Needlesticks: who pays the price when costs are cut on safety?

Needlestick incidents have risen to staggering and epidemic proportions among health care workers, a group that includes physicians, nurses, lab personnel, technical staff, and housekeeping. According to the Centers for Disease Control and Prevention, U.S. healthcare workers will suffer 800,000 to 1 million needlesticks annually - that estimate does not include the vast number that go unreported. One study found rates of underreporting to be as high as 92% for lab personnel.(1)

Traditionally, needlestick injuries and needle safety have been greater issues for nurses, who have the highest rate of injury(2) and who operate a number of different sharps devices. Laboratorians, however, may be closer to these issues that they think. In addition to general lab safety and a responsibility in specimen management, lab personnel often draw blood. Hollow-bore needles, the type used for phlebotomy, cause injury in 68.5% of cases.(3) The highest possibility of seroconversion occurs with these devices because the blood remaining inside the bore of the needle contains a higher titre of virus than blood remaining on the outside of a solid needle, such as a suture needle. Some studies report that phlebotomy is associated with 13-62% of the injuries documented with hospitals.(4)

Risk of infection depends on the disease - and tracking this information has begun relatively recently. Fear of infection with HIV is enough to make anyone's blood run as cold as the steel of a syringe, but hepatitis B (HBV) is a much greater threat. THe risk of becoming infected with HBV from a needlestick is 30%, hepatitis C (HCV) is 2-10%, and HIV is 0.3%.(3) As of July 1996, there have been 52 documented cases and 111 "possible" cases of occupationally acquired HIV. Of those 52 cases, 19 were laboratory workers.(5) Although that number is comparatively low, occupationally acquired HIV is rising each year,(3) and many feel that these incidents can be prevented.

In the sobering face of these statistics, then, Whey are conventional needles still being used? Needles engineered with safety controls (including syringes, blood collection tubes, IV systems, and catheters) have been available for more than a decade, yet according to the International Health Care Worker Center, only 5-10% of syringes used for injections by U.S. healthcare workers have safety features.(6) To attribute this lack of implementation to the extra expense of the safety needles is only to scratch the surface. First, the research is contradictory. While there are studies demonstrating cost effectiveness and reductions in incidents using safety needles,(4) others point out that not all devices work equally well in all situations.(3) The data also cannot isolate safety needles as the reason for needlestick reductions because there are behavioral and institutional controls, such as better educational programs, involved as well.

In addition, group purchasing organizations (GPOs) not only have limited choices for purchase on contract, but may indirectly restrict front-line workers' knowledge of off-contract products and are accused of blocking new technology with exclusionary contracts. Government regulations on the subject are vague, but pressure for change has caused some activity in regulatory agencies and Congress.

The value of a dollar

It's old news that hospitals need to cut costs, and safety needles do cost more than conventional needles (putting aside for the moment the moral and ethical issues of a greater human cost). At least, it appears that way when the cost analysis merely places cost per item of the two devices side by side and considers no other data.

Robyn Gershon, MT, MHS, DrPH, lead researcher on a Johns Hopkins University study on the cost effectiveness of safety needles says, "You must consider the direct and indirect costs of treatment when a worker is stuck, and when you factor these things in, safety needles pay for themselves." Costs include testing for both the worker and the patient and prophylaxis for potential HIV infection, which is about $4,000 alone. Add to that the cost of lost productivity, disability, and a temporary replacement for the worker undergoing treatment because the side effects of treatment can be severe. And the emotional toll cannot be measured in monetary terms.

These costs skyrocket if true infection occurs. Gershon quotes the following figures, "A liver transplants as a result of hepatitis is $150,000. Lawsuits for occupationally acquired HIV settle at $2-5 million on the average." Five million dollars would certainly buy a lot of safety needles.

Cost-shifting. Despite the obvious consequences of an adverse outcome, many still write off this technology as too expensive, illustrating the short-sightedness of cost-cutting in the healthcare industry. Susan Wilburn, MPH, BSN, RN, and senior occupational health and safety specialist at the American Nurses Association describes the prevailing attitude as "reactive,