Preventing Injuries to Nurses in Home Care Settings

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Preventing Injuries to Nurses in Home Care
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• Stephanie Chalupka, EdD, APRN, BC, FAAOHN,
  Margaret Quinn, ScD, Pia Markkanen, ScD,
  Catherine Galligan, MSc, Letitia Davis, ScD,
  Angela Laramie, MPH,
  Natalia Firsova, MA

June 7, 2007
University of Massachusetts Lowell
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OH S Hazards in Home Health Care

• Job Stress
• Variety of environments/Conditions
• Limited supplies/Equip
• Isolation
• Musculoskeletal (all same as HCPs)
• Working alone/No mech. lifting/transfer devices
• Awkward posture/beds not adjustable
• Latex
• Needlestick Other Sharp Injuries
• Violence
• Mugging
• Animals
• Weather
• Icy roads sidewalks
• Unsafe Home
• Stairs
• Communicable Disease Transmission
• TB
• Auto Injuries

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Home Health Care Nursing Risk Factors for Blood
Exposures and Sharps Injuries
Project SHARRP

• Margaret Quinn, ScD, Stephanie Chalupka, EdD,
  APRN, BC, FAAOHN, Pia Markkanen, ScD, Catherine
  Galligan, MSc, Angela Laramie, MPH, Letitia
  Davis, ScD, Natalia Firsova, MA

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Acknowledgements
Project SHARRP

• Project SHARRP (Safe Homecare and Risk Reduction
  for Providers) Research Team
• School of Health and Environment, UMASS Lowell
• Massachusetts Department of Public
  HealthOccupational Health Surveillance Unit
• U.S. NIOSH
• SHARRP research partners
• VNA Care Network
• UMass Memorial Home Health Hospice
• Home Health VNA of Lawrence
• Gardner VNA
• Greater Medford VNA
• Boston VNA
• Home Staff
• SEIU
• MNA

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Home Health Care
Project SHARRP

• Home as work environment
• Inadequate surveillance - Needlesticks
  other sharp medical devices (SHARPS) unknown
• Risk of infection to blood-borne pathogens
• - HBV, HCV, HIV
• Size of the US home healthcare industry
• 2004 6 of overall healthcare workers
• 56 growth in home health aide occupation
• in next decade US Bureau of Labor Statistics,
  2006
• Women and minority workers

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Major Aims

• Establish surveillance system
• Survey home healthcare clinicians
• Qualitative characterization
• Focus groups
• One-on-one interviews
• - Cross-sectional survey

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Methods Focus groups In-depth
interviews
Total 17 7 24

Total 10
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ResultsAdvantages Challenges

• Flexibility, independence
• Long-term patient relationship appreciation/grati
  tude of patients patients health progress
  patients family
• Diversity and challenge of nursing diversity of
  diagnoses, multi-tasked work duties

• Stress Detailed paperwork
• Medicare billing, insurance, reimbursements
  often continues at home
• Long-distance driving
• time, gas expenses
• Emotional attachment
• e.g. patient death

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some of these...apartments are atrocious. They
are cluttered to the point that there is no place
to put even a cup. Things are boxed, boxes are
piled up, youve seen it. Blankets are piled up.
there isnt a pathway to walk. So theres no
clean surface area to work from
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Security and safety probably being first and
foremost. The staff are going into environments
that we have no control over and sometimes
they're going into lovely homes and patients that
we really don't have concerns about and in other
circumstances you have patients that are
involved in illegal activity and the housing
situations are located in very questionable
neighborhoods, it might be dark, there might be
no light, there might be people looking either
to rob somebody, mug somebody, there are all
kinds of security issues that crop up
periodically.
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Results General Work Hazards

• Hygiene
• insects
• dirty environment
• rodents
• hot/ poor in-door air quality (smoking)

• Security and personal safety concerns
• unsafe neighborhoods
• violent or unstable patients/ family members
• isolation
• animal attacks
• chaos and clutter
• poor lighting
• fire hazards
• Rapid work pace/ time constraints
• clinicians feel rushed to complete
  work

• Lack of work stations
• Heavy lifting and moving patients
• Lack of supplies

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Results Sharps injuries blood exposure

• Medical conditions/ treatments
• diabetes, HIV
• Malfunctioning/ ineffective safety sharp device
• Clutter/ lack of work space
• Unexpected bleeding
• Recapping
• No glove use/ slippery gloves
• Sharp supplies in nurse bags
• Various DME suppliers

• Sharp disposal
• lack of containers
• overfilled containers
• poor container design
• leaving sharps around in trash
• Patient characteristics
• moving when using the needle
• violent, confused, or uncooperative behaviors
• unsafe sharps disposal
• Wound care
• dressing change/ disposal

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Results Reasons for Not Reporting

• Time-consuming, frightening big deal
• frightening possibility about a potential
  infection and not wanting to know about it
• not want to be seen as a careless, bad nurse
• temporary vs steady employment
• disease history of a person
• non-severe stick (scratch not a deep puncture)
• Health insurance factor
• personal insurance fees may go up
• negative consequences toward a new health
  insurance

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Lessons Learned

• Safety analysis based on self-blame vs. systems
  approach
• Social context of home as a workplace
• home work is invisible
• gender, race/ ethnicity
• Focus groups vs in-depth interviews both needed
• Focus groups clinicians personal experience at
  homes when caring for patients
• Interviews educative and factual examples of
  incidents,
• practices, and policies at the workplace or
  in the healthcare community

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Advice from Participants on Prevention of Blood
Exposures and Sharp Injuries

• Safety sharp device design easy to use
• Needleless system designers - collaborate with
  users to improve retractable needle design
• No splash-backs or pain to patients

• Device fully tested before market debut ? cost
  for safety devices
• Consistency among manufacturers and vendors
  standardize sharps devices for improved safety
• Promote culture of safety

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Advice From Participants to Improve Exposure
Reporting

• Use reports as lessons learned from staff safety
  and patient safety perspective
• Require monitoring of reports for licensing
• Single reporting form for all workplace injuries

• Training-Not punitive action when injuries
  reported
• Pre-event planning for an injury (patient care
  plan, risk category of a patient)
• Educational intervention for sharp injury/ blood
  exposure reporting is a right thing to do

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HELP!

• Expanded regimens and expert advice indicated for
  severe exposures or when resistance is suspected
• AIDS Education Training Centers (AETCs) Funded
  by HRSA
• National Clinicians Post-Exposure Prophylaxis
  Hotline (PEPline)
• (888) HIV-4911

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CDC Post-Exposure Prophylaxis Guidelines
MMWR 200554(No. RR-9).
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Safe Work Practices
www.cdc.gov/sharpssafety/index.html
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Safe Work Practices
Source http//www.sustainablehospitals.org
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Safer Work Practices Tips for Selecting Safe
Needle Devices

• Evaluate and select products systematically
• Keep your eyes open for new products
• Ask for samples hands-on look is essential
• If samples look promising
• do a clinical evaluation in the appropriate dept
  
• Eval tool http//www.TDICT.org
• Note employee evaluation and feedback
• When you buy a new device, use the manufacturer's
  representative for training staff

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Safe Work Practices Tips for Selecting Safe
Needle Devices

• Keep contracts short because products are rapidly
  changing and improving
• Criterion for selecting a product
• manufacturer must train throughout all your
  facilities
• Encourage staff members to question and offer
  constructive criticism to the manufacturer's rep
• (The representative is a direct link back to the
  design engineers - way products get refined and
  improved)

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Safe Work Practices Tips for Selecting Safe
Needle Devices

• Use existing product lists to be informed about
  safe needle devices on the market
• http//www.dhs.cahwnet.gov/ohb/SHARPS/disclaim.htm
  The California List of
  Needleless Systems and Needles With Engineered
  Sharps Injury Protection
• http//www.med.Virginia.EDU/medcntr/centers/epinet
  /products. html
  
  International Health Care Worker Safety center at
  the University of Virginia Health System
• http//www.sustainablehospitals.org
  
  Sustainable Hospitals Project-
  information about alternative healthcare products
  and practices

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Safe Work Practices How to Make an Inventory
List of Sharps Devices for Your Facility

• The list can serve as a tool to help you
• ID conventional devices lacking safety features
• Work with your clinicians to understand why
  conventional devices are still used
• No viable alternatives?
• Conventional device without a viable alternative
• establish next review date to determine
  availability of safer devices
• Provide a copy of the list to key committees -
  status of safety device use
• Safety Committee
• Product Evaluation Committee

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Safe Work Practices How to Make an Inventory
List of Sharps Devices for Your Agency

• Why you need one
• Can be a powerful tool to complement your
  
• existing sharps injury prevention plan
• Our work with hospitals has shown
• Reorder old-style sharps devices that lack an
  integral sharps injury prevention (safety)
  feature
• often unintentional
• Frequently only AFTER needlestick injury realize
  a conventional device was still being used
• Having too many different kinds of safety
  devices
• ITSELF a risk factor for injury.

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List of devices for which a safety alternative is
(or was) not available or
appropriate -Shows use/phase-out status of
conventional devices,
-Provides an effective way of documenting
exceptions to OSHA or state regulations.

-List shorter as
more devices are converted to safety devices,
the list becomes shorter shorter.

e.g.
remove a converted product from the list after
the completion of 2 satisfactory follow-up
user surveys
Source http//www.sustainablehospitals.org/PDF/Sh
arpsList.pdf
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Comprehensive list that shows all sharps used
throughout a facility Organized as a
spreadsheet-easy to sort the information in
different ways.
Source http//www.sustainablehospi
tals.org/PDF/SharpsList.pdf
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Summary

• Fuller characterization of HHC work
• Invisible yet growing industry
• Interventions needed
• Eliminate/ minimize hazards
• Preserve or enhance positive work aspects