By Jackie Brown

Editors Note: Part I of this series reviewed disinfection best practices in small animal hospitals; part II delves into the daily nitty gritty of cleaning and sanitation.

It's easy to become lax about daily cleaning and disinfecting, especially if you don't have high volumes of infectious patients coming through your doors. However, high standards of sanitation protect patients and staff. Sanitizing exam rooms, surgical suites, and patient treatment areas is top of mind, but other key areas should be evaluated to ensure your policies and procedures are up to date.

Hand hygiene

The No. 1 way to stop the spread of pathogens is proper hand hygiene, which includes hand washing with soap and warm water, using alcohol-based hand sanitizers, and wearing gloves. It sounds simple, but hand-washing practices are woefully lacking in the veterinary industry.

"Hand hygiene is so important, but we're really cavalier about it," said Jason W. Stull, VMD, MPVM, Ph.D., DACVPM, assistant professor in the Department of Veterinary Preventive Medicine at The Ohio State University's College of Veterinary Medicine in Columbus. "When you look at some of the data around hand hygiene in veterinary facilities, there's a huge area for improvement. That's not only amongst the veterinarians, it's amongst all of our staff members."

Dr. Stull recommends thinking about hand-hygiene moments: before and after touching a patient, after gross contamination of your hands from the environment, after using the restroom, and before eating.

"A lot of people contaminate themselves when they take off gloves, so performing hand hygiene after taking off gloves is key," he said.

In many situations, using hand sanitizer is as effective as or even more effective than hand washing, and it's faster and easier for staff to do frequently.

"In veterinary medicine, we seem very uncomfortable thinking about using alcohol-based hand sanitizers," said Stull, who also is adjunct professor at the Atlantic Veterinary College in Prince Edward Island, Canada, and owner of Island Dog Consulting. "For whatever reason, we might think of veterinary medicine as being more dirty or that hand sanitizers aren't going to work as well, and that's just not true. Alcohol-based hand sanitizers have been shown to be extremely effective, even in veterinary situations, as long as our hands don't have gross matter on them."

If you have anything on your hands that you can see or feel, or if you're touching a patient that might have a pathogen that's resistant to alcohol-based hand sanitizers (for instance, parvo), wash your hands with warm soap and water. Otherwise, if your hands are free from gross matter, Stull said that using an alcohol-based hand sanitizer is actually preferable.

Periodically review proper hand washing with your staff.

"Wet them, cover all surfaces with soap, including between the fingers and wash—20 seconds of scrubbing and sudsing—and then rinse and dry," 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. "You really do want to
dry because drying is part of the disinfection process. Single-use paper towels are best."

To use hand sanitizer properly, ensure that you have complete coverage and ample contact time.

"Make sure you do your whole hand and do each finger separately to make sure that it's all covered," 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. "Let it air dry before you touch another animal."

Gloves are another hand-hygiene tool that are underutilized in veterinary practice. To improve compliance, provide gloves in various sizes in many accessible places throughout the clinic, and educate your staff about when and how to use them.

"Gloves are a great assistance in reducing contamination of hands," Stull said. "They're not going to completely solve the problem, but they're going to dramatically reduce how much we contaminate our hands. Anytime that we're worried about transmitting pathogens, materials, from one area to another, we want to be thinking about gloves."

Gloves should be worn any time a staff member is concerned about transmitting pathogens, whether from animal to animal or animal to human. Key times include when touching an infectious or potentially infectious patient, cleaning the cage or exam table where the patient was examined, and when touching blood, tissue, urine, or feces. For safety purposes, gloves also should be worn when mixing or using strong chemicals like disinfectant. Discard and replace gloves when moving from a dirty area to a cleaner one, remembering to perform hand hygiene after removing and discarding gloves (hand washing or hand sanitizer).

Bowls

The average veterinary clinic goes through a lot of bowls. Cleaning and sanitizing bowls properly is one way to prevent the spread 
of disease.

"We're seeing veterinary clinics have boarding facilities or dog day cares, and with those, different types of risks that are involved in terms of infectious diseases," Stull said. "We have to really be careful about all of the lines of possible transmission. Bowls are part of that, as well as anything that's used in and around their environment. Make a point of trying to keep those things as separate as possible."

Keep dishes and other supplies that are used for isolation animals out of common areas.

"You probably want a separate area for cleaning dishes that were contaminated by an animal that may have an infectious disease simply because you don't want to be moving those into a cleaner area of the hospital," Dr. Isaza said. "Make sure you have dedicated food bowls for your isolation area and they stay there, with a sink. A lot of animal shelters have commercial dishwashers to heat the water really hot so you almost get a steam effect so that's going to kill just about everything."

If you don't have a dishwasher, consider soaking bowls in bleach or Rescue (accelerated hydrogen perioxide) after washing with dish detergent and warm water.

"Clean the dishes well to remove all organic matter first," Dr. Karsten said. "Put them in a big Rubbermaid bin with Rescue at a 1:32 dilution for at least 10 minutes, but you can put them in and go about your day and then pull them out later and let them dry. You can keep using that bin as long as it's not dirty and it's at the concentration that you want because Rescue, once diluted, is stable for 90 days."

Laundry/Scrubs

Laundry is never-ending in small animal practice. It might seem like a simple thing, but some best practices will help reduce the possibility of disease transmission in your clinic, especially for highly contagious pathogens.

Wash all laundry on the longest wash cycle using hot water and dry it using the highest heat setting. Instruct staff to remove as much solid waste like hair and feces as they can before putting the laundry in the washer, and to not overload the washer or dryer. Load it loosely—don't pack it in. Following these practices will kill most pathogens, including ringworm spores.

"Store your clean laundry in a separate room," Karsten said. "Once it comes out of the dryer it should go into a clean bin and then be taken elsewhere to be folded and stored. There is risk for fomite transmission if you keep your dirty and clean laundry in the same room." To prevent accidental mixing of dirty and clean laundry, consider using different colored bins or baskets for dirty and clean laundry.

Some items are difficult to effectively launder.

"If there's something that's really soiled, especially something from a dog with an infectious disease like parvo, it's probably better to just throw it out because it's going to be difficult to really clean that without spreading it all over the hospital, especially if you don't have a washer and dryer in your isolation," Isaza said. "We separate the laundry from animals that may have infectious disease like ringworm. We use a red bag laundry bag."

Another consideration is the procedure for your employees' work scrubs. It's best to keep all scrubs on the hospital premises rather than allow staff to wear them to and from work. Isaza recalls a large outbreak of hemorrhagic calicivirus about 10 years ago where the sentinel cat was a kitten that came from a shelter and was housed in a small animal practice.

"The employees were all cuddling the kitten with their scrubs on, and then they went home and cuddled their own cats, and unfortunately a lot of those employees' cats died from this virus," she said. "Our employee scrubs stay here in a cabinet and we launder them separately. When they come in in the morning, they change into them."

Floors

When sanitized properly, clean floors not only make your hospital look and smell good, they also cut down on the spread of pathogens. All too often, though, floors are cleaned inefficiently.

Ideally, a specialized hard floor cleaner will do the best job. For instance, Isaza's facility uses a Hoover Floormate, which has dual tanks for water and disinfectant, and a separate reservoir for the dirty water. "It's kind of nice that you're not putting that stuff that you just picked up back in the rinse water," she said. "When you first start out [mopping] it's fine, the water's clean, but then you're putting the mop back into that water and you're rinsing it, and by the time you finish mopping the floor, that rinse water is brown. You're essentially putting that back on your floor."

If you do use a mop to clean the floors, it's best to have a two-sided bucket so the rinse water is separate from the disinfectant water. Change out the mop water when it becomes visibly dirty, or at least a few times a day.

Carefully consider what product you're using in the mop bucket, especially if you want to truly disinfect the floor. Unless you use a one-step disinfecting cleaner like accelerated hydrogen peroxide, you must first mop with a detergent product and rinse, let the surface dry, then mop again with a disinfectant product.

"Mopping with bleach is never acceptable unless you mop with [a detergent] first because once organic matter gets into a bleach mop bucket the bleach is completely inactivated and bleach has absolutely no detergent activity so you're not cleaning the floor," Karsten said. "For most areas at most times, just a detergent works to clean the floor." If you're concerned about possible disease transmission, follow with a disinfectant.

The big picture

Scrutinizing the sanitation practices in your veterinary clinic goes beyond cleaning basics—it's all about the big picture.

"When we think about hand hygiene or cleaning and disinfection, these are all pieces of the same puzzle," Stull said. "We really need to be thinking globally about infection control. All these pieces that come together can help us to reduce disease concerns for ourselves, our staff, our clients and our patients."