Procedures overview As the foundation for infection control practices, patient and staff flow, hand hygiene, cleaning and disinfection, and PPE should be addressed in all practice ICPB programs. Patient and Staff Flow Attention to the movement of patients and staff into and through a practice can affect HAI risks.8 The ability to identify and manage infectious patients as early as possible (ideally before they enter the facility) will have the greatest success for reducing environmental contamination, direct and indirect patient contact, and within hospital pathogen transmission. Taking an appropriate history prior to patient arrival can prevent pathogen introduction. SOPs and staff training should address identifying high-risk patients when possible during appointment scheduling. When an infectious disease is suspected prior to the appointment, the client should be instructed to call upon arrival and use a designated path to an appropriate, dedicated area for examination. Practices should determine the best path based on their facility, with the intention of minimizing contact with the general patient population and staff. Animals suspected or confirmed to pose a high risk should be examined and housed in a dedicated isolation area. Because an isolation room may not always be available, facilities should develop an SOP for where and how such animals will be housed. Facilities’ procedures should be consistent with those used for isolation (i.e., housed physically and procedurally separate from other patients). Complete discussion of facility design is beyond the scope of these guidelines.4,19 Isolating an Infectious Patient As an example, before a dog suspected of parvovirus arrives at a practice, staff should consider Mode of transmission for the suspected pathogen (in this case most likely to be spread by fecal, direct, or fomite transmission). Individuals with anticipated patient contact should wear appropriate PPE (i.e., gowns, gloves). Carrying the patient or use a gurney with a disposable cover through a separate entrance directly into the exam or isolation room. Use of a similar transport procedure for patient’s admission to isolation or during practice discharge. Use of a disinfectant that is effective against parvovirus. Some patients will be identified as potentially infectious during the appointment or while hospitalized. In such cases, staff should minimize owner and patient contact with other patients, staff, and surfaces (e.g., provide outpatient treatments and complete checkout process in the same exam room or designated infection control area). Staff should identify places where contact between infectious patients and other patients or where exposure to common areas may have occurred. These areas should be promptly cleaned and disinfected. Hand Hygiene Hand hygiene, using soap and water or an alcohol-based hand sanitizer (AHS), is the responsibility of all individuals involved in healthcare. Generally considered the singlemost important way to prevent infections in healthcare, hand hygiene should be the subject of considerable attention to availability, encouragement, and compliance auditing.21,24 Effective hand hygiene kills or removes microorganisms on the skin while maintaining skin integrity (i.e., prevents skin chapping and cracking). The objective is to reduce the number of microorganisms, particularly those that are part of the transient microflora of the skin, because these are easily shed and include the majority of opportunistic pathogens. In most circumstances, either method of hand hygiene (soap and water or AHS) is effective if performed appropriately and when indicated (Table 2). In the practice, hand hygiene should occur Immediately before and after patient contact, especially invasive procedures. Before and after contact with items in the patient’s environment. After exposure to patient bodily fluids (e.g., discharge, specimen handling). Before putting on gloves and especially after glove removal. After using the restroom. Before eating. AHS is the preferred method when hands are not visibly soiled because these products have a superior ability to kill microorganisms on the skin, can quickly be applied, minimize skin damage, and are easily and inexpensively made available at any point of care.24,25 AHS is not effective against bacterial spores (e.g., Clostridium spp.), Cryptosporidium spp., and nonenveloped viruses (e.g., parvovirus). When these pathogens are suspected, washing hands with soap and water is encouraged. Bar soaps should never be used in practices due to risks for microbial contamination and transfer to other personnel. Dispenser-provided liquid or foam soap should be used; if containers will be refilled, they must first be disinfected. Cleaning and Disinfection The environment and equipment in veterinary hospitals can serve as important routes of pathogen transmission to patients, owners, and staff.26,27 Cleaning and disinfection aim to reduce key pathogens. However, when cleaning and disinfection are improperly performed, pathogens are likely to remain and can result in HAIs.28–30 Cleaning and disinfection are two separate tasks. Cleaning involves the removal of visible organic matter (e.g., feces, urine, food, dirt) with soap or detergent, whereas disinfection involves the application of a chemical to kill the remaining microbes. Cleaning is essential because organic matter increases the environmental survival of many pathogens and decreases the effectiveness of many disinfectants. Surfaces that are porous (e.g., unsealed wood, concrete, grout) or with poor integrity (e.g., cracks) are difficult to effectively clean and disinfect and should be repaired or replaced. Disinfection can only be maximally effective if it is preceded by cleaning. Some pathogens (e.g., clostridial spores) are highly resistant to disinfection; therefore, cleaning in these cases is particularly important to mechanically remove the organisms. Disinfectants should be selected based on pathogens of concern, compatibility with materials, and level of risk (Figures 3, 4; Table 11). For instance, a quaternary ammonium compound may be reasonable for routine disinfection in general animal areas, but a disinfectant with an extended spectrum (e.g., oxidizing agent that also kills nonenveloped viruses) would be indicated in an isolation or critical care area. To be effective and meet expected spectrum of activity, disinfectants must be applied at the correct dilution and for the designated contact time (allotted time required for disinfectant to remain wet on the surface to kill the pathogens of interest; this time is based on the product, concentration, and targeted pathogens, but is generally 5–10 min). If the disinfectant dries before the allotted time, it must be reapplied so that the surface remains wet throughout the contact time. Use of the proper disinfectant concentration is critical from a cost, effect, and safety standpoint. Because disinfectant products can have a range of efficacious concentrations depending on the specific pathogen, the concentration used for disinfecting is pathogen- and situation-dependent. ICPs should identify surfaces for cleaning and disinfection and establish a desired frequency that can be incorporated into a checklist (Table 13). In general, animal-contact surfaces should be cleaned and disinfected between patients. This includes exam rooms; floors where patients (e.g., large dogs) are examined/treated; and equipment such as thermometers, stethoscopes, bandage scissors, clippers handle and blades, otoscope handle and tips (if reused), monitoring equipment (e.g., Doppler cuffs, electrocardiogram leads), and endotracheal tubes. Surfaces such as lobby floors should be cleaned and disinfected on a regular basis, at least daily; when knowninfectious animals have been in contact with the surface; or when surfaces are visibly soiled with feces, urine, or body fluids (Table 11). Nonanimal-contact surfaces should not be forgotten (e.g., light switches, door handles, computer keyboards/mice). Enhanced disinfection is important after contact with a suspected or confirmed infectious patient. Efforts will vary with the pathogen(s) suspected, including route of transmission, pathogenicity, persistence, and risk for the practice’s patient population. For an examination room, this would include careful attention to cleaning all patient-contact surfaces (including floors as indicated), followed by broad-spectrum disinfection (e.g., oxidizing agent) if more narrow-spectrum disinfectants are used routinely. Because many of the pathogens involved in veterinary HAIs can survive in the environment for an extended period, leaving an area closed for several days is unlikely to prove beneficial.31 Instead, as indicated by the level of risk, a second round of disinfection may be advisable. There is no evidence that appropriately chosen disinfectants should be routinely rotated to reduce the development of pathogen resistance.32 In all circumstances, protect involved staff by requiring the use of gloves and eye protection when splashes are likely (e.g., pouring or mixing disinfectants) and ensuring areas are well ventilated. PPE PPE should be considered a last line of defense for hazards that cannot be overcome with other preventive measures. Nevertheless, given the inherent risk of exposure to pathogens in veterinary practices, the proper use of PPE is a critical component of an ICPB program. The purpose is to reduce the risk of contamination of clothing, reduce pathogen exposure to skin and mucous membranes of personnel, and reduce transmission of pathogens between patients by personnel. Common examples of PPE include lab coats, scrubs, gloves, gowns, eye protection, facemasks, and shoe covers. The type of PPE used will vary with procedure and suspicion for an infectious disease and its route of transmission (Table 14). Some form of PPE should be worn in all clinical situations, including any contact with animals and their environment, and should not be worn outside of the work environment. Lab coats and scrubs should be laundered at least daily or when contaminated (e.g., contact with an infectious patient). Gloves, gowns, and shoe covers should not be reused, even when attending to the same patient. Correct removal of PPE is critical to limit contamination of clothing and skin and mucous membranes (Table 4). Gloved hands should not be used to contact surfaces that will be touched by nongloved hands, with care taken to avoid contamination of personal items (e.g., telephones, pens). There is limited data on the effectiveness of footbaths and foot mats in infection control.32,33 Careful use of other approaches (e.g., shoe covers) is reasonable and may have fewer concerns (e.g., maintenance of disinfectant, spills).