IAGS 38:793-796, 1990
Needlestick Iniuries and Needle Disposal in Minnesota Nuking Homes I
Kent Crossley, MD,*f Karen Willenbring,* and Joseph Thurn, MD*f
W e examined needle use and disposal, needlestick injuries and their management, and employee education regarding the acquired immunodeficiency syndrome and needle use by means of a questionnaire sent to all long-term care facilities certified for skilled care in Minnesota. Responses were received from 297 of 349 (85.2%) homes. Nearly all homes (271 of 293; 92.5%) provided education for new nursing employees about use and disposal of needles. Disposal of needles and sharps was generally consistent with current recommendations for short-term care hospitals. Needlestick injuries were usually related to recapping and
R
elatively few patients with acquired immunodeficiency syndrome (AIDS) and other manifestations of human immunodeficiency virus ,(HIV) infection have been in long-term care facilities in the United States. However, with the increasing numbers of AIDS patients and their improved survival rates, this is likely to change.' Before patients with HIV infection can be easily assimilated into longterm care settings, education of nursing home staff about the unique issues surrounding the institutional care of patients with HIV infections will be needed. One obvious concern for nursing home employees planning to accept HIV-infected and AIDS patients is the proper care and handling of needles and other sharps. In short-term care hospitals, employee concern over potential injuries associated with sharp objects has been a significant issue in the care of the HIV-positive patient. In this article, we examine the present methods of needle handling and disposal of sharps in a large group of nursing homes.
were most common in registered and licensed practical nurses but were infrequent (i.e., < 2 injury per home per employee-year) probably because parenteral therapy is infrequently used in long-term care settings. Only slightly over half (266 of 286; 58O/o) of the homes had protocols for management of needlestick injuries. Although Minnesota nursing homes properly dispose of needles and sharps, many of these institutions need to develop policies for management of needlestick injuries that are consistent with current recommendations. J Am Geriatr SOC38:793 - 796,1990
MATERIALS AND METHODS
The state of Minnesota collects and publishes data, including addresses and telephone numbers, for all licensed and certified health-care facilities in the state. From this data base for 1988, all long-term care facilities with skilled-care beds in Minnesota were identified; they comprised our study group. The survey tool was composed of 30 yes/no and short-answer questions on a one-page standardized form. It was based in part on a prior telephone survey of physician offices dealing with needlestick injuries and topics related to AIDS.ZQuestions pertaining to demographics, needle use and disposal, and needlestick injuries and their management, as well as issues regarding AIDS and employee education on needle use and AIDS, were all included. To validate its utility, the survey was administered by telephone to directors of nursing (nine people) or the administrator (one person) of 10 longterm care facilities that had been systematically selected so that they were distributed throughout the state. Minor revisions were made in the wording of several survey questions on the basis of the comments obtained in this preliminary study. -~ ______ The survey was mailed to the director of nursing of From the *Departmentof Medicine, Section of Infectious Diseases, the facilities in the study group. We asked that if this St. Paul-Ramsey Medical Center, St. Paul, Minnesota, and the tUniversity of Minnesota Medical School, Minneapolis, Minnesota. individual was unable to reply, the survey be forwarded Address correspondenceand reprint requeststo Kent Crossley, MD, Section of Infectious Diseases, Department of Medicine, St. Paul- to the most appropriate person to complete it. The respondent was instructed to indicate his or her job title on Ramsey Medical Center, 640 JacksonStreet, St. Paul, MN 55101. 0 1990 by the American Geriatrics Society
0002-8614/90/$3.50
794
IAGS-]LILY 1990-VOL. 38, NO. 7
CROSSLEY ET AL
ported working at each facility was 12.6 (range, 2 to 78). A mean of 48 nursing assistants per home (range, 0 to 295) was reported. Frequency n (Oh) Education for new nursing employees about the use 68 (23.1) Never and disposal of needles was nearly universal in Minne108 (36.6) Rarely sota nursing homes; 271 of 293 (92.5%)homes provided Sometimes 63 (21.4) this training. Policies about needle use and disposal ex39 (13.2) Usually isted in 87.1% of homes. Although some of these poli17 (5 8) Always __ cies were based on local hospital guidelines (in 87 of 289; 30.1YO), most homes reported having developed their own policies. Four of five homes (233 of 292; the survey form. Included with the survey was a cover 79.8%) had copies of the publication “Recommendaletter that described the study and its purpose, identified tions for Prevention of HIV Transmission in Health Care the study investigators, and indicated that participation Settings” published by the Centers for Disease Control.3 was voluntary and that all results would be confidential. Nearly all homes (273 of 294; 92.9%) reported having Two weeks after the initial mailing, the survey and a had one or more in-services on AIDS in their facility. Disposal of needles and sharps generally followed new cover letter were remailed to those institutions from which a response had not been obtained. A third mail- available recommendations. Virtually all of the homes ing was sent 2 weeks after the second to those institu- used hard plastic containers for needle and scalpel disposal. Only 5 of 296 homes (1.7%) reported using cardtions that had failed to respond. Statistical analysis was performed using x2 with one board containers. Needle disposal containers were lodegree of freedom and Yates’ correction and, where ap- cated in medication rooms in 250 of 297 (84.2%)homes, on medication carts in nearly half of the homes (127 of propriate, Fisher’s exact tests. 297; 42.8%), and less frequently at nursing stations (44 RESULTS of 297; 14.8%), in utility rooms (20 of 297; 6.7%), or in Responses were obtained from 297 of the 349 (85.1YO) patient rooms (11 of 297; 3.7%). Containers of sharps licensed nursing homes in the state of Minnesota certi- were disposed of by incineration in 145 of 297 (48.8%) fied to have skilled-care beds. The response rate from and by a hazardous waste contractor or hospital in a nursing homes within metropolitan areas (Minneapolis, similar percentage (132; 44.4%). Only 11 of 297 (3.7%) St. Paul, Rochester, and Duluth) (117 of 148; 79.1%) homes reported that needles were disposed of in regular was significantly less than from institutions in other garbage. parts of the state (180 of 201; 89.6%) (P = .01, x2).Most Although over 80% of the homes (240 of 295; 81.4%) of the respondents (226 of 293; 77.1%) were directors of had a policy in place specifying that needles should not nursing. The balance of the questionnaires were an- be recapped after use, almost 80% of homes indicated swered by assistant directors of nursing (20; 6.8%), infection control practitioners (17; 5.8%), or other nursing home employees (30; 10.2%). The distribution of respondents did not differ according to metropolitan and TABLE 2. REPORTED SITUATIONS IN WHICH nonmetropolitan respondents. NEEDLESTICK INJURY OCCURRED IN MINNESOTA NURSING HOMES The mean number of skilled-care beds in the homes was 105 (range, 5 to 559). Sixty percent of responses Number of Injuries were from homes with less than 100 skilled-care beds. While recapping needle Homes of this size were significantly more frequent in 19 After filling syringe nonmetropolitan areas than in metropolitan areas (P < After giving injection 173 .01, x2). Only a few institutions were owned or operated After blood drawing 14 by a hospital (43 of 293; 14.7%); a similar proportion Total 206 was reported to be physically connected to hospitals. Unrelated to recapping Nearly all of the homes (266 of 294; 90.5%) had an indiWhen filling syringe 4 vidual designated as an infection control practitioner. A After giving injection 50 slightly higher proportion (291 of 295; 98.6%) reported After drawing blood 14 having an infection control committee. Injury from sterile needle 18 The mean number of physicians practicing in responFrom used scalpels 7 During trash removal 27 dent nursing homes was 15.1 (range, 1 to 158). AlUnknown 19 though there was again a broad range, the mean number Other 22 of registered nurses per home was 9.9 (range, 1 to 294) Total -~ 161 and the mean number of licensed practical nurses reTABLE 1. FREQUENCY OF REPORTED NEEDLE NURSING HOMES RECAPPING IN 295 MINNESOTA - ~-
~
~
~
~
~
~
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~~
IAGS-IULY 1990-VOL 38, NO. 7
NEEDLESTICK INJURIESAND NEEDLE DISPOSAL
795
TABLE 3. MANAGEMENT OF NEEDLESTICK OR SHARP INJURY IN LONG-TERM CARE* Hepatitis B
Prevention After injury
HIV
Educate employees about universal precautions, bloodborne diseases, and avoidance of injury. Immunize employees potentially exposed to No vaccine available. blood. Assess the significance of the injury and estimate the likelihood that the patient has a bloodborne disease. Obtain informed consent, draw blood and test for hepatitis B antigen (HBsAg) and HIV antibody. Provide appropriate counseling. Document the testing and results carefully. Protect the confidentialityof the patient and the employee. If source patient is HBsAg-positive and the emIf source patient is HIV-positive or refuses testing, evaluate employee for HIV antibody at time of ployee is not immunized, administer one dose of hepatitis B immune globulin (HBIG) and injury and at 3 and 6 months. Consider use of start vaccination series. If employee has been m.t antibody titer (anti-HBs)’ Employee should follow guidelines for prevention If source patient is unknown or refuses testing, of transmission for at least 6 to 12 weeks (restart vaccination series if not previously given. frain from blood donation, use appropriate proIf patient is at high risk for being HBsAg-pitection during sexual intercourse.) add HBIG’V the has imIf source patient is negative, follow up exposed munized, measure antibody titer. worker at worker’s request in 6 to 12 weeks. If source patient is negative, complete immunizaSource unknown: Individualize. Test and followtion series for employee. up employee. tiveg
HIV, human immunodeficiency oirus. This is a brief summary of recommendations in early 1990.3,6,7 t Zidooudine (AZT) is a potential prophylactic agent for use ufter needlestick injury from HIV-positive indioiduals. Consult with an expert in this area before initiating the druga
that needle recapping took place in their institution (Table 1). The frequency of needlestick injuries in the homes was reported to be low. Virtually all of the homes kept records about needlestick injury. The mean reported number of needlestick injuries during the year before receipt of the survey was 1.38per institution. Risk was highest for registered nurses and licensed practical nurses (with means of 0.45and 0.75 injuries per home per employee-year, respectively). Needlesticks were not reported for laundry workers and occurred very infrequently for nursing assistants and housekeeping and maintenance personnel (means of 0.05,0.02,and 0.01 injuries per home per employee-year, respectively). Of the reported injuries, nearly half occurred after administering an injection. Other causes of needlestick injuries are summarized in Table 2. Only 166 of 286 (58.04b)homes reported having a written protocol for management of needlestick injuries. After a needlestick injury the most common reported response was to report that it had occurred (217of 268; 81.04b).A small proportion of homes (32of 268;11 . W o ) indicated that the wound was cleansed but nothing else was done. Decisions about further workup or evaluation were made by a physician in 101 of 268 homes (37.7%) and by nursing administration or the infection control nurse in 160 of 268 (59.74b). If the patient with whom a needle had been in contact could be identified, testing of
the individual for hepatitis B was done in 80 of 268 (29.946)homes and for HIV antibody in 65 of 268 (24.3%) homes. After needlestick injury, employees were tested for hepatitis B susceptibility in 56 of 268 (20.94b)homes, offered HIV testing in 73 of 268 (27.246)homes, given gamma globulin in 51 of 268 homes (19.04b)or hepatitis vaccine in 22 of 268 homes (8.2%), and offered counseling in 66 of 268 (24.646)of homes. Over 90% (90.8%) of the homes that tested for HIV in the source patient also tested for hepatitis B antigen. It is interesting that of those homes that tested for hepatitis B or HIV in the source patient, only approximately 25% offered counseling to their employees. Although only a few homes in Minnesota reported that they had cared for HIV-infected patients (44of 294; 15.0%), a majority of homes had developed plans for caring for patients infected with HIV (208 of 285; 73.()yo).
DISCUSSION We believe that these data make three important points about needlestick injury in long-term care institutions in Minnesota. First, the risk of needlestick injury seems quite low. Second, nursing homes need to ensure that their policies for the management of needlestick injuries are in keeping with current recommendations.
796 CROSSLEY ET AL
Third, disposal of needles and other sharps is appropriate in the vast majority of homes. Although we were surprised at the low frequency of reported needlestick injury, most nursing homes do not provide parenteral therapy except for administration of insulin to diabetic patients. Although we are not aware of data about the frequency of needle use in long-term care institutions compared with short-term care hospitals, the lower apparent risk almost assuredly largely reflects a much more limited usage of injections in these settings. Given the increasing trend toward briefer short-term care hospital stays, it is likely nursing homes will care for more and more patients who need parenteral therapy in coming years. In contrast to what we observed in the offices of Minnesota physicians,* disposal of needles and other sharps was largely consistent with existing regulation. Once needles were collected and removed from the facility, they were nearly always handled in a manner that is appropriate (e.g., by incineration or destruction by a company licensed to handle infectious waste). The majority of needlestick injuries apparently resulted from recapping. Although data from short-term care hospitals are not directly comparable with information derived in long-term care settings, recapping may be the most frequent source of injury for employees in both health-care environments.' The type of employees who sustained the largest number of injuries in nursing homes -registered and licensed practical nurses -supports this observation because they are also most commonly involved in recapping injuries in short-term care hospital^.^ Although needlestick injuries appear to be uncommon in the long-term care setting, the management of these injuries and the follow-up available to employees should be identical to that in short-term care hospitals. It is of concern that relatively few institutions had written
IAGS-/LILY 1990-VOL. 38, NO. 7
policies for the management of needlestick injury and that testing either patients or employees for hepatitis B or HIV infection is done relatively infrequently. We believe that employees in long-term care facilities deserve the same counseling that is provided to employees in short-term care hospitals and that much more frequent postexposure testing for hepatitis B and HIV infection is indicated. Guidelines of the Centers for Disease Control need to be monitored and followed by those responsible for employee health in nursing homes.3.6-8 Current guidelines are summarized in Table 3. If these data are representative of the situation in other parts of the country, expanded educational efforts about needlestick injuries and their management need to be a priority for long-term care institutions in the United States.
REFERENCES 1. Crossley K, Henry K: AIDS: implications for long-term care. Clinical Report on Aging (American Geriatrics Society) 1:1, 3, 5, 6, 9, 1987 2. Thum J, Willenbring K, Crossley K: Needlestick injuries and needle disposal in Minnesota physicians' offices. Am J Med 86:575, 1989 3. Centers for Disease Control: Recommendations for prevention of HIV transmission in health-care settings. MMWR 36(suppl 2S):IS, 1987 4. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD: Rates of needle-stick injury caused by various devices in a university hospital. N Engl J Med 319:284, 1988 5. McCurdy SA, Ferguson TJ, Schenker M: Mucocutaneous injuries at a university teaching hospital. West J Med 150:604, 1989 6. Centers for Disease Control: Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR 38:1, 1989 7. Centers for Disease Control: Recommendations for protection against viral hepatitis. MMWR 34:313, 329, 1985 8. Centers for Disease Control: Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 39 (no. RR-l):l, 1990
Needlestick Iniuries and Needle Disposal in Minnesota Nuking Homes I
Kent Crossley, MD,*f Karen Willenbring,* and Joseph Thurn, MD*f
W e examined needle use and disposal, needlestick injuries and their management, and employee education regarding the acquired immunodeficiency syndrome and needle use by means of a questionnaire sent to all long-term care facilities certified for skilled care in Minnesota. Responses were received from 297 of 349 (85.2%) homes. Nearly all homes (271 of 293; 92.5%) provided education for new nursing employees about use and disposal of needles. Disposal of needles and sharps was generally consistent with current recommendations for short-term care hospitals. Needlestick injuries were usually related to recapping and
R
elatively few patients with acquired immunodeficiency syndrome (AIDS) and other manifestations of human immunodeficiency virus ,(HIV) infection have been in long-term care facilities in the United States. However, with the increasing numbers of AIDS patients and their improved survival rates, this is likely to change.' Before patients with HIV infection can be easily assimilated into longterm care settings, education of nursing home staff about the unique issues surrounding the institutional care of patients with HIV infections will be needed. One obvious concern for nursing home employees planning to accept HIV-infected and AIDS patients is the proper care and handling of needles and other sharps. In short-term care hospitals, employee concern over potential injuries associated with sharp objects has been a significant issue in the care of the HIV-positive patient. In this article, we examine the present methods of needle handling and disposal of sharps in a large group of nursing homes.
were most common in registered and licensed practical nurses but were infrequent (i.e., < 2 injury per home per employee-year) probably because parenteral therapy is infrequently used in long-term care settings. Only slightly over half (266 of 286; 58O/o) of the homes had protocols for management of needlestick injuries. Although Minnesota nursing homes properly dispose of needles and sharps, many of these institutions need to develop policies for management of needlestick injuries that are consistent with current recommendations. J Am Geriatr SOC38:793 - 796,1990
MATERIALS AND METHODS
The state of Minnesota collects and publishes data, including addresses and telephone numbers, for all licensed and certified health-care facilities in the state. From this data base for 1988, all long-term care facilities with skilled-care beds in Minnesota were identified; they comprised our study group. The survey tool was composed of 30 yes/no and short-answer questions on a one-page standardized form. It was based in part on a prior telephone survey of physician offices dealing with needlestick injuries and topics related to AIDS.ZQuestions pertaining to demographics, needle use and disposal, and needlestick injuries and their management, as well as issues regarding AIDS and employee education on needle use and AIDS, were all included. To validate its utility, the survey was administered by telephone to directors of nursing (nine people) or the administrator (one person) of 10 longterm care facilities that had been systematically selected so that they were distributed throughout the state. Minor revisions were made in the wording of several survey questions on the basis of the comments obtained in this preliminary study. -~ ______ The survey was mailed to the director of nursing of From the *Departmentof Medicine, Section of Infectious Diseases, the facilities in the study group. We asked that if this St. Paul-Ramsey Medical Center, St. Paul, Minnesota, and the tUniversity of Minnesota Medical School, Minneapolis, Minnesota. individual was unable to reply, the survey be forwarded Address correspondenceand reprint requeststo Kent Crossley, MD, Section of Infectious Diseases, Department of Medicine, St. Paul- to the most appropriate person to complete it. The respondent was instructed to indicate his or her job title on Ramsey Medical Center, 640 JacksonStreet, St. Paul, MN 55101. 0 1990 by the American Geriatrics Society
0002-8614/90/$3.50
794
IAGS-]LILY 1990-VOL. 38, NO. 7
CROSSLEY ET AL
ported working at each facility was 12.6 (range, 2 to 78). A mean of 48 nursing assistants per home (range, 0 to 295) was reported. Frequency n (Oh) Education for new nursing employees about the use 68 (23.1) Never and disposal of needles was nearly universal in Minne108 (36.6) Rarely sota nursing homes; 271 of 293 (92.5%)homes provided Sometimes 63 (21.4) this training. Policies about needle use and disposal ex39 (13.2) Usually isted in 87.1% of homes. Although some of these poli17 (5 8) Always __ cies were based on local hospital guidelines (in 87 of 289; 30.1YO), most homes reported having developed their own policies. Four of five homes (233 of 292; the survey form. Included with the survey was a cover 79.8%) had copies of the publication “Recommendaletter that described the study and its purpose, identified tions for Prevention of HIV Transmission in Health Care the study investigators, and indicated that participation Settings” published by the Centers for Disease Control.3 was voluntary and that all results would be confidential. Nearly all homes (273 of 294; 92.9%) reported having Two weeks after the initial mailing, the survey and a had one or more in-services on AIDS in their facility. Disposal of needles and sharps generally followed new cover letter were remailed to those institutions from which a response had not been obtained. A third mail- available recommendations. Virtually all of the homes ing was sent 2 weeks after the second to those institu- used hard plastic containers for needle and scalpel disposal. Only 5 of 296 homes (1.7%) reported using cardtions that had failed to respond. Statistical analysis was performed using x2 with one board containers. Needle disposal containers were lodegree of freedom and Yates’ correction and, where ap- cated in medication rooms in 250 of 297 (84.2%)homes, on medication carts in nearly half of the homes (127 of propriate, Fisher’s exact tests. 297; 42.8%), and less frequently at nursing stations (44 RESULTS of 297; 14.8%), in utility rooms (20 of 297; 6.7%), or in Responses were obtained from 297 of the 349 (85.1YO) patient rooms (11 of 297; 3.7%). Containers of sharps licensed nursing homes in the state of Minnesota certi- were disposed of by incineration in 145 of 297 (48.8%) fied to have skilled-care beds. The response rate from and by a hazardous waste contractor or hospital in a nursing homes within metropolitan areas (Minneapolis, similar percentage (132; 44.4%). Only 11 of 297 (3.7%) St. Paul, Rochester, and Duluth) (117 of 148; 79.1%) homes reported that needles were disposed of in regular was significantly less than from institutions in other garbage. parts of the state (180 of 201; 89.6%) (P = .01, x2).Most Although over 80% of the homes (240 of 295; 81.4%) of the respondents (226 of 293; 77.1%) were directors of had a policy in place specifying that needles should not nursing. The balance of the questionnaires were an- be recapped after use, almost 80% of homes indicated swered by assistant directors of nursing (20; 6.8%), infection control practitioners (17; 5.8%), or other nursing home employees (30; 10.2%). The distribution of respondents did not differ according to metropolitan and TABLE 2. REPORTED SITUATIONS IN WHICH nonmetropolitan respondents. NEEDLESTICK INJURY OCCURRED IN MINNESOTA NURSING HOMES The mean number of skilled-care beds in the homes was 105 (range, 5 to 559). Sixty percent of responses Number of Injuries were from homes with less than 100 skilled-care beds. While recapping needle Homes of this size were significantly more frequent in 19 After filling syringe nonmetropolitan areas than in metropolitan areas (P < After giving injection 173 .01, x2). Only a few institutions were owned or operated After blood drawing 14 by a hospital (43 of 293; 14.7%); a similar proportion Total 206 was reported to be physically connected to hospitals. Unrelated to recapping Nearly all of the homes (266 of 294; 90.5%) had an indiWhen filling syringe 4 vidual designated as an infection control practitioner. A After giving injection 50 slightly higher proportion (291 of 295; 98.6%) reported After drawing blood 14 having an infection control committee. Injury from sterile needle 18 The mean number of physicians practicing in responFrom used scalpels 7 During trash removal 27 dent nursing homes was 15.1 (range, 1 to 158). AlUnknown 19 though there was again a broad range, the mean number Other 22 of registered nurses per home was 9.9 (range, 1 to 294) Total -~ 161 and the mean number of licensed practical nurses reTABLE 1. FREQUENCY OF REPORTED NEEDLE NURSING HOMES RECAPPING IN 295 MINNESOTA - ~-
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~
~
~
~
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IAGS-IULY 1990-VOL 38, NO. 7
NEEDLESTICK INJURIESAND NEEDLE DISPOSAL
795
TABLE 3. MANAGEMENT OF NEEDLESTICK OR SHARP INJURY IN LONG-TERM CARE* Hepatitis B
Prevention After injury
HIV
Educate employees about universal precautions, bloodborne diseases, and avoidance of injury. Immunize employees potentially exposed to No vaccine available. blood. Assess the significance of the injury and estimate the likelihood that the patient has a bloodborne disease. Obtain informed consent, draw blood and test for hepatitis B antigen (HBsAg) and HIV antibody. Provide appropriate counseling. Document the testing and results carefully. Protect the confidentialityof the patient and the employee. If source patient is HBsAg-positive and the emIf source patient is HIV-positive or refuses testing, evaluate employee for HIV antibody at time of ployee is not immunized, administer one dose of hepatitis B immune globulin (HBIG) and injury and at 3 and 6 months. Consider use of start vaccination series. If employee has been m.t antibody titer (anti-HBs)’ Employee should follow guidelines for prevention If source patient is unknown or refuses testing, of transmission for at least 6 to 12 weeks (restart vaccination series if not previously given. frain from blood donation, use appropriate proIf patient is at high risk for being HBsAg-pitection during sexual intercourse.) add HBIG’V the has imIf source patient is negative, follow up exposed munized, measure antibody titer. worker at worker’s request in 6 to 12 weeks. If source patient is negative, complete immunizaSource unknown: Individualize. Test and followtion series for employee. up employee. tiveg
HIV, human immunodeficiency oirus. This is a brief summary of recommendations in early 1990.3,6,7 t Zidooudine (AZT) is a potential prophylactic agent for use ufter needlestick injury from HIV-positive indioiduals. Consult with an expert in this area before initiating the druga
that needle recapping took place in their institution (Table 1). The frequency of needlestick injuries in the homes was reported to be low. Virtually all of the homes kept records about needlestick injury. The mean reported number of needlestick injuries during the year before receipt of the survey was 1.38per institution. Risk was highest for registered nurses and licensed practical nurses (with means of 0.45and 0.75 injuries per home per employee-year, respectively). Needlesticks were not reported for laundry workers and occurred very infrequently for nursing assistants and housekeeping and maintenance personnel (means of 0.05,0.02,and 0.01 injuries per home per employee-year, respectively). Of the reported injuries, nearly half occurred after administering an injection. Other causes of needlestick injuries are summarized in Table 2. Only 166 of 286 (58.04b)homes reported having a written protocol for management of needlestick injuries. After a needlestick injury the most common reported response was to report that it had occurred (217of 268; 81.04b).A small proportion of homes (32of 268;11 . W o ) indicated that the wound was cleansed but nothing else was done. Decisions about further workup or evaluation were made by a physician in 101 of 268 homes (37.7%) and by nursing administration or the infection control nurse in 160 of 268 (59.74b). If the patient with whom a needle had been in contact could be identified, testing of
the individual for hepatitis B was done in 80 of 268 (29.946)homes and for HIV antibody in 65 of 268 (24.3%) homes. After needlestick injury, employees were tested for hepatitis B susceptibility in 56 of 268 (20.94b)homes, offered HIV testing in 73 of 268 (27.246)homes, given gamma globulin in 51 of 268 homes (19.04b)or hepatitis vaccine in 22 of 268 homes (8.2%), and offered counseling in 66 of 268 (24.646)of homes. Over 90% (90.8%) of the homes that tested for HIV in the source patient also tested for hepatitis B antigen. It is interesting that of those homes that tested for hepatitis B or HIV in the source patient, only approximately 25% offered counseling to their employees. Although only a few homes in Minnesota reported that they had cared for HIV-infected patients (44of 294; 15.0%), a majority of homes had developed plans for caring for patients infected with HIV (208 of 285; 73.()yo).
DISCUSSION We believe that these data make three important points about needlestick injury in long-term care institutions in Minnesota. First, the risk of needlestick injury seems quite low. Second, nursing homes need to ensure that their policies for the management of needlestick injuries are in keeping with current recommendations.
796 CROSSLEY ET AL
Third, disposal of needles and other sharps is appropriate in the vast majority of homes. Although we were surprised at the low frequency of reported needlestick injury, most nursing homes do not provide parenteral therapy except for administration of insulin to diabetic patients. Although we are not aware of data about the frequency of needle use in long-term care institutions compared with short-term care hospitals, the lower apparent risk almost assuredly largely reflects a much more limited usage of injections in these settings. Given the increasing trend toward briefer short-term care hospital stays, it is likely nursing homes will care for more and more patients who need parenteral therapy in coming years. In contrast to what we observed in the offices of Minnesota physicians,* disposal of needles and other sharps was largely consistent with existing regulation. Once needles were collected and removed from the facility, they were nearly always handled in a manner that is appropriate (e.g., by incineration or destruction by a company licensed to handle infectious waste). The majority of needlestick injuries apparently resulted from recapping. Although data from short-term care hospitals are not directly comparable with information derived in long-term care settings, recapping may be the most frequent source of injury for employees in both health-care environments.' The type of employees who sustained the largest number of injuries in nursing homes -registered and licensed practical nurses -supports this observation because they are also most commonly involved in recapping injuries in short-term care hospital^.^ Although needlestick injuries appear to be uncommon in the long-term care setting, the management of these injuries and the follow-up available to employees should be identical to that in short-term care hospitals. It is of concern that relatively few institutions had written
IAGS-/LILY 1990-VOL. 38, NO. 7
policies for the management of needlestick injury and that testing either patients or employees for hepatitis B or HIV infection is done relatively infrequently. We believe that employees in long-term care facilities deserve the same counseling that is provided to employees in short-term care hospitals and that much more frequent postexposure testing for hepatitis B and HIV infection is indicated. Guidelines of the Centers for Disease Control need to be monitored and followed by those responsible for employee health in nursing homes.3.6-8 Current guidelines are summarized in Table 3. If these data are representative of the situation in other parts of the country, expanded educational efforts about needlestick injuries and their management need to be a priority for long-term care institutions in the United States.
REFERENCES 1. Crossley K, Henry K: AIDS: implications for long-term care. Clinical Report on Aging (American Geriatrics Society) 1:1, 3, 5, 6, 9, 1987 2. Thum J, Willenbring K, Crossley K: Needlestick injuries and needle disposal in Minnesota physicians' offices. Am J Med 86:575, 1989 3. Centers for Disease Control: Recommendations for prevention of HIV transmission in health-care settings. MMWR 36(suppl 2S):IS, 1987 4. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD: Rates of needle-stick injury caused by various devices in a university hospital. N Engl J Med 319:284, 1988 5. McCurdy SA, Ferguson TJ, Schenker M: Mucocutaneous injuries at a university teaching hospital. West J Med 150:604, 1989 6. Centers for Disease Control: Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public-safety workers. MMWR 38:1, 1989 7. Centers for Disease Control: Recommendations for protection against viral hepatitis. MMWR 34:313, 329, 1985 8. Centers for Disease Control: Public Health Service statement on management of occupational exposure to human immunodeficiency virus, including considerations regarding zidovudine postexposure use. MMWR 39 (no. RR-l):l, 1990
