Sharps injury risk higher in home health

Focus groups reveal hazards in homes

Home health nurses face a substantial risk of sharps injuries but often do not get prompt follow-up, according to a study by researchers at the University of Massachusetts Lowell.1

In focus groups and interviews, nurses also told of exposed sharps in their patients' homes, a lack of safety-engineered devices, and sharps containers that overturn and spill in their cars. The study highlights the need to tailor sharps injury prevention to home health care needs, says study co-author Stephanie M. Chalupka, EdD, APRN, BC, CNS, FAAOHN, professor in the Department of Nursing in the School of Health and Environment at the university.

"In the hospitals, it's very rare, and people frown on people leaving improperly disposed of sharps around. In the home care setting, insulin-dependent diabetics are going to leave their equipment around in places that nurses may not expect to encounter it," says Chalupka. "There are frequently used devices left unsheathed until the next use. When you're on a fixed income, in an effort to be economical, you may say, 'I can use this until the needle gets dull.'"

Meanwhile, patients being treated in the home have an increasingly high acuity. "More and more demanding medical procedures are moving into the home setting," says co-author Pia Markkanen, ScD, research assistant professor at the Department of Work Environment and Lowell Center for Sustain-able Production at the University of Massachusetts Lowell.

In all, 17 nurses and seven home health aides participated in five 90-minute focus groups. They were recruited from participating home health agencies and worker unions. The researchers also conducted 10 in-depth interviews with managers and union representatives.

Many of the nurses, aides, and managers had experience in the hospital setting, and they noted that hospitals provided a more supportive environment for reporting and follow-up of bloodborne pathogen exposures.

Home health nurses 'working in isolation'

The home health nurses lack backup, notes Chalupka. "[Home health] nurses are working in isolation. They are the only person caring for that patient," she says. They are reluctant to seek care for their needlestick if there is no other nurse or aide who can take over for them, she says. Meanwhile, the closest health care facility may be many miles away, Chalupka adds.

In fact, the isolation of home health workers also makes their workplace hazards less visible, the authors conclude. Meanwhile, the home health workers are dedicated to patient care — and report that they enjoy the independence of the job. "In some ways, people we have spoken to take it just as part of the job [if they suffer a needlestick]," says Chalupka. "I find that to be one of the most unfortunate aspects of work in home care with sharps injuries."

Researchers have used the focus group results to craft a survey of 1,225 home health workers. The surveys will provide more information about sharps safety in home health care and may lead to recommendations for improvements, says Markkanen.

"Home health care can be made safer," she says. "These interventions should preserve the wonderful aspects that home health care can provide and as much as possible to minimize the hazards

Here are some issues raised by the focus group study:

  • Do the home health nurses have access to safety-engineered devices? The focus groups revealed significant differences in the availability of sharps safety devices. At one agency, for example, focus group participants reported that more than 90% of the devices they used had safety features. Yet at another agency, participants said safety devices weren't available to them in some categories, such as lancets used by diabetics. Hospitals also need to encourage insurance companies to reimburse patients for safety-engineered devices, says Chalupka. Home health nurses often educate patients in how to use their own devices — and often those do not have safety features, she says.
  • Are home health workers included in sharps safety device evaluations? The U.S. Occupational Safety and Health Administration requires employers to include frontline health care workers in the evaluation of sharps safety devices. Home health nurses need to be part of that dialogue because they have some unique issues, the study authors say. For example, a sharps container that works well on the wall of patient's room in the hospital may overturn in their trunk, spilling contaminated needles and creating a risk for exposure.
  • Is worker safety a part of the home health assessment? Bloodborne pathogen exposure is just one workplace hazard that confronts the home health nurse. The focus group nurses raised concerns about lifting patients and violence in the home or neighborhood. The risk of injury also may be greater because of cramped workspace or clutter in the home. "Home health care nurses have very little control over their work environment," notes Chalupka.
  • Are home health nurses receiving adequate training? OSHA requires employers to provide training as a part of the bloodborne pathogen standard. For home health nurses, that training must be focused on their particular needs but also broad enough to encompass the wide variety of devices that their patients may be using. Home health nurses should know how to get immediate follow-up care if they have a needlestick and there should be a method to provide backup care for the nurse's other patients, says Evie Bain, MEd, RN, COHN-S, FAAOHN, associate director and coordinator of the Division of Health and Safety with the Massachu-setts Nurses Association in Canton, who helped coordinate focus groups. "A lot of nurses don't know that the best outcomes for bloodborne pathogen exposure are to get treatment in the first hour [after exposure]," she says.
  • Can a patient's home be made safer? To enhance safety, home health should incorporate needless devices whenever possible. For example, some medications may be available in transdermal patches or inhalers. Of course, when home health nurses go to a new patient's home, there always will be an element of unpredictability. Chalupka recalls when she worked as a home health nurse and was bitten by a German shepherd while starting an IV line. "Very seldom do you have a German shepherd jump up on the bed in the hospital," she says. "One of the first things you'll learn [in home health] is to lock pets in the bathroom."