A survey of needle handling practices and needlestick injuries in veterinary technicians

Abstract

A survey of veterinary technicians identified that needlestick injuries are very common, with 210/226 (93%) technicians reporting at least one needlestick injury over the course of their career. One hundred sixty-seven (74%) had experienced a needlestick injury during the preceding year. Exposure to animal blood and various drugs was common. It was particularly concerning that needlestick injuries involving chemotherapeutic agents and prostaglandin were reported. Eight (3.5%) technicians had required medical care for a needlestick injury and 2 (0.8%) had lost time at work. The approach to sharps handling and needlestick injury avoidance was poor and most needlestick injuries had not been reported to employers. Measures need to be undertaken to improve sharps handling practices to reduce the number of needlestick injuries among veterinary technicians.

Introduction

Handling of needles and other sharp implements is commonplace in veterinary practice. Accordingly, needlestick injuries (NSIs) are an inherent risk. In human medicine, considerable time and resources have been expended to reduce the incidence of NSIs largely driven by the infection of healthcare workers (HCWs) with bloodborne agents such as hepatitis B virus, hepatitis C virus, and human immunodeficiency virus (HIV). Despite aggressive educational campaigns regarding NSI prevention and mandated implementation of prevention practices and surveillance, NSIs still occur in human medicine. Various estimates include 800 000 needlestick injuries/y in American HCWs (1) and 100 000 needlesticks/y in British HCWs (2).

A similar proactive approach towards NSIs is lacking in veterinary medicine, likely because of a poorly developed culture of concern about occupational health and safety in the profession and because serious bloodborne zoonotic pathogens of domestic animals are not recognized in most regions. Few studies have investigated NSIs in veterinary medicine, and where data exist, studies have often been superficial and use variable methodology.

Career NSI incidence rates in veterinary personnel of 64% to 87% have been reported (3–5). A survey of companion animal practice owners and managers reported a needlestick frequency in veterinary technicians of 0.17 needlesticks/person/3 y (6), with a rate of 0.13/person/3 y in a similar survey of large animal practices (7). However, in human medicine, it has been estimated that NSI rates may be underestimated by 90% to 900% (8,9), thereby limiting our understanding of the scope of the problem. It is reasonable to assume that similar under-reporting could exist in veterinary studies, particularly in surveys that depend on the recall of past events.

Overall, it is apparent that needlestick injuries are relatively common in veterinary practice. However, there has been minimal study of needle handling practices, risk factors, NSI reporting practices and rates, and other relevant factors. The objective of this study was to evaluate needle handling practices and needlestick injuries in veterinary technicians in Ontario, Canada.

Materials and methods

A survey regarding sharps handling practices and needlestick injuries was developed and tested with 12 veterinary technicians. An invitation to participate in the survey was then sent to members of the Ontario Association of Veterinary Technicians (OAVT) through a newsletter insert and e-mail to approximately 1500 OAVT listserve members. The questionnaire was completed using an online survey tool (http://www.surveymonkey.com) and covered various aspects of demographics, practice type, needle handling practices, NSIs, and injury reporting. Multiple choice and open ended questions were included. Various response options were available, including yes/no and always/usually/sometimes/rarely/never, depending on the question type. Incidence data were collected by asking questions pertaining to activities (including NSIs) over the past week, month, year, and over their career. Respondents were permitted to skip questions that they did not want to answer.

Categorical data were compared using the Fisher’s exact test (two-tailed). Spearman’s correlation coefficient was used to evaluate the strength of association between specific technical procedures and different methods for recapping needles with ever having had a NSI. A P-value of < 0.05 was considered significant. Only associations that were statistically significant were reported. All analyses were performed using SAS statistical software (version 9.1, SAS Institute, Cary, North Carolina, USA).

This study was approved by the University of Guelph Research Ethics Board.

Results

Two hundred twenty-six technicians completed the survey, 221 (98%) of whom were female. Respondents had worked in veterinary practice for 3 mo to 35 y [mean = 6.6 y, standard deviation (s) ± 6.7]. Most (164, 73%) were engaged in small animal practice, while 19 (8.4%) were in mixed animal practice, 17 (7.5%) were in laboratory animal facilities, 5 (2.2%) were in large animal practice, 4 (1.8%) were in equine practice, 2 (0.9%) were in wildlife practice, 2 (0.9%) were in exotic animal practice, and 1 (0.4%) worked in an animal shelter. Specific practice type was not reported for the remaining 12 (5.3%).

Needlestick injuries were very common, with 210 (93%) of technicians reporting having experienced an NSI in the past (Table 1). Seven of the 16 (44%) technicians who reported never having had an NSI had only worked in veterinary practice for ≤ 1 y. Most technicians had experienced numerous NSIs. The last NSI had occurred in the previous week for 18 (8%) technicians, within the past month for 53 (23%), and within the past year for 167 (74%). Technicians identified various factors that they believed had contributed to NSI (Table 2) but no needle handling practices (techniques performed, recapping method, needle disposal) were statistically associated with NSIs. Needlestick injuries were reported to have occurred when performing various procedures (Table 3).

Table 1.

Number of career needlestick injuries reported by veterinary technicians (n = 226)

Number of needlestick injuries	Number of veterinary technicians (%)
0	16 (7.1%)
1	12 (5.3%)
2–5	107 (47%)
6–10	56 (25%)
11–20	27 (12%)
≥ 21	25 (11%)

Table 2.

Factors reported by technicians as contributing to the risk of needlestick injuries by veterinary technicians (n = 226)

Factor	Number of veterinary technicians (%)
Time constraints/rushing	113 (50%)
Poor needle handling practices by veterinarians	61 (27%)
Inadequate availability or quality of personnel for animal restraint	43 (19%)
Improper disposal of needles	25 (11%)
Lack of training in needle handling	24 (11%)
Inadequate availability of sharps containers	17 (7.5%)

Table 3.

Procedures associated with the most recent needlestick injury and procedures that have ever caused a needlestick injury in veterinary technicians (n = 226)

	Most recent needlestick injury	Procedures that have ever caused a needlestick injury
Withdrawal of drugs from bottles	12 (5.3%)	63 (28%)
Withdrawal of, or injection into, fluid bags	21 (9.3%)	94 (42%)
Withdrawal from, or injection into, IV lines	3 (1.3%)	40 (18%)
Blood collection	43 (19%)	127 (56%)
Fine-needle aspiration	1 (0.4%)	3 (1.3%)
Vaccine administration	10 (4.4%)	43 (19%)
Drug administration	17 (7.5%)	73 (32%)
Needle recapping	50 (22%)	139 (62%)
Handling laundry	0 (0%)	5 (2.2%)
Handling garbage	1 (0.4%)	10 (4.4%)
Taking a needle from a co-worker	3 (1.3%)	15 (6.6%)
Reaching for something across a countertop	6 (2.7%)	19 (8.4%)
Holding a vial while someone withdrew from it	1 (0.4%)	2 (0.9%)
Restraining an animal	20 (8.8%)	76 (34%)

Eighty-four (37%) technicians reported having experienced pain or swelling at an NSI site, while 33 (15%) reported a laceration, 4 (1.8%) had an allergic reaction to needle contents, and 3 (1.3%) developed an infection. Eight (3.5%) technicians had required medical care for an NSI, and 2 (0.9%) had lost time at work.

One hundred and thirty-three (59%) technicians reported being exposed to animal blood one or more times during their career as the result of a NSI, with 92 (41%) having been exposed to sedatives, 87 (39%) to antimicrobials, 80 (35%) to vaccines, 68 (30%) to anesthetic agents, and 29 (13%) to euthanasia agents. Single individuals reported exposure to chemotherapeutic agents and prostaglandin.

One hundred and eighty-three (81%) individuals stated that they believed they had received adequate training regarding needle handling; however, high-risk needle handling practices were common. One hundred and seventy eight (79%) technicians reported that they always or usually recapped a needle manually. Only 31 (14%) usually or always used a “one-handed scoop” method to replace the needle cap while only 1 (0.4%) usually or always replaced the cap using forceps. Twenty-three (10%) individuals usually or always placed the needle and syringe directly into a sharps container without recapping. Only 3 (1.3%) technicians reported using the needle removal device on sharps containers. Twenty-six (12%) individuals reported that they did not have immediate access to a sharps container in areas where needles were used. Nine (4.0%) technicians reported they always placed needles in a temporary storage container prior to proper disposal, while 22 (9.7%) reported doing this usually and 23 (10%) reported doing this sometimes.

Only 45 (20%) respondents stated that their place of employment had a written policy regarding NSIs, and only 55 (24%) had a policy mandating reporting of NSIs. Only 53 (23%) technicians reported their last NSI to their employer. Reasons for not reporting the injuries included not thinking about it (n = 82, 36%), lack of their employer expressing a need to know (n = 64, 28%), thinking that reporting would not have any effect (n = 54, 24%), considering the injury insignificant (n = 20, 8.8%), not wanting to admit it had happened (n = 3, 1.3%), forgetting (n = 3, 1.3%), or that such reporting is not done in their workplace (n = 2, 0.9%). Twenty-three (10%) reported that they always report NSIs, while 20 (8.8%) reported “usually,” 37 (16%) reported “sometimes,” 59 (26%) reported “rarely,” and 64 (28%) reported “never.”

Safer injection devices (retractable needles, hinged caps) were not used in any clinic.

Discussion

The reported incidence of NSIs in this population was higher than in any previous studies of veterinary personnel (4–7), but was not surprising, based on anecdotal information about NSIs in veterinary practice. In some respects, it was surprising that 7% of technicians did not report having experienced a NSI in the past; however, 44% of those who did not report a NSI had worked in veterinary practice for ≤ 1 y. The number of individuals who reported recent NSIs was striking, with 8% having experienced an NSI in the past week and 23% in the past month. These data clearly indicate that NSIs are a common occurrence in veterinary technicians, at least in Ontario.

Despite the lack of significant concern about bloodborne disease transmission, NSIs can be associated with adverse effects through physical trauma, exposure to non-bloodborne infectious agents and exposure to drugs. Adverse effects that have been reported in veterinary personnel and animal owners include severe local inflammation, abscess formation, joint infection, localized necrosis, skin slough, local nerve damage, brucellosis, severe allergic reaction, psychedelic experience, bronchial and laryngeal spasm, chronic granulomatous reaction, ischemic necrosis requiring finger amputation, miscarriage, and blastomycosis (5,10–13). Severe reactions, including death, have been reported in association with inadvertent injection of tilmicosin (14). While medical care was not commonly required for NSIs in this study, it is important to consider that 3.5% of individuals required medical care for an NSI, and 0.9% had lost time at work. Reports of allergic reactions and infections are concerning because of the potential severity of such reactions. While these are not common events, they should be considered in the context of the large number of veterinary technicians, the preventable nature of NSIs, and the possible legal ramifications for veterinary practices that do not adequately address NSI prevention and reporting (15). In addition to drug exposure, NSIs can cause significant pain and discomfort, which were reported by a large number (37%) of technicians. Infection can also develop from needle contents (fine-needle aspirates, needles contaminated with bacteria from the skin of an animal) or because of secondary infection.

A variety of factors were cited as contributing to NSIs. The most common was time constraint, which is not surprising as rushing to complete procedures can result in suboptimal practices. The high number (27%) of technicians reporting that needle handling practices by veterinarians contributed to NSIs was concerning and highlights the necessity for education on needle handling for all members of the veterinary healthcare team. Nineteen percent of individuals reported that inadequate assistance with restraint of animals was a contributing factor. Whether this involved poor quality of restraint by assistants or lack of adequate personnel is unclear, but this is an area that should be addressed. The potential for increased injury rates should be considered when evaluating veterinary clinic staffing and workload. Inadequate access to sharps containers, reported by 7.5% of technicians, can be easily rectified in clinics, and all clinics should review their sharps container numbers and placement.

Technicians were exposed to a variety of substances from NSIs. Animal blood was the most common. This is much less concerning than in human medicine, based on the very low prevalence of significant bloodborne zoonotic pathogens in companion animals in North America. However, this should not be taken as an excuse to ignore NSIs, since zoonotic diseases continue to emerge and veterinary personnel may be among the first individuals exposed to emerging zoonoses (15). The high rates of exposure to antimicrobials, sedatives, anesthetic agents, and euthanasia agents were concerning because of the potential problems from the direct effects of these drugs or allergic reactions. While rare, exposure to chemotherapeutic agents and prostaglandin is of concern, as veterinary technicians are predominantly women, and exposure may result in adverse reproductive effects (17). Wilkins and Bowman (5) report miscarriage in a veterinary technician following an NSI involving prostaglandin.

While most technicians (81%) stated that they had received adequate training regarding NSIs, their reported needle handling practices indicate that this training was either inadequate or routinely disregarded. Unsafe handling practices were very common and it is unclear whether or not technicians understand that their current practices are considered unsafe. Particularly concerning practices were manual recapping and placing needles in “temporary”storage containers. Manual recapping is a leading cause of NSIs (18), through missing the cap and puncturing a finger or driving the needle through the side of the cap and into a finger. Use of temporary storage containers, although common, is considered unacceptable. The use of temporary containers leads to a need for someone to subsequently transfer the needles to an approved container, an unnecessary additional handling step that presumably increases the risk of NSI. This is a completely unnecessary risk based on the ease and low cost of placing approved sharps containers in all areas where needles are used. Other concerning and completely preventable situations that resulted in NSIs include handling garbage and laundry. There is absolutely no reason for sharps to be in laundry or garbage if basic handling practices are adhered to, and any such injury should be investigated as a serious breach in protocol. These can be particularly concerning for a clinic from a liability standpoint if there are injuries to personnel from external cleaning or laundry agencies. Injuries that occurred while taking a needle from a co-worker are also completely preventable using safe and logical handling practices that would preclude passing uncapped needles. It was quite surprising that 8.4% of individuals had experienced an NSI reaching across a countertop, indicating poor needle handling or disposal practices. That type of injury should also be completely avoidable.

Despite NSIs clearly being occupational injuries, reporting of them was uncommon and few clinics had mandatory reporting policies. It is likely that NSIs are so common and typically minor that they are considered an inherent part of veterinary practice, so they are not reported. The perception that employers would not want or need to know also likely leads to low reporting rates. Documentation of NSIs is important for various reasons. Most NSIs are inconsequential, but serious sequelae can occur, and it may be important for the worker to have documented an occupational injury should complications develop. Failure to report and record NSIs prevents the veterinary community from understanding the scope of the problem and limits the identification of changes in rates over time or in response to different interventions.

This study did not identify any factors that were statistically associated with the likelihood of NSI; however, this should be taken in the context of the study population and other results. Needlestick injuries and poor needle handling practices were very common, and the relatively homogenous nature of the population with respect to needle handling practices limits the ability to identify factors associated with NSIs. It is possible, if not likely, that many of the poor needle handling practices documented in this study predispose to NSIs. It is also possible that the sample size was inadequate to detect some true statistical associations.

Potential biases must be considered. This study only involved OAVT members. Membership is not mandatory for veterinary technicians and there may be differences between OAVT members and non-members. The survey was only accessible online, but considering widespread Internet access, this is unlikely to have significantly biased the results. It is possible that this selected for a younger population, something that must be considered, since the mean duration in practice was only 6.6 y. Possible effects of this are unclear. It was not surprising that most respondents were engaged in small animal practice, considering the nature of veterinary practice in Ontario; however, it was surprising that 7.5% of respondents worked in laboratory animal facilities. This is presumably disproportionate to the general technician population and could have biased results; however, it is reasonable to assume that laboratory animal facilities would have stricter needle handling and NSI reporting practices. Considering how common poor needle handling practices are, the effects of this potential bias were likely limited. Another potentially important consideration is non-response bias. Because a minority of invitees participated, selective response must be considered, and it is possible that people who have a greater interest in NSIs, or who have had more serious problems with NSIs, would be more likely to respond.

This study has demonstrated that NSIs are very common in technicians in veterinary practice, and that potentially unsafe needle handling practices are widespread. Veterinary practices and individuals need to consider NSIs as occupational injuries that can result in adverse effects and take logical and proactive measures to reduce the rate of injury (15).