Infection Control in the Veterinary Practice

What is the duty of care for the veterinary practice regarding waste?

Waste is stored and disposed of responsibly.
Waste is only handled or dealt with by those authorised to do so.
Waste records/transfer notes are kept for all waste that is transferred or received (keep for a minimum of 2 years).
Having a duty of care means you have moral or legal obligation to ensure the safety or well-being of others.
The safe and correct management and disposal of waste is required to ensure human, animal and environmental health and safety. Veterinary Practices have a duty of care to ensure their waste is stored and disposed of responsibly in addition to complying with the relevant legislation.

What are the regulations for waste management and disposal?

Waste disposal is regulated by the Environment Agency in England and Wales.
The duty of care for the management and disposal of clinical waste is imposed under the Environment Protection Act 1990.
Additional legislation relating to the control of clinical wastes are imposed by:
-Control of Pollution (amendment) Act 1974.
-Special Waste Regulations (amended) 1996.
Veterinary practices must obey the same waste regulation laws as any other business operating within the UK. This means that they must ensure that all reasonable steps are taken to appropriately manage and dispose of any waste that is produced at their facility.

What are the important points to consider when managing and disposing of waste?

Have an understanding on the type of waste you are dealing with.
Only handle what you have been trained to work with.
Wear PPE (this will vary for each type of waste).
Good general/personal hygiene and infection control standards.

What are the different types of waste?

Hazardous waste.
Non-hazardous waste.

What are the different types of hazardous waste?

Sharps
Cytotoxic and cytostatic waste
Infectious/clinical waste
Photographic/radiographic chemicals
Other (fluorescent light tubes, light bulbs, batteries).

How should sharps be disposed of properly?

Include partially an fully discharged sharps, hypodermic needle (e.g. insulin needles) and other sharp items such as surgical blades.
Segregate needle from syringe.
Internal disposal \= yellow shapes bin (internal disposal is within the veterinary practice).
External disposal \= high temperature incineration (external disposal is how waste is disposed of once it has left the Veterinary Practice by the waste disposal company).
For best practices and orange sharps bin may be used to dispose of sharps not contaminated with pharmaceuticals.
-Includes sharps contaminated by blood or bodily fluids such as surgical blades and needles.

How to manage and dispose of cytotoxic and cytostatic waste properly?

Cytotoxic \= toxic to cells.
Cytostatic \= inhibition of cell growth and multiplication.
Waste contaminated with cytotoxic or cytostatic pharmaceuticals, which are medical products that are toxic, carcinogenic, toxic for reproduction or mutagenic.
-A carcinogenic drug/substance is one that is capable of causing cancer.
-A mutagenic drug/substance is one that is capabel of causing mutations (a change in the DNA of a cell).
-Ciclosporins are a group of immunosuppressive drugs.
Examples include cancer chemotherapy drugs, antivirals, ciclosporins and some hormone preparations.
Includes glass bottles and vials, clinical materials (masks, gloves), syringes, shaprs and animal bedding contaminated by cytostastic and cytotoxic pharmaceuticals.

Internal disposal is done through purple and yellow bags or bins.
External disposal \= high temperature incineration.

How to manage and dispose of infectious/clinical waste properly?

Includes items containing viable microorganisms (or their toxins) which are known to cause disease in humans and other living organisms.
May include:
-Animal tissue, body parts or other body fluids.
-Clinical waste items (swabs, gloves, masks, aprons including blood contaminated items).
-Waste from infectious disease and zoonotic patients).

Internal disposal \= yellow clinical waste bag.
External disposal \= high temperature incineration.
Orange clinical waste bag also for infectious waste.
No body parts or cadavers.
Externally disposed of via alternative methods (for example, autoclaving) for best pracitce.

How to manage and dispose of photographic/radiographic chemicals?

This type of waste includes fixer and developer solutions (chemicals used to develop a manual/film-based x-ray).
The two solutions should be disposed of separately.
No standard packaging requirement (depending on the individual disposal company).
Waste containers must be leak proof and labelled.

What are the different types of non-hazardous waste?

Pharmaceuticals (non-cytotoxic/cytostatic)
Offensive waste
Cadavers (unless harbouring a notifiable disease)
Domestic waste

How to manage and dispose of pharmaceuticals properly?

Includes non-hazardous items contaminated with pharmacueticals such as vaccine bottles, empty injection bottles, syringes bodies, whole drugs and denatured controlled drugs.
No sharps or hazardous waste..
Internal disposal \= blue bins.
External disposal \= high temperature incineration.
Controlled drugs are regulated by the Misuse of Drugs Regulations 2001. Includes human prescription only medications which are schedule to specific requisition, storage, record keeping, prescribing, supply and disposal.
-Controlled drugs must be disposed of using a denaturing kit.
-Disposal of schedule 3 controlled drugs must be witnessed.
Controlled drugs are often subject to abuse and this is why there are strict controls in place.
Solid and liquid pharmaceuticals must not be mixed together as this may cause chemical reactions, toxic fumes and fires.

How to manage and dispose of offensive waste?

Defined as waste that is non-hazardous or non-clinical but one that is unpleasant and may cause offence to the senses.
Includes faeces, animal bedding and clinical materials (masks, gloves, blood contaminated items providing they are not infectious).
Internal disposal \= tiger stripe bag.
External disposal \= landfill.
Infectious clinical waste must not be disposed of in these bags.
This type of waste is often confusing to many staff members as clinical materials can be disposed of via this method as long as they are not infectious. The British Veterinary Association (2011) state that waste must have been subjected to a detailed item and patient-specific assessment that clearly states it does not present a risk of infection or other potential hazard to any animal or person that may come into contact with it, even if mismanaged.

How to manage and dispose of cadavers (unless harbouring a notifiable disease) properly?

A corpse or deceased body.
A form of waste and needs to be handled and disposed of respectively, safely and correctly.
Non-infectious cadaver \= buried at home by owner, buried as a pet cemetery or cremated by a pet crematourium.
If the cadaver is suspected or confirmed to be harbouring a notifiable disease, disposal should be arranged via APHA/DEFRA.
No specific packaging requirements for this type of waste (opaque packaging recommended).

How to manage and dispose of domestic waste?

May also be known as household waste.
Includes recyclable materials such as paper, cardboard, food waste, unsoiled newspapers and magazines, plastic food containers and drinks cans.
Internal disposal \= black bags, recycling bin.
External disposal \= land fills for non-recyclable waste and recycled if recyclable.

What happens if there is poor waste management and disposal?

A poor and lack of understanding on waste disposal may lead to detrimental consequences.
It is also a legal obligation for waste to be managed and disposed of correctly.

What is the purpose of the waiting room?

Often the first area the client and patient will enter when visiting the Veterinary Practice.

Appearance and management must be professional and safe.

Allows client and their pets to wait and be seen by a veterinary professional.

How should the waiting room and reception area be kept clean?

Keeping the reception and waiting room area clean and tidy is achieved by walking through on a regular basis, removing out of date and damaged stock, emptying waste bins and disposing clutter.

If additional items such as magazines and plants are located within the reception and waiting room area, staff must manage these appropriately to ensure good standards.

The presentation of staff working in these area must also be of a high standard to ensure confidence and respect from clients.

Veterinary staff working within the reception and waiting room area must manage these areas correctly to ensure a smooth running of consultations and client/patient management.

Staff must also ensure that animals are kept under control within these areas by advising clients to keep hold of leads when bringing in their dog and keep cats and other small pets contained within a secure carrier.

How high is the risk of infection within the waiting room?

These areas are often deemed low risk for infection but they have the potential to be high risk areas if not managed correctly.

* If you are expecting a patient to arrive who has suspicious symptoms such as sneezing or coughing do not allow them into the waiting room in case they are contagious. You must explain this to the client to prevent them from feeling unwelcome and most clients will understand.

Cleaning equipment and hand sanitisers should be available at all times in these areas to help prevent and control infection. The reception and waiting room area (including the flooring) should be cleaned and disinfected at least once a day.

What is the purpose of the examination room?

Often referred to as the consultation room.

Purpose:

* Obtain clinical history
* Perform clinical examination
* Private, interrupted discussion of patient with the client
* Minor procedures
* Including microchipping, vaccination, emptying of anal glands, examining eyes/ears etc are routinely performed with the client present within the examination room.
* Provide a safe environment for counselling.

Certain drugs and equipment that are commonly required during a consultation should be stored securely within the examination room.

What is the importance of a consultation room being layed out correctly?

The space and layout of the examination room is essential to ensure consultations are effective and safe for all involved. These factors can dictate whether an examination room is efficient and comfortable to work in. Space required for the veterinary surgeon and/or the registered veterinary nurse and the patient, however, if it is too spacious it can be tricky when restraining the patient as there will be multiple escape routes.

An extremely spacious examination room may also look ineffective and empty to some clients and it may also be intimidating for some patients, especially the prey species. Gaps and spaced behind cupboards and other pieces of furniture should be filled to prevent escape and difficult retrieval.

How much of a risk is the consultation room for infection?

This area is deemed high risk for infection if not managed correctly. Every patient entering the practice will enter this area so control measures must be in place.

Cleaning equipment and hand sanitisers should be available at all times to prevent and control infections.

If the examination room is used for suspected or confirmed contagious case, the practice’s standard operating procedure should be followed to ensure adequate cleaning and disinfection prior to using the room for another patient. This includes the cleaning and disinfection of equipment used on the patient.

The examination table is often the focus of this room as this is where most patients are positioned for their examination and communication will take place over and around the table.

What are the design features for the examination room?

Colour:

* The colour scheme used within the room should be neutral, clean and bright. This will promote wellbeing for staff, client and hopefully the patient too.

Privacy:

* Privacy is an important factor in the design and management of the room. The types of consultations are wide ranging from simple vaccinations to complex medical diagnosis and euthanasia.
* Privacy can be maintained by ensuring the doors and any windows are shut and the use of soundproofing materials can also aid this.
* Some practices have two doors in the room, one for the client enterance and another to enable staff to leave the room and enter the back of the practice if required.

Lighting:

* Adequate lighting for visualisation of the patient’s anatomy is vital.
* Standard ceiling lighting is often insufficient so many practices install wall mounted and table mounted lights to help illuminate area requiring examination.
* The use of modern LED ceiling lighting is becoming more and more popular, especially is newer practices due to their efficiency and ability to produce daylight like lighting. This helps to promote wellbeing in addition to providing adequate lighting for this type of environment. Natural lighting is not essential but it can make the environment more pleasant for anyone working within this area.
* Window blinds should be fitted to keep out direct sunlight and to enable staff to darken the room if needed in some circumstances such as when dealing with anxious patients or patients requiring ocular examinations.
* Many practices have a cage like fitting on the windows to prevent the risk of escape.
* Light bulbs should be replaced as required and any electrical faults should be dealt with by a qualified electrician.

Easy to clean and disinfect:

* This can be made easier by ensuring surfaces, equipment and pieces of furniture are made from hard wearing material that can withstand regular cleaning and disinfection.
* The examination room should be spot cleaned in between each patient (depending on the type of patient examined and waste produced) and at least once a day it should be deep cleaned. This is often performed in-between consulting blocks when the room is not in use.
* A broad-spectrum disinfectant product is usually adequate within this area.

Non-slip flooring.

Storage:

* Storage within this are is essential as there are several pieces of equipment required for use in this area. However, too much storage can encourage to build-up of clutter and dust.

Ventilation and heating:

* Are a key design feature throughout the veterinary practice.

Equipment.

Furniture:

* The main pieces of furniture located within the examination room is the examination table, stools and/or chairs, cupboard units, refrigerator and hand washing/sink facilities. All should be maintained correctly to ensure good health and safety and infection control.

Waste disposal:

* It is highly unlikely that every type of waste bin needs to be available in the examination room but as a minimum, there is usually a domestic bin, clinical waste bin, offensive waste bin and at least a yellow lid sharps bin.
* Waste bins should be of the correct size for good management as if they are too small they will require emptying too often but if they are too large, they may not be emptied frequently enough and begin to smell.

What are the key features of the examination table?

Sturdy and stable.

Non-slip surface.

Hard wearing.

Easy cleaning and disinfection.

What are the different types of examination table?

Static stainless steel.

Hydraulic.

What are the key features of a static stainless steel examination table?

Fixed height.

* One of the main advantages of this types of examination table is the fact that it is of a fixed height.
* Staff and clients using this type of table will be of a different height so some may have to bend their back to be able to work on this table whereas others would have to reach up. Over time, this can lead to postural changes and injury so there are health and safety concerns associated with its long term use.
* Some patients may feel intimidated when placed on the table as they may be too high up. This can also lead to staff and client injury if the patient tries to jump off or even worse if they try to bite as they may be at face height.

Sturdy.

East cleaning and disinfection.

Often come with a thick rubber matting on top.

* Appropriate cleaning and disinfection is often neglected as the rubber matting may not be removed by some staff during cleaning and disinfection. If possible it should be removed to enable effective infection control.

What are the key features of a hydraulic examination table?

Adjustable height and tilt.

Stainless steel for easy cleaning and disinfection.

Hydraulic system operated by pedal or electronically.

Often come with a thick rubber matting on top.

These types of examination tables often require further maintenance in contrast to others to ensure their mechanisms are functioning correctly. This involves annual servicing. Any electrical faults should be dealt with by a qualified electrician to ensure health and safety. These tables are more expensive that other examination tables due to their additional features.

What are the important considerations to remember with the examination table?

Physical barrier between the veterinary professional and the client (and drugs/equipment).

Professional vs intimidation?

Many practices are moving towards a more relaxed approach to consultations.

What is diagnostic equipment?

The RCVS Practice Standards Scheme (PSS) dictate what equipment must be available in the veterinary practice.

Common pieces of diagnostic equipment you will find within the examination room and ward include:

* Stethoscope
* Oto-oopthalmicscope
* Thermometer
* Weighing scales
* X-ray viewer
* Tonometer
* Blood pressure monitoring

The pieces of equipment you will come across in practice will vary depending on the type of practice you work in.

Why is a stethoscope needed in the examination room?

Should be available in every examination room and ward for auscultation (listening) of the patient’s heart and thorax.

Must be correctly maintained and cleaned.

The tubing of the stethoscope should be checked for cracks or perishing of the material as this type of damage can prevent adequate auscultation.

The ear pieces should also be cleaned in-between each use.

Stethoscopes are usually classed as non-critical items.

Why is an oto-opthalmoscope needed in the examination room?

Should be available in every examination room and ward for ocular and ear examinations.

Maintained correctly and disinfected after every use.

Batteries charged/replaced as required (light source).

The metal or plastic speculum should be cleaned and disinfected after every use. Sterilisation of the attachments should be carried out via autoclaving if made from a hard wearing material that can stand autoclaving.

Clean the tips after every use to reduce the risk of spread of disease.

Why is a thermometer needed in the examination room?

Digital and mercury thermometers available for use.

To assess the patient’s core body temperature (rectal).

Other types available for use:

* Aural thermometers
* Microchip thermometers

Maintained correctly and disinfected after every use.

* Thermometers should be checked daily for damage and replaced if required. Additionally, digital thermometers should have their battery changed when required.

Why are weighing scales needed in an examination room?

Weighing scales should be available to allow weighing of the full range of species treated.

* Should be available in the examination room and ward, they may also be found in the waiting room too.

Patient weight should be routinely recorded.

Regularly disinfected to reduce the risk of cross infection.

* When cleaning and disinfecting the floor, scales should be pulled out so the flooring underneath can be cleaned appropriately.
* Additionally, the rubber matting on top of the scales should be removed during cleaning and disinfection.

Yearly servicing is recommended to ensure accuracy.

Electrical faults should be dealt with by a qualified electrician as required.

Floor scales are extremely hazardous as a lot of people trip over them, tape can be placed around to make them more noticable.

Why is an x-ray viewer needed in an examination room?

Useful to have a viewer in at least one examination room.

Being phased out due to the use of digital x-ray.

Can be used to show the client any x-ray findings.

Viewers should be kept clean and bulbs replaced as required.

Why is a tonometer needed in an examination room?

Used to measure intraocular pressure and diagnose/monitor glaucoma.

* Glaucoma = ocular condition where there is an elevation in intraocular pressure due to inadequate drainage of aqueous humour within the globe.

Extremely delicate and must be handled with care.

Must be stored in a suitable container.

Use of rubber tip cover every time tonopen used.

Calibration needed every time tonopen used.

Why is a blood pressure monitoring machine needed in an examination room?

Used to measure blood pressure in the diagnosis and management of certain cases.

* The two main types of blood pressure monitoring in practice are Doppler and oscilometric.
* If using a battery powered machine, the batteries should be checked and replaced as required.
* Classes as non-critical item when it comes to cleaning and disinfection.

Electrical or battery operated.

Uses a range of cuffs to fit a variety of patients.

Maintained correctly and disinfected after every use.

What is the purpose of the ward?

Patient accommodation area.

Facilities are dependent on the size and type of veterinary practice.

Excellent management essential to ensure health and safety and to prevent infection outbreak.

What are the proper infection control management for the ward?

A less recognised method of controlling infection within the ward area is the implementation of a ‘no touch’ policy. This enforces strict controls to ensure that only staff who are dealing with/nursing patients are permitted to touch them (unless in an emergency situation), rather than all staff being allowed to touch the patients.

Consider kennel design.

A variety of equipment types and materials will be found within the wards but it is important to prevent a build up of clutter. General pieces of equipment and materials such as scissors, bandage materials, needles, syringes, bedding, food and water bowls etc are found in any ward with the addition of further pieces where required.

Not usually seen by clients but still need to be cleaned in order to prevent the spread of disease between patients.

High risk area for infection.

Risk assessments and SOPs should be conduced and regularly updated.

Why is infection control management so important?

Practice protocols to ensure ares and equipment are well maintained and checked on a regular basis for faults that may affect safety and reliability.

Risk assessments and SOPs. Staff members are often designated to one area to oversee management.

Company names and numbers should be accessible for all equipment so repairs can be carried out quickly and efficiently by the correct people.

All service and maintenance records should be filed and kept for health and safety reasons. RCVS will need to see this information also at time of inspections.

Cleaning protocols should be in place to ensure rooms are cleaned, checked and stocked at least once daily. Stock control is essential.

Management of these areas will vary depending on the type of practice you work in.

What is a standard operating procedure?

An SOP is a written protocol for each job within the veterinary practice (not veterinary specific but has been adapted).

* Must be personalised to each task/practice.
* Examples include: kennel cleaning, inpatient care, anaesthetic machine checks etc.

What is the purpose of an SOP?

An SOP document provides all staff with detailed instructions on how to conduct a task to ensure it is completed safely and consistently every time.

* Clear
* Concise
* Easy to read

So that all users can understand what the task entails.

SOPs must be readily available to all staff.

Considered a ‘living document.’

Should be updated regularly to ensure that everyone is following it properly in case it is too long or too vague.

Quite often have a time stamp on them to say when they was last updated.

How are SOPs used within the veterinary practice?

SOPs are unique to each task and practice.

Aim to ensure consistency and in turn the H&S of staff and patients.

A risk assessment of the task needs to be conducted prior to the formation of a SOP.

Minimises risks of mistakes being made.

Should ideally be evidence based, where possible.

* Reason why they should be changed regularly cause the science of anything can change at any time as more stuff is found out and normal procedures may change.

What is the importance of layout?

The aims of the layout are to reduce infection, to comply with health and safety legislation, to ensure the ease of movement and to ensure easy cleaning and hygiene.

What three areas does the operating suite consist of?

The preparation room.

The scrub room.

The operating theatre.

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Located where there is low traffic flow.

* End of corridor area rather than a middle room with doors connecting each room.
* It is unacceptable to have to walk through other rooms to access the operating suite.
* This increases the levels of contamination and risk of surgical site infections (SSIs).

One entrance.

* Fire safety regulations may dictate that a separate exit is required for health and safety purposes but this should be labelled and used as an emergency exit only.

Divided into clean areas and contaminated areas.

Clear divide between these areas.

What is the preparation room?

Ideally should not be used as a treatment room.

Patients are prepared for surgical procedures.

Including:

* Induction of anaesthesia
* Clipping of fur
* Skin cleaning
* Skin disinfection
* Transfer to theatre

Although this room is often contaminated by the patient during preparation (for example, by hair, faeces, urine etc), it should be treated like a clean environment and maintained like an operating theatre to prevent the spread of infection.

The patient is prepared for surgery in this room to prevent contamination of the operating theatre with hair and dirt particles.

The first skin scrub on the patient is performed in the preparation room as this dramatically reduces the level of contamination and microorganisms from the skin.

This is often performed using chlohexidine gluconate (hibiscrub) but other antiseptics may be used.

Dirty procedures are often performed in this room (for example, abscess lancing, aural haematoma, dental procedures etc) but these should ideally be done within a dirty theatre to contain the level of contamination.

Equine:

* Induction of anaesthesia in specialised “known down” box
* Patient transported straight to theatre using mechanical hoist
* Surgical prep starts prior to induction

The preparation room should be lightly coloured/painted to help visualise dirt and tissue and promote staff wellbeing.

It should ideally have sky lights as natural light is better. Moveable spotlights are also useful.

The preparation room should also contain separate equipment including anaesthetic machines and table to prevent cross contamination into the theatre.

This room is often used to store surgical supplies to reduce content in the operating theatre.

What is the scrub room?

Where surgical personnel perform surgical hand preparation.

Separate from operating theatre.

Should contain a deep, waist height, hands free/foot pedal sink, antiseptics, sterile hand towels, scrubbing brushes and a work surface.

* Waist height sink - to prevent splashing onto surgical attire when scrubbing up.
* Hands free/foot pedal sink - to prevent contamination of cleaned hands during scrubbing up.
* The sink should have hot and cold running water and this should only be used for the purpose of scrubbing up and not for filling and emptying mop buckets.
* Non-slip/rubber flooring is required in this room to reduce slip hazards (rubber mats may be used but they require regular cleaning).

What is the operating theatre?

Surgical procedures take place here.

Should be an end room (no walking through).

What are the classification of surgical procedures?

Clean.

Clean-contaminated.

Contaminated.

Dirty.

What is a clean surgical procedure?

Non traumatic wound.

No entry into a contaminated cavity.

No break in aseptic technique.

What is a clean-contaminated surgical procedure?

Entry into contaminated cavities (gastrointestinal, respiratory, genitourinary) by no spillage.

Minor break in aseptic technique.

E.g. cystotomy to remove urinary calculi.

What is contaminated surgical procedure?

Traumatic wounds

What is a dirty surgical procedure?

Bacterial infection present.

Devitalised tissue.

Traumatic wounds >4 hours old.

E.g. degloving (skin is torn away from underlying tissue) injury from a RTI.

What are the importance of correct walls and flooring in the operating theatre?

Theatre design should be aimed at reducing the risk of infection.

Walls and flooring should be easy to clean, impervious, non-staining and hard wearing. Flooring should also be non-slip.

Strictly no drainage systems or taps in the operating theatre.

Walls and flooring must be able to withstand regular wet/deep cleaning.

Ceramic wall tiles are appropriate within the operating theatre as long as they are disinfected regularly. They are hard wearing but the crevices between the tiles can be difficult to keep clean and can harbour bacteria, dust and moisture.

The flooring should be cove forming which means it should travel seamlessly up the bottom of the wall (\~5-6 inches) to prevent a build up of dust and dirt (polyvinyl chloride). This also makes it easy to clean.

What is the importance of correct doors and windows in the operating theatre?

A one-way system.

* A one-way system is required to prevent unnecessary traffic and reduce bacterial contamination (requires strict discipline and protocols). Ideally, doors should not have handles.

Double swinging doors and self-sealing.

* Are required to allow scrubbed staff to move through without touching the door with their hands and to decrease bacterial counts in the theatre. Doors must also be fire proof.

Doors kept shut.

Frosted permanently closed windows.

* Frosted windows are required to prevent internal and external distraction.
* They must be kept closed to decrease bacterial contamination.
* Good quality glass is required to prevent condensation as this can increase the risk of infection.

What is the importance of temperature and ventilation in the operating theatre?

Ambient temperature of 20-21 degrees celsius.

Humidity of 40-60%.

* Temperature control and humidity is essential for patient and staff comfort.
* The correct levels are also required to control.

Positive pressure ventilation system required to ensure 20 air changes per hour. Performed through a pressure gradient system/ may also be used for temperature control bacterial levels in the theatre.

Heaters.

* Wall mounted or built into the wall panels - better as built in, easy to clean but can be expensive.
* Fans cause air and dust movement and should not be used - they are however cheaper.
* Ideally theatres should be warmed through the PPV system (warm air).

Ventilation.

* 20 air changes per hour (1 every 3 minutes) is required to ensure a fresh flow of air.
* This helps to prevent dust and insects from entering the theatre.
* A pressure gradient is set up between the clean and contaminated areas.
* The higher air pressure in theatre forces air towards the contaminated areas as these are a lower pressures.

Why is correct lighting important in the operating theatre?

Natural light = windows (frosted), sky lights.

Artificial light = fluorescent room lighting.

Theatre lights needs to be adjustable.

* Adjustable electrical lighting should be freely adjustable to any position or angle.
* Ceiling lights are preferred in comparison to floor standing lights as they avoid clutter and more easily positioned.
* Make sure lighting is not positioned too close to the patient to prevent infra-red burns.
* Some electrical theatre lights are fitted with blue and white bulbs to produce the colour of daylight which helps surgeons distinguish between healthy and diseased tissue.

Electrical plugs must be dotted around the room with waterproof cases around them.

What additional equipment are we likely to see in the operating theatre?

Operating table.

Instrument trolley.

Kick bowl.

X-ray viewer/screens.

Patient monitors, warming devices.

Powered equipment such as suction and cautery.

Infusion equipment.

Furniture must ideally be stainless steel and easy to clean.

There may be small waste receptacles in some operating theatres. Some may only have a kick bowl for items that have been removed from the operating table (contaminated swabs etc) and others will have infectious waste bags. All bins should be emptied and cleaning in between procedures.

Ancillary surgical equipment should be kept elsewhere and only put into theatre when required to prevent clutter.

What are the theatre rules?

Aimed at preventing the spread of infection as surgical cite infections (SSIs) are one of the most common causes of morbidity in the surgical patient.

Every theatre should have its own set of rules to ensure standards are set and maintained. This includes the use of SOPs.

Theatre management requires a thorough understanding of the roles of staff, the promotion of good theatre practice, arranging theatre lists and creating and monitoring an effective cleaning protocol.

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The use of prophylactic antibiotics should not replace the need for excellent theatre hygiene protocols.

Administered to prevent an infection from occurring in high risk situation.

Administered as a precaution to prevent an infection,rather than to treat it.

Overuse results in antibiotic resistance.

What are the consequences of SSIs?

Prolonged recovery and delayed healing.

Surgery failure.

Surgery repetition.

Increased cost for the client.

Sepsis.

Pain.

Increased mortaility.

What are the personal hygiene rules for the operating theatre?

Daily showering and hair washing.

Keeping nails short and clean.

* Finger nail length exceeding 2mm has been identified as a statistically significant risk factory for increased bacterial counts on the nails and fingers of clinical veterinary staff.

Hair tied up into a bun.

BBE, removing all jewellery and nail polish.

* There is inadequate evidence on bacterial counts between polished and non-polished finger nails but to be on the safe side it should not be worn.
* Additionally due to the risk of polish flaking off and entering and clinical field it should not be worn.
* From a professional appearance point of view, nail polish should not be worn by clinical staff.

Hand washing.

Wearing clean surgical attire (washed and stored in the practice).

Keeping your environment clean and tidy.

What is a circulating RVN?

Does not scrub up with the surgical team. They are responsible for circulating within theatre pre, peri and post operatively.

Works outside the sterile field.

What is a Scrubbed RVN?

Scrubs up for surgery and wears sterile theatre attire to enable them to work with the surgeon in the sterile operative field.

What is a clinical audit?

A record of all surgical procedures should be documented.

This is to enable the detection of any problems that may have arisen which resulted in infection and other complications and to enable adjustments to be made.

Often performed by designated theatre staff (e.g. senior theatre nurse) or management.

How should the patient be prepared for surgery?

The majority of patient preparation should be carried out in the preparation room. This may include:

* Bathing and grooming.
* Clipping and cleaning.
* The administration of an enema.
* The placement of a urinary catheter.
* The application of foot and tail bandages.
* The placement of a purse string suture.

What is proper theatre hygiene?

Cleaning protocols should be in place and monitored by a designated theatre supervisor.

A few golden rules:

* Decontamination prior to disinfection.
* Use of a broad-spectrum disinfectant.
* Use designated theatre cleaning equipment.
* Use disposable cleaning cloths and paper towels.
* Hot wash mop heads after every use (washing machine).
* Use PPE when cleaning and wash hands when finished.

What should be done at the beginning of each day?

All flat surfaces and lighting in the operating theatre should be wiped down using a broad spectrum disinfectant.

This is called damp dusting as it removes the dust that has settled overnight.

What should be done in between surgical cases?

Collect all instruments and place them into a warm water and detergent solution.

Collect all waste materials and dispose of correctly.

Wipe down the operating table and instrument trollies using a broad spectrum disinfectant.

Clean any items that have come into contact with the patient.

Check the floors, walls and other surfaces and spot clean.

The veterinary surgeon should ideally remove all sharps to prevent injury.

What should be done at the end of the day?

Remove all furniture from the theatre and disinfect (including wheels).

* To disinfect the wheels on trolleys and tables, pour a small puddle of disinfectant onto the floor and wheel them through the puddle.

Empty waste receptacles, disinfect and re-line.

Check ceiling, walls, floors and all other surfaces and disinfect.

Check and restock supplies.

Dry vacuum and wet mop the flooring (start furthest away from the door).

Finally put all furniture aback into the theatre ready for next use.

What should be done in the weekly clean?

Once a week a more thorough clean should be carried out.

All equipment should be removed from the theatre and thoroughly scrubbed using a broad-spectrum disinfectant (including wheels).

All walls and flooring should be thoroughly scrubbed using a broad-spectrum disinfectant.

Equipment disinfection and maintenance (including ventilation system).

Replace all equipment and record weekly clean.

What are the pre-operative considerations?

Preparation of the surgical patient will vary from patient to patient:

* Routine/elective surgery
* Emergency surgery
* Pre-existing medical problems (for example, diabetes mellitus)
* Patient status (for example; age, weight, general health etc).

Preoperative examination by a veterinary surgeon.

Initial vital sign measurements provide the foundations towards patient monitoring.

How should a patient be prepared for surgery?

Restriction of food and water.

* Anaesthetic drugs can provoke regurgitation and food can go back into the lungs.
* Dogs, cats, ferrets (over a short period of time.
* Shouldn’t be done in rabbits and guinea pigs as it can cause hypogluycaemia.

Bladder and bowel management/evacuation.

* Provide your patients with the opportunity to urinate and defecate prior to A+S as you don’t want it to happen during surgery.
* Consider the simple methods
* Be aware of the more complex methods
* Consider the procedure (surgical or non-surgical)
* Rectal enema = often required prior to surgery of the colon, rectum, or anus
* Purse string suture = often required to surgery of the colon, rectum or anus
* Manual bladder expression or urinary catheterisation often required prior to surgery to abdominal and/or urinary tract.

Bathing

* Bathing has been shown to temporarily increase the exfoliation of skin cells, hair shedding and increase the population of resident microflora
* Often reserved for higher risk patients
* Patient should be fully dry after bathing

Hair removal.

* Better site of the surgical area
* Lower the risk of infection
* To allow effective cleaning of the skin
* Should be done in the preparation room
* Make sure you have the correct patient, understand what surgical procedure will be performed, understand where to clip and how much hair to remove
* Also consider PPE use

What is antisepsis?

The removal of pathogenic organisms from the skin or mucous membranes and the prevention of sepsis through the use of an antiseptic.

What is an antiseptic?

An agent that is safe to use on living tissue to reduce the number of microbes (used in the process of antisepsis)

What is the process of antisepsis?

We begin the process of antisepsis before transportation into the operating theatre (primary scrub). Usually performed in the preparation room.

Change your PPE before you being antisepsis to reduce the risk of any cross contamination and to reduce the risk of infection.

The patient’s skin and hair are two of the greatest sources of wound contamination.

It is impossible to remove all microorganisms from the skin’s surface because we can’t make the skin sterile because the skin isn’t completely flat.

Several techniques are commonly used to prepare and animal’s skin.

What are the ideal properties of an antiseptic?

Fast-acting.

Broad-spectrum - inhibits the growth of a wide range of microorganisms.

Non-irritating.

Effective in the presence of organic matter (plants and animal residue e.g. faeces, skin cells).

Good residual effect - continues to affect any of the microorganisms that land on the skin after it has been applied.

Inexpensive.

What are the common antiseptics used?

Chlorhexidine gluconate (hibiscrub).

Povidone iodone (Vetasept).

What are the properties of chlorhexidine gluconate (CHG)?

Broad-spectrum (less effective against Gram-negative bacteria and fungi).

Residual activity of approximately 6 hours.

99% of bacteria killed within a minute of application.

Effects in the presence of organic matter.

May cause skin sensitivity.

Must not be around the eyes and ears (corneal irritant and ototoxic).

What are the characterisitics of Povidone Iodone (PI)?

Effective antiseptic, broad-spectrum.

Minimal residual activity.

Inactivates by the presence of organic matter.

15 minute contact time for sporicidal action.

May cause skin sensitivity.

May stain the skin and other materials.

Often reserved for antisepsis prior to ocular and aural surgery.

What are the different methods of hair removal from a patient before surgery?

Razors

Depilatories (hair removal cream)

Electrical clippers

When is hair removal with a razor seen?

Shaving the patients hair with a razor is rarely seen in veterinary practice.

Some veterinary staff may still do this to reduce stubble but there is lots of evidence to suggest that this is detrimental to the patient.

Razors cause an increased risk of epidermal cuts which will increase the risk of surgical site infection.

When are Depilatories used for hair removal?

Is generally not effective for use in veterinary patients due to the length of hair (although they are sometimes used in small animals such as chinchillas and rabbits).

They may also cause skin reaction due to the chemicals contained within the cream.

When using these products it is highly unlikely that you will achieve a neat area of hair removal.

They cause a lot of stress.

When are electrical clippers used for hair removal?

Is the most commonly used method for hair removal in veterinary patients (and also recommended method). They have the lowest incident of surgical site infection (if used safely and correctly).

Should we clip the patients hair before or after induction?

Consider each patient on an individual basis.

Consider the influencing factors = site and size of surgical area, patient temperament, type of surgery.

What are the advantages to clipping prior to induction?

Reduce the total anaesthetic time.

What are the disadvantages to clipping prior to induction?

Skin damage.

May cause and increase in the exfoliation of skin cells, hair shedding and the population of resident microflora = increased risk of SSI.

Unlikely to achieve a neat clip.

What are the important considerations when removing hair from a patient?

Skin trauma including thermal burns = poor technique.

Surgical site infection = poor clipper hygiene and maintenance.

Postoperative patient interference = clipper rash.

What is the clipping technique?

Initial clipping follows the lie of the hair to remove the bulk.

Secondly clip against the lie of the hair to achieve a close surgical clip.

Be gentle and do not apply too much pressure.

Keep the blade parallel to the skin.

Be neat and symmetrical.

Consider you clip size and margins.

Open wounds.

* Avoid further contamination of the wound during clipping.
* Saline soaked gauze swabs
* Sterile water soluble gel - e.g. KY jelly, intrasite gel

Around eyes.

* Avoid contamination and ocular trauma.
* Ocular lubriaction - Ocry-gel, Lubrithial.
* Close eyes if possible during clipping.

Once clipping is complete, remove the loose hair clippings to prevent them from entering the wound as well as to lower the chance of infection if they enter the surgical site.

Areas close to the surgical site may be covered to prevent contamination (for example the foot).

* Bandage material, gloves, bags.

What is the step by step guide for surgical site preparation?

1. Wear PPE to prevent cross contamination
2. Use either of the mentioned skin disinfectants


1. Chlorhexidine gluconate is preferred as it has more disadvantages
3. Be sure to remove all clipped hair from the surgical site.
4. Mechanically scrub the area using a scrub solution and lint free gauze swabs or cotton wool. This reduces the number of microorganisms on the skin and removes surface dust.


1. Cotton wool is not as abrasive but is fibrous and can cause a lot of dust to linger on the surgical site.
5. Start scrubbing at the incision site (centre of clipped area) and work towards the edge. Once the edge is reached discard the swab. Never return a swab to the centre once the edge has been reached because otherwise you will be bringing dust and bacterial into the centre of the surgical site from the edge of the hair line which is an area of high level of bacteria and dirt.
6. Include hair at the edges to remove debris but avoid excessive wetting.


1. Because you do not want the hair to come back into the middle of the surgical site
2. Avoid excessive wetting of the hair due to the risk of hypothermia.
7. Repeat until the skin is clean - no discolouration on the swab, minimum 5 times to ensure all the dirt is gone.
8. Apply surgical spirit to the skin.
9. Once the primary scrub is complete, transfer the patient into the operating theatre for the final scrub.

What are the two major groups of microorganisms on the skin?

Transient - exogenous.

Resident - endogenous.

What are transient - exogenous microorganisms?

“Contaminating”

Do not normally colonise skin.

Easy to remove from skin through physical action of scrubbing.

Almost completely eliminated by antiseptics.

What are resident - endogenous microorganisms?

“Colonising”

Live on normal skin (and mucosa) and help to protect it from invasion of pathogens.

Minimal pathogenically, but may cause infection following surgery or invasive procedure.

What are some examples of non-surgical procedures?

Blood sampling.

IVFT.

Clinical trranfusion.

Enema.

Urinary catheterisation.

Diagnostic imaging (radiotherapy, ultransonography, endoscopy etc).

Chemotherapy.

Medicine administration.

Rehabilitative procedures.

What preparation of the clinical environment needs to be done for a non-surgical patient?

Do you have all of the required equipment and materials?

Is the room/environment prepared?

* Lighting, ventilation, bedding for your patient, noise levels, away from other patients, personal preparation etc.

Has the table been cleaned and disinfected?

Has the flooring been cleaned and disinfected.

Are you prepared?

What is needed for a clinical examination?

Patient preparation.

* Often no patient preparation required.

Required equipment.

* Stethoscope.
* Thermometers.
* Lubrication.
* Oto-opthalmoscope.
* Further pieces of equipment may be required.

Why do we take blood samples?

Diagnostic purposes, to monitor on-going treatment (medical conditions), Surgical patients (including pre-anaesthetic blood sampling), emergency patients, healthy patients (for routine health checks) etc.

What patient preparation is needed for blood sampling?

Ideally fasting for 8-12 hours - this reduces the risk of samples becoming lipaemic, which could affect the results.

Some tests require the animal to be fed e.g. bile acid stimulation test (BAST) and glucose checks.

What equipment is needed for a blood sample?

Electrical clippers (with a no. 40 blade).

Antiseptic (we often use chlorehexidine gluconate and surgical spirit).

PPE (gloves and apron).

Tourniquet (personal preference).

Cotton wool or gauze swabs.

Needle of suitable size (normally a green needle - 21G x 5/8).

Syringe of appropriate size.

Appropriate blood container.

\+/- wound dressing.

What are the different blood tube colours and what do they represent?

Haemtaology - EDTA pink or red.

Biochemistry - Lithium heparin orange.

Glucose estimation - Fluoride oxalate yellow.

Coagulation tests - Sodium citrate green.

Serum tests - plain white.

Courier or serum separation - serum gel brown.

What is sepsis?

Presence of pathogens in the blood or tissues i.e. infection.

What is asepsis?

Absence of pathogens, i.e freedom from infection.

What is antisepsis?

Prevention of sepsis by the destruction of pathogens.