Infection Prevention and the Veterinary Hospital
Veterinary hospitals have proven to be creative and resilient when it comes to their infectious disease prevention efforts.
It’s amazing the difference 45 miles makes. For instance, Austin, Texas, was an intensely managed community when it came to COVID-19 protocols, said Steven Golla, DVM, MS, regional operations manager, Central Texas, for Innove˘tive Petcare. Across the board, the Texas capital shut down harder than anybody else in the state, he said. Their mask policies and containment policies were stricter than most, “and the clinics that I managed there locked their doors.”
But 45 miles to the south in a small Texas town of about 6,000, the response was different. There the restaurants didn’t close down, and the grocery stores remained open. The doors to the veterinary hospital were never locked. People still came to the door, but only when it was their turn. Clients and staff wore masks, and there was a lot of handwashing going on. If an animal were brought in with a leash, the veterinary hospital staff would take another leash to put on the dog so that they didn’t have to touch the owner’s leash.
“I think that’s what’s really unique about veterinary medicine – there isn’t this across-the-board way we treat pets,” Golla said. “It is very regimented to the local communities. And I think our COVID-19 response has been the same.”
Veterinary Advantage reached out to veterinarians and industry stakeholders to gauge what their response was to the initial challenges of infectious disease prevention amid the pandemic and how those responses may have developed into long-term approaches and solutions.
Creative PPE solutions
In late March and early April 2020, Innove˘tive Petcare veterinary hospitals had more than enough personal protective equipment. But, they didn’t hesitate to relinquish PPE to local hospitals to help alleviate the critical shortage on the human side of medicine when the need arose. “We very quickly went from a very regimented, systematic program to handing over our sterile gloves, masks, and extra gowns,” said Golla. “And then we had to get creative on how we continued our processes.”
Some of the more creative solutions involved staff members sewing together surgical masks and creating gowns to use out of bedsheets, “because we knew we could function in that capacity so that our human brethren could have what we had in the clinics to be able to function and protect themselves,” he said.
While that generosity did create a temporary shortfall of available PPE in July 2020 when cases of COVID-19 began to rise in Central Texas, Golla said Innove˘tive hospitals worked through those disruptions. “In the beginning, it was the unknown – we didn’t know what we didn’t know,” he said. “There was a lot of fear driving decisions, and some of those fears may have driven things a bit to the extreme. But when human lives are at stake, you’re going to err on the side of caution, and you’re going to do things that you think can work.”
Like most veterinary hospitals, Innove˘tive veterinarians and staff experimented with different safety measures. Some worked, and some didn’t. For instance, Golla said staff experimented with 50/50 shifts where the staff was split in two. Half worked one day and half the next. “The problem with that was you had half the staff trying to do all of the work,” he said. “That very quickly became unsustainable. After two weeks, the staff were saying they couldn’t keep pace. ‘Yeah, I get the next day off, but I’m sleeping from the day I worked with the 12-hour shift until my next shift.’ With the volume we had, it didn’t work.”
While some hospitals went directly to curbside service and a couple locked their doors, many hospitals found a way to navigate people coming in using a regimented manner with their masks on, separated from everybody and doing a one-at-a-time, concierge-type service.
“What I would say in terms of infectious disease control and veterinary medicine, it’s been very, very rewarding to me in that it hasn’t been a one-size-fits-all approach that we try to do with a lot of these things,” said Golla. “We’ve been able to do it location by location, figure out what works for a clinic in its community, that makes the most sense, based upon not only the anecdotal data we have at the location but also the traditional reaction of the community.”
While that individualized approach created challenges from an organizational standpoint, Golla said he wouldn’t have it any other way. “At times, that’s been hard for me to navigate because you’ve got people that believe it can only be one way based upon their community experience. But when you look at it from a clinic-by-clinic viewpoint, that’s not necessarily what’s the best case for that scenario. I’m very proud of the fact that we’ve been able to navigate it that way. We’ve been very successful with how we’ve been able to handle and stay open and be functional with COVID-19.”
Golla said it was also encouraging to see a lot of sharing going on within the veterinary community. While Innove˘tive has preferred vendors for the organization, each clinic orders its own supplies. No clinic ever gave more away than they could afford to, but within Innove˘tive’s corporate structure, it made it easy to be able to share among members if a need arose, Golla said. Veterinarians knew that if they gave extra PPE supplies away if they needed PPE later on, it would come back because of the community support and team approach.
By the fall of 2020, Golla said there was no abnormal shortage of PPE supplies, and the supply has maintained itself through the beginning of 2021. “There are no PPE shortages in the clinics today,” he said. “Maybe every now and then, something goes on backorder, but that’s nothing abnormal in our industry. There’s always something that goes on backorder.”
New protocols and product monitoring
Laura Betts, DVM, owner of Parkdale Animal Hospital in Manistee, Michigan, has always taken infection prevention seriously. But with the pandemic, she put those efforts in writing. In June 2020, Betts and her team created a COVID-19 Preparedness and Response Plan to comply with the Michigan governor’s Executive Order and OSHA Guidance on Preparing Workplaces for COVID-19 that they posted on their website.
According to the plan, Betts serves as the worksite supervisor with the responsibility to implement, monitor, and report on the COVID-19 control strategies. In Betts’s absence, the client care supervisor, Bonnie Knysz, acts as the supervisor. In case neither of them is present, the team member with the most seniority working at the front desk will be the supervisor, according to the plan. The supervisor will remain on-site at all times when employees are present on-site. After regular business hours, including lodging, the last remaining on-site employee is designated to perform the supervisory role.
In regards to supplies needed to ensure infection prevention and safety amid the pandemic, Betts said she is ordering more PPE to have on hand in case of any potential backorders. “We’re not hoarding, but we are aware when gloves or masks are getting low.” She said she’s frustrated by increased prices and estimates that she’s paying 30% to 50% more for PPE than what she paid pre-COVID. “We’re spending a lot more, and we need a lot more.”
Trying to get N95 masks has been difficult. “We don’t use them regularly, but we want to have them on hand in case a situation arises where we need more protection.” In general, she and her team are going through a lot more masks because everyone needs a new one each day unless they are wearing cloth masks.
Betts does the ordering for her practice and said she is much more proactive about monitoring their PPE supply. Because PPE has become more critical, she has those supplies locked up, as she would pharmaceutical products. “I trust everyone here, but I need to have everything in one spot, and people tend to spread things out,” she said. “So that’s why it’s locked up. But I need to be able to, just at a glance, look inside the storage area and say, ‘Okay, we’ve got four of these gloves boxes left; it’s time to reorder.’ So yeah, we’re definitely more proactive.”
Betts and her team have also increased infection prevention efforts and maintained those efforts. Every two hours, touch surfaces in the office get disinfected – floors, countertops, exam tables, chairs, etc. Each night, a cleaning services provider comes in and does deep disinfection. “We’re more aware of infection prevention,” Betts said. “It’s taking up more of our budget.”
Like many veterinary clinics, Parkdale went to curbside service for client engagements. In the spring, summer, and fall of 2020, they moved euthanasias outside so clients could be with their pets. In the winter, they moved euthanasias back inside, but otherwise, no client was allowed in the building. During curbside engagements, team members are wearing masks and gloves. When the dog or cat is handed off to the tech or assistant, they switch the owner’s leash out for one of the clinic’s. With pet lodging, clients come to the back door and place their pet in a large cage, where a tech will retrieve the pet once the client has left. The surfaces touched are then disinfected.
Although most of these safety procedures are more intensive and time-consuming, they are worth the effort to assure infection prevention, Betts said. “That’s the way we’re doing it now, and we’ll be doing it for the foreseeable future.”
Her clinic uses Petriage, so they’re able to do a lot more virtually. “We do all of our surgical progress exams and a lot of our medical progress exams virtually through telemedicine,” she said. “That has really opened up the exam space on the schedule, not having those have things that can be done virtually come into the hospital.”
An understanding of disease outbreaks
As Golla reflects on the last year, he noted that veterinary hospitals were actually well-positioned to handle the pandemic, maybe more so than other businesses. “Our veterinarians are epidemiologist trained,” he said. “They understand that if anybody can handle a disease outbreak, it’s us. We deal with this all the time, whether it’s a dog, cow, or horse. We’re exposed to rabies and take precautions every day. We’re exposed to bacterial infections that are antibiotic-resistant every day. There are certain viruses that can transmit from those species to people that we have to deal with every day. And I think we’re used to that. So this was just another threat that we’ve had to guard against.”
The Innove˘tive hospitals doubled down on handwashing and found ways to limit the exposure of high-risk staff members to the general population. “From an infectious disease point, we really did try to identify who on our staff was the most at risk. Very quickly, we understood the demographic of people that were high risk, including age, so we tried to mitigate the exposure they had to the population. We asked people, ‘Who is comfortable?’ For those that were more comfortable and willing, then they obviously were more in the target zone, so to speak, in terms of being exposed to people. For those that weren’t, we were able to shuffle them into another role.”
Golla said at each location; veterinarians were not cavalier with their approach. They took risks for themselves, staff and clients very seriously because they understood the damage viruses could do. Innove˘tive has provided organizational guidelines from the start and revised them whenever the CDC has an update. But each clinic worked out its own plan based on those guidelines if they didn’t already have a plan in place pre-pandemic. “At every location, we already had disease control officers in place,” said Golla. “It wasn’t like other businesses that had to train people on that. It was a very natural thing for us to adapt.”
A ‘bigger picture’ approach
The COVID-19 pandemic has changed the way we think about infection prevention across all aspects of veterinary medicine, said Jackie Harris, executive director of marketing and customer success, Virox Technologies Inc. While protecting animals from infection has always been a focus, we are now starting to consider how patient, client, and team member health are all interconnected. “This means implementing measures to protect the health and safety of clients as they bring in their pets for appointments, such as curbside services to maintain physical distancing, and cleaning and disinfecting high-touch surfaces throughout the day,” she said. Increased hand washing, wearing of personal protective equipment (PPE), and encouraging sick employees to stay home have become routine in the push to keep veterinary teams healthy.
Although there is a light at the end of the tunnel with the ongoing COVID-19 pandemic, it is likely that this “bigger picture” approach to infection prevention is here to stay, said Harris. “With the threat of zoonotic pathogens, along with our newfound awareness of the impact of human outbreaks, infection prevention programs of the future will likely incorporate strategies to protect people, animals, and even wildlife from infection. Looking at infection prevention through this ‘One Health’ lens may be our key to preventing the next pandemic and protecting us from disease during everyday life.”
With the increased focus on infection prevention, Harris said veterinarians are thinking critically about the products they choose to ensure that their patients, clients, and team are being fully protected in the event of a disease outbreak, as well as for everyday use. For instance, while many disinfectants claim to be effective against canine parvovirus or SARS-CoV-2, the virus that causes COVID-19, some have unrealistic contact times and are readily inactivated in the presence of dirt and debris. Others are associated with occupational health concerns, which should never be a trade-off. While there has been much “smoke and mirrors” marketing throughout the pandemic, veterinarians understand the importance of choosing products that don’t just work on paper but are actually effective in real clinic or hospital environments, Harris said.
“Another key lesson from the pandemic has been that supply chains are more fragile than we often realize,” she said. “Critical items such as disinfectants and PPE have been in short supply in recent months, prompting many veterinarians to consider having extra supplies on hand as a contingency plan. Choosing products that are easy to store and have a long shelf life can help with this.”
The starting point for a successful infection prevention program is having every member of the veterinary team on board and invested in building a rigorous protocol, regardless of whether they are directly involved. Even the best infection prevention protocol will only work if it is followed correctly, so it is important to stress to each team member that infection prevention is everyone’s job, Harris said. A designated ‘point person’ may be appointed to oversee compliance with protocols. Communication and accountability are key to infection prevention success.
Good infection prevention practices require planning ahead as much as possible by investing in strong protocols and ensuring that every team member is fully trained on every aspect of the process, she said. For instance, this may involve making a list of all surfaces that need to be cleaned and disinfected, the frequency of disinfection needed, and the product and protocol to disinfect each one. In addition, regular training on hand hygiene, aseptic procedures, and all other aspects of infection prevention is non-negotiable.
“It is often said that ‘what gets measured gets done,’ and this absolutely applies to veterinary infection prevention as well,” Harris said. “Routine surveillance and reporting should be built into infection prevention protocols to track trends as well as to monitor compliance and ensure that measures are successful. This also gives practices the opportunity to evaluate their protocols and identify opportunities for improvement.”
Photo credit: istockphoto.com/yacobchuk
COVID-19 preparedness and response plan
Editor’s note: The following is part of Parkdale Animal Hospital’s COVID-19 Preparedness and Response Plan posted on its website.
COVID-19 Training and Education Provided to Employees
The following materials have been presented to staff in preparation for offering services to our clients on 06/06/2020.
- Workplace infection-control practices – see CDC Cleaning and Disinfecting Your Facility.
- The proper use of personal protective equipment, see:
- CDC PPE-Sequence.
- PPE use in specific situations.
- Steps the employee must take to notify the business or operation of any symptoms of COVID19 or a suspected or confirmed diagnosis of COVID-19.
- Employees who have symptoms should notify their supervisor and stay home.
- Sick employees should follow CDC-recommended steps. Employees should not return to work until the criteria to discontinue home isolation are met, in consultation with healthcare providers.
- Employees who are well but who have a sick family member at home with COVID-19 should notify their supervisor and follow CDC recommended precautions.
- How to report unsafe working conditions.
- Contact your worksite supervisor immediately.
- If you do not receive satisfaction, you should file a complaint with MIOSHA michigan.gov/leo/0,5863,7-336-78421_11407-93835–,00.html.
- You should not fear retaliation as it is illegal to retaliate against workers who report unsafe conditions during the pandemic.
Health Assessments for Staff
We will conduct a daily entry self-screening protocol for all employees or contractors entering the workplace, including temperature check, a questionnaire covering symptoms, and suspected or confirmed exposure to people with possible COVID-19 utilizing the COVID-19 Daily Self Screening Form.
Storylines to watch
Certainly, the biggest story currently dominating the infection prevention world is how we will emerge from the pandemic and what the “new normal” will look like, said Jackie Harris, executive director of marketing and customer success, Virox Technologies. “It will be interesting to see whether veterinary hospitals adopt more of a ‘One Health’ approach to infection prevention, implementing strategies designed to protect animals, clients, and staff from infection.”
Another story that continues to unfold is the rising challenge of antimicrobial resistance in animal health. “While this has been on our radar for some time, it promises to continue to be a defining threat to veterinary medicine,” she said. “This may lead to changes in our approach to antimicrobial use, and an increased focus on prevention as our first line of defense, including strategies such as hand hygiene, isolation, and routine cleaning and disinfection.”
AVMA: Operational changes and precautionary measures vet clinics took amid the pandemic
The AVMA conducted two large surveys of practice owners in April and July 2020 to better understand how COVID-19 has affected veterinary practices. In all, AVMA collected over 3,500 responses representing different practice sizes, types, and species. Questions covered operational changes, client numbers, use of personal protective equipment (PPE) and other supplies, financial impact, and other topics.
Practices have implemented a wide range of operational strategies and precautionary measures to continue providing veterinary care while limiting the spread of the coronavirus and prioritizing the safety of team members and clients.
On the operational side, the most common approach has been asking clients to wait in vehicles during animal exams and treatment (curbside care). Other operational changes include contactless payment processing, taking patient history by phone or virtually, and drive-thru pick-up and drop-off.
Data show that between April and July, a small number of practices reduced several of these approaches. For example, in April, 84% of practices asked clients to wait in vehicles during treatment, and in July, that number had gone down to 73%. The number of practices implementing contactless payment processing and taking patient history by phone or virtually also declined during that time. In contrast, the percentage of practices taking client visits by appointment only increased from 56% in April to 75% in July.
The number of veterinary practices that reported using telemedicine in April and July remained constant at 32%. Eighteen percent of practices were seeing only emergency-related cases at the time of the second survey (down from 20%).
Precautionary measures have included asking clients to maintain social distancing, asking team members with symptoms of illness to remain at home, and canceling at least some appointments. As veterinary teams adjusted to life in a pandemic, the AVMA saw significant changes in the percentage of practices implementing specific precautionary measures between the two surveys. In April, 60% of practices had canceled appointments due to the pandemic, and in July, that number was just 35%. A similar decline was seen in the number of practices asking staff to sanitize PPE for reuse — down from 57% to 40%. On the other hand, the percentage of practices that had asked clients displaying symptoms to leave the clinic nearly doubled from 31% to 57%.
For more information, visit avma.org/resources-tools/animal-health-and-welfare/covid-19/covid-19-impact-veterinary-practices.
PPE in review
Premier, Inc., a group purchasing organization, released a report in the spring that analyzed new data from its supply chain forecasting technology to assess the long-term impact on the supply chain one year into the pandemic. While most hospitals are seeing greater availability of many types of PPE, the health care supply chain remains fragile and constrained.
“Massive increases in global PPE demand created the imbalance in the supply chain and have driven up raw materials prices, which impacts the cost of finished goods,” Premier said. “This has cascaded to providers who have incurred additional costs to acquire PPE, adding to existing margin pressures.”
For example, the American Hospital Association (AHA) estimates the additional costs associated with purchasing needed PPE for hospitals and health systems was $2.4 billion over a period of just four months, from March through June 2020, or roughly $600 million per month.
The following are some of Premier’s findings related to PPE products:
N95s and surgical masks. N95 respirators and other masks have been among the most challenging products for health care providers to source and secure amid COVID-19. Active COVID-19 cases drove N95 demand spikes up to 17 times higher during the first wave. Most health systems had approximately 23 days of supply on hand at the time, according to a Premier survey, but providers with active COVID-19 patients had an average of just three days’ worth. One year later, the N95 market remains constrained but not in active shortage.
Isolation gowns. By mid-April 2020, global manufacturing ramped up to help meet the unprecedented demand spike for face masks and respirators, but this also produced an unintended consequence for isolation gowns supply.
Gloves. Exam glove supply has been constrained throughout the COVID-19 pandemic, and availability challenges are expected to persist into 2023. Global demand for nitrile exam gloves currently exceeds existing production capacity by an estimated 215 billion units or nearly 40%. Raw material scarcity, port closures and delays, and a two-fold increase in gloves usage since June 2020 have exacerbated ongoing shortages.
Other areas of need
And that’s just health care. Demand for PPE wasn’t just coming from the healthcare space. Billy Harris, CEO of Sri Trang USA, Inc., said last year, as the pandemic ramped up, that his company had received an unprecedented amount of interest in gloves from businesses and organizations across all industries. Think restaurants, grocery stores, retail chains, cruise lines, etc.
Indeed, big changes are happening in the supply chain, Harris said. The market’s going to look very different, and the demand will probably jump from the 70 billion it was at pre-COVID to possibly 90 billion when it all starts to settle out, “because we’re all going to be doing more cleaning, deep cleaning, things of that nature.”
Photo credit: istockphoto.com/Morsa Images