Vol. 5 Issue 3
When A Nurse Gets Stuck
Under Maryland law a patient does not need to submit to HIV testing if a nurse gets exposed to his blood via a needlestick
When children ask for permission to do something, it's usually a request that has relatively minor implications in the grand scheme of things. Even adults, whether in the workplace or a personal situation, might need to seek permission from a higher authority or their soul mate. But, again, it's generally not a matter of life or death if that permission isn't granted.
Nurses and other health care personnel in the state of Maryland, however, can find themselves in a potentially life-threatening situation because of permission not given.
The issue involves accidental needlesticks and the need to start a prophylactic regimen for the health care worker within a few hours if the source patient is HIV-positive.
But what if the patient refuses to be tested for HIV and under state law can't be forced to do so? That is the current predicament and, although such a dire situation doesn't occur frequently, when it does it can wreak havoc with the mental state of the person suffering the accidental stick. Just ask Susan Kalaine, BSN, RN, CEN, CFRN, EMT-P, who while working at Johns Hopkins Hospital, Baltimore, in November 2001, was stuck with a contaminated needle used on a patient with a known intravenous drug abuse history (see accompanying article, "Accidental Needlestick").
Corrective Legislation Defeated
Unlike 32 other states that have some sort of legislation in place to cover this type of situation, Maryland's legislature has defeated two bills in the last 6 years regarding this issue. One would have amended a 1991 law requiring patient consent for HIV testing and, instead, would have provided for prompt testing when patients refuse to give permission.
Note the word "prompt," which is key many medical experts, including Johns Hopkins physicians, say the risk of transmission of HIV is greatly reduced when post-exposure prophylaxis is started within 2 hours of the exposure incident. Combivir® (lamivudine/zidovudine, GlaxoSmithKline) is the current recommended prophylactic therapy. The health care worker can choose to begin the therapy without knowing the status of the source patient; however, it is not an easy choice because of Combivir's potential side effects headache, nausea, fatigue, weakness, diarrhea, neuropathy, muscle or bone pains, sleep problems and, in some cases, liver damage.1
Valuable Time Lost
Impacting the need for amending the 1991 legislation is the length of time it often takes to get consent under certain circumstances, said Carolyn Means, BSN, RN, nurse manager in the occupational clinic at Johns Hopkins Medical Institutions (JHMI). "It can take hours to locate the patient's physician or a relative for permission to get the test," she commented, adding, "There are a lot of issues to this. For instance, a baby in the NICU may need testing, but the mother can't be reached promptly to give consent. The nurse may be on the therapy unnecessarily for a whole week before we know the facts."
Currently, two laboratory tests (Rapid HIV SUDS test (Abbott-Murex Diagnostics, Norcross, GA) and OraQuick Rapid HIV-1 Antibody Test (Orasure Technologies, Bethlehem, PA)) now exist that can determine the source patient's HIV status in 1 hour if permission is granted.2,3 Thus, the decision on whether to begin Combivir therapy can be made within the preferred 2-hour framework.
There is a drawback, however the test is expensive, which makes medical personnel hesitant to use it unless the source patient is considered at high risk for being HIV-positive.
Major Issue in Recruiting/Retaining Nurses
This current Maryland law has many implications for the health care profession, not the least of which is the added difficulty in hiring and retaining nurses in Maryland facilities when those same nurses can work in a neighboring state with legislation authorizing immediate testing.
Again, just ask Kalaine, who was also stuck several years ago while working in Virginia, where, because of its regulations ("There were no questions on having to get anything signed.") the issue was resolved within a couple of hours.
Fear of injury and of contracting serious illnesses on the job are known deterrents to recruiting and retaining nurses, said Mary A. Linton, MA, RN, COHN-S, co-author of Workplace Advocacy: A Guide for Maryland Nurses4, a booklet published by the Maryland Nurses Foundation. According to the 2001 American Nurses Association Health and Safety Survey, 88 percent of RNs reported that health and safety concerns influence their decisions to remain in the nursing profession. And 45 percent were concerned about contracting HIV or hepatitis from a needlestick injury. In addition, the Maryland Commission on the Crisis in Nursing reported in 2001 that a number of Maryland high school students have stated they do not want to become nurses because of a fear of contracting communicable diseases.
"Pennsylvania, Virginia, West Virginia and Delaware all have laws that permit testing without consent under certain conditions, so it's a big issue for recruitment and retention," added Linton, who has been an occupational nurse for 20 of her 30 years of practice.
Reasoning Behind 1991 Law's Passage
Linton, who serves as chair of the Workplace Advocacy Committee of the Maryland Nurses Association (MNA), explained the whole issue stems from the 1991 state law requiring informed consent to test for HIV. "For many years, HIV/AIDS was viewed as a disease of the homosexual community," she said. "The social stigma behind HIV, including lifestyles, lost livelihoods and insurance coverage, prompted legislators' concerns about protecting the confidentiality of HIV/AIDS patients.
"Since 1991, drugs have been developed that have been shown to block HIV transmission. This has changed the whole picture," Linton emphasized.
In 1997, a bill (HB254) that would have allowed mandatory testing of hospital patients under certain circumstances was passed in the Maryland House of Delegates but defeated in the Senate. And a similar bill (HB1065) that would have repealed the requirement that a patient give prior consent was defeated in the House in 1999, so the issue still is unresolved, even though statistics indicate the fear of transmission is real.
The National Institute for Occupational Safety and Health5 reports that accidental needlesticks sustained by health care workers are estimated at 560,000 per year. And Johns Hopkins' Edward Bernacki, MD, director of the Occupational Medicine Department, says that 1-in-10 (42 out of 470 in 2001) "true exposures" to health care workers at JHMI are, when tested, from an HIV-positive person. While figures were not available on the actual number of non-consents, Means said 131 out of the 549 evaluated for exposure "did not get tested for various reasons (e.g., expired, discharged or non-consent).
Now, Linton is hopeful legislation will soon be passed to fix the problem as a new administration takes over the governor's post. In ad.dressing the MNA as a gubernatorial candidate last fall, she noted, Robert L. Ehrlich Jr., the successful Republican candidate, was very supportive, indicating there was no reason this kind of barrier should exist. This is in contrast to the previous administration, which "vehemently opposed any changes to the legislation and won the support of numerous legislators who saw it as a violation of patients' rights," she added.
Linton has been trying to raise awareness of the issue on three different fronts: her position as the MNA Workplace Advocacy Committee chair, as a member of the Maryland Commis.sion on the Crisis in Nursing and as an occupational health professional. She said the MNA workplace advocacy committee is currently preparing "to put the issue before the MNA board of directors."
Linton believes the strongest argument for changing the 1991 statute "is our moral obligation to provide the best care available when a nurse or health care worker is injured. In addition, we need to understand that our current law sends a negative message to those who provide professional nursing services in Maryland.
"We need to educate employers of nurses [on this issue] for three reasons," Linton stressed: 1) they are responsible for the care of their injured health care workers; 2) they need to be aware that certain contributing factors (i.e., understaffing, lack of protective equipment, inadequate training) create a greater potential for injuries; and 3) employers can use their influence to lobby for change.
The law affects more than just nurses, she stressed, and those organizations have expressed concerns as well. "We need to work closely with other stakeholders firefighters, police, ED workers, physicians, emergency technicians, dentists and dental hygienists to make a difference."
An interesting fact in all this, Linton added, is that corrections personnel in Maryland are an exception to the law; prisoners can be tested for HIV without their consent because they are considered to have no rights under state law.
Timing Right for Action
Linton believes three factors indicate that the timing may be right to try again to get legislation passed: A supportive new administration in place, enough concerned people, and advances in drug therapy that are now available to prevent HIV transmission if started within a few hours.
"Susan Kalaine's experience should be a wake-up call," she said. "Nurses and other health care workers risk injuries and illness each day in the performance of their routine patient care. Maryland's current law sends the wrong message to nurses and health care workers and it clearly devalues their intrinsic worth. Are we willing to pay the price for this unfortunate oversight?"
If people could see the anguish, uncertainty and fear, "the absolute panic and terror on the faces" of health care workers who have been accidentally stuck, Linton added, they would understand and support such a measure. "It is life-changing for some people," she said. "To have this sword hanging over your head is horrible."
1. HIVandHepatitis.com. (2002). HIV and AIDS treatments: Combivir Ð What are the side effects? Author: San Francisco. Retrieved Dec. 18, 2002 from the World Wide Web: www.hivandhepatitis.com/hiv_and_aids/combivir_effects.html
2. University of Iowa Health Care. (2002, July 3). Rapid HIV SUDS test. The University of Iowa Department of Pathology Laboratory Services Handbook. Retrieved Dec. 31, 2002 from the World Wide Web: www.medicine.uiowa.edu/Path_Handbook/handbook/test1008.html
3. University of Illinois Center for Drug Information. (2002, March). Drug Information Center. Retrieved Jan. 10, 2003 from the World Wide Web: www.uic.edu/pharmacy/services/di/hivtest.htm
4. Linton, M., & Newell, M. (Eds.) (2002). Workplace advocacy. Linthicum, MD: Maryland Nurses Foundation.
5. NIOSH alert: Preventing needlestick injuries in health care settings. (1999, November). NIOSH Publication No. 2000-108.
Bette Mooney is a freelance writer and retired editor at ADVANCE.
A Maryland nurse suffers the unknown, getting stuck with a needle from a patient who is a known drug abuser
Susan Kalaine, BSN, RN, CEN, CFRN, EMT-P, has suffered two accidental needlesticks over the course of her 18-year health care career, one in Virginia and the second in Maryland. A former firefighter who put herself through nursing school working as a paramedic, she got the first needlestick in 1989 while doing paramedic duties in an ED.
Virginia's laws were clear on procedures: test the source patient for HIV, with or without consent. The hospital did, and she was told the result (fortunately negative) "within a couple of hours," knowing her worries were over.
When she was stuck again in November 2001 while working in the ED at Johns Hopkins Hospital, Baltimore, it was a completely different scenario. Kalaine immediately reported the incident to her supervisors, who said Maryland's laws required that the source patient consent to have his blood tested for HIV. A known IV-drug abuser who already had tested positive for hepatitis C, the patient refused to give consent.
"I was in tears, because so many things run through your mind," Kalaine told ADVANCE. "Fortunately, a doctor on call for this type of emergency told me what I needed to do" start taking Combivir® (lamivudine/zidovudine, GlaxoSmithKline) within 2 hours for best results to hopefully prevent HIV transmission. Previously vaccinated for hepatitis B, she also worried about the risk of contracting hepatitis C.
Sick and Angry
The medication made her "so sick for the better part of the time I had to take it that I couldn't work," she said. "The whole experience was truly a nightmare."
To her consternation, she also later learned that Combivir can cause liver damage, to the point where, she said, a couple of the drug's recipients needed liver transplants.
Kalaine also became angry and still is over the lack of health care workers' rights. "I think it's very sad that in Maryland there are all kinds of things to protect patients, but what is there to protect us? Who helps us?" she said. "I'm still very angry about the whole thing. It's not just a nursing issue; it's a medical profession issue.
"If there is a positive aspect to all this," she added, "it is the 50-50 chance of this patient not being HIV-positive, even though he is considered high-risk because of his IV drug abuse history." So far, all Kalaine's HIV and hep C tests have come back negative. (The sero-conversion timeframe is 2 years for HIV and 4 months for hep C.)
Advocating for Action
But the experience has spurred her into advocating for the state legislature to correct the situation. Involved with Maryland's Commission on the Crisis in Nursing even before her second needlestick, she began attending committee meetings and soon linked up with Mary Linton and Elise Handelman, members of the workplace issues committee of the commission, who lightheartedly call Kalaine their "poster child."
Aware that achieving corrective legislation is an "uphill battle," considering two previous defeats, Kalaine is networking with friends in law enforcement and emergency services to get support.
"Emergency services folks have even more of a disadvantage than hospital employees in the event of a needlestick," she noted, "because when they take patients to the hospital the patients become part of the hospital system and it's difficult to get information."
Along with her networking efforts for legislation, Kalaine is continuing her education so she will have more nursing career options. "I don't want to continue putting myself at risk on a daily basis if there is nothing to back it up," she said. "People wonder why nurses are leaving the profession; this is why."
– Bette Mooney