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Safety Risks Among Home Infusion Nurses and Other Home Health Care Providers

In the United States, home health care (HHC) is a rapidly growing industry and home infusion therapy is a rapidly growing market. HHC can present substantial occupational safety and health (OSH) risks. This article summarizes major OSH risks relevant to home infusion therapy by illustrating them through real-life scenarios collected systematically using qualitative research methods by the National Institute for Occupational Safety and Health-funded research projects at the University of Massachusetts Lowell. The need for home infusion therapy will continue to grow in the future, and safety interventions to prevent or minimize OSH risks are essential.

are now expected to master a rapidly expanding set of demanding hands-on skills and to educate other caregivers and patients.
For all types of home-based caregivers, the home work environment is both dynamic and unpredictable. In contrast, patients in acute care settings are usually in a standardized environment (eg, in a room or bed) where conditions are familiar to the nurse and where, when something unexpected happens, the nurse can call for backup assistance. 6 Several studies and US government reports have documented the occupational safety and health (OSH) challenges of HHC work.  OSH hazards in HHC include but are not limited to bloodborne pathogen (BBP) exposures, demanding patient mobilization and transfer tasks, threat of violence and other personal safety issues, exposure to secondhand tobacco smoke and cleaning and other household chemicals, long-distance driving, and the presence of pets. Some of these hazards are present in any health care setting, but the work in isolation in variable and unpredictable home environments can increase home-based caregivers' vulnerability. Some recently developed HHC training curricula now include modules on OSH 28,29 ; however, research is still needed to identify feasible public health interventions to protect HHC providers and patients alike.

OBJECTIVES
The objectives of this article are to summarize the major OSH risks in HHC, in particular those relevant to home infusion therapy, and to illustrate them through real-life scenarios. The scenarios derive from a systematic analysis of focus groups and interviews of home health nurses and other caregivers with similar working conditions.

METHODS
This article presents 10 scenarios describing the main OSH findings from 2 different research studies at the University of Massachusetts Lowell: (1) Project SHARRP (Safe Home Care and Risk Reduction for Providers), an examination of BBP exposures among HHC nurses and other clinicians in Massachusetts (2004Massachusetts ( -2009 17,24,30,31 ; and (2) the Safe Home Care Project (2010-2014), which evaluated risk factors for sharps injuries in HHC, as well as a wide range of other OSH hazards and promising prevention practices among home care aides. 16,18,26,27 Both projects comprised 3 research phases: presurvey qualitative phase, cross-sectional survey, and postsurvey qualitative phase to interpret survey findings and recommend interventions. Detailed methods of the studies are reported elsewhere. [16][17][18][19]24,26,27,[30][31][32][33][34] This article is based on data from the pre-and postsurvey qualitative methods phases of both projects, which involved a total of 29 focus groups of frontline HHC providers and in-depth interviews with a total of 35 HHC agency managers, industry trade association directors, and labor union representatives. Out of all 29 focus groups, 8 focus groups involved home health nurses and aides who performed or supported home infusion therapies, in addition to other HHC duties. The audio of all focus group and interview sessions was recorded and transcribed. A computer-assisted thematic analysis was used as the data analysis method. Transcripts were coded with NVivo qualitative research software (NVivo; QSR International [Americas], Burlington, MA) to obtain 3-to 4-level hierarchical coding of themes.
This article also presents previously unpublished qualitative data findings from the Project SHARRP cross-sectional survey; the quantitative analysis of the SHARRP survey has been published elsewhere. 24,30 The survey included open-ended questions to accompany quantitative reports on injuries experienced from sharp medical devices (ie, sharps injuries). These qualitative open-ended narratives of the survey were also coded with NVivo to identify hierarchical themes.

RESULTS
Ten scenarios were identified that illustrate important OSH risks frequently identified in the focus groups and interviews, including BBP exposure hazards; working in isolation; uncontrolled home environmental conditions related to housekeeping and hygiene; inadequate workstations or technology; unpredictable disruptions by family members or pets; and lack of assistive devices, in particular, for patient mobilization and transfer tasks. Seven scenarios focus on BBP exposures and hazards reported by home health nurses in focus groups and interviews. Three scenarios relate to other hazards: violence, risk of musculoskeletal strain and injury related to demanding patient mobilization and transfer tasks, and patient cigarette smoking during oxygen use reported by a home health nurse as well as 3 home care aides.

BBP Exposures
Project SHARRP identified multiple risk factors for occupational sharps injuries in HHC. Figure 1 illustrates themes collected from the open-ended answers of the Project SHARRP survey that accompanied quantitative reports of sharps injuries. Concentric rings in different shades represent thematic levels identified and coded using NVivo software. Focus groups and in-depth interviews of the Project SHARRP study supported these survey findings. The most coded sharps injury themes included (1) sharps disposal factors (eg, clinician's overfilled sharps containers, used sharps left around the home by clients); (2) patient characteristics (eg, patient moves suddenly, uncooperative/ mentally unstable patient); (3) home work environment and work organization factors (eg, distractions and clutter); (4) specific medical procedures and other activities (eg, vascular access); (5) worker characteristics (eg, time pressures); and (6) sharps device characteristics (eg, lack of safety features in medical sharps).

Scenario 1: A Seriously Cluttered Home Presenting a Hazardous Work Space to Provide Home Infusion Therapy
A home health nurse needed to place a peripherally inserted central catheter (PICC) in the patient's arm to administer antibiotic medication. The patient's home was very cluttered. There was no table to use, and garbage had piled up. The nurse's first task was to replace a dressing on the patient's leg. At the same time, she needed to decide whether to insert the PICC in these conditions. After about an hour, having finished the dressing and asking for information, she determined the situation was not safe for inserting the PICC; however, the patient needed the antibiotic medication. The nurse asked the patient about options. The patient indicated that the kitchen sink was the cleanest place in the house. The nurse completed the task successfully and safely; however, she had to make a difficult decision, and the situation could have turned out quite differently. She described: It took me about a half hour to be creative, create a safe little space, a space to dispose of my sharps immediately, and how I would do it to insert that PICC. And I used his kitchen sink, of course, and made sure it was safe, but I was very angry that the hospital sent him home knowing that he was going home to that situation when they could [have done it safely in hospital].
-Project SHARRP focus group participant

Scenario 2: Technology, Patient Characteristics, and Distractions
A debilitated multiple sclerosis patient had been recently discharged with an IV catheter in place. Soon after, a home health nurse visited the patient to start an infusion and noticed the catheter was not functioning properly. The patient did not want to go back to the hospital. The nurse tried to insert a catheter several times unsuccessfully. Both the nurse and the patient got frustrated. The nurse said, "I'm done." The patient became agitated and said, "Please, please, please don't go." Then the nurse was stuck with the used needle. She said: -Project SHARRP focus group participant

Scenario 3: A Sharps Injury Near-miss
A home health nurse was removing a patient's noncoring needle, which did not have a safety feature. The patient didn't want to lie down. The patient also didn't want to take off her shirt and had it pulled over to the side. The work space available to the nurse was so restricted that the nurse had to perform the procedure closer to the patient than she judged to be as safe as possible. She pulled the needle out effectively; however, she experienced a rebound from the device, and the needle punctured the side of her glove, fortunately missing her finger.
You just feel the snag on the glove and it was like, Oh, man, that was too close for comfort there. I shouldn't have done that. I should have had her pull that sleeve down more. I should have maybe had her in a recliner or lying down so that she wasn't sitting up in the chair where you tend to move a little bit. And I, myself, probably was not in the best position as I could have been in.
-Project SHARRP in-depth interview participant

Scenarios 4 to 6: Dangerous Distractions During a Medical Procedure
The following 3 scenarios were described by 3 different infusion nurses in the same focus group. In the first case, scenario 4, a nurse had an infusion patient with 2 small children. The patient did not feel it was necessary for the children to leave the room. In the middle of the procedure, the nurse had a sippy cup thrown at her head. The patient told the nurse not to worry about the child. The nurse was not able to place the IV catheter. He said:

Scenario 8: A Challenging Neighborhood and Threat of Violence
A nurse visited a patient discharged from the hospital after having a bowel resection following a serious bicycle accident. In the home, there was no electricity, heat, or hot water. The nurse understood immediately that the patient had financial problems and arranged for the social worker to meet her there. The social worker and nurse discussed  Figure 1 and scenarios 1 to 7 illustrate BBP exposure risk factors that were reported by home health nurses. The Project SHARRP survey, following the focus groups and interviews where these scenarios were identified, found that approximately 35% of nurses had experienced at least 1 injury with a previously used sharp during their HHC career. 24 The annual sharps injury incidence rate for home health nurses was 5.1 per 100 full-time equivalent nurses. 24 The rate was consistent with the literature findings in hospitals and nonhospital facilities. 11,12,35 Two hundred seventy-five nurses who reported sharps injuries in the SHARRP survey were engaged in the following medical procedures either during or immediately before the sharps injury: injections (31%), fingersticks or heelsticks (23%), blood draws (22%), and using an IV catheter (8%). 24 HHC clinicians are covered by the Occupational Safety and Health Administration's BBPs standard, 36 which requires the use of engineering and work practice controls to eliminate or minimize BBP exposures among employees. Engineering controls include sharps with injury prevention features (SIPFs). However, the SHARRP survey found that SIPFs were not frequently used in home care, in particular when the sharps were procured and used by patients (eg, lancets or insulin syringes). 24 In addition to a lack of SIPFs, a follow-up qualitative study identified the reuse of sharps and challenges in sharps disposal practices among home users. 16

Back Injuries and Other MSDs
Workers' compensation records indicate that back pain/ injuries and other MSDs are the most reported and costly incidents in HHC. 18 The biggest risk factor is patient/ client mobilization and transfer tasks, which become more demanding when patients have limited or no mobility or when they are overweight as described in scenario 9. Also, caregivers who perform homemaking duties (ie, cleaning, laundry, and grocery shopping) reported musculoskeletal strain. 18 Among the 1249 home care aides who completed the Safe Home Care survey, more than 10% experienced some type of work-related injury serious enough for the aide to seek medical care and/or lose work time in the 12 months before the survey. 27 Of these, the most common was a musculoskeletal injury related to client handling, followed by slips, trips, or falls outside the home (eg, falling on icy stairs, snowy walkways). About onethird of all aides experienced back pain in the previous 12 months; three-quarters of this group considered the pain to be somehow related to their work. 27 The physical home space limits the use of high-tech devices to the same or greater extent as in hospitals and skilled nursing facilities. However, low-tech devices can improve both caregiver and patient safety (eg, grab bars, shower chair/bench, adjustable bed).

Other Safety Risks
Scenario 8 illustrates a situation in which the threat of violence is imminent during a home health nurse's visit. All home health nurse participants in Project SHARRP's focus groups were concerned about the threat of violence (either physical or verbal) in a patient's neighborhood or inside a patient's home. In the Project SHARRP survey, 11% of 275 nurses reported that an aggressive or uncooperative patient was a contributing factor to a sharps injury. 24 In the Safe Home Care survey, approximately 7% of the 1249 home care aides reported experiencing physical violence, while nearly 20% experienced verbal violence in the 12 months preceding the survey. 27 Medical oxygen combined with smoking or other sources of ignition is a serious fire and explosion hazard that threatens not only workers who visit homes but also community members (scenario 10). 34 Home cooking equipment, smoking materials, and heating equipment are leading causes of residential structure fires, injuries, and civilian home fire deaths. 37 The Safe Home Care survey results reinforced focus group findings. Medical oxygen was present in 9% of aide visits (314 of aides' 3484 recent client visits), and 25% of clients on oxygen therapy were described as smokers. 34 Other HHC hazards that may not be visible in workers' compensation records but were cited by aides and their supervisors include bed bugs, infectious diseases, indoor air quality concerns (eg, secondhand smoking and the use of harsh cleaning chemicals), clutter/hoarding, and clients' pets. 18 Table 1 summarizes occupational hazards identified in scenarios 1 to 10, as well as interventions that both HHC managers and nurses could undertake to improve safety.

Interventions for HHC Workers and Patient Safety
The Joint Commission and other sources have shown that health care worker safety is closely linked to patient safety in all care settings and that a strong business case can be made for safety. [38][39][40] Discharge planning is critical in determining whether the patient's home environment is appropriate for a required medical procedure or technology. Boling emphasized that "transitions of care are hazardous times with much at stake" 41(p146) and that care transitions should account for the needs of the patient, the family, and the providers across all care settings.
In the Safe Home Care Project interviews, HHC agency supervisors reported on essential interventions. A baseline assessment is critically important for both HHC clinician and patient safety. An initial evaluation is carried out by a case manager or other authorized clinician before a new patient/client is accepted as a new case. 18 This evaluation informs development of a care plan. At the same time, it is an opportunity to recommend specific safety interventions (eg, implementing assistive devices or home environment modifications). During the first assessment, application of a household safety checklist, such as the one developed by Gershon et al, 9 would be beneficial to ensure that caregiver safety aspects have been taken into consideration.
Agency managers value teaching safety at new employee orientations and believe these programs have had a major role in curtailing sharps injuries among employees. 18 Regular continuing education and in-service training have been reported as important opportunities for teaching safe work practices, including protections from BBP exposures, personal safety, back safety, and care for clients with dementia. Table 2 lists selected assessment checklists and training tools developed specifically for HHC.

CONCLUSION
The need for home infusion therapy will continue to grow in the future and warrants thoughtful consideration regarding safe delivery of medical care in the home environment. Home health nurses and other home-based caregivers experience substantial OSH hazards, many similar to those faced by clinicians in institutional settings. HHC clinicians also experience hazards unique to the home workplace. Preventive OSH interventions developed for hospitals and skilled nursing facilities can serve as models for HHC, but may require adaptations for home conditions. Entirely new solutions designed for the unique delivery of care at home are also needed. When safety interventions are implemented and evaluated, the positive HHC job dimensions-such as job autonomy, flexibility, and the ability to develop caring relationships-can and must be preserved.