From Editorials of
Occupational Medicine
http://occmed.oxfordjournals.org/cgi.../kqp053?ck=nck
It shouldn't happen to a vet
Veterinary medicine is hazardous and there is evidence that small animal work in particular has a significant injury and disease morbidity. The paper by D'Souza and colleagues investigating the management of health and safety in small animal practices is therefore important and as a veterinary surgeon and practice standards inspector for the Royal College of Veterinary Surgeons (RCVS) Practice Standards Scheme (PSS) I found the research to be significant [1]. While the paper shows the positive effect of standards schemes on health and safety in veterinary practices, the situation has moved on considerably since the survey was conducted in 2002.
In 2005, the British Small Animal Veterinary Association and British Veterinary Hospitals Association standards schemes were combined and expanded into the RCVS PSS [2]—a voluntary scheme in which practices are inspected every 4 years. Practices may choose to join this scheme at three different levels—‘core standard’, ‘general practice standard’ or ‘hospital standard’. Health and safety requirements are included in the core standard, so apply to all practices in the scheme. Over 50% of practice premises are registered with the scheme (Royal College of Veterinary Surgeons, personal communication) and it now includes equine and farm animal practices, widening the availability of health and safety information to encompass these areas of work. As mentioned in the article, the PSS has been a major driver and source of advice for improvements in health and safety in the profession, and even those practices that decide not to join the scheme can access the relevant information.
It is well recognized that there are some areas of health and safety where veterinarians are good at identifying risk. For example practices clearly understand the risks of radiography, and PSS inspectors check that practices are complying with their Radiation Protection Adviser's advice. Veterinary practices are also very conscious of risks of pollution in anaesthesia, and the PSS asks for evidence of either measurement of personal exposure to anaesthetic gases or an annual test certificate for an active scavenging system. However, as noted by the research authors, extraction ventilation is sometimes overlooked and can be a particular problem in recovery wards where animals are still exhaling anaesthetic gases.
PSS inspectors find that most practices make a good assessment of the risks of veterinary medicines. In a recent report, Irwin [3] a Health & Safety Executive inspector visiting practices on a voluntary basis in West Yorkshire commented that although the information on Control of Substances Hazardous to Health (COSHH) was not always in the form required by the legislation, vets and veterinary nurses showed good knowledge on this subject. The availability of safety data sheets on disc and online has made it much more straightforward for practices to access the relevant information. Where cytotoxic drugs are used in practice, a comprehensive and detailed assessment of risks to staff in intravenous administration is asked for in the standards. However, if oral formulations are administered at home, the discussion of the potential hazards with owners is not specifically required. D'Souza's paper showed that although all practices gave some advice on precautions to owners, these did not cover disposal of animal waste and possible health risks in >50% of cases.
Another area mentioned in the survey by D'Souza and others is a lack of awareness of workplace allergens. Latex gloves are mentioned briefly in the COSHH section of PSS, but they are widely used and many practices do not provide alternatives. Cases of latex allergy in veterinary practices have been documented [4]. Animal allergens are completely overlooked in the guidance to practices; these are more of a problem in pig practice (C. Clarke, personal communication) but clearly there is a need to consider occupational health in drawing up the practice standards. The observation that while 24% of practices used some form of pre-employment health screening, only 14% sought advice from a doctor or nurse qualified in occupational medicine is also significant.
Manual handling is another significant problem area in veterinary practice; it is now quite well addressed by both risk assessments and training but moving heavy, wriggling, potentially aggressive patients is still a challenge! Lifting boxes of drug deliveries and moving cadavers and oxygen cylinders also needs to be considered and the risks minimized. Needlestick injuries in practice (22% of reported accidents in one veterinary hospital) [5] are a real risk not only to vets and veterinary nurses but also to clients who might get in the way of the needle while restraining their fractious pets. An American survey [6] of these injuries in female veterinarians showed effects ranging from mild and localized to systemic illness, with one report of spontaneous abortion following accidental self-injection of a prostaglandin. In this country, new waste regulations have encouraged practices to separate syringes from needles for disposal, but in many cases, no risk assessment of this procedure has been carried out.
Bites, scratches (accounting for 48% of accidents reported in one veterinary hospital [5]) and, in large animal practice, kicks are an everyday hazard for practice staff. In an Australian survey [7], it was found that vets had a 9-fold greater relative risk of serious injury compared to their medical general practitioner colleagues. In small animal practice, cat bites can be a particular danger as most normal cats carry a variety of pathogenic bacteria in their mouths—including Pasteurella multocida, Streptococci and Fusobacterium organisms—which can be deeply implanted when the cat bites. Early antibiotic therapy is usually required (particularly where a joint is involved) and failure to do this can lead to partial or complete loss of a finger. Effects can be serious or even life threatening in people with prostheses and in individuals with a compromised immune system [8,9]. A significant proportion of cats also carry Bartonella species, now considered to be the cause of cat scratch disease. Tetanus, while not to be ignored, is of lesser significance.
Lone working is another area where risks need to be assessed and the requirement for 24 h cover and home visits to unknown clients can put staff members at risk.
The use of display screen equipment, while not mentioned in 2002, is now an area listed as requiring risk assessment in the current version of the standards, as is the employment of young persons, so if the survey was to be repeated now we would expect to find a noticeable improvement on the 2002 results. In my experience, practices are generally very good at assessing and implementing the proper use of work equipment.
Many practices use health and safety consultants to assist in fulfilling all these requirements, as observed by the HSE inspector [3] these need to be customized by the practice itself, rather than imposed generically by a commercial company. Only 31% of practices in the survey had a member of staff who had received training in health and safety, but this may have improved as veterinary nurses now receive training on risk assessments as part of their course, but it is still an area needing further development by the profession. Staff consultation is similarly neglected—while all practices inspected have to demonstrate that their staff have access to health and safety information and risk assessments—consultation with staff on their health and safety concerns is not routine. Staff concerns should always be addressed when introducing new equipment or work procedures.
A major health concern in veterinary practice not considered in the article is work-related stress. Sources of stress to vets in practice include long working hours, on-call commitment, problems with work-life balance, client expectations and unexpected outcomes. In a New Zealand survey [10], vets in small animal or mixed practice experienced more stress than those working in other areas and women more than men. With the changing gender balance of the profession, this is an increasingly important consideration. A German study [11] also showed that practising vets are more frequently affected by psychosocial stress and have a greater risk of alcohol or drug consumption than those working in non-clinical areas. The proportion of deaths by suicide in the veterinary profession is four times higher than the general population and twice as high as other high-risk groups such as farmers, pharmacists, doctors and dentists [12]. Possible explanations for this include ready access to drugs, social and professional isolation, subconscious acceptance of euthanasia as a treatment option, rising client expectations and financial pressures. In response to this, the profession have set-up the Veterinary Surgeons Health Support programme to give specific help and action on alcohol, drug abuse and addiction. There is also a ‘Vet Helpline’ a 24-h confidential helpline run by volunteers from within the profession to assist members in distress [13].
In conclusion, this very interesting paper shows that veterinary practices are very conscious of health and safety issues and that they get most of their advice from their professional organizations and PSS. Those of us involved in setting and implementing practice standards must be mindful of the health issues affecting our profession and must be prepared to take advice from our colleagues working in human occupational health.
The RCVS PSS scheme is currently consulting on a revision in the standards which would be a very good opportunity to promote co-operation between our two professions.
Pamela A. Mosedale
RCVS Practice Standards Inspector and BSAV,A representative on RCVS Practice standards group
e-mail: pam.mosedale@btinternet.com
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References
1. D'Souza E, Barraclough R, Fishwick R, Curran A. Management of occupational health risks in small-animal veterinary practices. Occup Med (Lond) 2009; doi:10.1093/occmed/kqn125.
2. Practice Standards Group. RCVS Practice Standards Manual (2007)
http://www.rcvs.org.uk/Shared_ASP_Fi...ual_310309.pdf (date last accessed 14 April 2009).
3. Irwin M. Summary Report of Recent HSE Inspections in Yorkshire (2004)
http://www.rcvs.org.uk/shared_asp_fi...HSE_report.pdf (date last accessed 14 April 2009).
4. van Veen L. Sterility & hygiene pays the price, latex allergy. Tijdschr Diergeneeskd (2000) 125:476–481.[Medline]
5. Tielen MJ, Elbers AR, Snijdelaar M, van Gulick PJ, Preller L, Blaauw PJ. Prevalence of self reported respiratory disease symptoms among veterinarians in Southern Netherlands. Am J Ind Med (1996) 29:201–207.[CrossRef][Web of Science][Medline]
6. Wilkins JR 3rd, Bowman ME. Needlestick injuries among female veterinarians—frequency, syringe contents, side-effects. Occup Med (Lond) (1997) 47:451–457.[CrossRef][Medline]
7. Lucas M, Day L, Fritschi L. Injuries to Australian veterinarians working with horses. Vet Rec (2009) 164:207–209.[Abstract/Free Full Text]
8. Hu V, Dong B, MacFarlane A. Visual loss after cat scratch. J R Soc Med (2005) 98:28–29.[Free Full Text]
9. Ciampolino J, Timperley J, Morgan M. Prosthetic joint infection by cat scratch. J R Soc Med (2004) 97:441–442.[Free Full Text]
10. Gardner DH, Hini D. Work-related stress in the veterinary profession in New Zealand. N Z Vet J (2006) 54:119–124.[Web of Science][Medline]
11. Harling M, Strehmel P, Schabion A, Nienhaus A. Psychosocial stress, demoralization and the consumption of tobacco, alcohol and medical drugs by veterinarians. J Occup Med Toxicol (2009) 4:4.[CrossRef][Medline]
12. Bartram DJ, Baldwin DS. Veterinary surgeons and suicide, influences, opportunities and research directions. Vet Rec (2008) 162:36–40.[Abstract/Free Full Text]
13.
www.vetlife.org.uk.