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.
7. Looney AL, Bohling MW. Bushby PA, et 81 The Association of Sheltcr Veterinarians veterinary medical care guidelines for spall-neuter programs. J Am Vet Med Assoc. 2003;233(1):74-86. doi: 10.2 460/javma.233.1.7 4.
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.
8. Scheffel Jr,/i,Elchos BL Cilerry B. et 31.Compendium of veterin3l"Y standard precautions for LOOIIO lie disease preventiun in veterinary personnel: national association of state ~ublic health lJeterinarians veterinary iniection control committe8 2010. J Am Vet Med Assoc.
necessary in surgery and discontinuing in 24 hours.19
10. Steneroden KK Hill AE Salman MD. A needs-as· sessment and demographic survey of infectioll-control and disease awareness ill western US animal shelters. Prey Vet Med. 2011 ;98(1):52-57. doi:1 0.101 6/J. prevetmcd.2010.11.o01.
of research on preventing nosocomial
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.
REFERENGES 1. Cockcroft P. Handbook of Evidcncc-Bascd Veterinary Medicine. John Wiley & Sons: 2008. 2. Simoneit C, Heuwieser W. Ailt SP.lnter-obsel'Jer agrcement on 3 checklist to evaluate scientific publications in the field of animal reproduction. J Vet Med Educ.
2012;39(21119~127. 3. Arlt SP, Heuwieser W. Training students to appraise the quality of scientific literature. J Vet Med Educ.
2011J8(2) 135~140 4. Mit SP, Haimerl P. Hcuwieser VI. Training evi· dence-based veterinary medicine by collaborative developmcnt of criticall~ appraised topiCS. J Vet Med Educ.
201239(2n 11~118 5. Fausak E.Qur evaluative process. PICOgrams: A blog about EBVM in practice. http://picograms.blogspot. comf2015/01 !our-8valuative·process.html. Published 2015. Accessed April 23, 2015.
22. Stubbs WP, Bellall JR, Veltllaas-Hekillan 0, Purich B, Kubilis PS. Chlorhexidine gluconate versus cilloroxylenol for preoperative skin preparation in dogs. Vet SUl"g.
1996;25(61487~494 23. Portner lA, lolmson JA. Guidelines for redUCing pathogens in vctcrinary hospitals: disinfectant selection, cleaning protocols, and hand hygiene. Compend Cont Edue Vel (Yardley, PAl. 201 D;32(5):E1-El1: quiz E12. 24. ovorakG, By PR, RolhJ, Amass S. Disinfection 101. Cent Food Secul Public Heal Iowa State Univ Ames, IA. 2005.
do; 10.11))/1 098672X15588450.
12. Traverse M Aceto H. Environmental Cleaning and Disinfection. Vet Clin North Am Small Anirn Pract.
scale, but surgical site infections are known
21 Alfa MJ, Lo E,Olson N, MacRae M, Buelow-Smith I.. Use of a daily disinfectant cleaner instead of a daily cleaner reduced hospital-acquired infection rates. Am J Infcct Control. 2015;43(2J:141-146. dOi:1D.1016/j. ajic.201410.D16.
9. Weese JS, Dacosta T. Button L Goth K. Ethier M, Boehnke K. Isolation of Methicillin-Resistant Staphylococ" cus 3UfeliS irom the Environmenl in (I Veterinary Teaching Hospital. 2004:468-470.
Human medicine has focused a great deal
1014;5( 41194~200
201O:23l(l217 403~7422.
taining peak serum by redosing when
1m 1.
13. Anderson MEC, Foster BA, Weese JS. Observational study of patient and surgeon preoperative preparation in ten cornpanion animal clinics in OntariO, Canada. BMC Vet Res. 2013;9:194. doi: 10.1186/1746-6148-9-194.
20. McMillan S. An evidence-based approach to infection control in the opcrating theatre. Vet Nurse.
25. Donskey CJ. Does improving surface cleaning and disinfection reduce health care-associated infections? Am J Infect Control. 2013:41(5 SlJppl):S12-S19. doi:1 0.1016/j. JJic.2012.12.010. 26. Lambrecllts NE, Hurter K, Picard JA, Goldin Jr, Thomp· son PN. A prospective curllpal"ison between stabili7.ed glutaraldehyde and clilorllcxidinc gluconate for preoperative skin antisepsis in (logs. Vet Surg. 2004;33(6):636·643. doi: 1D.1111/j.1532 ·950X.2004 .D4D8S.x.
14. Muto CA. Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocurnial transmission 01 multidrug·resistant strains of StJphylococclis aut·eus and enterucoccus.lnfect Control. 2003:24(05):362-386.
27. PHILIPS MF. VASSEUR PB, GREGORY CR. Chlor· hexidine diacetatc versus povidone-iodine for preoperative preparation of the skin: A prospective randomized comparison in dugs and cats. J Am Anim Hosp Assoc.
15. Portner JA, Johnson J a. RoutinG Cleaning and Disinfection Protocol. Compendium Cont Education Vet (Yardlcy, PAl. hllps:! !s3.am8zonaws.com! assets.prod.vctiearn. com/mrnah/2d!86dd9a25114a3aa3db5111a594f792! filePV051 O_portnerLCE.pdf. Published 2010. Accessed January 4. 2016.
199);2)705~ 7DB.
16. Gasson J. Redu~ing surgical complications using a safety checklist. Vet Rec. 2011;169(19):503. doi:l0.1136/vr.d7107. 17. Gillespie 8M, Marshall A.lmplemcnlalioJl of safety checklists in surgery: a realist syntheSiS of evidcllce. Implement Sci. 2015;10(1): 137. doi:10.1186!
28. Bedard S, Desrochers A, Fecteau G, 1·liggins R. [Comparison of four wotocols for preoperative preparation in callie]. Can Vet J. 2001 ;42(3):199-203. 29. McDonald CP, Lowe P, Roy A, et al. Evaluation of donor arlll disinfection techniques. Vo~ Sang.
2001 ,80(31135~141 30. Glo Germ: Handwashing training, aseptic & isolation techniques. infection control, Conlagion. http://www. glogermcollli. Accessed January 4. 2016.
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