Health care hazards: steering clear of needle sticks
Universal precautions and keeping track of your sharps can help prevent deadly accidents
From the October 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.
By Bryan Walpert
To this day, Benedict J. Farino, ACP-ASIM Associate, wonders if he could have avoided the needle stick. Early in his residency, he was putting a central line in place and was having a tough time getting the needle in. He used his hand to spread the skin and caught himself as he pulled the needle out.
"Could I have been more careful? Probably," recalled Dr. Farino, chief resident for internal medicine at Maine Medical Center in Portland, Maine. "But accidents happen. You can be as careful as you want, but you're not going to prevent every needle-stick injury."
Nonetheless, guarding against needle sticks and other exposures to blood and bodily fluids is critical, particularly for residents. Although Dr. Farino believes he was well-trained, residents acknowledge that accidents do happen, particularly when physicians are tired, juggle too many tasks, are rushed or just get lazy.
While Dr. Farino never contracted HIV or hepatitis as a result of his needle stick, some are not so lucky. Health care workers stick themselves with needles an estimated half a million to a million times each year. About 2% of those needle sticks involved patients with hepatitis C, while 2% involved patients with hepatitis B, according to the Centers for Disease Control and Prevention (CDC). Six cases of HIV or AIDS among physicians as a result of occupational exposure have been documented since 1981, with another 11 cases thought to have occurred as a result of such exposure. Six of the latter were surgeons.
The issue of safety, particularly when it comes to how well residents are trained to perform procedures safely and the extent to which they adhere to that training, gained national attention last December, when a jury awarded $12.2 million to a doctor who pricked her thumb with an HIV-infected needle while inserting an arterial line. The physician, whose name was given only as Jane Doe, contracted the AIDS virus in 1988 when she was a 25-year-old medical resident.
The doctor sued Yale-New Haven Hospital for improperly training her. According to the physician's attorney, Michael Koskoff, JD, the senior resident who taught the procedure kept the needle in her own hand after removing it from the catheter and later observed the resident imitate that technique without correcting her. Mr. Koskoff said that when his client performed the procedure on her own, she moved her other hand to stem a sudden flow of blood and pricked her thumb on the needle.
Yale's attorney, William J. Doyle, JD, said the woman was properly instructed by the resident, who never taught housestaff to keep the needle in the field. Yale has appealed the ruling.
Residents and physicians who work with residents have reacted in varying ways to the ruling. August J. Valenti, FACP, an epidemiologist at the Maine Medical Center, lectures residents about safety issues every year. Though he is not familiar with the details of the Jane Doe case, he said he was disappointed by the outcome.
"There were groans from people who were wondering how somebody could say he or she was not aware of the risks," said Dr. Valenti, who did an infectious disease fellowship at Yale in the 1970s. "I just can't believe someone bright enough to get into Yale was not familiar with the dangers of exposure to blood."
But Arif A. Nawaz, ACP-ASIM Associate, a gastroenterology fellow at Nassau County Medical Center in Long Island, N.Y., said he sympathizes with Jane Doe, though he, too, is not privy to details about the case. "It's definitely a scary thing to happen to anyone," said Dr. Nawaz, who also chairs the ACP-ASIM Council of Associates. "Is it worthwhile studying housestaff to see how safe they feel about their training? I feel safe about my training. Is that true across the board?"
Educators acknowledge that training varies from institution to institution and resident to resident. Some residents are trained in medical school to follow universal precautions and treat every patient as a possible source of exposure to blood-borne disease. In addition, residency programs typically require interns to attend orientations that include presentations about the use of gloves, masks and gowns as well as other safety procedures.
"At orientations for new housestaff, we put the fear of God into them," said Robert Bing-You, FACP, program director for internal medicine residency at the Maine Medical Center. "Right off the bat, we want to drive home the need to be careful." He said that safety is also part of what senior residents and attendings are supposed to teach when they observe or supervise interns and other residents performing procedures that require needles.
Though hospitals increasingly use specific teams of nurses or technicians to start intravenous lines and draw blood, residents still do these tasks in a pinch. Moreover, residents still do plenty of other procedures such as central line placement, lumbar puncture, thoracentesis and paracentesis that potentially expose them to body fluids.
As a result, most training programs teach housestaff about safety. The Medical College of Georgia's internal residency training program in Augusta, for example, requires first-year residents to watch instructional videos that include safety precautions for such procedures, said Connie T. DuPre, FACP, associate internal medicine program director. In addition, supervisors monitor interns to ensure they are working safely, and attendings will not credential a resident on a specific procedure if safety protocols aren't followed, explained Shilpa P. Brown, ACP-ASIM Associate, chief internal medicine resident at the VA Medical Center in Augusta, Ga.
"A lot of safety training is on the job," said Alex S. Niven, ACP-ASIM Associate, a third-year internal medicine resident and chair-elect of the College's Council of Associates. "From the time you're a medical student, it's reinforced that you have to be careful with sharps. Every time I've come close to picking up a needle, that's been reinforced to me by housestaff, attendings and surrounding support staff."
In practice, however, not all supervising physicians pay close attention to safety protocols. "Some are better than others," noted Heather R. Boxerman, ACP-ASIM Associate, a second-year medical resident at Sinai Hospital in Baltimore. "Some are very good about telling us to be very careful, that this is an HIV patient, and some are more carefree. They don't talk about it or don't use universal precautions themselves."
In fact, physicians and residents alike said it's not uncommon for residents to sidestep basic safety procedures and not wear gloves, not recap needles and not immediately place sharps into a nearby needle disposal box, particularly when they are fatigued or rushed, such as in a code situation.
"We all do things we shouldn't from time to time," Dr. DuPre said. "Residents do get in a hurry, or they get tired and take risks unnecessarily. That's when most accidents occur, when people are tired or overworked."
Safety on the mind
The challenge, according to educators, is to be vigilant about safety. "I think everybody is aware of the consequences," said Michael J. Reichgott, FACP, associate dean for students and clinical education at Albert Einstein College of Medicine in the Bronx, N.Y. "I'm not so sure everybody is thinking all the time about the process."
Here are some tips from residents and their supervisors on how to keep safe:
- Follow universal precautions. This means treating all human blood and human body fluids as if they are known to be infectious for HIV, hepatitis or other blood-borne pathogens. Obviously, a patient infected with HIV or hepatitis may not show any symptoms. "Any time there's risk for contact with blood or body fluids, gown and glove appropriately," Dr. DuPre said.
Dr. Boxerman is always careful to mask and glove and will even wear a mask when a patient is actively coughing. "Patients might think I'm rude," she acknowledged. "I'm more compulsive than some."
She said she has seen colleagues abandon gloves during sensitive procedures, and she understands why. "Frankly, it's a lot easier to feel a vein and do procedures without gloves. It can get exasperating if you can't feel the vein," she noted. Even so, she takes a different approach. "Some people remove their gloves. I just miss."
- Listen to other staff members, particularly nurses. "If a nurse suggests something, doctors should heed that suggestion," Dr. Bing-You said. "They're very well-versed in safety procedures."
- Don't do a procedure if you are not comfortable. Speak up and risk embarrassment if you must; it will head off surprises that could lead to mistakes. If you're not expecting a certain amount of bleeding during a particular procedure, for example, it's easy to grab for a gauze pad while you have a needle in your hand and jab yourself or someone else.
"If a resident is uncomfortable or anxious about a procedure, that tends to make him do things impulsively, and impulse actions result in needle sticks," Dr. Bing-You noted. "He should feel OK saying to his supervising resident or attending that he is not comfortable, that he may need to walk through the procedure a little more."
- Assume others do not know what you're doing. Particularly if you are working with medical students, don't assume they know you are about to reach for a certain instrument or perform some other action. They need to be aware of what will happen before you even start, Dr. Bing-You stressed.
- Do not recap needles. This is one of the most basic safety instructions, yet it is often ignored. "People use the needle and then put the cap back on the needle to protect themselves," Dr. Reichgott said. "They stick themselves while putting the cap on."
- Always know where your needle or scalpel is. "It protects you to some degree if you always are conscious of where your sharps are," Dr. Valenti noted.
- Dispose of needles yourself in the appropriate place. Hospital rooms have needle boxes and so do crash carts. Don't leave needles on trays or under pieces of gauze or anywhere else for someone else to clean up. "Clean up after yourself, but do it right," Dr. Reichgott stressed. "There are sharps containers all over the place, big red boxes that are changed regularly."
- If you are stuck, report it immediately. Hospitals have protocols for needle-stick injuries, including a needle-stick hotline, to report the incident to infection control. Residents at Johns Hopkins Hospital, for example, are given a card with that number and specific instructions to put in their wallets. You'll be tested and so will the patient, as long as permission is given, to determine the risk. In some cases, you will be put on medication to head off infection.
There is a cult out there that believes that reporting accidents and injuries makes you a wimp, acknowledged Dr. Reichgott. If residents don't stop perpetuating that attitude, he said, "there are going to be more problems."
Remember, no matter how well you are trained and how carefully you follow protocols, it's still possible to stick yourself. "Most needle sticks are accidental, not necessarily the result of poor technique," noted Franklin H. Herlong, FACP, associate dean for student affairs at Johns Hopkins University School of Medicine. "Something can slip out of position."
"The question is where you draw the line for unfortunate accidents," Dr. Bing-You said. If an institution provides adequate training and supervision but a mishap occurs, he said, "is that acceptable in residency training or not? My personal opinion is yes. You have to accept a certain degree of risk in learning."
Bryan Walpert is a freelance writer in Denver.
Avoiding trouble outside of the hospital
If you're a resident, blood-borne infections aren't the only dangers you face each day. Running from one crisis to the next during a long shift, it's easy to lose track of your valuables-leaving you open to theft. In addition, late shifts and odd hours can mean walking through deserted streets or dim parking lots to a car.
"If they're on call, they could be leaving late or very early in the morning, especially during winter, when it's still dark in the morning," said Phillip Crans, a sergeant with the Medical College of Georgia Police Bureau who gives safety talks at residency orientations. "Sometimes in outlying locations, residents are expected to go to different counties and clinics and they have to deal with the highway."
In other words, you not only deal with dangers on the job, you also face the prospect of crime as you travel to and from work.
Concerned? Here are a few common-sense tips:
- Don't carry valuables. If you can't lock up your valuables, bring only what you need and can carry. Avoid bringing large amounts of cash or expensive jewelry, suggested Connie T. DuPre, FACP, associate program director of internal medicine at the Medical College of Georgia in Augusta.
- Take a self-defense course. The Medical College of Georgia offers a 12-hour rape defense course to students, faculty, residents, staff and others. Employees pay $25. Mr. Crans noted that similar courses are available at many campuses.
- Walk in groups. There is safety in numbers. Walk with co-workers and cross streets at intersections with other pedestrians. "I'll wait five minutes to walk with somebody else as opposed to walking by myself," said Shilpa P. Brown, ACP-ASIM Associate, chief resident at the VA Medical Center's Department of Internal Medicine in Augusta, Ga.
- Call security for an escort. Johns Hopkins Hospital in Baltimore offers a 24-hour escort service. Some employees take advantage of the service late at night, even if they're parked in a neighboring garage. Many campuses and hospitals provide security officers to either walk or drive you to your car.
- Be aware of your surroundings. If the door is glass, take a look and clear the outside before opening the door. Avoid alleys and other shortcuts and avoid driving unfamiliar roads. Always keep a mental map of the last safe spot you've passed. "Here's a store with a camera in it, a security system; I noticed it was open. If you're confronted in the next block, that should be the safety zone you have to get back to," Mr. Crans explained.
- Park in well-lit areas. When you get to your car, "always look into the vehicle before you get in to make sure you don't have somebody hiding inside waiting for you," said William McLean, director of security for Johns Hopkins University's East Baltimore campus.
- Have your car keys ready. Take out your key before heading to your car, "so you don't have to hesitate at the car and become a target while you fiddle for the keys," Mr. McLean said. In addition, "the key can basically be used as a weapon. You can jab someone in the eye if it comes down to that."
- Avoid help from "good Samaritans." Use a professional to help you with your car. If someone asks if they can help, tell them to call the police. "Don't all of a sudden become trustful," said Mr. Crans.
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