May-June 2011 | Features in Bethesda Health

Sharp Lookout

Karen Daley knows what an accidental needlestick can do to a person-it ended her nursing career and threatened her life. Now she works to ensure that doesn't happen to anyone else.

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That fall, Karen Daley began suffering fatigue and nausea so debilitating she couldn’t eat. She dropped 12 pounds over a couple of months. She struggled through work, determined not to take a sick day from her job as a senior staff nurse in the emergency department at Brigham and Women’s Hospital in Boston.

The illness was, to say the least, “unusual for me,” Daley recalls during a recent interview at the Silver Spring headquarters of the American Nurses Association (ANA). The 58-year-old ANA president looks healthy and trim in a fitted blue jacket and black skirt as she calmly recounts the harrowing experience nearly 13 years later.

After Daley became ill, she dismissed the symptoms as a reaction to the death of a brother killed in a car crash a year earlier. When she finally sought help, her doctor couldn’t figure out what was wrong. Daley didn’t think to mention the puncture wound she’d gotten at work that July.

She was working in the ER when a co-worker asked for help drawing blood from an elderly patient. Although drawing blood wasn’t among her regular duties, Daley didn’t hesitate. She expertly inserted the needle into the arm of the man. Applying pressure to the injection site with her left hand, she reached back with her right hand to dispose of the needle in a box mounted high on the wall, not knowing it was overflowing with used instruments. That’s when she felt a needle puncture her index finger.

“I knew it was deep right away because the blood came right through the glove,” Daley says.

In 26 years of nursing, she had been stuck three or four times—as had many colleagues—so her first reaction was to ignore the puncture. I don’t want to deal with this, she thought.

But another nurse urged her to follow protocol and get examined in the hospital’s urgent care area. A course of prophylaxis was strongly recommended after needlesticks to try to prevent HIV infection. Risk of infection could be reduced by 80 percent. But Daley was leery. She had seen fellow nurses practically incapacitated by vomiting after taking the toxic medications.

She considered the odds: The needle that punctured her finger had been sticking out of the box, exposed to the air, which typically reduces the risk of infection.

Daley decided to forgo the drugs. It was a decision she would always regret.

On New Year’s Eve 1998, about six months after the incident, Daley learned the devastating news that would end her career and threaten her life: She was infected with HIV and hepatitis C—two of the most serious of 20 blood-borne pathogens to which health care workers can be exposed.

Today, Daley divides her time between her home in Cotuit, Mass., and a condominium in Silver Spring. She travels the country promoting awareness of the 2000 Needlestick Safety and Prevention Act, a federal law she fought for more than a decade ago to protect health care workers from preventable sharps injuries that expose them to potentially deadly diseases.

The law requires employers to provide safer devices, such as retractable needles, to protect health care workers, and to maintain a log of sharps injuries. It also requires front-line workers to be involved in the evaluation, selection and implementation of safety devices.

At Suburban Hospital in Bethesda, for example, officials established a “Safer Sharps Team” whose evaluation of all sharp instruments has led to the use of safer devices, according to Cindy Notobartolo, Suburban’s director of occupational health and safety. In addition, staff members are trained to use the devices and to fill out detailed reports if they sustain puncture wounds. The hospital closely monitors needlestick incidents and sets annual reduction targets. In the past year, the operating room has reduced infection exposures by 12 percent, Notobartolo says.

Needlesticks still occur nationwide, however, which is why Daley and the ANA have revived their campaign. In a 2008 ANA survey of more than 700 nurses, nearly two-thirds reported being accidentally stuck by used needles or other sharp devices. And a study published in the April 2010 Journal of the American College of Surgeons found that injuries actually have increased by 6.5 percent in operating rooms since passage of the federal law, Suburban’s figures notwithstanding. The study suggests that safety policies are not being practiced or enforced in operating rooms as often as they are in nonsurgical settings.

Precise data isn’t available on the number of needlestick and other sharps injuries that occur in the United States, according to the Centers for Disease Control and Prevention in Atlanta. But the agency estimates that 600,000 to 800,000 injuries occur annually, with many others unreported. The CDC estimates that 0.3 percent of those injuries result in HIV infection, and 1.8 percent in hepatitis C infection.

Daley was among the unfortunate few.

In December 1998, she underwent a six-month follow-up after the needlestick, as required by her hospital. When she went, she neglected to mention that she’d been feeling ill and had seen her own doctor.

A week later, she decided to check on the lab results while working one afternoon. When she called the office, the nurse practitioner on duty asked her to come right up. Daley remembers looking at her watch and worrying about getting back to work as the nurse practitioner asked her to sit down.

The results “weren’t negative,” the nurse told her. “She couldn’t say the words,” Daley recalls. “It was such a horrific thought that [infection] could be the outcome of this.”

The nurse told her the tests would have to be repeated. When Daley returned to the lab for her results on New Year’s Eve, several people were waiting for her, including the hospital’s medical director. She knew it was bad news. “I remember the medical director crying,” she says.

At that moment, “I knew I couldn’t go back to the ER, to the work I loved,” she says. “I think I was absolutely in shock. I didn’t know what was going to happen. I didn’t know what my future was going to be.”

Daley’s life changed in major ways in the years following her diagnosis. Since her viral loads were “very high,” she was told she needed to start treatment quickly. Daley knew she couldn’t be treated at the hospital where she worked because colleagues would learn of her illness. So she contacted doctors at Massachusetts General Hospital in Boston.

She began a daily regimen of potent antiviral drugs, taking as many as 21 pills a day, plus an injection, all the while worrying that her depressed immune system might not be able to fend off the development of full-blown AIDS. Her hair fell out; she broke out in horrible rashes; she lost weight. She wasn’t sure she’d make it through the year.

Even so, she began learning about needlestick injuries, propelled by the fact that her injury should have been preventable. Daley discovered that because of costs, many hospitals—including her own—didn’t use the safest available needles or disposal devices, such as puncture-proof containers.

With support from the Brigham and Women’s administration, she looked into where improvements could be made. “Nurses themselves started to get engaged in advocating for their own safety,” she says. “I saw a change in terms of the culture where I worked.”

Previously elected head of the Massachusetts Nurses Association, she successfully pushed for the state legislature to pass a needlestick safety and prevention bill in 1999. It mandated that hospitals report all sharps injuries annually to the Massachusetts Department of Public Health.

Daley traveled around the country, at times battling fatigue and illness from the drug therapies, telling her story to educate others about the prevalence of needlestick injuries and how they could be prevented.

“For me, it was about survival,” she says. “For me to get involved in the policy arena allowed me to make sense out of a senseless thing.”

Daley’s efforts, along with the advocacy of the ANA, state nursing associations and grassroots supporters, led to the passage of the federal law. Last June she was elected president of the national nurses association. She and the ANA currently are working to make sure that medical facilities adhere to the law by using the safest devices available and educating workers about reporting injuries.

“As ANA president, this is a natural progression for my advocacy work,” she says. But she misses her direct nursing career. “I’ve never gotten away from that in my heart and in my head.”

For the most part, Daley leads a normal, active life. She is among roughly 30 percent of patients who respond positively to yearlong treatments for hepatitis C, and she no longer needs treatment. For six years, she has taken a stable regimen of drugs to treat HIV. She will take sharp lookout the drugs for the rest of her life.

“Occasionally I have a rough day” and feel ill, she says. “But I know the next day I’ll do well.”

For her nursing doctorate, completed last May, Daley researched the emotional stress experienced by nurses who suffer needlestick injuries. During in-depth interviews with a dozen or so nurses in Massachusetts, she heard stories of severe reactions to the post-exposure prophylaxis and of the anxiety and stress suffered while waiting to see if infections develop—all due to injuries that could have been prevented.

“I can tell you the distress that nurses go through,” Daley says. After all, she lived through it.

Julie Rasicot lives in Silver Spring. Her work has appeared in The Washington Post, among other publications.