Lisa Black used to take care of sick people every day. Now the 28-year-old nurse is the one who needs help.
Her life changed forever on Oct. 18, 1997, during a seemingly ordinary shift at a small hospital in northern Nevada. She prefers not to name the facility because of an ongoing workers' compensation case.
During rounds Black noticed that blood was backing up and starting to clot inside the intravenous line attached to a terminally ill AIDS patient. Like thousands of nurses who confront this problem daily, Black used a syringe to clear the blockage and spare the man the pain of starting a fresh IV.
In an instant, however, clinical routine turned to terror. The startled patient jerked his arm away, and the bloody needle leapt from the rubber port on the IV line and pierced Black's left palm.
"It's horror," she says, "but you don't think anything will happen."
Most nurses know, as Black did, that only 1 in 300 sticks with needles carrying HIV-contaminated blood lead to infection. To better her odds, Black immediately started a one-month, emergency regimen of AIDS drugs to stop any virus from taking hold.
After six months of negative lab tests, Black thought she was in the clear. But she was hospitalized three months later in July 1998 with an excruciating headache and other symptoms that suggested meningitis but instead were caused by HIV. Three months after that she also tested positive for hepatitis C.
Unable to work, Black is one of many who have fallen victim to the tools that are supposed to heal and is one of few who are willing to talk about it.
Black says everything would have been different for her if the patient had been connected to a safer IV system. Safer alternatives have been on the market for more than 10 years, and the Food and Drug Administration has recommended them since 1992. In fact, a safer system was available but not required at the hospital where she was injured.
"If that needle-based system was not there, I wouldn't have been stuck," she says. "If there's no needle-there's no needlestick."
Deadly lottery. Hepatitis and AIDS are the wretched prizes in a healthcare lottery that nobody wants to win.
As many as 600,000 times each year, healthcare workers across the country risk infection when needles, scalpels or other sharp instruments break their skin. At best, these unlucky women and men must endure days and sometimes months of worry about whether they will fall ill. Sometimes, their fears prove well-founded, and like Lisa Black, they turn to emergency treatments to stop infections in their tracks. At worst, they must resign themselves to life, perhaps cut short, with an untamable infection such as hepatitis or AIDS.
Each year as many as 39 workers are infected with HIV while more than 4,400 contract one of several forms of hepatitis, according to estimates from the International Health Care Worker Safety Center at the University of Virginia.
Nurses and phlebotomists, the specialists who draw blood, face the highest risk. But every day healthcare workers of all stripes brave the possibility that routinely injecting a patient, drawing blood for laboratory tests or starting a lifesaving intravenous line could change in the blink of an eye into a deadly occupational accident.
Needlesticks account for about two-thirds of sharps injuries. But hospitals can prevent most of these potentially infectious pinpricks and other sharps injuries, experts say, by using devices designed with safety in mind.
These new tools put the healthcare industry at a crossroads for workplace safety. Products already on the market could dramatically cut the risk of injury and illness for healthcare workers. But cost and administrative inertia have slowed their adoption, spurring legislators and regulators across the country to get into the act to compel change.
"Despite what's been available for over a decade, the large majority of institutions are not choosing to use (safety products)," says Karen Daley, president of the Massachusetts Nurses Association. Daley, 46, contracted HIV and hepatitis C from a needlestick while working in the emergency department at Brigham and Women's Hospital in Boston last July.
Even before she tested positive, Daley started work on needlestick safety legislation in Massachusetts because she was convinced that was the best way to make workers' safety a priority for employers. "There's very little incentive in the system for hospitals to switch over without some kind of mandate," she explains. Workers' compensation laws insulate hospitals from lawsuits and much of the financial pain from needlestick injuries, Daley and other activists say.
Legislation picks up steam. Lawmakers-spurred by harrowing stories from injured workers like Daley and relentless union lobbying-are taking action. A legislative steamroller is gathering speed to force hospitals across the country to do more to protect their workers from injuries caused by sharp medical objects.
As is often the case, the movement began in California. Last September, then-Gov. Pete Wilson signed a law requiring healthcare providers to use products designed to prevent injuries, formally evaluate new safety products as they become available and keep detailed records of all sharps injuries. The teeth in the law came this year through regulations enforced by California's Occupational Safety and Health Administration. The regulations became effective last week.
Now the rest of the nation seems poised to follow California's lead. Maryland and Tennessee enacted similar laws earlier this year, and legislators in 20 other states are proposing various measures. In Congress, Reps. Fortney "Pete" Stark (D-Calif.) and Marge Roukema (R-N.J.) co-sponsored a bill in May that would require federal needlestick prevention laws like California's.
The American Hospital Association has opposed the federal legislation, saying current laws are adequate and raising concerns that safety designs may create tradeoffs that could compromise patient comfort or ease of care. Supporters of the laws dismiss the latter objection as a red herring, unsupported by data, and say that penny-pinching, rather than patient protection, is to blame for the opposition. Laws are needed, they say, because even those safety devices that have been around long enough to have the kinks worked out aren't used enough.
"If these devices were designed to protect patients at this level of cost, and the potential risk to patients was death-and it is death-you can be sure that hospital administrators would consider this relatively minimal cost well worth it," declares Janine Jagger, director of the International Health Care Worker Safety Center at the University of Virginia. She says the writing is on the wall: Safety products are the best way to reduce injuries. But hospital administrators can't seem to read, she adds.
The cost of safety. Whether pushed by legislators or pulled by competition for scarce nursing talent, hospital executives across the country are confronting anew the question of how to safeguard their workers' health. Their decisions about what, if any, of the new products to buy could recast some of the most basic and frequent contacts between clinicians and their patients.
At least in the short run, these new products could break the budgets for such commonplace supplies as syringes and blood-drawing kits. Manufacturers commonly charge twice as much for the safety products as for the traditional models they replace. Devicemakers attribute the price differences to start-up costs, low manufacturing volume and additional parts. They say prices will decline as demand picks up.
New technology can help prevent many, though not all, injuries. But the cost of lowering the rate of these already rare events is high, at least for now. Like plane crashes, though, these infrequent mishaps carry the potential for catastrophic consequences. A needlestick leading to HIV infection can cost upward of $1 million in treatment and lost wages.
Nobody wants to be added to the ranks of the infected. Yet many healthcare workers, perhaps in psychological self-defense, believe the accidents could never happen to them. They know what they are doing, they say. Yet the numbers and the personal tragedies behind them show that no one is immune to the dangers unleashed by inadvertent needlesticks.
In such macho industries as construction and mining, specialized safety equipment-from hard hats to steel-toed boots-have been used for years to reduce workplace injuries. Ironically, healthcare, whose guiding purpose is to make people well, has lagged behind other industries at using safety products to reduce the risk to workers' health from the communicable diseases in the patients they treat.
Technically, no excuses. "There's not a technical reason that people shouldn't be going to these devices," says Robyn Lit, a biomedical engineer and project officer at ECRI, a Plymouth Meeting, Pa.-based product testing organization. ECRI has evaluated more than 50 kinds of safety devices. Lit says that although some don't quite live up to their billing, "in every category we have acceptable devices."
According to the national Centers for Disease Control and Prevention, existing safety devices, such as intravenous access needles that automatically blunt themselves after insertion into veins, can slash accidental injuries to workers by about 75%.
Some say a lack of adequate safety products has been remedied only recently. Others say healthcare executives haven't attacked workplace injuries aggressively enough, fearing the price. Better intravenous systems that don't require needles to add drugs or to mix solutions in the lines running into patients' arms have been around for years, yet they are used only about two-thirds of the time.
To be sure, the advent of AIDS and the emergence of highly contagious and hard-to-treat strains of hepatitis have made eye shields, exam gloves and protective gowns de rigueur in many hospital departments.
Yet some clinicians still resist. Even when available, safety products aren't always used, contributing to the risk of injury. Some experts like Jagger, however, lay blame at the feet of hospital executives who fail to embrace safety products fast enough.
Now, if somewhat belatedly, a broad array of devices designed to protect healthcare workers from inadvertent injuries is being brought to bear, and ground zero is California. California hospitals represent roughly one-tenth of the market for medical products, and they are set for a buying spree for safety products to comply with the new state regulations.
Expenses and savings. Healthcare supertanker Kaiser Permanente, Oakland, Calif., began steering a new course toward improved worker safety early this decade. In the early 1990s two Kaiser workers, one in a laboratory and the other in a clinic, contracted AIDS from needlesticks.
Across Kaiser's 29 hospitals and more than 100 medical offices in California, healthcare workers sustain between 800 and 900 needlestick injuries each year-three injuries per 100,000 hours worked, according to Enid Eck, nurse coordinator in charge of HIV and infectious disease prevention for Kaiser's California division.
"These (safety) devices are not cheap," Eck says. But Kaiser, she explains, decided to embrace safety products even before state regulations required them. Employee recruitment and retention in the face of a nursing shortage were big reasons. She says the message to Kaiser workers is: "Your health and well-being are more important to us than the unit cost of a widget."
Eck declines to provide the cost of implementing safety devices systemwide, although she says most safety products cost two or three times more than the devices they replace. One indicator of the scope of the Kaiser program, however, came last month: a three-year, $30 million purchasing agreement with needlemaker Becton Dickinson and Co., Franklin Lakes, N.J., for safety-engineered medical devices. While acknowledging the costs, Eck maintains that the overall economic effect of the safety program is nearly a wash.
Banishing needlesticks also eliminates the costs of emergency drug treatments, employee counseling and stress leaves, she says. Avoiding the costs of debilitating illnesses such as hepatitis C, which is incurable and is the leading cause for liver transplants, represents another huge savings. "If people lose their livers, you're talking big money," Eck says.
The budget hit for switching to safety products should not be underestimated. "As director for materials management, I have fiduciary responsibility," says Larry Carlson, of ValleyCare Health System, a two-hospital system based in Pleasanton, Calif. That put him between a rock and a hard place when he looked at the devices. Carlson says he saved some money by buying safety devices under contract with Health Services Corporation of America, based in Cape Girardeau, Mo. But he adds that the technology is definitely more expensive and will increase his budget by about 20%.
Yet he supports the switch and would have made it even without California OSHA's regulation. ValleyCare started evaluating safety products in early 1998 for "ethical reasons," when government intervention wasn't a sure thing. Carlson's team zeroed in on hypodermic needles, catheters used in angiography and blood-drawing sets used in the clinical lab, because those were the highest-risk categories for injuries, he says. In late May, ValleyCare completed a systemwide switch to safety products.
He cautions hospitals that are jumping on the safety bandwagon to be thorough.
"It's shortsighted to stick with the first one or two products you see," he says. And even the best ones won't cure every problem. "There is nothing that I know of right now that is a fail-safe."
New ways. Even the best safety devices require clinicians to change their ways. Like a driver learning the quirks of a stick shift on a new car, healthcare workers must adjust to the safety devices. The most routine clinical tasks-learned by rote and reinforced by years of practice-are unfamiliar when using the new devices.
"There is not a single safety device that's as easy to use as a nonsafety device," says Trisha Barrett, a nurse and director of infection control and sterile processing at Alta Bates Medical Center, in Berkeley, Calif.
Patients don't like needles. And the more than 800 nurses and hundreds of doctors at Alta Bates use great care to ease the pain of each injection, blood draw or IV line, Barrett says. Some new products make for clumsy procedures, she says, and even the best ones are a little tricky to use.
For this reason, the standard approaches under OSHA inevitably cause friction.
"It's not just a worker and a piece of machinery," Barrett explains. "The 'thing' I'm working on is a patient."
Nevertheless, a changeover to safety devices is possible; it just takes careful planning, ample training and supervision.
"What we all know is that . . . getting people to understand and perceive the risk correctly is the first and biggest hurdle," Barrett says. Once workers really understand the dangers, she says, "they'll use the devices consistently, and then you've won the game."
Taking the initiative. Across the country, in Florida, needlestick legislation has yet to become law. But some hospitals are moving ahead anyway.
"We've reached the point where we need to use our wonderful technology not to cure the patient but to protect our caregivers," says Shelba Bobet, a registered nurse, director of materials management and chairman of the nursing products committee at Indian River Memorial Hospital in Vero Beach, Fla.
When Bobet started evaluating the needlestick problem, she zeroed in on intravenous access needles and syringes, two of the highest-risk and highest-cost areas.
At Indian River, she estimates that switching to a protected IV system would cost $43,000 per year, or 138% more than nonsafety products. Replacing the 500,000 syringes with safety models would cost $165,000, she estimates.
Bobet says an earlier attack that relied on education and changes in IV systems cut employee needlesticks to about 1.25 per 100,000 hours worked in 1994 from about 5.4 per 100,000 in 1990.
"We hit a plateau and just stuck there," she says, and that's why the hospital decided to look at new products.
Some improvements don't require fancy new technology. Bobet says an analysis of accident rates at the hospital showed that the critical-care unit had the best needlestick record. The reason: The department had installed two sharps disposal boxes, one on either side of each patient's bed. Used needles are disposed of immediately, Bobet says, and injury rates have plummeted.
Indian River is in the midst of a field trial of new technologies as part of the Premier group-purchasing organization's evaluation of various safety products for inclusion in its group-purchasing contracts.
The Teamsters are negotiating their first contract at the Vero Beach hospital, Bobet says, but that didn't prompt the recent needlestick prevention drive.
"There really is resistance to change, and nurses will admit this," Bobet says. "But they're starting to think about themselves, and they need to."
At Wilmington, Del.-based Christiana Care Health System, where needlestick regulations aren't on the books, safety products are being evaluated.
The two-hospital system is reviewing a broad array of safety products to determine which to put into service.
Although nobody at Christiana Care has contracted a disease from being stuck on the job, the system documented 10 to 12 employee exposures to HIV last year and about 20 to hepatitis C, says Chris Collins, a nurse practitioner who manages the employee health program.
"We've accepted (that) this is something that we have to do to protect employees. Cost won't be a barrier," Collins says.
Charles Smith, M.D., president and chief executive officer at Christiana Care, backs her up: "Needlesticks are bad, and we don't want them to occur."
Technology, however, can't replace education and the right clinical culture, he warns.
For that reason, Smith says he prefers voluntary measures over laws and regulations that require technological solutions.
"I don't want to be mandated to do something that may not be better than what we're doing now," he says.
Look for the union label. Although the union isn't a factor at Christiana Care, the Service Employees International Union, for one, has made needlestick legislation a top priority.
The powerful union was instrumental in pushing for the legislation in California. "No small feat," says Bill Borwegen, health and safety director at the SEIU in Washington.
Stay tuned for more. "It's really a question of how much activity we can generate," Borwegen says. "We're working on many fronts."
For unions in healthcare, as for those in other industries, occupational safety is an issue nonpareil for recruiting new members and reminding those already in the ranks that the union matters.
"The healthcare industry continues to live in a state of denial," Borwegen says. "It boils down to trading their own employees' lives for the price of a postage stamp. It's simply greed."