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A supervisor's view: AIDS safety policies are impractical.

Employees don't always follow mandated policies on gloves and needle disposal, and they may face higher risk because of universal precautions on all specimens.

The author is laboratory shift supervisor at St. Catherine's Hospital in Kenosha, Wis.

It seems impossible to pick up a laboratory journal these days and not read something about AIDS. With virtually every article on the subject preaching the importance of following safety recommendations, who would dare suggest that policies concerning this deadly disease are too strict?

I would, and I am the person responsible for enforcing such policies in my 213-bed hospital laboratory. In my other role as a working supervisor, I know that AIDS policies are being circumvented, modified, liberally interpreted, and just plain ignored by far too many employees. These edicts are not practical in all situations, which leaves Laboratorians torn between doing their jobs and following the rules.

The problem began when the Occupational Safety and Health Administration, the Centers for Disease Control, and the National Committee for Clinical Laboratory Standards issued guidelines and recommendations, with OSHA levying fines of up to $10,000 for noncompliance with the Federal guidelines. Because of the prestige of these organizations and the OSHA penalties, hospitals have adopted the policies verbatim. They will not consider modifying or challenging them. So we no longer discuss the problem but just administer and enforce what has been handed down to us.

Glove use is the biggest headache in administering AIDS policy. I have seen employees cut off one glove fingertip before drawing a patient's blood, wear the same contaminated gloves all day, wash gloves instead of changing them, and refuse to wear them at all.

Most policies mandate the use of gloves as barrier protection but fail to recognize the use of other protective measures, such as plastic-backed gauze and devices that remove stoppers from evacuated tubes. Laboratory staff members should be free to evaluate each situation and choose what they think is the appropriate protection.

All situations are not the same. The NCCLS's proposed guideline at least recognizes some of the problems we are experiencing. True, the section on blood banks states that universal precautions should be followed. But the guideline also considers the incidence of HIV in donors, donor fears, and the cost of gloves and concludes that policy-making should be left to each institution-as I feel it should be.

What works well in one laboratory may fail in another; for example, a large reference lab, and a physician's office lab operate in vastly different ways. In fact, what works on one shift may not work on the next shift in the same laboratory.

If policy is left to the discretion of individual institutions, we may be able to discuss the assumption that gloves provide the best protection against HIV. I would challenge that assumption on the ground that ill-fitting gloves tend to make one clumsy and thus more prone to needlestick injury. This risk must be weighed against the possibility of contamination if a residual drop of blood from the venipuncture spills onto the laboratorian's skin and the skin is not intact.

I would rather take my chances gloveless. Intact skin has been shown to be an effective barrier against HIV-there are no reported cases of HIV seroconversion after contamination of intact skin. Accidental needlesticks, on the other hand, haveresulted in HIV seroconversion.

Instead of making a choice between gloves and no gloves, some laboratory workers deceive themselves by cutting off a glove fingertip to better feel the patient's vein. This enables them to do the job they are paid for and still comply with hospital policy. It makes very little sense, though, since the fingertip is the most likely part of the hand to be contaminated.

I can understand staff members wanting to do their job well with a single stick, and I know they have trouble finding some patients' veins. What I cannot understand is the logic behind purposely destroying the integrity of a device they expect to protect them.

Worse than exposing oneself to the risk of AIDS is to place others at risk. Yet this frequently happens when technologists do not remove blood-contaminated gloves. They are protected because the blood is on the gloves and not on their hands. But when they answer the phone, process paperwork, and draw other patients still wearing the same pair of gloves, they increase the possibility that others will be exposed to pathogens. If they were not wearing gloves, technologists might be more conscious of the need to wash their hands.

When confronted, those who wear the same gloves throughout the day often claim that they wash them just as carefully as they wash their hands. This is usually not the case.

Most laboratories are understaffed, and their employees do not have time to constantly change gloves and still get the work out. Many of us, especially on odd shifts, have a wide variety of responsibilities besides test analysis. We must also answer the phone, draw patients, and record results.

We could not keep our lab running with the current staff and provide the same level of service if we tried to change gloves and wash our hands between all activities. We would also run out of gloves very quickly and substantially increase operating costs. More important than the cost of the gloves would be the cost of labor in changing them and in washing hands.

I am not advocating that we stop using gloves, but rather that we have a choice, and that when we use them, we do so wisely to provide a degree of safety for ourselves and our co-workers while meeting workload demands.

Besides misusing gloves, we also tend to ignore the dictum not to recap needles. Since most accidental needlesticks occur during recapping, it has been declared that the way to solve the problem is to refrain from recapping. Wrong.

Not recapping may work in outpatient drawing areas where there is plenty of room to organize supplies, but in the patient's room it is often difficult to find space for the phlebotomy tray let alone bring needle containers within reach of the patient. Phlebotomists must compete with TV stands, ventilators, suction devices, electrocardiogram and portable x-ray equipment, and other paraphemalia.

What then do you do with the needle while you hold the puncture site so the patient's skin doesn't tum a rainbow of colors? I think it is safer to recap the needle than to leave it uncapped on the patient's bed or attempt a juggling act. All AIDS prevention guidelines expressly prohibit this, but there must be a need to recap needles, as evidenced by the number of sheath protectors that have come out.

Using sheath protectors, which add to laboratory expense, we might sidestep the no-recapping rule. There is an alternative, however: the economical and very effective one-handed method. All it requires is adequate training in technique.

With one hand on the needle holder, you insert the tip of the needle into the sheath, which is lying close by. Then you scoop up the sheath. Your fingers always remain behind the needle, never in front of it. If you miss the sheath, just try again. No one needs to get hurt recapping needles, nor is there any additional expense for needle sheaths or a need to make more room for yet another device on a crowded phlebotomy tray.

I also object to the reasoning and the impact of the policy that considers all patients to be potentially infected with HIV. This type of thinking avoids the real issue of patient confidentiality and our right to know when we are working with HIV-suspected specimens.

A simple blood precautions label could be used for such specimens as well as those suspected of containing hepatitis virus. While any patient may have HIV, most do not. It is important to identify those who have a high probability of harboring HIV.

Nothing in life is black and white; we must deal in probabilities. Dangerous curves and nopassing zones are marked with warning signs, even though all roads have the potential for a fatal accident. Similarly, why shouldn't we identify patients who pose a significant risk to health care workers?

Requiring us to take special precautions all the time for all specimens tends to make lab safety mediocre. It's like the old saying, "If everything is Stat, then nothing is Stat."

The idea that everything in the lab harbors a possibly fatal disease also promotes AIDS hysteria. It is no wonder that so many feel we deserve hazardous-duty pay. If this attitude persists, the traditional lab coat may be replaced by a protective suit like the one pictured on page 48.

We have dealt with hepatitis for a long time. Patients with a high probability of harboring hepatitis B virus were identified and their specimens used to be labeled accordingly. Response to the risk of hepatitis was calm, even though the HBV transmission model has now become the worst-case scenario for HIV transmission.

Patients can recover from hepatitis, but not from AIDS. Another big difference is in the way society treats AIDS patients and their families. The social stigma of AIDS blows everything out of proportion.

We are more concerned about dying from AIDS than from dying in an auto accident, perhaps because death from AIDS is not socially acceptable. Yet the odds for harm are much higher as we drive to and from work than during the time we spend in the laboratory. If protection and preservation of human life are of the utmost importance, we should channel our efforts where they will do the most good-into the prevention of drunk driving, the use of seat belts and air bags, and making cars more crashworthy.

As a driver, I can choose a level of protection-size of car, for example, and whether or not to use the seat belt. I could even wear a helmet, though that is more appropriate for auto racing, where the risks are greater. In contrast, I have no say about my level of protection at work, largely because of a reactive policy to the social alarm over AIDS.

The public attitude toward AIDS is changing, but it is still not very enlightened. Patients once were offended if we wore gloves, because it implied they had AIDS. Today, they are concerned if we don't wear gloves, even though we are the ones who are at risk.

Laboratorians have a long way to go to educate the public and ourselves if we are to change attitudes and deal with this safety issue. We must be able to discuss the problems openly and challenge the assumptions. The mandated safeguards against AIDS may lead us to jump from the frying pan into the fire.

Protection should be available, of course, but we should be the ones to decide how best to protect ourselves. Even more important is the protection of co-workers. We must be conscious of preserving a safe work environment for all.

This is what everyone wants, but the methods of accomplishing it have been dictated from on high regardless of our individual situations in our own institution. It is time to review well-intentioned policies in light of the rapid changes in our understanding of the AIDS crisis.
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Author:Lassen, Roger
Publication:Medical Laboratory Observer
Date:Feb 1, 1989
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