By Virginia Sinnott-Stutzman DVM, DACVECC
Chair, Angell Infection Control Committee
The National Association of State Public Health Veterinarians has created a model infection control plan that can be downloaded and used by veterinary hospitals.1 While this document is an excellent and editable scaffold to create your own plan, it is necessarily general so as to apply to a multitude of practice settings. Thus, the recommendations can seem vague and inapplicable to situations employees encounter in their daily practice. The ideal infection control plan should be readable by a new hire or a current employee with questions about a new or unique situation and should be sufficiently specific that that employee will know exactly what to do and where to go to get the equipment needed to deal with a given situation. It should have an index or be searchable. (I suggest keeping it electronic as a word processor document loaded onto the desktop of every hospital computer, or as a link on the hospital’s intranet homepage).
The first section of every infection control plan should include routine infection control practice. It should outline the tasks employees do every day to prevent the spread of disease. This section is often overlooked as it feels like one is explaining common sense tasks, however it is VITAL that all employees perform hand washing and cleaning procedures effectively and all know when they need to don extra personal protective equipment (PPE). The more specific this section, the better. Outlining the proper way to wash hands and use hand rub is important. Additionally, highlighting the location of all handwashing stations and hand rub dispensers in the hospital either by schematic site map, photograph or description shows new employees where to go to perform this task conveniently. This section can also include a prompt and a signature line for new employees to demonstrate appropriate handwashing technique and have it signed off by the house safety officer or infection control officer. (Demonstrating proper hand washing technique is something we’ve added to our new hire process at Angell.) The indications for performing hand hygiene should be outlined in this section and should be specific to your practice to emphasize the importance of hand hygiene at your facility. For example rather than saying “hand hygiene should be performed before and after each patient contact, before clean procedures or after dirty procedures” you could write:
Hand hygiene should be performed:
- Before starting each appointment [because patient contact will inevitably happen]
- After dirty procedures such as taking a rectal temperature
- Before drawing blood, including SNAP tests performed in the exam room
- Before performing a cystocentesis or passing a urinary catheter
- After handling dirty laundry
- After each appointment
This list should be as practice-specific as possible because the number one reason veterinary staff site for not performing hand hygiene when indicated is that they forget.2 Looking deeper, often the reason is that they don’t recognize in the moment that the action they are performing IS an indication for hand hygiene. When an employee reads this specific list, they call to mind the times they have been in that situation and realize they SHOULD have performed hand hygiene. They thus learn to associate the vague recommendations of “before clean procedures” with the concrete instance when they draw blood to run a 4DX during an annual physical appointment and visualize themselves in that moment performing hand hygiene.
The second section should include how to clean anything that must be cleaned on a daily basis. Again, being specific may seem overly pedantic, but it is vital to write these procedures down so that high-touch areas are not missed routinely. A recent study found that during video observation of 47 veterinary clinics, exam tables were cleaned 76% of the time after an appointment and the exam floor was cleaned 7% of the time after an appointment.3 Additionally, the median contact time for disinfectants on exam tables was 9 seconds, far below the contact time required for disinfection by most cleaning products.3 Inserting ideal cleaning practices written in the form of a step-by-step protocol may improve consistency and technique. Include in these protocols what equipment should be gathered, the appropriate time(s) to perform hand hygiene in the steps and the order in which items should be cleaned (generally from the area expected to be least contaminated to the area expected to be most contaminated). If the item is to be disinfected, this is a second step, as it can only be performed after the surface is visibly free of debris. Finally the appropriate contact time for your disinfectant should be listed. For examples of cleaning protocols devised by our infection control committee at Angell, don’t hesitate to contact me at firstname.lastname@example.org
The third section of the infection control plan outlines the specific situations in which barrier precautions and personal protective equipment should be used. In the model infection control plan the indications are general. For example an indication for wearing gloves is, “when touching feces, body fluids, vomitus, exudates, and non-intact skin.” While this seems like common sense, an employee may not make the connection that, for example, patients with incisions have “non-intact skin” so it may make sense to wear gloves when touching those patients. Similar to indications for handwashing, a more practice-specific list could include:
Don gloves when:
- Transferring dirty laundry to the washing machine [potential feces contact]
- Emptying a urinary catheter collection system [potential urine contact]
- Cleaning up after a dirty procedure such as wound debridement or lancing abscesses [potential exudate exposure]
- Performing a urinalysis [urine contact]
- Running an in-house CBC/Chem [body fluids contact]
- Handling a patient with a wound or incision [potential non-intact skin contact]
- Taking a rectal temperature [feces contact]
The reality is that many employees are unaware that the above situations as well as the situations listed as indications for hand hygiene are reasons to wash hands and protect hands from contamination with gloves. Historically, infection control practices were weakly emphasized in veterinary education as compared to human medicine as the risk of disease transmission from pet to healthcare worker is much less than the risk of transmission between a human patient and physician. With the rise of multi-drug resistant infections and the increase in leptospirosis diagnoses in the state of Massachusetts, this is no longer the case. While vets report they know they should take these infection control precautions, a recent video observation study of veterinary clinics revealed that hand washing compliance is about 14%.2,4 This means that for every one hundred indications for hand hygiene the observers identified, hands were actually cleaned 14 times. Although similar studies don’t exist for barrier precautions, it seems reasonable to assume the gap between knowing one should don gloves or a mask or a gown and actually doing it similarly exists. Creating a specific infection control plan from the model document provided by the NASPHV and having it available throughout the clinic is an excellent way to narrow that gap in your hospital environment.
- Available at: nasphv.org/Documents/ModelInfectionControlPlan.docx. [Accessed on 10 December 2018].
- Anderson ME, Weese JS. Self-reported hand hygiene perceptions and barriers among companion animal veterinary clinic personnel in Ontario, Canada. Can Vet J. 2016;57(3):282-8.
- Anderson ME, Weese JS. Video observation of sharps handling and infection control practices during routine companion animal appointments. BMC Vet Res. 2015;11:185. Published 2015 Aug 6. doi:10.1186/s12917-015-0503-9
- Anderson ME, Sargeant JM, Weese JS. Video observation of hand hygiene practices during routine companion animal appointments and the effect of a poster intervention on hand hygiene compliance. BMC Vet Res. 2014;10:106. Published 2014 May 7. doi:10.1186/1746-6148-10-106