I get a lot of emails about vet clinic access from a wide spectrum of individuals. This includes:
- Owners that are upset they aren’t allowed in the clinic with their pet
- Owners that are worried that their vet clinic isn’t doing enough to prevent transmission
- Vets that want to know how to increase owner access to clinics safely
- Vets that want to keep people out of the clinic as much as possible
- (And still some that just yell at me regardless what I say).
There’s no ‘on-size-fits-all’ approach to veterinary medicine in the COVID-19 era. I’ve written about this before but since I get so many questions, here are some more thoughts.
Why can’t we just say “here’s what you should do”?
There’s too much variation between clinics. This includes things like the degree of COVID-19 activity, local rules, staff and management risk tolerance, clinic size, waiting room layout, exam room numbers, ventilation and exam room size, among others.
What are the basic concepts?
- Restrict access as much as possible
- Choreograph movements in the clinic
- Restrict close contact situations, esp in small rooms
- Use appropriate PPE
I’ve said to keep owners out ‘as much as possible‘ in the past. This has led to issues since ‘as much as possible’ is very subjective, but I can’t really say more. There’s a cost-benefit consideration. Every time someone new comes into a clinic, there’s some risk. The more that happens, the more the risk. The better our control measures, the lower the risk. (We can get away with more by doing everything else right).
We can limit access but still allow some people into clinics, with some preventive measures. There may be logistical reasons (e.g. owner walks to the clinic and would have to wait outside in -20C weather) or patient care reasons (e.g. something needs to be shown to the owner, and that can’t be done well remotely, euthanasia, patient where curbside transfer might be risky.) where the limited risk is worth it. There are many others where it’s not. We can still do a lot with telemedicine, curbside dropoffs and hybrid appointments (e.g. telemedicine appointment followed by a dropoff for a quick in clinic like vaccination or blood sampling, where the owner doesn’t need to be present.
I was in a clinic the other day looking at flow, and it’s a good exercise. It’s not usually too hard to come up with a logical flow system where there’s one way traffic and there’s no mixing of people…..if……numbers are limited. Minimizing the number of people that come into the clinic lets us maximize our preventive measures in the clinic. With that, some markings, furniture re-arranging, designated direction of movement and designated entry/exit points can limit contacts.
Restrict close situations
Close contact. Closed spaces with poor ventilation. Droplet generating procedures like talking. Those are the big risk situations and those describe a vet clinic exam room. Time plays a big role. 15 minutes isn’t a magical number but it’s the one typically used to indicate the time that risk goes up. The smaller the space and the worse the ventilation, the higher the risk.
All those things together show how the normal exam room visit needs to be rethought. For me, exam rooms are now owner waiting spaces. If the owner needs to accompany the animal into the clinic, they check in and are admitted directly to an exam room (again…numbers of people in the clinic need to be limited to some degree for this to work). Vet personnel come in and retrieve the animal, keeping chatting to a minimum, distance to a maximum and everyone’s masked. A little conversation is fine and is good for patient care and the vet/owner relationship, but should be distanced and short. The pet is then taken to a treatment area for examination and whatever needs to be done. Vet personnel can pop into the exam room or connect electronically to ask more questions or talk about things. The owner and pet are re-united in the exam room, and a short conversation can be had to explain things or demonstrate things. If a demo is needed and restraint is needed, someone from the clinic joins in so the owner does not have to help out. (That’s still a potential issue because of the reflexive nature of owners jumping in to help hold, but that just needs some communication).
Use appropriate PPE
As much as they are annoying, masks are critical. Masks need to be worn for any close contact situation….owners and clinic personnel.
Lots of questions remain, I know. I’ll touch on a couple here but am sure there will be more to follow up on.
What do we do with the exam room after the owner leaves?
The room is ideally minimally stocked with easy to disinfect surfaces. A quick routine disinfection, focusing now on owner contact surfaces vs our previous focus on things like the examination table, is straightforward. A sign on the door indicating it’s been disinfected is useful and is good for clients to see.
What about the airspace? Can the next person go right in?
That’s a tough one. We focus on droplets and direct contact. Yet, there is likely some risk from accumulating aerosols in closed spaces with poor ventilation. It’s probably limited in time and risk but we just don’t know. Most aerosols settle out quickly so they’ll be taken care of with surface disinfection. However, should we leave 1 minute, 2 minutes, 5 minutes….between owners? Who knows. We don’t see this in similar human healthcare situations and I haven’t seen any real evidence of risk. A few minutes between occupancies, with disinfection performed after that waiting period, is probably reasonable, based on what we know. That’s particularly true with good mask compliance, as that reduces aerosol release.
Related to the above, what about ventilation in the exam room?
More is better. Looking at how much airflow can be achieved in the clinic is useful, as better ventilation disperses and dilutes. Ventilation rates of < 3 L/s per person have been suggested as being high risk, with 8-10 L/s per person resulting in low risk. If you don’t know what your ventilation rate is and can’t figure it out, go with the ‘more is better’ approach.
Anyway…quick thoughts that I’m sure I’ll add to soon (and get more questions about).