Halfway through his 12-hour shift in the emergency room of Northeastern Hospital in Philadelphia, PA, Jeffrey Heebner, D.O., took a blood sample from a 45-year-old male patient. Heebner was a fourth-year medical student when he saw this patient four years ago, and was inexperienced in drawing blood.
After taking a sample from a vein on the man's right arm, Heebner tried to unscrew the 20-gauge hollow bore needle from the vacutainer, a needle-holding device. His clinical education had not yet taught him safe disposal techniques. So when the needle finally popped out, the 28-year-old medical student fumbled to grasp it before it hit the floor. The sharp end stuck Heebner on his left thumb.
Terrified, he alerted the attending physician of the incident. ER staffers told the young physician what to do to find out if he'd just contracted Hepatitis B (HBV), Hepatitis C (HCV) or AIDS.
Heebner is infection-free today because the blood's source or patient was negative for disease. But Heebner was sick with worry until the fourth set of blood test results came back six months after he was stuck.
But up to 12,000 clinicians are infected with HBV annually, according to data from the Center for Disease Control (CDC) and the National Phlebotomy Association. As many as 200 health care professionals die annually from occupationally acquired diseases, such as HBV, and 4,500 new cases of HCV cropped up in 1994, CDC statistics reveal. Fifty-two documented cases and 111 possible cases of occupationally acquired HIV infections were reported to the center in late 1996. And as many as 50 cases of AIDS and HIV infection occur annually, according to phlebotomy association numbers.
Though more than 800,000 needle sticks happen to health care workers such as Heebner every year, say medical researchers, nobody knows exactly just how many of the aforementioned infections result from these sticks.
OSHA enforcement doesn't control needle sticks or diseases such as Hepatitis or AIDS. Only 14 hospitals were fined for potential violations of OSHA's bloodborne pathogen standard in 1997. Plus, only two percent of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 5,600 accredited hospitals might have received a recommendation in the area of hazard controls last year.
This article details exactly what occupational nurses, physicians and other health care workers who are exposed to blood should do in the event of a needle stick, and offers suggestions for how to prevent sticks in the future.
Determining the blood status
OSHA regulations state that once a needle has been injected into a patient, that needle and its contents are contaminated. So if a health care worker is stuck with a 'contaminated needle', five steps should be taken to control the risk of worker infection, according to experts ISHN spoke to:
Hospitals are more concerned about workers contracting HBV or HCV than AIDS, says Cyndy Darcy, RN, head of the Infection Control Department at Suburban General Hospital in Norristown, PA. That's because contracting hepatitis is more common than getting AIDS, she says.
OSHA requires employers to vaccinate employees soon after hire (some hospitals vaccinate employees as soon as 10 working days after date of hire) and requires that employers pay for the HBV vaccination. Employees can refuse the HBV preventive medicine, but they must sign an OSHA-required waiver indicating their refusal.
"Most studies claim you're 97 percent protected if you've had the vaccination series for Hepatitis B," says Darcy. Chances of contracting HIV increase if the amount of virus in the needle is high, says Donald Waite, D.O., M.P.H, member of the American Osteopathic Association and professor emeritus at Michigan State University. But testing the source's blood for disease can only happen if he consents.
"Determining the infectious status of the source blood is a specific and complicated process because of HIV regs," says Darcy. Patients can refuse to have their blood tested under ACT 148 of federal regulations, she says. So if a health care worker is stuck with a needle and the patient does not give written consent to a physician to test it for disease, the victim has few options, say experts:
Rarely does the issue go to court because extra blood has usually been drawn and doctors are allowed to test those samples, say medical experts. Under federal law, if extra blood was drawn from the source for additional tests and before the needle stick occurred, physicians are permitted to test that blood for HIV because it was taken from the source before the exposure and with permission.
Necessary medical attention
After assessing risk or determining whether or not infection has occurred, needle stick victims need to seek medical attention. Medical experts interviewed by ISHN explain the proper protocol for HBV, HCV and AIDS.
HBV Employees should be immunized against HBV. Eight years after the initial immunization, conduct a "titer" blood test to see if the HBV antibody is still in their system. If it's not, a booster shot is needed. Employees who are not immunized and contract HBV through a needle stick should take the HBV immunoglobulin within a few hours of exposure to combat the infection.
HCV No vaccine exists for Hepatitis C. But Similar to HBV, a three-percent chance exists for contracting the virus if a worker is stuck with an HCV-infected needle. If a worker contracts HCV, a 50-percent chance exists for contracting liver disease. But Interferon therapy is the only treatment currently available for chronic HCV, according to a recent article in Family Practitioner Recertification magazine.
AIDS The HIV virus and AIDS are the most serious of needle stick-contracted infections, but also the least prevalent, say experts. Drugs to treat symptoms of AIDS have been available for years, but the Food and Drug Administration (FDA) has yet to approve AIDS prevention drugs, according to CDC research.
If a worker is stuck with a needle suspected or known to be AIDS-contaminated, he should immediately be tested for AIDS to see if the virus was in the worker's system prior to the stick. If the results of the first test are negative, the worker should be AIDS-tested again six weeks after the first test, then again after 12 weeks, with a final AIDS test conducted six months later. If he is positive for AIDS after the fourth test, medical personnel assume the worker was infected by the needle stick, say experts.
While testing is being conducted, CDC guidelines suggest starting on AIDS drugs immediately, though only a .3 percent chance of infection exists. AIDS therapy after an occupational exposure includes taking zidovudine or AZT in combination with several protease inhibitors to slow down the replication process of HIV. Workers with ow-risk exposure to AIDS should still be offered AIDS therapy, according to guidelines for blood exposure sued by the Becton Dickinson [Co.] Vacutainer Safety Institute.
Preventing needle sticks
Pain, suffering and worry aside, the expense of a needle stick warrants preventive action. Costs associated with AIDS therapy, including AZT exclusively or in combination with protease inhibitors, range from $400 to $2,000, say researchers. Cost of lifetime treatment for AIDS runs as high as $500,000.
But some methods of preventing needle sticks are free, such as disposing a used needle immediately and not placing it on a tray even for a moment where someone could be accidentally stuck with it, says Waite. He remembers when he was in practice 43 years ago and physicians had to reuse needles. "I stuck myself twice back in those days," he says. "Once on the back of a hand and another time right in a vein. In addition to local wound care, we would do appropriate lab tests if we knew the patient had a communicable disease such as syphilis."
Using protective devices on needle tips can also prevent sticks, say other experts. In fact, up to 80 percent of all needle sticks could be prevented by using the right technology, says Janine Jagger, M.P.H, Ph.D., director of the International Health Care Worker Safety Center, University of Virginia Health Sciences Center.
"OSHA's bloodborne pathogen standard was significant, but they [OSHA] can do much more to enforce how health care institutions must provide engineering solutions to prevent needle sticks", says Jagger.
CDC research reveals that using blunt suture needles can reduce needle sticks during surgery up to 86 percent. And though the FDA evaluates needle devices, it doesn't recommend which ones are best for preventing sticks.
CDC recommendations for preventing sticks include:
"The CDC told health care workers to stop recapping needles back in 1987," says Sara Critchley, a nurse consultant for the hospital infections program at the CDC in Atlanta, GA. Critchley understands that capping needles may seem practical, but the CDC suggests keeping those sharps containers in the rooms where needles are used.
JCAHO's guidelines for hazardous materials and controls are similar to OSHA's mandates identify infectious risks and provide appropriate engineering controls. But, specific guidelines for needle sticks do not exist.
For an overview of OSHA's bloodborne pathogen standard, see the September 1996 issue of ISHN.
An information network
Since 1992, the Exposure Prevention Information Network (EPINet) has served as a standardized surveillance and data sharing system to hospitals in the U.S. and in several other countries.
Developed by the University of Virginia's International Health Care Worker Safety Center, part of the University of Virginia Health Science Center, sharps (needle) injuries and other blood exposures are tracked, as well as job categories of injured workers, devices causing injuries, and when in the use/disposal cycle injury occurred.
EPINet data helps its member hospitals comply with OSHA standards. Currently, 1,500 hospitals use EPINet, and some are located as far away as Italy and Australia. Seventy-seven of those hospitals participate in a data-sharing network so other users can determine how injuries and exposures occur in order to prevent them.
For more information on EPINet, call the International Health Care Worker Safety Center at (804) 982-0702.
Top ten reasons how health care workers sustain percutaneous wounds Based on 1995 EPINet data, the following items punctured the skin of hospital workers and exposed them to contaminated blood more than any other sharp devices:
2.other types of needles
3.other sharp items, such as glass
4.fingernails and teeth
9.retractors, skin/bone hooks
Lynda Arnold's mission
When you visit www.healthcaresafety.com, you'll see a picture of a young woman with a vibrant smile. You'll also see pictures of her two kids and her husband. But your emotions will be bittersweet once you start reading the copy.
Lynda Arnold is 29 years old and dying of AIDS. She contracted it from a needle stick in 1992 while working as a registered nurse in the intensive care unit at the Community Hospital of Lancaster, in Lancaster, PA. She's now on a mission to prevent bloodborne illnesses in hospitals by asking health care facilities nationwide to provide workers with devices designed to prevent needle sticks. Her campaign is called the National Campaign for Healthcare Worker Safety.
After contracting the disease herself, Arnold volunteered for others afflicted with AIDS. She also saw little or poor HIV educations available to health care workers, and decided to increase needle stick safety on her own. "What I thought would be an 18-month commitment turned into a two-and-a-half-year commitment," says Arnold cheerfully. "And we don't know when it will end."
By the time this article is in print, nearly 550 hospitals will have signed a pledge to use safer blood drawing devices and catheters. Arnold makes speaking engagements nationwide to reinforce her commitment to needle stick safety.
Averaging eight days of travel per month, Arnold also busies herself with helping husband Tony, and sister Susan, run the non-profit Campaign from their suburban Philadelphia home.
Through 1999, the campaign aims to:
Since its inception in 1994, the campaign has created a video documentary available for hospital workers to explain the importance of needle stick safety, educated the public about supporting legislation like the Pete Stark House Bill No. 2754 which encourages hospitals to use safer needles in order to get Medicare funding and set up interactive chat groups online.
The release of two children's books written by Arnold, My Mommy Has AIDS and Angels of Love, from Dream Publishing, is her most recent endeavor. Proceeds from the first book are divided between the campaign, the Elizabeth Glazer Pediatrics AIDS Foundation, the National Pediatrics Family and AIDS Resource Center, and Camp Heartland. Ninety percent of monies from the second book go to adoption agencies nationwide to assist special needs children, another cross which Arnold carries because her own two kids, David and Ashley, are adopted, special needs kids. Those books can be purchased online from www.Amazon.com.
For more information about Arnold's campaign, call (800) 936-7370, or to make a donation, send it to: the National Campaign for Healthcare Worker Safety, 3108 Jolly Road, Norristown, PA, 19401.
There was standing room only for about 50 nurses, physicians and maintenance personnel who packed the second floor Walkup Conference room at Suburban General Hospital in Norristown, PA. All were present for their annual OSHA bloodborne pathogen training session, coordinated by the hospital's own infection control director, Cyndy Darcy. Personnel watched a 25-minute video on safe working methods recommended by OSHA. Video contents addressed universal precaution measures to take when working around blood, such as using personal protective equipment and considering all needles contaminated.
After the video ended, Darcy, a tall, blond, 40-something woman with a warm smile, shocked the audience with hand-washing statistics: If health care workers know they aren't under surveillance, they'll only scrub up 12 percent of the time. When they know they're under surveillance, they'll wash up 32 percent of the time after handling patients or contaminated objects.
"My trade journals say enough of us still aren't washing our hands properly," she said in a mildly scolding tone. "Make sure you're washing them for 1015 seconds even after you remove your gloves." Toward the end of the program, she reminded workers about the protocol for needle sticks: Wash immediately, go to the emergency room immediately, and if it's a high-risk stick, such as being stuck with a late-stage AIDS victim, you may need to start therapy within two hours of the incident.
Infection control at Suburban General addresses injury trends as a means of preventing needle sticks. For example, if most injuries in a given year result from inexperienced medical students or from overworked laboratory technicians drawing blood, then perhaps additional training or a new protective needle stick device is needed to prevent incidents.
Still got questions? Call an expert