Implementing High Quality, High Volume …...1 August 16, 2014 Implementing High Quality, High...

transcript

August 16, 2014

Implementing

High Quality, High Volume

Spay/Neuter:

Challenges & Solutions

Carolyn Brown, DVM Kathleen Makolinski, DVM

Spay/Neuter Operations Shelter Medicine Service

carolyn.brown@aspca.org kathleen.makolinski@aspca.org

Who are you?

What type of spay/neuter program do

you work with?

Are you familiar with… The Association of Shelter Veterinarians

veterinary medical care guidelines for

spay neuter programs

(JAVMA 2008)

Where will we go?

• Review highlights of medical care guidelines

• What challenges are faced when implementing?

• How have programs overcome such challenges?

• Training available to implement guidelines

• Small surprise at the end!!

Feel free to ask questions

as we go along or at end

Definition

High-quality, high-volume spay/neuter

programs are efficient surgical initiatives

that meet or exceed veterinary medical

standards of care in providing accessible,

targeted sterilization of large numbers of

dogs and cats in order to reduce their

overpopulation and subsequent euthanasia.

JAVMA (2008)

Medical Guidelines for

Spay/Neuter Programs

Instill confidence in

public regarding

use of spay/neuter

programs

Promote

acceptance of this

practice area by

veterinary

profession

Provide guidance

for veterinarians

involved in

spay/neuter

programs

Allow funding

agencies to

determine if

spay/neuter

programs provide

acceptable level of

animal care

Provide reference

for use by state

boards of

veterinary

medicine

Medical Guidelines for

Spay/Neuter Programs

Recommendations meant to enhance, not replace, state veterinary practice acts.

Where differences exist between guidelines and state acts, veterinarians are encouraged to

comply with the more stringent guidelines

The Association of Shelter Veterinarians

www.sheltervet.org

Task Forces and Committees

Veterinary Task Force to Advance Spay/Neuter

Medical Care Guidelines

Four sections of

guidelines document

• Preoperative care

• Anesthesia

• Surgery

• Postoperative care

Preoperative Care

• Withholding food prior to surgery

- Pediatrics to be fed 2-4 hours prior to surgery

- Other animals: Fast minimum of 4 hours

• Client communication about animal

- Any medical problems? Medications?

• Client consent

– Acknowledging risk, authorizing surgery

• Establish medical record for each patient

Preoperative Care

Every animal to be examined by veterinarian

• Helps establish vet/client/patient relationship

• Helps protect against certain liability issues

• Good medicine!

Preoperative Care

Every animal to be examined by veterinarian

• Helps establish vet/client/patient relationship

• Helps protect against certain liability issues

• Good medicine!

Cooperative Animals • Examined prior to

sedation/anesthesia

• May find something

that affects

anesthesia/surgery

Fractious Animals • Done after sedation

but prior to surgery

Preoperative Care

• General appearance

• Mucous membrane color

• Hydration

• Auscult heart/lungs

• Confirm gender

• Is patient already spayed/neutered?

• Assess reproductive system

• Hernias

• External parasites

• Evidence of infectious disease

• Record body condition score

• Ensure body weight recorded

Preoperative Care

Animal Housing

• Proper identification

• Adequate temperature, ventilation, stress reduction

• Good visibility of animal

• Adequate space & safety at various stages of sedation

• Pediatric littermates can be housed together

• Intractable animals in cages/traps that allow for

administration of anesthetics without

handling of animal

Preoperative Care

Infectious Disease Control

• Tables, equipment, kennels cleaned and disinfected

between patients with appropriate agents

• Staff to wash or sanitize hands between

patients and litters

• Animals with any evidence of infectious disease

should undergo surgery at end of day

Preoperative Care

Despite label claims, independent studies have

shown quaternary ammonium compounds to be

unreliable in activity against non-enveloped

viruses such as canine parvovirus,

feline panleukopenia & feline calicivirus

Anesthesia

Needs to achieve

• Pain control

- Opioid

- Non-steroidal antiinflammatory

- Alpha2 agonist

- Local anesthetic

• Stress reduction

• Muscle relaxation

• Unconsciousness

Anesthesia

Pain control

• Multimodal analgesia

• Preventative administration of analgesics

Anesthesia

Mask/Chamber Induction of Anesthesia

Refers to effecting general anesthesia

from consciousness through the

delivery of inhalant anesthetics

via mask or chamber

Anesthesia

Mask/Chamber Induction of Anesthesia

NOT recommended for following reasons

• Higher degree of patient stress

• Loss of consciousness is poorly controlled

• Bronchial irritation

• risk aspiration of gastric contents - unprotected airway

• High concentration of anesthetic may harm patient

• Substantial environmental contamination

Anesthesia

Anesthesia supplementation via mask

• Should be minimized to avoid bronchial irritation &

environmental contamination

• If extensive, consider other options

- Intubation

- Better analgesia/sedation

Anesthesia

Thermoregulation

• Reduce contact with cold surfaces

• Provide carefully protected contact with circulating

warm water, heated containers, or use of forced hot

air warming devices

• Avoid close contact with electric heating pads, blow

dryers, heat lamps, drying cages

• Avoid excessive use of alcohol

Rice Sock

Anesthesia

Fluid Therapy

• Consider fluids in patients predisposed to

hypothermia, hyperthermia, or dehydration

(pregnant, lactating, small, or ill patients)

Anesthesia

Be prepared for emergencies

• Source of oxygen with means of ventilation

• Drugs, reversal agents

• Emergency drug charts (volume of drug by body weight)

• Staff training

- ID respiratory/cardiovascular arrest vs. depression

- Fundamentals of CPR

- Role in emergency

Surgery

• Separate, sterile instruments for each patient,

maintain sterile gloves and surgical field

• Surgeon: Properly performed hand

and arm scrub with appropriate agent

• Surgeon should wear cap,

mask, and separate pair

of sterile gloves for each surgery

(sterile gown is optional)

Surgery

• Ovariohysterectomy and ovariectomy are acceptable

• Both testes and ovaries need to be removed

• Prescrotal and scrotal approaches for neuter

are acceptable

• Ventral midline, flank, and laparoscopic approaches

for ovariohysterectomy are acceptable

• Gentle tissue handling, meticulous hemostasis,

aseptic technique

• Either interrupted or continuous suture pattern is

acceptable for abdominal closure

Surgery

Permanent identification of animals

as spayed/neutered

Choose a consistent means of identifying

animals that have been neutered

TATTOOS

EAR TIPS FOR FERAL CATS

Ear Tipped Cat

Postoperative Care

Minimize risk of complications…observe

• Heart rate/pulse quality

• Respiratory rate/character

• Airway patency

• Temperature in patients at risk for developing

hypothermia or hyperthermia

Also look for

• Emergence delirium

• Hemorrhage

• Pain, stress

• Urination, defecation

Postoperative Care

• Offer small amount water to all patients

as soon as ambulatory

• Offer small amount of food to pediatric,

geriatric, frail patients as soon as possible

Postoperative Care

Before release of patient

• Patient should be ambulatory with no signs of distress

• If animal allows, check surgical site

Review with animal’s caregiver

• Oral and written

discharge instructions

Postoperative Care

Spay/neuter programs to establish policies for

handling postoperative questions, complications, &

emergencies within at least 48 hours following surgery

• Staff member carries cell phone that receives calls

• Voice mail that is checked frequently

• Establish relationship with local veterinarian or

emergency hospital who will see patients for recheck

Morbidity and Mortality Data

In the event of patient death, necropsy should be

performed to establish cause

Program to identify

• Trends in deaths that occur during stay at spay/neuter

program or following surgery

• Trends in post operative complications

(Ex: Incision site infections, dehiscence, suture reaction)

Compare data collected from one year to the next

and to other similarly structured programs

Discuss

and Let’s

From You!

What challenges have you faced

when striving to implement

recommendations or making

changes within your organization?

Discuss

and Let’s

From You!

How has your organization

overcome challenges and

implemented guidelines

or made changes within

organization?

Here’s what we have seen

in regard to how others have

implemented spay/neuter

guidelines…

Preoperative Care

Standardized consent forms assist in collection of

information and can be combined with medical record

$0.16 per triplicate form

Physical Exams

Anesthesia

When considering a change in

anesthetic protocol…

When considering a change in

anesthetic protocol…

Change is… SCARY !!!

What can make this easier?

• Speak with veterinarians and visit spay/neuter

programs who routinely utilize protocol

• Help staff realize what are normal and abnormal

animal responses

Anesthesia

The following anesthetic protocols

• Follow discussed guidelines

• Used in HQHVSN settings

• Prices of drugs recently researched

• Does not include cost of isoflurane or staff

• Drug doses may vary from one protocol to next

• Mortality rates & further information can be

obtained

Anesthetic/Analgesic

Protocol

Cost for

6 Pound

Cost for

30 Pound

Acepromazine/Buprenorphine • SubQ as pre-med for CATS

Acepromazine/Morphine • SubQ as pre-med for DOGS

Diazepam/Ketamine • IV as induction for CATS & DOGS

Meloxicam • SubQ following spay/neuter

$0.72 $3.00

Protocol

Cost for

6 Pound

Cost for

30 Pound

Acepromazine/Buprenorphine • IM as pre-med for CATS

Acepromazine/Morphine • IM as pre-med for DOGS

Telazol • IV as induction for DOGS

• IM as induction for CATS

$1.83 $2.48

Protocol

Cost for

6 Pound

Cost for

30 Pound

Dexmedetomidine

(Cats 45 mcg/kg)

(Dogs 35 mcg/kg)

Butorphanol (10 mg/ml)

Ketamine

• Combined IM to cats/puppies

• Combined IV to adult dogs

• Rarely supplement with isoflurane

• Antisedan to reverse pediatrics

$4.34 $17.60

Protocol

Cost for

30 Pound

Medetomidine (compounded)

Morphine

Ketamine

• Combined IM to dogs

Surgery

Various surgical techniques

allow for safe and efficient

spay/neuter surgeries

Veterinary Seminars in Spay-Neuter Surgery:

Pediatrics

Obese Dog Spay

(Humane Alliance)

General Operations

• When doing 30 spays/neuters per day

- One veterinarian to three well trained medical

staff members is ideal

• Need to determine responsibilities of medical versus

administrative staff

- Medical ‘stations’

• What time can veterinarian leave for the day?

Standard Operating Procedures

Standard Operating

Procedures

What’s it for?

• Standardize policies / procedures

• Define expectations

• Define quality of care and service

• Act as a training tool

• Enforce work standards

and accountability

Training Opportunities

Guess What’s Coming Next?

Upcoming Revisions!!

Implementing High Quality, High Volume …...1 August 16, 2014 Implementing High Quality, High...

Documents