [informed], and they are doing it by their bootstraps."
Such settings are essentially flying below the regulatory radar, even as a national needlestick safety mandate is being put in place for hospitals by the Occupational Safety and Health Administration (OSHA) and the Joint Commission on Accreditation of Healthcare Organizations. (See "Device vise: Joint Commission enforcing OSHA needle mandate," in this issue.)
But most observers expect that to change as the momentum on the issue continues to grow. Data from the study will likely end up being reviewed by regulating agencies because the study is funded by a grant from the Centers for Disease Control and Prevention, an agency whose guidelines often lead to OSHA and Joint Commission requirements.
"From my experience now over the last few months, I can see that there is a differential application of the [OSHA] standards and CDC recommendations," she says. "They don’t have what we call a safety climate. That could increase the risk to these people."
It is critical to define the prevalence of bloodborne infections and risk factors for exposures because there are now both effective primary (e.g., engineering devices) and secondary (e.g., post-exposure prophylaxis) prevention strategies for nonhospital workers, she emphasizes. Using direct observation, surveys and focus groups, the study looks to uncover risk factors, rates of injury, the availability and use of safety devices, and use of post-exposure prophylaxis (PEP) for HIV.
"HIV is one thing, but now we are seeing more and more hepatitis C virus in our patient populations," Gershon adds. "We really what to find out what are their risk factors and what kind of mechanisms are in place to reduce that risk."
The study is also using "field internships," which calls for a researcher to link up with a worker in one of the settings. "They are really like guided walkthroughs," she says. "We are shadowing’ the health care workers in each of these settings."
In addition, researchers will randomly select a sample of 6000 employees (about 600 per non-hospital group) throughout New York state to receive a confidential mailed survey. A sample of 1,000 hospital-based nurses will also be randomly selected to allow for occupational comparisons between hospital and nonhospital settings. "The data that we collect in year two, which is coming up these coming two months, will be by participatory action research teams,’ she says. "That way the frontline workers themselves can work collaboratively with the researchers to develop these interventions."
Ultimately, Gershon hopes to develop some kind of practical tool or "risk grid" that could be used by nonhospital workers to assess their duties and determine their risk of bloodborne infection.