January 24, 2018
The start of a new year is the perfect time to review your disinfection protocols. Disinfection is vital to prevent the spread of infectious disease, but often, veterinary staff are either unaware or confused about proper sanitation. Using the wrong products, or not cleaning and disinfecting surfaces correctly, might make all that hard work moot, and could leave your clinic open to an outbreak.
First, take a fresh look at your clinic’s cleaning and disinfection protocols. Are they written down? If so, are they posted where staff can see them or buried in a training manual in a drawer? If staff are trained only on cleaning and disinfection once when they first start working, consider more frequent reviews of the procedure.
“We have protocols posted in the prominent areas, and all duties are listed on our daily a.m./p.m. checkoff lists,” said Judi Bailey, CVPM, hospital administrator at Loving Hands Animal Clinic in Alpharetta, Ga. “We have shift leaders who are responsible to ensure all duties are done at every shift. We also have a safety protocol topic at every staff meeting and at least twice a year the topic will be on disinfection and cleanliness.”
Talk to your employees to get their feedback about your disinfection protocols.
“Staff may tell you the current protocols aren’t working or aren’t being implemented very effectively,” said Sarah Boman, project manager at Animal Arts Design Studios in Boulder, Colo. “Subtle changes—like relocating a glove or hand-sanitizer dispenser—might make following protocols easier and more convenient. Repetition and convenience are key factors in following protocol.”
When speaking to your staff, ask them to demonstrate how they clean an exam room or disinfect an area after a sick animal has been in the clinic. If you discover that some of your staff aren’t disinfecting properly, investigate why.
“Resistance or inability to follow direction is sometimes from simply a lack of clarity,” said Cynthia Karsten, DVM, outreach veterinarian for the Koret Shelter Medicine Program at the University of California, Davis School of Veterinary Medicine’s Center for Companion Animal Health. “I’ve seen so many protocols that get so complicated that folks may not understand them. We don’t want to waste time doing things that we don’t need to do and that are ineffective. Make sure it’s clear and easy.”
Also take a hard look at the protocol itself. Is it current? Are you using the correct type of disinfectant? Do the steps allow for proper disinfection? If staff is using a disinfectant as a general cleaner, it might not be doing much good. Likewise, using the wrong product, or using the right product at the wrong dilution, can negate all your efforts, or even harm animals.
|THE THREE-STEP DISINFECTION PROCESS|
|Step 1: Mechanically remove organic material (feces, urine, blood, respiratory secretions, and dirt).
Step 2: Clean the surface thoroughly with soap or a general cleaner, rinse, and dry. Once the surface is clean and dry, apply the disinfectant and allow it to sit for the required contact time.
Step 3: Rinse away the disinfectant with a damp cloth and dry the area well.
Look around any veterinary hospital, and you will see people constantly cleaning. But cleaning is not disinfecting.
“Cleaning is good and important,” Dr. Karsten said. “It makes things look and smell better, but it doesn’t necessarily kill all the pathogens that we’re worried about.”
To sanitize a surface, it must be cleaned and disinfected using a three-step process. The first step is the mechanical removal of organic material (feces, urine, blood, respiratory secretions, and dirt). Next, the surface must be thoroughly cleaned with soap or a general cleaner, rinsed, and dried. Once the surface is clean and dry you can apply the disinfectant, which must be allowed to sit for the required contact time (this varies by product but usually 3 to 10 minutes). Finally, rinse away the disinfectant with a damp cloth and dry the area well, and you’re left with a clean and disinfected surface.
“When I was a pre-vet student, we had a parvo puppy in one of our isolation areas,” said Natalie Isaza, DVM, clinical professor of shelter medicine and community outreach in the department of Small Animal Clinical Sciences at University of Florida’s College of Veterinary Medicine in Gainesville. “I can remember being directed by one of my bosses to spray bleach right on the poop, let it sit, and then wipe it up. Now I know that most disinfectants, and especially bleach, are deactivated by organic material.”
You must remove all organic material before applying a disinfectant. This includes soap in addition to dirt, feces, and other material.
“You have to really rinse the soap well, because spraying a disinfectant on top of soap will deactivate a lot of them,” Dr. Isaza said. “In addition, you have to remove all the water. If you have your disinfectant that you’ve diluted to a certain concentration and you spray it onto a wet surface, you’re diluting it more so it may not work as well.”
All disinfectants are not created equal. Carefully read the label to understand a product’s uses and dilution instructions. Some products both clean and disinfect, making them great for routine cleaning and disinfection. Some, like bleach, disinfect only, which means you must first clean the surface with a detergent before rinsing, drying, and applying the disinfectant.
“There are so many disinfectants out there like Trifectant, Virkon, Rescue, and even bleach,” Isaza said. “Most shelters and animal hospitals use quaternary ammonium compounds. They smell flowery and sweet, and they make your clinic smell good. They’re really good at basic pathogens, but they don’t kill tougher viruses like parvo, calicivirus, and adenovirus, and they certainly don’t kill ringworm. It’s important to have more than one disinfectant in your arsenal—one that you use for routine disinfection like exam rooms and a bigger gun disinfectant for when you have an outbreak of disease like parvo.”
Both Isaza and Karsten are big fans of accelerated hydrogen peroxide (marketed under the name Rescue), which is a good routine disinfectant, but it also kills parvo and panleukopenia at higher dilutions (10 minutes contact time at 1:32 or 5 minutes at 1:16).
“Rescue has good surfactants in it, so it actually is a good cleaner, but it’s also a good disinfectant,” Karsten said. “It penetrates into surfaces, so if you have a porous surface, it gets in the cracks. It’s not toxic. If it were to spill, we don’t see any reactions on their pads. You can use it in your mop bucket because it’s not inactivated (by water or organic material).”
While bleach is a good and inexpensive disinfectant, it must be used on clean surfaces or it will not kill pathogens.
“Unfortunately, we see a misunderstanding with the use of bleach,” Karsten said. “It is not a detergent. The minute it touches dirt, you’ve inactivated it. If you don’t use it on a clean surface, it’s just like using water. Bleach in mop buckets is a huge waste of time and is not effective.”
When applied to a clean surface for 10 minutes, bleach kills parvo and panleukopenia, calicivirus, and adenovirus at a 1:32 dilution, and ringworm at 1:10.
|MOST COMMON DISINFECTANT MISTAKES|
Inadequate contact time: “My biggest pet peeve is people who just spray disinfectant on an exam table and then immediately wipe it away. If they’re cleaning it, that’s fine, but if they truly want to disinfect it they’re going to need to leave it for probably 10 minutes.” —Natalie Isaza, DVM
Using the wrong products around cats: “A lot of people don’t know that Lysol or Pine-Sol can be toxic to cats, and so can quaternary ammonium compounds if they’re not diluted appropriately.”—Cynthia Karsten, DVM
Not diluting disinfectants properly: “Don’t follow the ‘more is better’ scenario when mixing product.”—Judi Bailey, CVPM
Not rinsing disinfectant: “If it’s not rinsed properly and a puppy licks the cage, they will get disinfectant in their mouth. Put the disinfectant down, leave it for the contact time, then wipe it away with a clean towel and then a damp towel. A lot of times people forget about the cage bars, too, either they don’t disinfect the cage bars or they don’t rinse the disinfectant off.”—Natalie Isaza, DVM
Cross contamination: “Moving from dirty to clean spaces and dragging a hose, mop bucket, or contaminated shoes across supposedly clean floors. It is critical to understand the line between clean and dirty spaces.”—Sarah Boman, project manager at Animal Arts Design Studios
Using footbaths: “We never recommend footbaths. You need contact time. No one is going to stand in a footbath for 5 minutes, and if you’re using bleach and your shoes are dirty, it’s not going to work anyway. It gives a false sense of security. In wards with high-risk patients, use dedicated footwear.”—Cynthia Karsten, DVM
Using a pressure hose on infectious material: “If you have animals that are sick with parvo or panleukopenia, if you clean with a high-pressure hose, you’re going to aerosolize all of that material, so that could get all over the hospital.”—Natalie Isaza, DVM
Different parts of the clinic will require varying levels of cleaning and disinfection.
“We have a universal protocol based on the type of surface, regardless of where it is in the building, which makes it much easier for compliance and ease of training,” said Bailey, who is also president of the Georgia Veterinary Managers Association. “We have more specific protocols for the isolation ward and our infectious disease exam room.”
In general, human work areas that don’t get much animal traffic, like reception, computer workstations, pharmacy and hallways, should be thoroughly cleaned, but it’s not usually necessary to disinfect every surface daily. Areas where sick or potentially sick animals are examined or treated require more stringent disinfection (even more stringent when parvo or other infectious cases come through), and surgical suites require the strictest protocol.
“We have specific protocols for cleaning our operating rooms because we obviously don’t want any pathogens where we’re opening up animals,” Isaza said. “Our techs usually disinfect the tables first, then they will do the light fixtures and the walls, and then vacuum and clean the floors.”
No matter which area you’re cleaning, always start with healthy animals (healthy puppies and kittens first, then healthy adults), then move on to sick animals and leave the isolation ward for last. To avoid cross-contamination, Isaza’s hospital uses different cleaning equipment for each area, including a designated vacuum cleaner, mop, bucket, and disinfectants. Everything is color coded with tape.
“Color coding is probably the best thing because it’s so visual,” she said. “Anyone can see if you’re in the wrong area with the wrong color, and you can immediately correct yourself.”
For healthy animals in boarding kennels and cages, or for those patients with non-infectious disease, spot cleaning is usually sufficient for the duration of their stay.
“In a housing area, we just want to spot clean,” Karsten said. “If it’s the same cat in the same cage, we don’t want to clean the whole thing until it’s time for them to leave. Between animals you certainly want to do a full clean.”
In areas that require the most stringent sanitation, like operating rooms and patient treatment areas, decluttering is key. Remove anything that doesn’t absolutely need to be there: desks, tables, chairs, paperwork, knickknacks, and even posters on the walls.
“Clutter makes cleaning more difficult and also creates more surfaces that could be contaminated,” Boman said.
The best sanitation protocols are those that are both effective and easy to understand and execute. Make sure your staff is trained on disinfection, and provide supplies they need, where they need them.
“Ensure hand sanitizing stations, gloves, cleaners, trash bins, etc., are conveniently distributed around your clinic,” Boman said. “It should be easy for staff to clean anything that comes into contact with animals—including their own hands.”
|THE PROBLEM WITH RINGWORM|
Ringworm is one of the trickiest pathogens to deal with, but recent studies suggest that mechanical removal of ringworm-contaminated material is the most important step in decontaminating an area.“We’ve come to realize that ringworm is ‘hairborne,’ it’s not airborne,” said Cynthia Karsten, DVM, outreach veterinarian for the Koret Shelter Medicine Program at the University of California, Davis School of Veterinary Medicine’s Center for Companion Animal Health. “If you physically remove all the hair and debris, you’ve decontaminated the area. Then we recommend cleaning three times and following with a disinfectant such as Rescue, and you’re good to go.”Natalie Isaza, DVM, clinical professor of shelter medicine and community outreach in the department of Small Animal Clinical Sciences at University of Florida’s College of Veterinary Medicine in Gainesville, recommends using Swiffer dry cloths to help mechanically remove hair and ringworm spores.
“They’re kind of electrostatic and they actually attract the ringworm particles,” she said. “Use them to wipe the walls and cages to get up any excess.”
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