It began as just another day at the Bellevue Hospital Center ED for 36-year veteran Helen Ornstein, NP, RN, who worked per-diem in the 10-bed shock—trauma unit. But it turned out to be her last day there, a day that Ornstein says “put her life on hold” and ended her career in the ED. It also was the beginning of six years of litigation with the New York City Health and Hospitals Corporation to receive compensation for injuries and losses related to a needlestick. In February, a jury awarded Ornstein six figures in damages and validated her position that the city, which owns that hospital, was to blame for what she calls “an utterly inexcusable, deplorable disregard for universal precautions.”
Ornstein's ordeal began in 2000, when she was stuck with one of two needles that were hidden in the bed of a patient dying from AIDS, left behind by a medical resident who admitted responsibility for her negligence in court. The patient's blood had such a high viral load—one of the main predictors of seroconversion in an exposed person—that the director of the hospital's HIV—AIDS unit immediately initiated Ornstein's postexposure prophylaxis (PEP) care. Although the hospital followed typical PEP protocol, it didn't address Ornstein's need for mental health counseling and follow-up. Despite testing HIV negative for the following six months, Ornstein suffered not only from peripheral neuropathy and other adverse effects from the antiretroviral cocktail, but also from severe anxiety and panic attacks, disordered sleep and night terrors, depression, and ultimately posttraumatic stress disorder (PTSD). As a result, she could not return to work at the ED.
“I couldn't get out of bed for the first six months,” she says. “It was horrible. I withdrew, ended a relationship, didn't see my friends, couldn't drive a car.”
One of Ornstein's main problems was that PTSD wasn't diagnosed until New York City's own workers' compensation physicians did so, when they were asked to evaluate her for what the city contended was “HIV phobia.” This made her legal victory the first of its kind, making a city agency accountable for not addressing the psychological needs of its employees who suffer from validated work-related PTSD.
In her case, Ornstein says the city's physicians considered several factors that contributed to PTSD, including the anxiety associated with six months of HIV testing and deciding to endure the adverse effects of PEP medications, the termination of her primary job—and source of income—as an NP in the operating room, and the involuntary change of lifestyle that often occurs when facing a possible life-threatening infection.
Ornstein's experience appears to be typical for many workers at U.S.-based health care facilities, which commonly use the PEP guidelines for exposure to HIV and hepatitis B and C viruses from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). The problem for hundreds of thousands of health care workers who are exposed annually is that those guidelines lack any reference to, much less recommendations for, mental health care. In fact, the most recent CDC publication on PEP (from Morbidity and Mortality World Report, September 30, 2005) includes only a superficial reference to mental health care: “Providing HCP [health care provider] with psychologic counseling should be an essential component of the management and care of exposed HCP.”
“There is little known about nurses' experience following needlestick injuries,” says Karen Daley, MPH, MS, RN, who became an outspoken advocate for needlestick safety after experiencing an injury herself and being infected with HIV by a patient not known to have the virus. She has started her own research to fill this knowledge gap. There is a limited amount of anecdotal and case study data in the literature that describes the distress and other effects that health care workers experience when they sustain a needlestick or are otherwise exposed to contaminated needles from HIV-positive patients.
“I am hoping my dissertation study will help us better understand the experience and meaning of these injuries,” Daley says. “Obviously, my own experience was life-changing, and I have spoken with many nurses around the country who have shared their traumatic experiences with me. However, the question of what impact these injuries have for nurses still remains unanswered.”
In the meantime, Daley's focus is on eliminating future tragedies by advocating strict enforcement of the federal Needlestick Safety and Prevention Act (NSPA), implemented in 2001, and the subsequent revision of the OSHA bloodborne pathogens and needlestick prevention standards.
“My sense is that there are many employers around the country who are doing their best to meet their obligations,” she says. “I think there are also employers who are still just meeting the letter of the law (such as using the cheapest safety devices rather than ones that have demonstrated effectiveness through formal testing and evaluation), as well as those who still don't understand what the law requires.”
Daley urges nurses to participate in the evaluation and selection of their institution's safety devices, because the law requires employers to involve them and it's a way to be proactive.
“Another component of the new federal regulations requires annual review of the exposure control plan,” she adds. “That means the plan should be updated based on what is learned about [needlestick] injuries that have occurred in the previous 12 months to prevent future injuries. Implicit in that process is the need to integrate more effective safety technology when inadequately designed devices are being used.”
Daley differentiates between devices specifically designed and engineered to protect the user from accidental injuries, such as syringes and catheters with retractable needles that become completely disabled after one use, and retrofitted devices, which she says are a “quick fix to help employers comply with the new law” and the “least expensive option among safety devices.”
Several companies make the type of specially designed safety products Daley describes, but she says they face tremendous obstacles to penetrating the market and putting safer needles in the hands of clinicians because large medical companies have the edge with group purchasing organizations.
So are nurses and their colleagues any safer today than they were before the NSPA and OSHA revisions were implemented? Daley looks at some needlestick-reduction data suggesting that, overall, they are safer, but she cautions that there's still a long way to go to address clinicians' needs.
“There have been major reforms across the country to allow more timely and appropriate care for nurses and other health care workers who sustain needlestick injuries,” she says. “Having said that, I am not sure employers always understand how anxiety-provoking these injuries can be for workers. And given the number of injuries that continue to occur in the United States every year and the staff shortages in health care, I don't think we can afford not to be more concerned about the potential toll needlestick injuries take.”