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Samantha Spells, Matt Sleeman,. Samantha Scritsmeier, Lindsay Towery,. Rebecca Brown, and Nathaly Gardona. This article is the i.:ulmination of an effort.
AN EVIDENCE-BASED APPROACH TO ENVIRONMENTAL DISINFECTION AND PATIENT PREPARATION Erik Fausak, Goral Westerhoff, Samantha Spells, Matt Sleeman, Samantha Scritsmeier, Lindsay Towery, Rebecca Brown, and Nathaly Gardona

This article is the i.:ulmination of an effort

Evidence-Based Veterinary Medicine

veterinary technician training.ll)c jour-

to address the prevention ofhospital-ac-

techniques to address clinical questions

nal club is composed of sL"regular student

qUlled iniecti6fJ;s (HAls). Bd-Rea Institute

or concerns that arise in the pre-clinical

members and a faculty member that con-

has a)"ournal cllibthat is trained in applying

environment where students apply their

tributed to trus effort.

---

PROFESSIONAL PULSE Journal Club members collectively arrived at the

evidence. The following questions in bold italics are

guidelines outlined in this article based on consult-

the PICas developed by the journal club.

ing the most current evidence. The journal club Illet and formed clinically answerable questions in the

Bias ill research is one

of the greatest obstacles in the quality of research. Bias can occur on two levels: I,

the primary research and the synthesis of primary research.

i[

I ,I[ I II

II

Funding bias: Are the authors of research being funded by a party interested in positive results of their work? This is usually described as a confiict of interest, no authors of this paper were funded by any outside agency. Selection bias: It is always easy to find information to support an argumen1, true evidence-based research is about finding all evidence, or evidence without predisposition. A good systematic review or critically appraised topic should describe what databases were used, what was found. and what inclusion criteria were utilized for the following studies. Publishing bias: Unfortunately, many publishers will not publish an article unless there are significant results; an article that supports a null hypothesis may not be

environment

cats, is the use of a written

checklist

• Patient (shelter dogs and cats)

tion better than not utilizing

one?

• Intervention (what changes were proposed)

There are two types of checklists

• Comparison

sideration

(what has been done to address the

checklist.

that merit con-

protocol

The first

set up in the form of a

This idea has been endorsed

ber of levels in human and veterinary

intervention, specifically)'

on a nummedicine.G-~

75% of all animal shelters have a written disinfecEvidence-based

veterinary medicine (EBVM) is cen-

tion policy in placew The presence of checklists

tered around one theme: transparency. The tenet

help cleaning compliance,

of the journal club was to be transparent in their

of quaternary

methodology

resistance."

and findings so that readers can draw

their own conclusions

with the information provided.

EBVM recognizes that there are many biases that

as improper

dilution

cleaners can result in microbial Creating a checklist

ensure compliance

in cleaning

is a way to help

habits. 20% of

HAl results from contaminated

surface environ-

can profoundly alter the findings of research and

ments, partially due to poor cleaning compliance

information gathering.

of hospital staff.12.13A checklist

can also include

cleaning equipment

that is in contact alcohol

with animals

In EBVM, it is important to establish inclusion crite-

with 70% isopropyl

ria of articles before searching. The iournal club met

protocol/checklist

weekly addressing one question at a time. Partici-

How often the area or object should be cleaned,

pants shared their keywords and research results.

what cleaning

7.14

The disinfection

should include the following:

or disinfectant

agent is being used,

Inclusion criteria of articles were fairly open; the only

what dilution and in what manner is it being used,

true excluding factor was whether the journal club

who is responsible

had access to the material. The journal club did not

will the area be audited.6•15

discriminate

for sanitation,

and how often

based on level of evidence (LOE), but

did consider better evidence versus weaker evi-

The second checklist is oral confirmation

dence in evaluation of the articles. Article saturation,

information about the patient by the surgery team.

or the maximum amount of articles incorporated, were two per journal club member. However, on many occasions, journal club members were unable to find any articles to examine.

(vetalltrials.org) initiative is an ambitious endeavor by the veterinary community to make sure that the unpublished research is made known. Readers are strongly encour" aged to further examine this initiative.

on PubMed (wliv\lv.ncbi.nlm.nih.govipubmed)

most of their searches and,

to reduce surgery

room errors.16

occasionally, Google Scholar (scholar.google.com).

Surgical checklists

VetS Rev (webapps.nottingham.ac.uk/refbase/J

stress work environment,

Best Bets for Vets (bestbetsforvets.org)

and

were utilized

of critical

Oral surgical checklists are strongly encouraged by the World Health Organization

The journal club conducted

are derived from another high flying. Ultimately,

but yielded no relevant results. VetMedResource

mistakes. The only way for these checklists

(www.cabi.orgivetmedresourcel)

is a preferred

it

helps the focus of the surgical team and reduces to

work is to tailor them specifically

to the environ-

resource, but the journal club did not collectively

ment at hand and to incorporate

checklists

have access to this database.

the workflow.16.IIThe posted a template

into

Animal Health Trust has for an oral surgical check-

Once the articles were retrieved, the journal club

list.'B Two factors that have been found to disrupt

reviewed each article using a checklist based

surgical environments

on Sebastian Arlt's evaluative guide for literature

distracting

are excessive

conversation;

noise and

surgical checklists

may

quality.2-5 Once the articles were reviewed, their

help reduce volume and redirect focus to the sur-

quality was assessed and the club would propose

gery at hand.'9.20

a general level of recommendation

THE NAVTA JOURNAL

for disinfec-

in the surgical environment.

is a disinfection

patient in the past)

published. The Vet All Tri31s

44

of shelter dogs and

format of a PICO:

• Outcome (what is the objective of using a new

1\,

In the surgical

I NAVTANET

based on the

PROFESSIONAL PULSE In shelter dogs and cats, is bleach a better

patient carries any resistant bacteria, they become

disinfectant

present in the environment.H1~

Surgical

than Roccal®D in terms of reducing

Site Infections?

The European Advisory Board on Cat Diseases

Keeping tabs on bacteria present in the surgical

suggests that quaternary cleaners like Roccal®D

environment and, more importantly, in patients is

(Zoetis) are not ideal disinfection agents because of

an important step in reducing HAls. This should be

the development

done by placing convex RODAC plates on sur-

of antibiotic resistant (specifically

resistance to chloramphenicols

but also beta lact-

faces and patients.'2,22.2d Isolating high-risk bacteria

ams and quinolones) bacteria at sub inhibitory con-

in patients may warrant delaying surgery until the

centrations."

infection is resolved, Identifying the common bac-

However, there is an advantage that

quaternary cleaners can be used in lieu of deter-

teria found in the operating environment can help

gents.'2•2' The bottom line is that the disinfectant

direct the choice of disinfectants.13

choice should be used to address the pathogens present. Quaternaries and most cleaners do just fine

In shelter dogs and cats, does chlorhexi-

at reducing the numbers of the main culprits, Staph-

dine have higher antimicrobial

ylococcus intermedius, Staphylococcus

povidine-iodine?

Enterococcus

Sp.'9.22-24

aureus, and

There are many resources to

examine the efficacy of disinfectants,

including the

information.23•24

manufacturer's

action than

The bottom line is that both surgical skin treatments have a similar effect. One study found that iodine caused 5 infections per 1DO patients and chlorhexidine caused 4 infections per 100 patients.27 Studies

Hands down, bleach is far better at disinfection

indicate either disinfectant

than any other cleaner, and has been for over 1DO

aspect of any patient preparation

years.ll.24.25Bleach is only effective with gross

a minimum of 5 minutes for iodine and 3 minutes

removal of organic debris. It is important to remember that cleaning and disinfection usually follow a

Secondary Research research that summarizes primary research LOE 1 - Systematic Reviews, Metaanalyses, Critically Appraised T apies, Knowledge Summaries, Best for Veterinary Practices Primary Research - any research being conducted directly on animals at the clinical/experimentallcvel. LOE 2 - Randomized Control Trials, Prospective Studies, Experimental Studies, Pmspective Cohort

is a good choice. A key is contact time,

LOE 3 - Retrospective Cohort Case Series, Case Studies, In Vitro. Ex Vivo LOE 4 - Expert Opinion

few steps: detergent to remove organic debris (key for most disinfectants

to work), rinsing, drying, and

disinfection with saturated surfaces for the minimum contact time.12•23

'(Modlned by Bel-Rea Journal Club)

Due to the susceptible nature of most surgical infections, quaternaries should work fine in the surgical environment, as long as the cleaners are properly diluted, surfaces are saturated, and minimum contact time is met.23 In shelter dogs and cats, is it better to take bacterial

cultures

than not in reducing

surgical

site infections? It is recommended contamination

to get a baseline of bacterial

in a surgical environment.

By itself,

it may not mean anything, but if done regularly, culturing surfaces can provide clues and trends as to the efficacy of environmental

cleaning.'2 Of

more importance and significance

is Active Sur-

veillance Monitoring, where patients are checked for the presence of Methicillin Resistant Staph-...---i Aureus (MRSA) or Vancomycin

Resistant Entero-

cocci (VRE). In human medicine, nasal swabs have significantly

LOE 5 - Research involving different species

reduced surgical infections for MRSA

and fecal examination

of VRE prior to surgery. If

the bacteria are present, surgery is resched.uled. Additionally, despite negative surface cultures, if a

PROFESSIONAL PULSE (x2 preparations) for chlorhexidine

The following should be included in a disinfection

4%. The average

onds (not long enough for either preparation).

agents for hand preparation

13

· Determining what cleaning or disinfeclion agent can be used • Determining what dilution and in what marillcr [spray, rag, microftber, etc) is appropriate ·Idenlifyingwho is mspollsible for sanitation

of shelter cats and dogs, is

it better to use clippers reducing

post-op

or shave with a razor for

in reducing infection?

skin irritation?

key factors for transmission infections,

accounting

of these infections

of hospital acquired

for 20-40% of the source

in hospitals.

Regular cleaning

Shaving with a #40 clipper alone is best.22•28 Another

of hands with soap and water or alcohol-based

key aspect to patient preparation in induction is

sanitizers should be standard practice.

cleaning the patient with a waterless shampoo

there was a campaign

prior to surgery. Patient shaving is best done during

awareness of hand sanitization.

induction and not prior.'9 An additional habit that

halved when alcohol-based

seems successful is to shave the patient, vacuum,

doubled. Another interesting

then rinse with tap water, dry, and prescrub with

Health Organization

chlorhexidine.22

Systematic

preparation

of shelter cats and dogs, or go back and forth?

traditional

In the UK,

to increase hospital worker Infection rates

hand cleaner use aspect is that World

guidelines

and a Cochrane

Review have both found that using

alcohol-based In patient

is it better to use circles

• Determining how often an area will be audited or area checked for proper application

sanitizing

Hand hygiene has been identified as one of the In patient preparation

or object

of a surgeon, is it better

to wash hands or use alcohol-based

protoco IIcheckl ist: • How often to clean area

In sterile preparation

scrub nurse only lets the disinfectant sit for 75 sec-

waterless solutions

is superior to

hand washing, yet very few human or

veterinary surgeons use this method. Reasons

It doesn't really matter as long as one starts from

cited for the use of alcohol-based

the incision and stops when one reaches the edge

formulas are that they are less traumatic

waterless scrub to the

of the shave site.13.20.29 Interestingly, more hospitals

skin, act faster, and reduce the risk of contamina-

than not (in Ontario, Canada) go back and forth from

tion from rinsing hands after scrubbing.'3.'~.2J

the incision site'0 In patient

preparation

of shelter cats and dogs,

In summary, hospital-acquired

infections

poorly quantified

medicine.

is it better for the preparer to wear sterile gloves

shocking

or use an applicator

death (infectious

reducing

surgical

verses just exam gloves in

site infection?

worldwide)

Sterile preparation is important. One at the best

in veterinary

are This is

because it is the 7th leading cause of disease in general is number 3

in human hospitals.'4

tions in veterinary

medicine

Surgical

infec-

are so poorly mon-

techniques to reduce microbes on a patient for

itored, that a range of 1-18% of surgeries may

blood donation was found when utilizing a sterile

result in a surgical site infection. '3

,

applicator stick.29 The Association

R.egistered Nurses has incorporated patient preparation

of Perioperative sterile gloves in

in their guidelines.?'o

PROFESSIONAL PULSE There are four key obstacles to prevention of hospital-acquired

o Veterinary

infections:

team compliance,

which

can be addressed through awareness. training. checklists, and auditing.12Y ..l9 Additionally, utilizing fluorescent materials to audit veterinary team compliance is a great toopO

fJ

Hand hygiene is key for all staff to prevent transmission.

Hand hygiene is

probably the most likely means of transmission of disease to patients.14.19

D Active

surveillance is necessary to

identify reservoirs of antibiotic-resistant bacteria and reduce surgical complications.l1.1L.19

9

Proper antibiotic

usage and main-

6. Sanitation in animal shelters. UC Davis Koret Shelter Med Progr. 2010. http://wwlI'.sheltermedicine.com/sheltcr·health·portal!inlormation-slleets! sanitation·in-animal-sllellers.

18. Animal Health Tl"llst.lmplelllentation of Surgical SJfely Checklist. http://www.aht.org.ukfskins!Oefaultlpdfs! implementation_oLsurgical_safety_checklisl.pdf. Publisl18d 2008. Accessed January 4, 2016.

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19. Verwilghen 0, Singh A. FightingSurgical Site Infections in Sillall Animals. Vet Clill North Am Small Anilll Pract. 2015;45(2):243-276. doi:l0.1016/j.c'lsm.2014.11 001.

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be preventable half of the time. Veterinary

11. Addie DO, Boucrallt-Baralon C, Egberink H. et al. Disinfectant cllOices in veterinary practices. shelters and households: ABCD guidelines on safe and eifective disiniection for feline environments. J Feline Med Surg.

medicine may not lose money on the same

201517(JI59H05.

infections. A very important reason for this is cost. It costs patients and the hospital a lot of money to treat infections that may

to slow healing and can increase the risk of mortality. The best medicine is preventive

207 5;45(21,299~330. do;10.7016/jmm2014.7

medicine; what technicians do in the surgical environment has a very tangible impact on the health of their patients after surgery.

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