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June 2023
This Job BITES!
Education, Protocols Can Lessen Risks of Bites and Scratches
Education, Protocols Can Lessen Risks of Bites and Scratches
Twenty-four hours after being bitten and scratched while retrieving his cat that had slipped out of the house, Pete was in the emergency department (ED) being advised that they suspected an abscess and a fast-moving infection in his arm.
Pete, an active, healthy senior who has had pets for nearly 40 years, thought he had done all the right things after the injuries. He had cleaned the wounds and applied antibiotic ointment. The next morning, fever and arm pain had sent him to urgent care where he got a prescription for oral antibiotics. But several hours later, with the pain worse, he had to go to the ED.
After emergency surgical debridement, he received intravenous (IV) antibiotics and fluids for several days before he was discharged. Three months and many dressing changes later, his wounds finally healed.
The emergency was listed as necrotizing fasciitis—what the US Centers for Disease Control and Prevention (CDC) calls a rare bacterial infection that spreads quickly and can cause death. Who’d have thought?
Cat and Dog Bites—How Common?
How many dog and cat bites are there each year in the US?
One CDC statistic estimated 4.7 million dog bites with 799,700 persons requiring medical care. But that data is from 1994. Of that number, an estimated 333,700 patients were treated in EDs with an estimated 6,000 (1.8%) hospitalized.
Asked for updated figures, the federal Agency for Healthcare, Research and Quality’s Healthcare Cost and Utilization Project (HCUP) offered discharge data from 2020. HCUP estimated 353,621 ED visits with injuries caused by dog bites and 66,404 ED visits caused by cat bites for that year. For visits due to dog bites, 3.5% or 12,529 turned into hospitalizations. For the cat bites, 11.7% or 11,764.
The counts did not include urgent care, primary care visits, or other outpatient visits. The numbers represent ED visits to 995 hospitals in 40 states and the District of Columbia—an area accounting for 85% of the US population that year—and approximate a 20% stratified sample of all US hospital-owned EDs.
Equal Opportunity Injury
Bites and scratches can happen to anyone.
“We have had our fair share over the 10 years I have worked here. Who hasn’t in this industry?” said Samantha Millet, CVPM, practice manager of Bluegrass Animal Hospital, Knoxville, Tennessee. “We always take these situations seriously due to the number of health issues that could arise.”
“The cat ended up lunging for my face, scratching me right below my eye.”
—Jamie Rauscher, LVT, Medical Manager, Animal Hospital of Towne Lake and Cat Clinic of Woodstock, Georgia, and president of NAVTA
Millet herself was bitten in the face just a few years ago. A new canine patient was initially frightened but became comfortable while she obtained a patient history in the examination room. When Millet put a leash around the dog, the dog did not want to walk so she picked the dog up and walked out.
The dog bit her cheek. Fortunately, the bite was not deep. After returning the dog to the family, she washed her face with surgery scrub and, later, was seen by a physician. While the dog had reportedly never shown aggression before, the family took the dog to a behaviorist to ensure it did not happen again, she said.
Jamie Rauscher, LVT, medical manager of Animal Hospital of Towne Lake and Cat Clinic of Woodstock, Georgia, and president of the National Association of Veterinary Technicians in America, noted that when she was younger, a cat bit her arm. The bite got infected, requiring her to be hospitalized with IV antibiotics and fluids to combat a terrible infection and fever.
But the worst bite/scratch she said she ever experienced was with a feral cat.
“We were trying to get hands on it to sedate it for surgery. The cat ended up lunging for my face, scratching me right below my eye. I ended up with a pretty nasty scratch and a black eye to go with it.”
Aimee Potter, CVT, an AAHA accreditation specialist, recalled an encounter with a dog with leptospirosis in an intensive care unit at a veterinary hospital where she had worked.
“I was trying to be very cautious because he was in some pain. I went to unhook his IV catheter and he bit my arm. Because he had lepto—which is transmissible—I had to go to the doctor, have the wound scrubbed out, and then go on antibiotics as I watched for signs of bacterial infection.
“Another time, a cat patient lashed out at the owner and bit or scratched five employees during the visit,” said Potter. “The cat had to be euthanized. We did not know it was rabies positive until after. Employees had to go to the doctor, get tested, and go through rabies treatment if they were not vaccinated.”
Missy Filarecki, CVPM, CCFP, practice manager of Just Cats Veterinary Clinic, Guilderland, New York, said her clinic has dealt with multiple bites, but none were too serious. “Sometimes, even if you do all the right things, the animals can still be fearful and lash out,” she said.
“I was trying to be very cautious because he (the dog) was in some pain. I went to unhook his IV catheter and he bit my arm.”
—Aimee Potter, CVT, an AAHA Accreditation Specialist, talking about her years working at a veterinary hospital
One of the worst bites she has seen happened to an assistant reaching into a cat kennel to clean a litterbox. The cat, who was rabies vaccinated, was not known to be aggressive and did not give off any warnings. The assistant ended up with multiple cat bites resulting in a trip to urgent care and a course of antibiotics.
Dangers Differ
Cat and dog bites and scratches present different dangers.
Avir Mitra, MD, an emergency physician in New York, assistant professor at the Icahn School of Medicine, and spokesperson for the American College of Emergency Physicians, explained that both cats and dogs carry a lot of bacteria in their mouths and nails.
Mitra said cats usually bite or scratch hands and arms. Unfortunately, these injuries can look benign so people often just wash them and don’t see a doctor. But cat teeth can easily puncture skin and drive bacteria deep into tissue.
A common bacteria from a cat bite is Pasteurella multocida, he said. And a cat scratch can bring the risk of infection with Bartonella henselae, which can cause cat scratch disease. In cases in which the bite extends to the tendon of the hand, Mitra has seen surgical management needed.
Unlike cat scratches, dog scratches are usually less deep but more abrasive. Also unlike cat bites, dog bites are not just simple puncture wounds. Instead, they more often involve tearing action, and dog jaws can exert significant pressure leading to worse wounds, said Mitra.
Dog bites can occur anywhere and can lead to serious cosmetic issues, especially when it involves a face, he said, such as the extensive lip laceration he recently saw on a patient.
“In my experience, this tends to happen with kids who are smaller and tend to put their faces closer to a dog. These wounds are highly prone to causing infection, so, just like with cat bites, we start patients on antibiotics to prevent infection.”
Mitra suggested that anyone bitten or suffering a significant scratch see a doctor. A tetanus shot also may be needed. While many people know the warning about a rusty nail, he said, many may be unaware that tetanus bacteria also can enter the body through an animal scratch.
Minimizing the Risks at Animal Hospitals
Because of the “nature of the beasts,” bites and scratches are unlikely to be eliminated. However, having protocols in place and specialized training can reduce unexpected consequences. Two popular offerings are the Cat Friendly Certificates of the American Association of Feline Practitioners (AAFP) and the Fear Free certification programs.
“We are a feline-only clinic, so it is especially important for our team to be as educated as possible to keep themselves and the cats safe,” said Filarecki, noting that most team members are Certified Cat Friendly.
They emphasize a minimalistic approach. They do not scruff cats, which used to be a common practice, because it can escalate a cat’s fear and aggression when it feels a lack of control and inability to escape, she explained.
“We are also big on the use of gabapentin,” she said. “Our protocol is to prescribe it to our known anxious patients and to have their owners give it two hours before they visit. We also prescribe gabapentin to premedicate all cats coming in for any sedated procedure.”
As a general rule, she said, staff are required to go to urgent care immediately after a bite, unless the bite does not break the skin. Any bite is recorded in the OSHA log and hospital records. It’s also important, she said, that the team knows what to do if someone is bitten when the manager is out.
Rauscher said her Fear Free Certified Practice is a “big believer in premedications for fractious patients, towel wrapping for cats, and positive reinforcement for both dogs and cats by rewarding them for their good behavior.
“I feel with better education in regard to handling and restraint, premedications, and educating clients on the benefits of these medications, we have seen bites and scratches reduced over the recent years.”
“Purr’fecting” Interactions“New evidence proves that nonphysical and physical human interactions that respect the cat are safer and more efficient for us, in addition to enhancing feline welfare,” explained Ilona Rodan, DVM, DABVP (Feline). The American Association of Feline Practitioners’ new Cat Friendly Veterinary Interaction Guidelines—endorsed by 29 organizations including AAHA and including several supplemental videos—can be found here:https://catvets.com/guidelines/practice-guidelines/cat-friendly-veterinary-interaction-guidelines. |
At the Knoxville hospital, said Millet, veterinarians, licensed veterinary technicians, and assistants are Fear Free Certified and all employees watch safety videos during onboarding.
“We do our best to stay aware if animals have stress, fear, and anxiety when they enter so our staff can appropriately handle them. We incorporate treats, restraint, and medication depending on what works best for the animal and our staff,” she said.
With any bite or scratch, the employee has the option to go to a doctor. In addition, any incident is reviewed to determine how the injury could have been avoided and what to do if a similar situation arises.
Keeping Clients Safe, Too
In keeping pets and themselves safe, team members also may find themselves educating owners.
“For children and the elderly, bites and scratches can be more detrimental to their health,” said Filarecki. Besides getting information during visits, clients can learn from informative articles in the practice’s newsletters.
Her practice also offers behavioral consults. “Clients fill out a questionnaire of behaviors and we educate them on how to best treat their cat to avoid undesirable behaviors such as biting and scratching.”
Millet said staff members communicate with pet parents about how they might make anxious pets more comfortable about coming to the hospital.
“For a dog, we might recommend treats, medication, waiting outside, or staying in the vehicle until a room is ready. We really try to cater to the animals and the pet parents to help them make it a positive appointment.
This cat owner suffered bites that became quickly infected requiring emergency surgical debridement for necrotizing fasciitis.
“We tell all our cat parents to bring the cat in a carrier and to set the carrier out in the cat’s sight a few days before a visit so the patient can get used to it. We suggest they spray [Ceva Animal Health] FELIWAY on the blanket in the carrier. And if needed, we prescribe medication to make the cat feel calm. Anything to make the cat seem less stressed during the commute and vet visit is what we strive for.”
Protect the Bottom Line
Another consideration is the potential adverse effect on a practice’s insurance costs.
“If a workplace has a high frequency and/or severity of claims, the more money the insurance carrier has to pay out,” explained Ryley Georgitsis, risk consultant, HUB International, a North American insurance brokerage. “For the insurance carrier to reduce its losses (or anticipated losses based on the business’ loss history), it increases the premium. A facility that has a long history of excessive claims may find it more difficult to market its insurance program than one that has a lower claims history.
“The good news is that bite and scratch claims costs are lower on average than claims for sprains, strains, slips and falls,” said Georgitsis.
Why? Because insurance carrier claim adjusters will encourage veterinary staff to seek medical attention regardless of the severity of the incident, he said. While a claim may drive up the number of these types of incidents, the overall cost of care and avoided lost time is less.
For example, in a claims pull of AAHA-accredited hospitals with The Hartford as their worker’s compensation insurer between Jan. 1, 2018, and Feb. 2, 2023, there were 1,477 dog and cat bite claims from 263 hospitals. Of those 263, 82 (31%) had only one claim each. Five percent of claims were for lost time, with a total cost incurred of $658,479 and an average cost per claim of $8,552. Of the remaining 1,400 medical-only claims, the total cost incurred was $1,110,997 or $794 per claim.
“We highly discourage employees to ‘wait and see if an injury feels better’ as this attitude often leads to worsening of the injury and higher claims cost,” said Georgitsis. “At the very least, we recommend hospitals file ‘notice only’ reports with their insurance carrier for claims that seem minor. The benefit is that the ‘lag-time’ stops and allows the carrier claims person to gather information, immediately freezing the facts of the case.”
Claims have the potential to result in severe injuries and be very expensive. Georgitsis offered this claim example: An employee was performing a routine dental cleaning on a cat that was under anesthesia, when the employee hit a nerve causing the cat’s jaw to clamp down on her finger. The puncture wound became infected and required surgery, IV antibiotics, labs, office visits, medications, and lost wages. Total payout: $58,000.
Hospitals even have to consider the costs of injuries to clients, according to Matt Gilmore, Senior Vice President and Risk Services Leader, HUB International, who offered this example:
“A mature cat was initially cooperative with a physical exam but then became unsettled, growled, and tried to jump off the table. The owner jumped up to help and reached to pet the cat’s head and was bitten. The practitioner instructed the owner to wash the bite and seek medical care. Several days later the finger was swollen and then the owner went to seek medical treatment. The owner suffered a serious infection and tenosynovitis of the hand with permanent disability. The injury was bad enough that amputation was recommended. The client sued. The claim was settled for nearly $200,000.”
A few controls that should have been considered, said Gilmore, are:
- Avoid having the owner hold the cat during treatment. Only employees trained in feline handling should hold the cat.
- Pay close attention to any growling, aggression, or attempting to escape.
- Consider using cat bags, towels, gauntlets, or a slip-free mat. Do not over-restrain.
While bites and scratches come with the territory of being in vet med, practical protocols and proper staff training can help minimize the risk of hospitalization and serious wounds.
Maureen Blaney Flietner is an award-winning writer and illustrator living in Wisconsin. |
Photo credits: DjelicS/E+ via Getty Images, gpointstudio/iStock via Getty Images Plus, Oksana Kalinina/iStock via Getty Images Plus, ©AAHA/Kate Moore, ©Mavourneen LLC/Maureen Blaney Flietner, ©AAHA/Kimberly Lamb