NEEDLE STICK RISK

Hundreds of medical workers become infected with the AIDS or hepatitis viruses from accidental punctures each year.

By Kathleen F. Phalen - The Washington Post Company

Tuesday, August 11, 1998; Page Z10

No Turning Back

The stories are hauntingly familiar. They are doctors, nurses, technicians, phlebotomists, dentists, aides and laundry workers, to name a few. And when it happens, there’s no turning back.

"I felt my heart lurch into my throat, I was so frightened at that moment that I had irrational thoughts," says Patti Wetzel, a Texas physician infected with HIV in 1991 after making a house call to draw blood from one of her dying AIDS patients. She wanted to save him the ambulance ride to the hospital. "The needle was dangling from my finger and I could see small drops of patient blood coating the needle, I thought about chopping off my finger to protect myself."

She didn’t. And now, like the others, Wetzel is hoping for the best. She has not developed AIDS, but about four years ago Wetzel stopped practicing medicine, afraid of exposure to tuberculosis. She spends about half of her time on the lecture circuit, educating people about needle stick hazards. The rest is saved for things like visiting with friends and family.

"I live in the moment. I learned that my career is not the be-all and end-all. My needs are more simple now," she says. "If I were cured tomorrow, I hope I wouldn’t change a thing."

Beth Anne Algie was 22 and six months out of nursing school when she was injured some 20 years ago. "I was injecting a sweet little old lady, she was 93 and we considered her a low risk. All of a sudden she swatted her hip and sent the syringe into my other hand," says Algie about the needle stick injury. "Right away I thought I’d be okay, she was considered low risk."

She wasn’t. The patient had received a blood transfusion and was carrying the hepatitis B virus, which infected Algie.

"My liver enzymes shot up and I was [critically sick] for months and months," says Algie. "Initially I was out of work for a very long time."

When she started feeling better, Algie says, she took risks because she knew she was dying. She became a flight nurse. "I was flying on missions in Central America . . . I figured who better to go than an ICU nurse who was going to die anyway," she recalls. "But as I got sicker and more afraid, I knew I had to remove myself from the clinical setting." More recently, she has been working in public education campaigns on the risks of needle sticks. "I live for today. There’s no way I’m going to see retirement, so for now I am doing what I can do to save the lives of my colleagues. . . . They are dying and that’s intolerable."

A Lack of Concern

Compounding the injury for some workers is a lack of concern by their employers. Arnold’s hospital has been very supportive. And officials there continue to help with

her needs. Other hospitals do not, health workers say. One of the most celebrated cases occurred in Montana, where a respiratory therapist became infected with HIV after using a defective needle in an arterial blood gas kit that the hospital knowingly received at no charge from a manufacturer. The hospital refused to pay any damages. When the therapist sued, the court ruled that the therapist could not recover damages from the hospital because the injury was covered under workers’ compensation. Other states have also adopted that rule.

"There are facilities who deny workers’ compensation," Arnold says. "And many employees are forced to pay their own expenses. People call me all the time because they aren’t getting the help and support they need. They don’t know where to turn, and they are often in dire straits."

Some employees discover only after an injury that they may not be reimbursed for wages or medical costs. That’s what happened to Wetzel.

"I didn’t have workers’ compensation," she says. "In Texas, an employer is not required to provide it."

In some cases, injured workers have also had their personal lives come under intense scrutiny as employers seek to determine if the infection could have been caused by sexual relations or drug use.

"The burden of proof should not be on the worker," says Andi Thomas, the executive director and co-founder of Hep-C ALERT!, a national advocacy organization based in Florida.

For those employers who don’t deny claims, the costs are staggering.

"I have a case right now where the worker has hepatitis C that she contracted in 1996," says Colleen Holland, a senior claims adjuster for South Carolina-based Palmetto Hospital Trust. "The medical and indemnity costs so far are about $165,000, and it is projected that the medical costs may exceed $300,000 and the indemnity will cap out at $218,895."

As Holland explains, every state is different, but in South Carolina, workers’ wage compensation, which falls under indemnity, is capped at two-thirds of the worker’s individual weekly wage or $436 (whichever is less) for a maximum of 500 weeks. That means that if a 23-year-old worker was totally disabled as a result of a needle stick injury, that worker would receive benefits for just under 10 years, or until he or she was barely 33.

"There is no cap on medical expenses if [patients] are permanently and totally disabled," Holland says.

But the costs can also be psychological. Donna Cieniawa, a registered nurse in Massachusetts, was injured with a needle while working in an emergency room in 1996. "I can’t put it into words, it’s a daily terror you live with, and my hospital did nothing to help," Cieniawa says.

Although the CDC had published recommendations for treatment to help prevent HIV infection after a health care worker is stuck by a needle or other sharp object, the doctor who initially examined her was reluctant to prescribe the drug combination of ZDV (zidovudine) and 3-TC (lamivudine). After some persuasion and pressure from a doctor at another hospital, Cieniawa was placed on the drugs. The patient who had been treated with the needle that stuck her had not been tested by the hospital for HIV because of a state law requiring the patient’s consent. That law has since changed.

Unlike Arnold, Wetzel and Algie, Cieniawa did not become infected with HIV or hepatitis, but the emotional scars remain. "Their attitude was, ‘We filled out the paperwork, we drew your blood, you’re done,’ " she says. "When I look back, I realize I was absolutely dysfunctional."

Mapping Strategies for Prevention

Researchers say there is no one easy technique for prevention because these injuries result from a multitude of causes and occur in a variety of situations. Among the causes are worker inattention and a lack of safety needles in health care settings.

"This is a multifaceted issue," says Wetzel. "It’s not just the workers. It’s not just the administrators or the needle manufacturers. It’s not just the regulators. Health care workers need to wake up and pull their heads out of the sand, then maybe we will have the leverage to make changes."

In 1991, the Occupational Safety and Health Administration required hospitals to regularly educate employees about handling blood and blood products. Most agree that hospitals comply with these educational guidelines for all employees, and some employees follow safety protocols to the letter. But others don’t.

Even following safety protocols isn’t foolproof. Lynda Arnold did. Patti Wetzel did. Beth Ann Algie did. Donna Cieniawa did. They all got stuck. "The people I worked with made fun of me because I always got my goggles, wore my gloves. That’s the irony of it," says Arnold, who spends a great deal of her time trying to educate workers about the hazards.

A variety of safety needles are available today and they include products that blunt during use, have protective sheaths or retract. According to a report from the CDC, these instruments, if used more regularly, could prevent injuries up to 76 percent of the time.

Hospital officials have complained that the safety products cost about twice as much as the conventional hollow bore needles and that manufacturers need to produce the safer devices more cheaply. But manufacturing leaders say that it’s a matter of supply and demand. As more are manufactured, the processes are streamlined and costs will drop, they say.

"We are becoming more efficient in manufacturing these devices and we are improving our procedures. We have been reducing costs by five to seven percent per year," says Clateo Castellini, chief executive officer of Becton Dickinson, an international medical technology company that focuses on disposable medical devices and diagnostic systems. "We’ve learned that this is a complex area and we have to work with others. . . . We think eliminating the transmission of infectious disease by sharps [needles and other devices that can cut or puncture the skin] is a role we have to play. We believe it is an ethical issue to protect users."

Some manufacturers, such as Bio-Plexus, manufacture only safety needles. "Every needle we make will be a safety device," says Tom Sutton, executive vice president of marketing and administration. "But there is a tremendous resistance to using safety devices. It’s just like seat belts, you know you have to use them, but it took a long time for people to comply."

With managed care pressures squeezing the bottom line at most health care facilities, executives say they can’t switch to the safety needles until the costs are lower. But advocates such as the Service Employees International Union, Arnold and Wetzel are campaigning nationally for safer devices in all hospitals. And Rep. Fortney "Pete" Stark (D-Calif.) has introduced anti-needle stick legislation.

"Hospitals ought to be thinking about the cost of supporting one HIV patient for the rest of their life," says Dana Trom, director of materiels management for Martha Jefferson Health Services in Charlottesville. "Just bite the bullet. You have to look at the whole picture and you need to support your employees."

One of the obstacles to a stronger prevention effort is that injuries happen in such a wide variety of ways. Arnold and Algie’s injuries occurred while the needle was in the patient’s arm. Wetzel’s was after the procedure. Forced to cap the needle because there was no sharps disposal container at the patient’s home, she was injured when the cap dislodged from the infected needle and punctured her finger. Cieniawa’s was with a needle she had not even used, but one that someone left carelessly behind.

"Every needle stick injury has a sequence of events, and you have to break these down categorically," says Murray Cohen, former CDC chief of medical device evaluations who heads the Frontline Healthcare Workers Safety Foundation. "That’s why you can’t get all excited about a product and think that it will solve it. If it was so simple, we would have already figured it out."

So for now Arnold, Wetzel, Algie and Cieniawa count their good days. "Sometimes I worry, if I die, what will happen to my family," says Arnold about her husband and two young children. "Health care worker safety is a right, not an option. . . . We have to remember, there are so many others. Somewhere out there, someone’s been infected with a deadly virus just because they went to work one day."

© Copyright 1998 The Washington Post Company