The Veterinary Nurse’s Role in Preventing Hospital-Acquired Infections
Veterinary nurses are integral in preventing, managing, and controlling disease transmission in veterinary hospitals. From the moment a client calls about a potentially infectious pet, the veterinary nurse’s knowledge of the disease process and hospital protocols is key to making informed decisions about patient handling. Understanding, following, and maintaining the facility’s isolation and cleaning protocols; ensuring the use of appropriate personal hygiene practices and equipment; and educating clients about disease transmission are all areas in which the veterinary nurse provides valuable assistance to the veterinary team.
PROTOCOLS FOR HANDLING INFECTIOUS PATIENTS
Human health-care workers have adopted a “universal protocol” when treating patients. The premise is that all patients are potentially infectious and are treated as such until proven otherwise. This practice should be used in the veterinary setting as well. Even the use of some simple precautions, such as cleaning and disinfecting tables and equipment between patients and washing hands before and after handling each patient, can help prevent nosocomial infections.
In addition, each facility should have its own written isolation protocols. These should be specific to the facility’s needs and circumstances; what works for hospital A may not be feasible for hospital B. The protocols should be reviewed frequently—at minimum, annually—to ensure that they are effective and that there are no “breaks” in the system. If a break in the system is discovered at any time, the protocols must be evaluated and corrected. Written protocols for cleaning and disinfecting equipment and surfaces should also exist and be reviewed on an annual basis or if there is an outbreak of disease in the hospital.
Many resources, such as veterinary texts on infectious disease and the Centers for Disease Control and Prevention (CDC) website, are available to assist facilities that do not yet have written protocols or that wish to review and update existing ones. When designing individual protocols, all staff members who will be using them—including receptionists, kennel technicians, veterinary assistants, and veterinary nurses—should be involved in the decision process to help ensure that the resulting practices are followed.
New staff should be thoroughly trained on all protocols before working with an infectious patient. It is recommended that the isolation protocol be posted outside and inside the isolation area to aid staff in adhering to it. All staff must have annual training on current procedures to protect themselves and patients.
SCHEDULING AND APPOINTMENT CONSIDERATIONS
Phone triage is an art that can help reduce exposure of healthy pets to infectious animals. When a client calls with concerns about a pet, the initial phone conversation should include questions about what clinical signs the animal is exhibiting. Owners of animals that are potentially or obviously ill (e.g., vomiting, diarrhea, coughing, upper respiratory signs) should be instructed to call from the parking lot when they arrive at the hospital so they can be taken into an examination room immediately, to limit contact with animals in the waiting room. Such patients should not be removed from the examination room (unless they are in distress) until it is determined that the cause of their illness is not infectious. To minimize the potential for spread of disease to other patients, these patients should be handled by as few staff members as possible.
Appointments for immunocompromised patients (e.g., chemotherapy patients) and puppy/kitten visits should be scheduled early in the morning, before any obviously sick patients. If possible, it is ideal to dedicate an examination room for use with immunocompromised patients. If this is not feasible, such animals should be examined in the room that is farthest away from any potentially infectious patients.
Each time a patient presents to the veterinary hospital, regardless of clinical signs, its vaccine status should be verified and a complete history obtained, including travel history. Many infectious diseases vary in incidence and prevalence by geographic area (e.g., canine influenza outbreaks), and diagnoses may be missed if complete histories are not available. Many cases of infectious diseases may be missed because animals are not showing the classic clinical signs.
When an animal is diagnosed as having an infectious disease, the owners should be informed that for the safety of other patients, their pet requires isolation from other animals. Any infectious patient that is hospitalized should be taken directly to the hospital’s isolation facility. Staff members who have interacted with these patients should limit their contact with any patients who could become infected for the rest of their shift as much as possible.
PERSONAL HYGIENE AND PROTECTIVE EQUIPMENT
Good personal hygiene practices are paramount to preventing disease transmission, and handwashing is one of the most fundamental. All staff should wash hands before and immediately after handling any patient, regardless of whether the patient is clinically ill, as well as immediately after removing gloves that have been used to handle clinically ill animals.
For handwashing, any soap product can be used, as it has been shown that the mechanical motion of handwashing for 20 seconds effectively removes most infectious agents.1 If handwashing with soap and water is not immediately feasible, the use of alcohol-based hand sanitizers is sufficient until they are able to wash properly.2
When an infectious disease is suspected, any team member interacting with that patient should wear personal protective equipment (PPE) appropriate for the specific infectious agent. The type of PPE required depends on the agent’s mode of transmission. At minimum, disposable gowns and gloves that are impervious to liquids should be used. For some diseases, protective goggles, facemasks, and hair covers should also be worn. These items need to be kept readily available outside the isolation room. To prevent cross-contamination, no disposable items should be stored inside the isolation room. Disposable shoe covers and footbaths containing a disinfectant that is shown to be effective against the infectious agent (e.g., a 10% bleach solution for parvovirus) should be used to prevent staff from carrying microorganisms out of the isolation area and throughout the hospital. Footbath solution should be changed at least every 24 hours or when it becomes contaminated with dirt from staff shoes.
ISOLATION AREA SUPPLIES
Dedicated equipment (e.g., fluid pumps, scales, thermometers, stethoscopes) should be used in isolation rooms. No other equipment should be stored in this area. If equipment cannot be dedicated for isolation, it must be cleaned and disinfected before it is used on another patient (Table 1).
It is recommended that any bedding used in the isolation unit be washed separately in hot water (minimum temperature 140°F [60°C])3 and bleach for 2 cycles. Alternatively, bedding used for infectious patients can be soaked in a disinfecting agent (e.g., 10% bleach solution for parvovirus, betadine for leptospirosis) before washing with laundry detergent. This bedding should not be used in general population, but immediately dried and returned to the isolation unit.
Disposable supplies should be used within the isolation area, and only as much as is needed to care for the patient should be introduced into the isolation unit. If possible, disposable food bowls and litter boxes should be used for infectious disease patients. If this is not feasible, any food/water bowls used for an infectious patient should be disinfected in the isolation area and used for only that patient during its hospitalization. Each patient in isolation should also have a thermometer dedicated for its individual use.
DISINFECTION AND SANITIZATION
Some infectious organisms can survive for months in the environment, making regular, effective sanitization and disinfection of surfaces and equipment critical practices in preventing the spread of disease. The frequency of each method depends on the location, use, and type of item being cleaned and should be specified in the facility’s written infectious disease protocols.
For example, examination equipment and tables should be cleaned of biologic debris and disinfected after every use. Floors, food bowls, and bedding should be thoroughly cleaned and disinfected daily. All food bowls should be autoclaved weekly to ensure any infectious agents are neutralized. All walls, cages, and equipment in the facility should be thoroughly cleaned and disinfected at least weekly, or immediately after the isolation room has been emptied. Any examination room used for infectious patients should be thoroughly disinfected before it is used again. This includes any surface that the owner has had contact with, including the reception area.
All laundry in the veterinary hospital not used for infectious patients should be washed in hot water (140°F) with laundry detergent and bleach.
Disinfecting and sanitizing agents are divided into 2 types: physical and chemical. The physical agents are heat—either dry or steam—and light. All other agents are chemical. Chemical agents are divided into 8 main categories (Table 2). Several cleaning agents in each category are commercially available. Some agents can be used for both sanitizing and disinfecting, depending on the concentration or contact time.
When it comes to choosing an effective cleaning agent, the myriad available products can be difficult to navigate. Not every agent is effective against the microorganisms that cause disease. In addition, some agents have to be used at differing concentrations and contact times to be effective against certain microorganisms. Always check the product label for concentration, application method, and contact time. Table 1 lists some common microorganisms of importance to veterinary medicine and effective disinfecting agents. Note that for any agent to be fully effective, gross organic material (feces, blood, vomitus, urine) must first be removed from the surface being sanitized or disinfected.
Good client education is imperative to prevent the spread of disease, and educating owners is every veterinary team member’s responsibility. For example, many pet owners do not realize that puppy and kitten vaccinations are a series of injections that are required to provide optimal protection against infectious diseases. Ensuring that patients receive this protection is the first step in preventing the spread of disease.
Clients whose pets are diagnosed with an infectious disease should be given directions on how to disinfect the home environment to prevent the spread of disease to their other pets, both current and future. If an animal has a zoonotic disease (e.g., leptospirosis), it is very important that the owner be given information on how to reduce their own risk of infection. Special attention must be paid to clients who have an animal or human family member (including themselves) that is undergoing chemotherapy or is immunocompromised. These clients must be made aware of the risks associated with any disease that could affect their own or their pet’s health.
It is heartbreaking when animals become ill due to preventable circumstances, especially when those circumstances involve transmission within the veterinary hospital. As patient advocates, veterinary nurses should be involved in every aspect of preventing infection, from creating hospital protocols to carrying them out. Handling infectious patients is inherent in veterinary medicine, and the entire staff should be aware of how to protect all animals in their care.
1. When and how to wash your hands. Centers for Disease Control and Prevention. cdc.gov/handwashing/when-how-handwashing.html. Accessed January 2020.
2. Handwashing and hand sanitizer use: at home, at play, and out and about. Centers for Disease Control and Prevention. cdc.gov/handwashing/pdf/hand-sanitizer-factsheet.pdf. Accessed January 2020.
3. Boil water [technical brief]. World Health Organization. who.int/water_sanitation_health/dwq/Boiling_water_01_15.pdf. Accessed January 2020.
4. Greene CE, ed. Infectious Diseases of the Dog and Cat. 4th ed. St. Louis, MO: W.B. Saunders; 2012.
5. Merrill L, ed. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Ames, IA: Wiley-Blackwell; 2012.
6. Canine influenza. Center for Food Security & Public Health. cfsph.iastate.edu/Factsheets/pdfs/canine_influenza.pdf. Accessed