Hello, everyone, and welcome to this webinar on antimicrobial resistance and stewardship and what we should know as RVNs. My name's Amanda Curtis, and I'm going to be taking you through this webinar this evening. So what are we going to be looking at and what are some of our learning outcomes?
Well, some of the main things we're going to be covering tonight are going to be around antimicrobial resistance itself. We're going to look a little bit at one health and how that can impact us as veterinary professionals and in practise, and that's going to be highlighted throughout this webinar. We're going to do a quick brief discussion on what antimicrobial resistance actually is.
And the main focus is hopefully going to be around. Kind of prevention strategies and how we as RVNs and can actually go about impacting this really major problem that's going to keep on growing unfortunately. So what can we do as the RVN when it comes to antimicrobial stewardships and areas that we can get really actively involved in with a bit of a focus around infection prevention, wound management, and surgery.
So what actually is one health? Well, it's a unified and collaborative approach between multiple professionals, and it's there and was created to kind of help protect, detect and respond to actual potential global threats. So it really is this larger umbrella term that covers human healthcare, environmental health, and animal healthcare.
With multiple disciplines that kind of sit within each area. So it's the idea that all of these concepts affect one another, so the environment can have an impact on human and animal health and vice versa for all three of these parts. So you've probably heard about most of these topics and some of these different areas in isolation, and sometimes you Might have heard of One Health and it being crossed over, but they really do fall under this full umbrella banner of One Health.
And what we need to do moving forward is looking for that future success in combating some of these major issues. And in particular tonight, the big one we're going to be talking about is antimicrobial resistance is how we need to take a combined approach and mindset to actually tackling them. So when it comes to us as veterinary professionals, our role within one health with a specific focus around antimicrobial resistance and introducing antimicrobial stewardship practises, there's generally more of a focus on the veterinary surgeons as they have those prescribing and diagnosing responsibilities, but it really does need to be a whole team approach, and we all have a vital role to play.
We know that from research into human emerged nurses that they are underutilised when it comes to antimicrobial stewardship practises. And as RVNs we can really have a big impact on various areas of AMS and factors that we can influence, and this is what we're going to be touching on in this webinar as research shows us that clients still unfortunately have a poor attitude to antimicrobial resistance, so we can impact on their education. We need to adopt a really clear message and a joint approach across not just us as veterinary professions in the in the veterinary team, but also with human healthcare professionals to make sure that we're giving a bit of a collaborative approach on this and when We talk about these topics we're bringing their health into it as well as their animals.
We need to give consideration to alternative management options and infection prevention methods, which again is going to be our main focus when we come to some of the practical areas later on. Quality improvement options, how we can impact on clinical auditing, what kind of checklists are available, implementing different protocols and guidelines off the back of quality improvement processes. So we're going to briefly look at what actually is antimicrobial resistance.
So to start with, the aim of pathogens are similar to those of any species. The aim is to survive, evolve, and replicate, and they will do what is necessary to try and thrive in the environment they find themselves in. So antimicrobial resistance is the pathogen's response to things that are trying to prevent them from doing this.
So it can occur naturally, but it makes them more difficult to manage and increases that risk of disease being spread. The term antimicrobial does actually include antibiotics, which is probably going to be most of our focus is going to be around in this webinar, anti-protozoal, anti-fungals, and all of these types of medications all fall under that antimicrobial banner. So we are going to be mainly focusing on bacteria and antibiotics, but we should not neglect these other pathogens and these other types of medications because we know that things like in equine now, we've reduced the amount of antiparasitic practises and altered the way that we go about managing and preventative measures around kind of worms.
So regular worming is dropped off where we're looking at instead doing egg counts. We're relying More on looking at the laboratory side of things and giving wormers as and when required. And this is where we can really start seeing that one health approach coming in because we need to see and consider the environmental factor.
So how much of the products that we're giving routinely, how much of that is being excreted into soil, water sources, potentially passed on to wildlife, which can be adding on to this antimicrobial resistant problem. So when it comes to thinking about how to bacteria acquire this resistance, firstly, we kind of need to know a little bit about how antibiotics actually target some species. So antibiotics will target certain mechanisms within the bacterial cell or the cell.
Wall. So they may target where that cell replicates, or they may destroy it altogether. So some antibiotics, and again, they're all going to work in different ways depending on the class of antibiotics that we're dealing with.
And again, the type of bacteria that they're aimed at targeting. But they may disrupt cell wall synthesis. So this essentially leads to a breakdown of that bacterial cell wall.
They might target the processes within the cell where DNA or RNA synthesis occurs, so where genetic material is produced. They might prevent ribosomes from producing proteins vital for cell replication. So there's a few different ways antibiotics can help us to get rid of these bacteria when they're inside a system.
So it can be useful to understand this when we start looking at then how pathogens become resistant. So there are a few mechanisms that can lead to antimicrobial resistance, and these actually include natural resistance. So we can see certain microbes or pathogens can actually acquire this resistance naturally, or some might just be harder to target.
So things like our gramme negative bacteria, things like pseudomonas, so they tend to be more challenging to treat due to their thicker outer membrane covering their cell wall. So it just makes them harder to target and kill. And then we've got some bacteria that actually develop a way of modifying where antibiotics target, rendering them useless.
So for example, they might evolve small pumps in their cell walls that actually expel antibiotics, or they can produce enzymes that inactivate the antibiotic altogether. So we can see that bacteria can kind of require resistance in two different ways. So whether this is through natural means or by through certain drivers that cause this, we get mutations.
So this is where we're looking at those cells that maybe evolve these small little pumps. So there'll be some sort of mutation through the process of cell replication. That a bacteria develop a mutation that makes them resistant to antibiotics, and this can happen in different ways.
Bacteria with resistant mutations have a better chance of survival. So when we treat those patients with an active infection, we have bacteria present. It might be that there's certain ones that are resistant to that bacteria.
That we've administered, they survive when other bacteria come in, they might share some of those resistant genes, which we're going to cover next, but they then start to replicate. So we just get more and more of this mutated bacteria that is now resistant to that antibiotic that we're using. So they're going to continue to multiply.
We can then see something called horizontal gene transfer. So this is where those antibiotic resistant. Microbes or pathogens have that genetic trait, and they will transfer that between other bacterial cells.
Most commonplace we can see this actually happening is when they become encased in things called biofilms. So we can see biofilms form on surfaces on medical devices. They talked a lot about more in wound care.
They can happen around things like urinary catheters, IV catheters, and these are basic communities of bacteria. That replicate inside this really slimy matrix and it makes them really difficult to kill off. It's basically a survival technique and within these little biofilm communities is where we can sometimes see this horizontal gene transfer, so they start to send genetic traits.
Really desirable back and forth between each other, and they can do this in different ways. We're not going to delve into that today. But they can do that in a few different ways and end up having other bacteria then inherit those resistant genes.
So you can see, there's a multitude of ways that bacteria can go about evading being destroyed. So when we talk about antimicrobial resistance, like I say, it can be naturally acquired by some pathogens, but there are some factors that have caused this to happen quicker, quicker than natural evolution. So we will see some dry.
Behind this and some of the main ones include misuse or overuse of antimicrobials. So this comes down to prescribing techniques, using them in cases that just in case antimicrobial that might be administered. Inadequate infection control measures, so not having appropriate cleaning protocols in place.
We're going to talk a lot about that later, but basically replacing those infection control measures and just giving something like a systemic antibiotic instead. So in one case we'll look at this would be wound care. If we perform inadequate wound bed prep, then relying just on systemic antimicrobials doesn't necessarily mean that we're going to prevent a wound infection from happening.
So we need to make sure we're doing the basics well, so that then we can use our antimicrobials appropriately. Poor sanitation and waste management and lack of knowledge and education, people not being aware of, again, some of the aspects around infection prevention. When we're dealing and talking with pet owners, they might not understand as to how and why we use these antibiotics.
They might not be following directions of the Antibiotic course that they've been given. We know that there's kind of a bit of lack of knowledge around it, keeping back some antibiotics because their animal got better quicker than they were expecting, then maybe using them at home inappropriately. It's all of these things that feed and drive together that all the drivers behind antimicrobial resistance.
So why is it such a concern? Why do we need to be worried about it? So in 2019, the World Health organisation, or who identified 32 antibiotics in clinical development development that address the WHO list of priority pathogens, and 6 of these were only classified as innovative.
So we've got pathogens that are basically evolving at a faster rate than we can tackle them. So the last class of antibiotics was discovered in 1987, and why this happened is probably due to a few factors, but unfortunately one of the main factors comes down to resources and there not being enough funds put behind tackling. Bacteria and new antibiotics being produced, so A lot of this comes down to high costs and along regulatory processes and potentially minimal revenue at the other end of it.
And then you add in declining private investment into this. So we really are fighting a losing battle when it comes to new antibiotics being produced. So we need to unfortunately start to consider alternative treatments.
The other thing we need to consider is the types of resistant pathogens that are emerging, so things like pan resistant bacteria. So these are bacterial isolates that are not susceptible to any clinically available drug, or they are an extreme drug resistant bacteria which are non-susceptible to antimicrobial agents in two or less antimicrobial categories, so they may be susceptible to the odd few. And it's these multi and pan resistant bacteria that can really start to cause us a problem.
You probably hear them more colloquially called superbugs. So these are more of a consideration now. We're starting to see more of these emerging as well.
And we need to look at that bigger picture again for veterinary professionals in the way in which animals are currently being treated and cared for could end up being affected and changed. We may lose access to Certain types and classes of antimicrobials, and then when we lose access to those, our patients suffer and we get the cost impact as well to those owners. So treating infections can become really costly.
And again, That impacts on both that human, so the pet owner affects us as, as veterinary professionals, as humans caring for these animals when you've got cost implications, you've got animals and pet owners suffering. It's all this horrible vicious cycle. So whose responsibility is it and how is this monitored?
What goes on behind the scenes? So the responsibility for antimicrobial surveillance is generally distributed across various professional roles. So for example, if you look at us as Healthcare professionals, so we might look at human health care clinicians, nurses, veterinary surgeons.
We might collect samples and document the clinical information and our patient histories. So we may at a very local level we'll call that do some surveillance in-house. When we then maybe send off our samples out to the laboratory staff, they perform their test.
This is then logged on to a wider database. That database then can be accessed by data scientists and epidemologists who can analyse, interpret, and report on the data then collected. This then feeds into higher up seniors and policymakers who use this data to then develop policies and practise based on what we're seeing at these kind of lower levels down.
For us then as clinicians and vets and in pharmacists, they then use all of that data and policies that are being created to come back around to look at how we treat our patients. So it's really a cyclical process that feeds into everyone's working practise. So we've got this big wider thing going on around us.
So where do we as RVNs fit into all of this? So when it to looking at what we can get involved with, we can obviously get involved with maintaining that documentation of clinical notes. We can get involved with auditing processes so we can look at infection rates within our hospital.
We can help to spot trends. We can help to spot where maybe problems are occurring, and then we can report and feed back that data and we can feed this back again. Into wider national surveillances we've got lots of things that our CVS knowledge has given us access to things like the National Small Animal audit for neutering.
There's lots of different vet AMR. We've now got upcoming systems that we can feed into so we can create some benchmarking for veterinary so we don't always have to feed off of all of that human data. So we're going to delve now into antimicrobial stewardship.
So we've kind of done a brief overview of antimicrobial resistance, and I'm going to share some resources a little bit later on in this webinar if you wanted to learn a little bit more about that and delve in a little bit deeper because it is a big topic in itself. But I want to really move into now what is our role as RVNs and how can we take a really a practical approach to antimicrobial stewardship in veterinary practise. So antibiotics have been used systemically for treating spreading and systemic infections, whether they be acute or chronic for quite a few decades now.
However, their widespread use and misuse in medicine, as we've talked about and in agriculture as well, has allowed this emergence of these pathogenic strains with resistance to one or more antibiotics. So when it comes to us looking at antimicrobial stewardship, there are certain things that we need to look at as a system. So there's going to be certain conditions where systemic antibiotics are always going to be deemed first line, but it's imperative that clinical practise that we minimise that reliance on just in case use of systemic treatments and start to look at our infection prevention protocols and guidelines and alternative treatment options.
Infection prevention is going to be our main focus now throughout the rest of this webinar on how we can take that multimodal approach to this because we know the best. Treatment for infection is going to be prevention. So when it comes to us creating a multimodal approach, this requires a real systemic change, and we can look at all of these kind of wider channels that are doing lots of things, you know, there's lots of big organisations out there doing lots.
There's lots of public awareness. Of it. And what we need to do is look at actually how can we through things that we're doing on our level in practise, how can we use those to help make a difference to this big wider problem where there seems to be lots of other people getting involved.
So there are certain initiatives that we can get involved with things like the antibiotic amnesty that's happening in November. So this is where we can encourage pet owners to bring back unused or out of date antibiotics so they can be appropriately disposed of. Antimicrobial, resistant Awareness Week is coming up in November.
So we can kind of look at actually, Maybe what are we doing in practise at the moment? What can we create campaign wise for our clients to show them that we are engaged with this topic? We do want to make a difference of it.
And when we talk about things like about what we can do in practise to kind of improve our antimicrobial stewardship, so early identification of signs and symptoms of infection. So We need to be able to determine infection risk factors and implement monitoring strategies. And some of this is reliant on knowledge and experience of that professional.
So is there things that we can do? Can we improve our knowledge ourselves and go out and hopefully you're listening to this webinar, so you're probably wanting to learn more about this topic. So again, I'm going to share some resources with you so you can go and learn a little bit more about that.
What surveillance programmes have we got in place in practise for infections can be simple as keeping a log of types of infections that you see, details on the management of them. Are there any trends, any patterns that are happening that we can then go and look at? Is there something that we need to make improvements to?
Clear and achievable metrics if you are doing this, look at your goal setting. Should it be adjusted again? Based on your type of veterinary practise setting, what resources you have available, make sure it works for you.
If you're going to implement antimicrobial stewardship practises, it needs to work for you and your practise. So again, if you're out in primary care, it's going to be a little bit different to the resources that you have at referral level. So we can look at those policies and make sure they're appropriate.
We need a multidisciplinary team approach to this. Ideally, we want all of the team involved, but sometimes just having a couple of advocates within the practise can make a big difference. Is someone supervising antimicrobial stewardship efforts, and again this doesn't have to be large scale.
If we're looking at the primary care veterinary practise, this is achievable on a local level. Discussing and auditing infection control methods, looking at whether the protocol and guidelines are in place, or can they be improved? Is there new evidence that we can kind of implement instead?
Accessible multiprofessional education programmes. So again, I'll share a few resources, but again, you can do this on a local level, creating clinical clubs, creating social media posts aimed at your pet owners generate more awareness around this. So there are lots of things that we can do as RVNs to try and get owners engaged, our team engaged, and ourselves engaged in this as well.
So let's go into the now some infection prevention. So the best way to manage wound infection really is through prevention methods. So what we're going to talk about now is looking at how we can routinely determine if infection is present.
We're going to look at surveillance. So how can we monitor for infections, what our record keeping looks like. We can look at some, or we're gonna look at some auditing tips as well.
And again, keeping that clear and achievable for everybody. So if we're putting a guideline or a protocol in place, it's pertinent to your practise. Sometimes you can take things from other guidelines from elsewhere.
Just make sure you're adapting them to work for you. We're going to talk a lot about the environment and staff and how we can make sure that we're. Maximising on infection control around there.
We're going to delve into a little bit of education and training as well. And to wrap up, we're actually going to be looking at wound care and how we can really impact on how wound care is carried out. And again, some of the signs and symptoms that we need to look out for so we can hopefully prevent these things from happening.
So let's take a tour of some of the areas of the veterinary practise that we can implement infection prevention in, and then we're going to look at wounded surgical management then after this. So to start with, we've got things like our cleaning protocols. When it comes to cleaning protocols, again, this is going to differ depending on the size of the practise, but we do need protocols in place for this instead of guidelines.
And the main kind of difference here is that a guideline is something that can be adapted, maybe dependent on the patient or the treatment regime or the plan, but protocols are a. Structured step by step list. So when we look at our cleaning protocols, do we have colour coding systems put in place?
You don't need to necessarily use this one here. This is just an example, but this can be really useful to make sure that we're not cross contaminating across different areas. Using checklists.
This can be a really good way of, of highlighting different areas that might require different levels of cleaning again. And just knowing when something was last cleaned. So, there's a few studies out there that look at, frequency of cleaning and how effective that is.
So one particular I found was from 2017 that looked at the reduction of MRSA within healthcare environment. So whole room cleaning once per day with frequent wiping of high touch areas is kind of the most effective way. And again, we're going to have different standards of cleaning dependent on the area and frequency of use, but whole room cleaning once per day alone only reduced, and this is with a 100% efficacy of that cleaning regime as well.
Only reduced the MRSA load within those rooms down to about 54%. So it did help having that high, wiping of high frequency touch areas. So again, any kind of computer, keyboards, we're looking at, light switches, things like that.
. Another thing to think about as well is things like our tabletops, cleaning the edges of those. How many of us, if we're going to place an IV catheter, maybe cut off a piece of your tape and place it on the edge of the table. This is potentially contaminating it before it then comes in.
For the IV insertion site. So we can get small autoclaveable trays where IV catheters or blood sample equipment can be prepared and stored for the day. So it's little steps like this that can make a big difference.
We need to look at training, training not just for our registered staffs, and not just as as RVNs, repeating that training as well, keeping up. Date with what the latest evidence is, but also we need to consider our support staff. Do they get thorough induction training on infection prevention?
We've got to remember that sometimes some of our support staff, so like our receptionists, our veterinary care assistants, or animal care assistants, whichever title it is that you use for them. And you know, they may have just come from thinking about infection prevention from a cleaning protocol that they'd use in the house, you know, their household cleaning is going to be different to what we need in the hospital or veterinary environment. So we need to make sure they've got training on how to make up disinfectants, if they're using it correctly, safe use of it, how is it stored, how do we dispose of it, even something simple as as As well as replacing disinfectant solutions regularly, are they aware that they need to be replaced as soon as they become contaminated?
If that solution is visibly contaminated with, gross contaminants, then they need to be replaced, same if they've used it to clean up blood or other bodily fluids. Ideally, this is really our mop buckets here that we're talking about. This is ideally should be made up and used and disposed of.
We don't want left sitting around because it can become contaminated. Again, if we then go and clean up, say, lots of diarrhoea, we hope people are cleaning, changing those mop buckets, but they've been trained to think about that. It's these little things that again can make a big difference and regularly monitoring it is really important.
We can do screening. And for screening, I always suggest to speak with your laboratory supplier as they'll be able to support you in how to go about this if you wanted to send swabs externally. Internal monitoring, then this can be carried out sometimes using those in-house UV torches.
We can use these for auditing things like hand hygiene and surface cleaning. We can then look as well at cleaning the cleaning equipment, really important, cleaning mop buckets, again, having a protocol set up around that, whether that's something that we do once a week, but just making sure if they're becoming contaminated, we're just taking our solution out of that, lifting anything that's on those surfaces and potentially cross contaminating other surfaces. So we do need to make sure that we're considering that as well.
So next then is our uniform and personal protective equipment. So our uniform is there as a form of PPE. It's there to protect patients, protect ourselves from contamination as well, but we do need to remember it can be a source of contamination.
In the ideal environment, try and have something spare. So if we do become grossly contaminated, we can change out of that. Thinking about if we're doing dirty procedures, so if we're involved in dentals that day, there can be lots of aerosol spray.
Around into the environment. If we're then going off to help with, say, a bandage change or a dressing change, or we could be handling a patient who's potentially immunocompromised, we're going to be a source of contamination. So we do need to make sure that we're using our PPE to protect our uniform so that we're then protecting our patients and the environment around those patients as well.
But just remembering that PPE is not a replacement for good hygiene protocols. It will aid in protecting those vulnerable patients. But again, if we've got heavily contaminated uniform, ideally we need to be changing out of it and making sure that we're clean for the next lot of patients that we're handling.
So hand hygiene, again, it comes off the back of us thinking about things that can be a contamination to our patients and the environment around us, remembering those five key points of contact. So we're thinking about before we go and touch and handle a patient. Maybe before we carry out any procedures after that procedure, or we've got bodily fluid exposure after touching the patient, and then after or after touching the patient's surroundings as well.
And just to remember that gloves are not a substitute for again, good hand hygiene. The alcohol versus soap and water, in the general environment. So if we're looking at whether we just need to use a alcohol prep on our hands or whether our hands need a full wash, it all comes down to gross contamination.
So if we come in contact with body fluid, anything that's going to grossly contaminate your hands or you've got physical material on there that needs removing, we're looking at soap and water to clean them. We don't necessarily need to be using antiseptic solutions for this. Just a good hand soap will do the job.
It's more about that mechanical removal. We're doing our proper WHO hand wash when we do do that. And if we haven't got any gross contamination, we're going, say, just about to touch that patient.
We can use an alcohol prep. When we look at surgical hand prep, just being careful if you have moved over to using the alcohol solutions for in between surgeries, that you're not washing with soap and water first. You can do your first prep of the day with soap and water.
If you use alcohol after it, it actually, actually inactivates it. So it's one or the other when it comes to surgery. Same with, again, if you're washing your hands, there's no point then straight away putting alcohol.
Whole hand rub onto them straight away. Do it as and when you need it. So it's just figuring out as and when you need that and really look after your skin.
There's a natural barrier to contaminants, so we need to make sure that we're looking after it, not just for ourselves, but our patient as well. Cracked hands or sore hands are going to harbour potentially more contamination. So we need to make sure that we're looking after that and having some, hand moisturisers around can be really useful for everybody in practise.
So kennel hygiene. So again, this is the background to looking after our patients and how we monitor those. So ideally these kennels should be cleaned once per day and then any time they soil them.
And I'm talking about here removing all of their bedding, giving them fresh. We're giving that kennel a cleaned down, making sure it's ready and fresh for the day. This can really help.
To minimise that risk of hospital acquired infections, especially if you've got a patient who is at a high infection risk, we definitely should be doing this. So any patient with breaks in their skin barrier, so again, we're looking at wound patients, postoperative patients anywhere we've got some form of immunocompromise when we ideally should be cleaning them down once a day at least and then when they're soiled. Isolation then versus barrier nursing.
Again, this is just considering actually when does the patient need to be fully isolated and actually do we sometimes need them a little bit closer and a little bit closer monitoring. So the major difference for me between this is your isolation is for those patients where there's something airborne and aerosolized that like kennel cough or cat flu, that they're going to be sneezing or coughing and that's going to get into the air and it's going to infect other patients. Within the kennel area.
Barrier nursing then would be more so for those really sick Parvo puppies where actually they need consistent monitoring and they need to be within kind of an eye within eyesight, and we need to be able to keep an eye on them, but actually they still need to be buried off for other patients or Compromised ones, so we're actually burying them to protect themselves. So it might be that they've got an immune status where they're at high risk. So we may just need to barrier those within the canal area.
So we would make sure again that we're looking at our hygiene protocols, our PPE, how we may be bored them off, making sure they've got somebody dedicated to them for that day. Cleaning protocols then. So again, we're cleaning saw kennels.
We're not just spraying and wiping down these kennels. We're using proper disinfectants at the correct dilution rate. We're leaving the correct contact time, and we're making sure we're cleaning those bars.
We're starting at the top, working our way to the bottom, and we're cleaning the fronts of those canals as well. Managing waste then, so we're making sure we're appropriately disposing of body fluids into the correct, clinical waste bags. Again, this may differ depending on the type of, company that you use for your waste disposal, but making sure you're following those guidelines.
Making sure people have got training on this as well, and making sure that they understand fully what needs to go where. So we can, one, look at our environmental impact, but also still make sure that we're following appropriate guidelines in disposing of things in the correct way. And just a few other things to know about when it comes to canals is also just thinking about our flaws in there.
So when it comes to things that we're cleaning out our canals, you're taking out soil bedding. Ideally, we don't want to just be throwing that into a pile on the floor, leaving it sitting there for a period of time. It should be removed and managed and taken out of the way because what we tend to do a lot in veterinary practise is we have to work sometimes from the floor.
So thinking about these little things again can make a big difference down the line. You know, how often have you maybe thrown a pile of bedding, dirty bedding onto the floor, someone's come next to it and then start placing an IV catheter into a larger patient. It happens.
So just thinking about the environment that's around these patients in our canal areas as well. So when it comes to laundering, again, some of this comes down to the size of practise and the type of equipment you have available unfortunately, but we still need to make sure that they're regularly maintained, that we've got good cleaning protocols in place for these. We're cleaning our cleaning equipment, so we're checking, cleaning and maintaining those washing machines and tumble dryers if you use those regularly.
We're cleaning out lint drawers. It's a fire hazard anyway, but we're making Sure we're on top of these things where we can, if we're, say, laundering things like our isolation bedding or our barrier nurse bedding, we can get dissolvable bags to store them in until they actually go into the wash. We can think about maybe laundering staff clothing if anyone's washing uniforms or theatre attire.
It might be that you've moved to things like non-disposable drapes. Again, you might be looking at the environmental impact of using disposable ones. So you've decided to do that.
Can we launder them separately? Can again we minimise the risk of potential infections to our surgical patients by looking at how we launder these things? And again, the movement of that soiled laundry, so it's not lingering around sitting on floors, piling up in the corner somewhere.
Maybe we're using again those bags that we can bag it up or we've got appropriate ways of moving it around to get it out of our patient areas as quickly as possible down to hopefully a separate laundry room. So clinical governance and clinical auditing, so this still forms kind of part of our infection prevention. And we've now got access to lots more information around kind of clinical governments and especially clinical auditing.
So RCVS Knowledge is a brilliant resource for this, and they've got lots of support around kind of where to start. But some of my big tips, if you're looking at auditing your in Action control procedures, keep it simple and keep it small. So we don't need to make huge strides straight away.
Start and look at some of the areas and then you will into a small area and then you will build on this over time. So for example, if we maybe wanted to look at auditing hand hygiene, it might be just start with a simple observation audit. So you might just observe, you know, people day in day out, or you might just do it via a questionnaire, gain a bit of access to how often people think they're washing their hands.
Then you might go down the route of observing, then you can kind of move on from there. You might even look at something like your, your surgical site infection rates or your complication surgical site are post complication rates. So we might say, look at dog cash rates and you might have found that you were over the national benchmarking.
So this benchmarking data can be accessed through the national audit for small animal neutering. So you can actually check how you're doing against that. But if you say found you weren't doing so well compared to this, you could then look at that kind of wider picture then.
So it might be that you say have a high number with clipper rash. So what you can start with then is looking at a protocol for your clipper use and maintenance. And Then build a new protocol from that audit, you would then reorder, see what you're doing from there, and then maybe look at something else.
You might need to look at surgical skin prep, how they're being managed up post-op surgical dressing. So we can look at all of these different things and it's all these like small, small steps that help to improve patient care, and you can build on from there. And the aim really when it comes to looking at our clinical governments and as clinical auditing, the aim is to be able to build these guidelines and protocols or care bundles that work for your team and practise, and we're basing them on patient-client outcomes that you see.
And then you're using best practise evidence to then go and make something off of the back of that. So if you haven't come across care bundles before, and they differ from care plans, and that care plan will be built around the individual patient. So a care bundle actually looks instead at a set of evidence-based practises that can be applied together.
To improve patient outcomes for specific conditions or procedures. They'll usually consist of 3 to 5 practises that are simple to perform and easy to implement, so such as the ones that can be seen here. So this is cats decrease surgical site infections.
So this looks at clippers, so how hair removal is performed, the maintenance and care. Then prophylactic antibiotic guidelines, maintaining normal thermia and glucose monitoring. So this kind of builds that care bundle that could be implemented for any, surgical patient.
And when we're looking at this as well, we want to make sure that if we're building in guidelines and protocols, because we're looking at how we can improve patient care, we need to also make sure that we're improving the documentation as well. So the documentation is just as important as that guideline or protocol itself. So what we're wanting to do is make sure that we're assessing and monitoring patients who are at risk of an infection occurring or who might have an active infection.
And when it comes to us documenting what we might want to include, is we're looking at that holistic assessment of the patients. This might highlight infection risk factors that can be documented on their clinical history, so everybody knows they've got these risk factors in place. Optimisation and management and referral of any comorbidities and potentially looking at referral where required.
A hydration and nutrition status of those patients who were body condition scoring, we're monitoring their hydration status, we're being proactive and regularly reassessing those things as well. Appropriate skincare and maintaining normal bodily functions, regular review of the patient's treatment and progress to identify lack of progression, or if they start to deteriorate quickly. So our documentation with these patients is just as important as the protocols and guidelines that we might put in place to take care of them.
So we're going to move on from some of the infection control side of things. We're going to look at how we can maybe help some of our surgical and wound care patients, because again, as RVNs, I think this is a place that we can really delve in and get involved. And it's also one of my favourite topics to talk about as well.
So, when it comes to wound care, we are involved in that assessing, treating, and monitoring of these patients with wound wounds or surgical wound. So we do have to consider our remit within this. Obviously, the vets are going to make the overall plan, but we can still assess and report back to them.
So we can evaluate wounds and other injuries for infections, so we can look out for those warning signs and any other complications. So this can help the veterinary surgeon build the picture of their holistic assessment and make an active plan for how they're going to go forward. Under direction, we can perform things like debridement, wound cleansing, we can apply dressings and apply bandages.
We can obtain cultures again under direction, and we can do this to make sure we're properly assessing wounds and other injuries. But it's important that we understand the correct way to swab a wound. We need to make sure we're doing this after we perform preparation.
So we've done that wound cleansing. And we're actually actively taking that sample from the wound bed itself. We almost want to be not taking all of that juicy X day off the top.
We need that gone. We need to know what's going on in that actual wound bed itself. We can work with others in the multidisciplinary veterinary team, so not just the veterinary surgeon working with our support staff, reception, veterinary care assistants, making sure again that they Getting on board with how we talk with these clients and pet owners because we need good collaboration with them to make sure we get them on board with our wound management plan.
Assessing complex patient wounds when they develop or when patients are admitted, but also surgical sites. We're usually the ones who are performing the initial checks and reporting back. So it's important we understand the physiology of wound healing and what's normal so we can pick up what's abnormal.
We need to be able to detect these post-op complications as well and report those back as soon as possible. So we know that wound infections are challenging, and we've talked a lot about prevention rather than cure. So to start to tackle wound infection prevention and management, we need a good understanding of that physiology of wound healing so we can identify when that abnormal occurs.
So I'm introducing you here to something called the wound infection continuum. And this describes the relationship between increasing microbial virulence within the wound bed and the clinical response to this change in that microbial vilence or replicating numbers of them. So the continuum is actually used to encourage vigilance and early identification, which should then trigger when intervention is required within the wound patient.
So the wound contamination is present. It's the presence of nonproliferating microorganisms within a wound at a level that does not evoke a host response. So any wound is going to be contaminated.
There's no such thing as a sterile wound. And when we're dealing with these patients with contamination, so this would be most post-op patients because there's always like they going to be a level of contamination sitting around that incision site, or patients with a traumatic injury that we've got to very quickly within it occurring. We've done good wound bed prep and we might have surgically closed it.
So unless we've got a host with a Immune compromisation or maybe they've got a coagulation problem, they should be able to mount an appropriate response to destroy any pathogens that are sitting in and around that wound bed. So actually vigilance is just required at this stage. We shouldn't be needing to aim for heavy antimicrobials and in particular not systemic antimicrobials.
Instead, we should just be able to manage these patients with good wound care. Colonisation is then when we have a presence of microorganisms in the wound that have undergone some proliferation, so they're starting to replicate in that wound bed, but still we've got no host reaction. So microbial growth occurs, but at this level it's non-critical, and the wound healing is not delayed or impeded.
So during both of these stages, same as with contamination, vigilance is required. So we're looking again at our wound bed prep. We're managing moisture imbalances.
We're doing a bit of a back to a basics approach. It's only when we start to see potential signs of localised infection. So this is where we've got multiplication of microorganisms in the wound of a susceptible patient, and it's at a rate that the host immune system isn't able to overcome it.
So they're now being overwhelmed. So we're going to start to need to do some intervention methods at this point and some of the signs we're looking out for, so some are going to be more obvious than others, so. Are covert signs, which are more subtle signs of localised infection, are things like hypergranulation.
So we get that excessive vascular tissue growing out of our wound bed, bleeding, friable granulation tissue. It might be quite pale in appearance. We might get some epithelial bridging and pocketing, wound breakdown, our wound gets bigger, not smaller.
Our wound isn't progressing, new or increasing pain, increasing mallodor as well as another big one. And some of More classic signs and of things like maybe localised wars, swelling, we might have some perulent thick discharge or exate. Our wounds, like say, are becoming delayed and we're going to maybe start seeing that increase in odour.
But even still, at this localised infection, it should be localised to the wound, but it's not spreading out into the surrounding tissues. Our patients shouldn't be unwell. They might be a bit uncomfortable, but they shouldn't be unwell.
This point and this is where we can look at intervening with things like our topical antimicrobials. Spreading and systemic infection then is where further intervention is going to be required. So this is where our patients are going to be unwell.
We're going to see signs of malaise, loss of appetite, and some of the other signs that we see with localised infection and obviously it's systemic, they're going to be in severe sepsis, shock, organ failure, and at high risk of mortality at this point. So if you know, we've got a bit more of an understanding about some of the signs that we might see in these patients and how we can kind of use that continuum, it then all comes down to making sure that we're assessing and reassessing these patients and looking at those risk factors. And that's what we're going to break down now.
So when it comes to factors associated with increased risk of wound infection, we're looking for things like diabetes, emergency procedures, poor body condition score, altered immune function, malnutrition, low body temperature. And it's all of these things and these factors that can make that patient potentially at higher risk from an infection developing, not just if they've got a wound actually, just in general, but if we've got no wound present at the moment, we're just going to note and document that this patient might have some factors that could cause us a problem if something developed. So when it comes to our next stage, so we might have a wound present, but no infection risk factors.
So at this stage, we might have an acute wound. It might be a little bit contaminated, could be trauma with maybe a little bit of delayed treatment. We might have had some spillage from gastrointestinal tract penetrating wounds over 4 hours, maybe some inappropriate hope, but we've got no problems.
Is kind of present or causing us any issues at this stage. They may have done some antimicrobial treatment during the surgery, but actually prolonged isn't necessary. We're going to follow certain strategy to reduce the risk of infection.
So we're promoting that good moist wound healing environment. We're making sure these post-op surgical wounds are covered, and we're making sure that we're handling these patients appropriately. So it's only when we start coming to those patients where we have a wound present and we've got risk factors already present.
This is where it comes down to looking at actually what is the wound doing at this stage, it progressing? Is it non-healing? Is it actually deteriorating?
So if we've got a progressing wound, again, we're just going to follow strategies that help us reduce infection risk and wound deterioration. So we're going to be promoting again that wound healing environment. But it might be that we have a non-healing wound.
It could be that actually debriding, cleansing. Going back to some of our basics and using localised wound dressings that might help us to again, reduce that risk factor and hopefully rekick start healing again. And we're going to be regularly reassessing these patients at regular, more regular intervals than maybe we would if we had a progressing wound.
If our wound is actually deteriorating, we're still going to do all of our back to basics wound care, but this is where we need to consider that actually is there a higher risk potential for spreading or systemic infection? Do we need to introduce one topical antimicrobials and to the veterinary surgeons are going to assess as to whether they're a candidate for systemic antibiotics at this point as well. So localised wound infections if if they actually happen.
Who is systemically well in themselves. It might be that topical antimicrobial agents are enough alongside all of our wound management protocols as well. So we're going to be implementing infection management control.
We need really good client compliance with this. We need to make sure that we're handling these wounds, with proper PPE. We're making sure we're minimising that risk of contamination increasing.
Be managing those patient factors, we might take some swabs at this point to send off to see what's going on. And topical antimicrobial age is no reason we can't again take a multimodal approach depending on where your problem is. If we're dealing with a breakdown of a gastrointestinal surgery, it may not be appropriate, but where we've got that Xfixator there, it might be that actually we can try to manage this topically as well as systemically and pair those two things together.
So just before we wrap up, there are some resources that we do have available to us that can really help us expand our knowledge around this topic. I'm hoping this webinar has helped spark some interest already for you. A couple of books that I find really interesting and really helpful around these topics is the infection control and small animal clinical practise and the one health of veterinary nurses and.
Technicians. So if you want to know a bit more about One Health and how we can get involved in that, this is the perfect read for it. Our CVS Knowledge have lots of valuable resources.
The new vet team, AMR hub, and they have one companion animal equine and also for large animals as a farm animal, definitely worth taking a look at. They've got lots of bite size, webinars on there and resources, the Fleming fund, this is, they offer a free antimicrobial resistance course. And so again, if you want to learn a little bit more about the background of antimicrobial resistance, this is a great resource to go and take a look at and things like my sals, AMR, this is a reporting.
And surveillance websites definitely worth it's in conjunction with our CVS knowledge again, worth checking out. And the BSAVA Protect me posters. There's one available for rabbits and also small animals.
So again, definitely worth having up and available in the practise. This is an exhaustive list of resources. This is just some that I've personally found quite useful.
So just to wrap up with just some of the take home messages, that I hope you take from this webinar, look at how, what guidelines and protocols we have in place and regularly audit them. Things do change quite quickly. So it's always that if we think we're doing well, we can potentially always do a little bit better.
Antimicrobial stewardship is the responsibility of all team members, plus those non-specialists and our pet owners. We really do need a collaborative approach to try and start tackling what is going to become a much, much bigger issue and a wider issue than it already is. Back to basics approach to infection prevention, simplicity.
We don't need to break the wheel. We don't need to. Do major changes, it can be little things that can make a big difference.
Lots of training, knowledge to identify signs of infection and understand when intervention is needed, training of our support staff as well, and retraining. Again, things change, we get new evidence. If we ever stop learning, it's probably going to be quite a problem.
So it's always worth just revisiting, is there something that we could be doing better. And that prevention, prevention of infection is the best way that we can try to mitigate this problem. So we're going to be promoting our antimicrobial stewardship practises.
We're adopting evidence-based prevention methods where we can and just looking at again how we can help improve this as RVNs because we really can make a big difference. Thank you all so much for listening. I hope you enjoyed this webinar.
If you'd like to reach out to me for any further information through my social media, the QIRVN, you can get in contact or I'm happy to be contacted by email as well, if you have anything following up, if you'd like me to share any of the resources that I've talked about. Thank you very much.