An instant hand sanitizer should also be used between patients. Gloves should never be solely relied on to prevent the transmission of disease. If the gloves become contaminated, punctured or torn while dealing with a patient they should be replaced as soon as possible. The gloves and aprons should always be changed between patients and before touching anything else.
While cleaning each cage and patient ensure that the patient has no contact with other patients in isolation. They need to be confined to their cage area and under no circumstances should they be allowed out to roam around.
Ideally they would also remain in the same cage for the duration of their stay. If possible, use the same bowls and litter trays for each patient, and these should be cleaned and disinfected between each use. The cages should be cleaned at least once a day however in some cases this may need to be more frequent, i. Ensure that clean bedding does not come into contact with any animals before use; it should be stored separately away from the cages and waste bins.
Footbaths should be prepared at the entrance and exit of the isolation unit and must be used each time someone enters and exits the unit. It should be prepared with an appropriate disinfectant that has a broad spectrum activity and is effective on fungal, viral and bacterial contamination, such as TriGene Advance.
A dilution of is most effective in high risk situations. The appropriate diet should be fed to each patient taking into account their individual needs, i. In some cases an animal may be nil per os.
The food requirement should be calculated to meet the patient's resting and maintenance energy requirements as well as their water requirement. The food preparation area must be well away from the waste bins and the cages. If a nurse is pregnant or suspects that she is pregnant she should take special care when handling patients in isolation, particularly in the instance of zoonoses. If possible, other nurses should deal with infectious patients and the pregnant nurse should be placed on other duties.
Finally it is essential that comprehensive hospitalization sheets are kept and filled out regularly. They need to include information on medications, demeanor, appetite, intravenous fluids, temperature, pulse, respiration as well as urination and faeces. Any changes or concerns should be brought to the veterinary surgeon's attention immediately. Communication is a key element in the wellbeing of these patients; all staff should be kept up-to-date on each individual patient's progress.
This includes reception staff who will be taking the phone calls from the worried owners. A rigorous disinfecting regimen should be employed for all cages and equipment that are used when caring for infectious patients. It is vital that the disinfectant used is effective against the organism in question. They need to be diluted to the correct strength according to the manufacturer's instructions and used appropriately to ensure the chemicals are safe and effective.
Disinfectants that are too weak will not sufficiently kill all of the bacteria or viruses present. Too strong and they can be harmful to animals and veterinary professionals as well as not being cost effective. Suitable disinfectants that are effective against fungi, viruses and bacteria include Virkon and TriGene. All cleaning materials should be kept in the isolation area or nearby and labeled For isolation use only.
They should not be removed from the area and used in other areas of the hospital. The cages must be cleaned first and all organic waste must be removed from the cages before they are disinfected as some disinfectants are inactive against organic materials. Any heavily soiled bedding, newspapers and other items used are disposed of in the clinical waste, usually a yellow bag with a biological hazard label according to the relevant regulations and stored until collection in a manner that will not contaminate other waste or equipment.
The isolation unit should have a sharps bin where all sharps are placed; they are not to go in the general hospital sharps collection bins. Non-soiled bedding can be soaked in a suitable disinfectant according to the manufacturer's instructions and washed separately to other bedding.
Personal protective clothing should be worn when cleaning the unit. It is important that all surfaces are cleaned, not just the cages, in the isolation unit including the doors and door handles, drip stands, bench tops, cage doors and handles and other surfaces that are touched often. They should be cleaned and disinfected and left for the appropriate time depending on the product used i. TriGene is usually 10 minutes in the presence of blood or a high organic load before other animals are placed in the cages.
It is important to remember that even though these patients must be kept in isolation that does not mean they should also be subject to complete sensory deprivation.
A radio left on for company is a must. Boredom, loneliness and stress can all hinder recovery and it is important that some time is spent with these patients each day as long as the nursing protocols are observed.
Figure 3 shows a litter of kittens all with upper respiratory disease. As they are from the same family and are receiving the same treatment they have been housed together. Feliway is a synthetic pheromone that mimics the cat's own facial pheromones which cats use to make them feel secure and safe in their environment. DAP is a similar product which can help dogs feel less anxious and fearful by producing a calming effect on the brain.
Many animals react positively to these products. The spray should be used 20 minutes before an animal is placed in a cage; often this is not possible in the isolation unit. A plug in diffuser is an acceptable alternative to the sprays and may be preferable in an isolation area. Dry catnip can be sprinkled in cages and catnip spray can be used for those cats that enjoy them.
Ping pong balls are a cheap and easy way to provide entertainment for cats; they can either be disinfected or thrown away when the patient is discharged.
Some cats enjoy playing with straws which can be disposed of once they become tatty. For low risk and non-zoonotic conditions the owners should be encouraged to visit as long as they follow the procedures, understand the risks and wear the appropriate personal protective clothing. They should pre-arrange a time when they will be visiting and should be met by the nurse who will then take them into the unit. They should not be left unattended in the isolation unit at any time.
As with all hospitalized animals, regardless of where they are, time should be spent talking and interacting with them, this is particularly important with animals that are in isolation. Patients need to have some positive experiences, not just see veterinary nurses when invasive procedures need to be done, i. Ideally barrier nursing would begin when the client rings to make an appointment to visit the practice. If the symptoms are suggestive of an infectious disease, the client should be informed to keep the animal in the car and avoid contact with other animals and people in the waiting room.
Clients should be phoned each day with an update on the patient's progress. As mentioned above, visits can be encouraged with low risk and non-zoonotic patients as long as the set precautions are followed.
In some instances when animals are discharged the owners need to be informed that their animal may still shed the microorganism into the environment for a period of time. They should avoid contact with other animals, public parks and pavements, and in the instance of zoonoses such as leptospirosis they should be informed of the hygiene issues relating to themselves.
Barrier nursing patients in isolation can offer many challenges to the veterinary nurses nurse designated to their care. It requires an excellent understanding of the infectious diseases present and how they can be transmitted from one patient to another and in some instances to people. The nurse needs to understand the process involved in how pathogens can transfer from one patient to another in order to keep other animals safe, both in the hospital and in the community.
Although time consuming and demanding, barrier nursing can greatly improve the patient's outcome and experience in the isolation unit. Disease transmission can occur either through direct or indirect contact and it is important to have an understanding of these two routes in order to prevent the spread of infection.
Hand hygiene is one of the most important factors in reducing the transmission of infectious agents. Personal protective clothing and personal hygiene are essential when it comes to nursing patients in isolation.
The psychological needs of patients in isolation should not be underestimated and time should be spent addressing this issue. Sign up to The Veterinary Nurse's regular newsletters and keep up-to-date with the very latest clinical research and CPD we publish each month. Review Principles of barrier nursing in the veterinary hospital. Conditions that require barrier nursing Animals that need barrier nursing can range from a kitten with ringworm to a dog with meticillin-resistant Staphylococcus aureus MRSA.
Table 1. Most common conditions requiring barrier nursing Canine parvovirus Infectious canine hepatitis Leptospirosis Canine distemper Kennel cough Feline panleukopenia Feline upper respiratory tract disease Feline infectious peritonitis FIP Feline leukaemia virus FeLV Feline immunodeficiency virus FIV Ringworm Campylobacter Salmonellosis Routes of infection within the hospital environment Infection may be passed between animals within the veterinary hospital in any number of ways Table 2 but they will all involve contact with infectious body fluids such as faeces, blood, pus, vomit, saliva, urine, ocular, nasal and vaginal discharge and wound exudates Aspinall, Table 2.
Common routes of infection within the hospital environment Shared ventilation between isolation and non-isolation areas Contaminated table tops, floors and cages Contaminated human footwear, hands, arms and clothing Inadequately sterilized or disinfected instruments, food bowls, litter trays, utensils, bedding, drip stands and other associated equipment Direct and indirect contact Disease transmission can occur either through direct or indirect contact Aspinall, Table 3.
Table 3. The isolation area As shown by Cooper and Lane and Jones and Mullineaux the design of the isolation facility should take into account the following factors: The kennels should be apart from the main hospital area. For cats a minimum of 3 m separation from the cat housing area is appropriate Ideally it would have its own separate entrance and exit away from the main hospital area.
This would reduce the risk of contamination to other hospitalized patients, and patients with suspected infectious disease can bypass the hospital area and be admitted straight into isolation It needs to have an effective ventilation system directed away from the main hospital area for the risk reduction of airborne disease. This is particularly important if there is more than one patient housed in isolation at a time There should be a heating and cooling system in place as well as good lighting.
Adequate humidity and temperature can be an important part of the patient's recovery The surfaces and floor should be designed to be cleaned easily Wall-mounted hand sanitizer units should be placed outside but next to the door to the unit. They should be used each time a person enters and exits the isolation unit Sneeze barriers should be present between cages to prevent cross-contamination The doors should be locked easily and the keys stored within easy reach.
They must enter and exit without walking through the hospital There needs to be adequate storage for food and water bowls, food bins, waste disposal, disinfectants, paper towels, newspapers and bedding as well as bandaging materials, needles and syringes, scissors, intravenous fluids, and any other medical supplies that may be needed by infectious patients An area should be set up for a foot bath as well as a sink with a hot and cold water supply for hand and bowl washing.
This would also provide a fresh water supply for the patients The sink should be a clinical non hand-operated hand basin A good pest control system to prevent vermin and for the control of flies, ants, lice and fleas A storage area for all disposable clothing and equipment needed for the nursing of the contagious patient A disposable paper towel unit for drying hands and cleaning will help to reduce the risk of infection.
Figure 1. Cat with feline upper respiratory disease in isolation. Infection control procedures The hospital should have standard operating procedures SOPs in place to ensure the safety of personnel.
Table 4. Standard operating procedures for infection control How to prevent cross contamination between patients Protection for the nurse and other personnel involved from infectious body fluids and objects What to do in the event of an accident, including exposure to a zoonoses, infectious agent or needle stick Appropriate hand hygiene techniques Cleaning and disinfection How to deal with clients who have a hospitalized animal Where to seek medical advice Hand hygiene is one of the most important factors in reducing the transmission of infectious agents as cited by Siegal et al and it is essential it is part of the SOPs.
Holston Moore and Rudd and Siegal et al recommend that hand hygiene should be performed: Before and after attending to a patient After contact with wounds, soiled dressings, blood, mucous, pus or other body fluid, faecal and urine contamination After taking a patient's pulse, lifting or moving a patient or other procedure Before and after examining wounds, drains or catheters Between touching contaminated and non-contaminated parts of the patient's body After contact with stethoscopes, thermometers and other inanimate objects in the immediate surroundings of the patient After removing gloves When leaving the isolation area.
These need to fully cover the nurse from the neck down to their feet and should be long sleeved Gloves — these must be changed after touching contaminated objects and before touching patients Disposable shoe covers or similar Plastic apron Mask and goggles.
Particularly important if dealing with airborne zoonoses, but also for protection in the use of vaporized disinfectant sprays A hair covering. Nursing the infectious patient Along with wearing the protective clothing mentioned above there are many basic nursing protocols that should be followed in the nursing of the patient in isolation. Table 5. Key elements in nursing the infectious patient Nurse the least serious up to the most serious.
Gloves should never be solely relied upon to prevent transmission of disease. Patients should never have contact with other patients while in isolation. A disinfectant effective against viruses, fungal spores and bacteria should be used. An appropriate diet is fed to each patient. Pregnant nurses should not work in isolation if possible. Comprehensive records are kept for each patient.
A high standard of aseptic technique for each patient. Cleaning and disinfection A rigorous disinfecting regimen should be employed for all cages and equipment that are used when caring for infectious patients.
Psychological needs of the patient in isolation It is important to remember that even though these patients must be kept in isolation that does not mean they should also be subject to complete sensory deprivation. Figure 3. As part of this programme, a medical officer consultant for anaesthesiology and intensive care, a medical officer undergoing training in internal medicine, two intensive care orderly sergeants and two medical orderly sergeants have been incorporated in the routine schedules at the civilian hospital.
They thus form part of the team that will deal with the patient should an genuine case be transferred to Hamburg specialised treatment centre. In , Hamburg Bundeswehr Hospital provided assistance to the Frankfurt specialised treatment centre by assigning there a medical officer consultant for infectiology and internal medicine for several weeks treatment of a patient with Lassa fever, and also provided support to Hamburg specialised treatment centre for several days in connection with a suspected case of Ebola fever in As part of the barrier nursing course, a collaborative exercise was undertaken, involving the transfer of a patient from the intensive care unit of Hamburg Bundeswehr Hospital to Hamburg specialised treatment centre Fig.
The joint training of all groups involved Hamburg Bundeswehr Hospital, Hamburg fire services, specialised treatment centre at Hamburg-Eppendorf University Hospital made possible the constructive exchange of experience and strengthened local ties between the military and civilian organisations.
Members of other specialised treatment centres participated in the course, and presented their own concepts for the transport and treatment of these patients. The course has since developed into a forum in which information is exchanged between the various groups and organisations.
The management and treatment of patients with highly contagious, life-threatening diseases are complex and wide-ranging tasks. Although it has not been possible in this article to discuss other related aspects, such as the handling of media, disposal of waste and material transport, the training of the medical personnel does take these into account.
An analysis phase study and work group SAGA is currently considering the final details for the establishment of a barrier nurse unit.
It is also planned to supply prepared material kits to the various Bundeswehr hospitals. These kits will include PPE and air pump equipment together with decontamination and isolation material designed for clinical use. The kits will enable personnel to provide for temporary isolation of patients under barrier nursing conditions until they can be transferred to a specialised treatment unit.
The same material kits will also be made available to the relevant units during deployment abroad, although there will be differences to the kits provided in the homeland in quantitative aspects. The materials, currently in store, conform to the corresponding civilian quality and certification standards. To date, some personnel have been trained in the fundamental skills of barrier nursing, and in a first refresher course was offered, which included a combined exercise with the professional fire services and Hamburg specialised treatment centre.
This represents the beginning of the standardisation of national and international protective measures. A symposium for experts and members of the standing working committee of specialised treatment centres StAKoB of the Bundeswehr and interested members of disaster management services, fire services and aid organisations is to be hold in the second half of by the Department of Tropical Medicine of Hamburg Bundeswehr Hospital at the Bernhard Nocht Institute in Hamburg.
Although barrier nursing may be considered a niche discipline, it clearly demonstrates the necessity for civilian and military collaboration and the establishment of national and international networks. Despite the problems of dealing with highly contagious, life-threatening diseases for which there are often no causal therapies, the management of such conditions — a not necessarily a priori hopeless undertaking — is feasible with a minimum of risk if hygiene guidelines are appropriately followed and isolation measures are systematically imposed.
First and corresponding author HptFw M. Article: M. KOCH GERMANY Barrier nursing or the management of life-threatening, highly contagious diseases at home and abroad Although barrier nursing may be considered a niche discipline, it clearly demonstrates the necessity for civilian and military collaboration and the establishment of national and international networks. Despite the problems of dealing with highly contagious, life-threatening diseases for which there are often no causal therapies, the management of such conditions is feasible with a minimum of risk if hygiene guidelines are appropriately followed and isolation measures are systematically imposed.
Possible scenarios in which barrier nursing may be required As a result of the increasing frequency of out-of-area deployments and the restructuring of the Bundeswehr that was undertaken to make it into an operational strike force, Bundeswehr service personnel are now exposed to a greater risk of infection with a VHF than the average tourist. The following scenarios involving German service personnel are conceivable: Onset of the disease in an individual case in the country of deployment Onset of the disease in an individual case after return from the country of deployment to Germany Onset of the disease in an individual case during the flight home from the country of deployment There would be no fundamental differences in the forms of care and treatment required in each of the above instances, although each scenario is characterised by specific and individual features.
Onset of the disease in an individual case in the country of deployment: Should an individual fall ill during deployment, repatriation of the case to the homeland is out of the question because of international patient transport regulations transit clearance. The case must be retained in the country of deployment and also treated there. This basic approach represents the main difference to the second scenario.
Onset of the disease in an individual case after return from the country of deployment to Germany: If an individual falls ill after their return from the country of deployment to Germany, the treating hospital must have the capability for the care and isolation of the patient in accordance with the requirements of barrier nursing until the case can be referred to a specialised treatment centre.
Every hospital must thus draw up appropriate hygiene plans and SOPs to deal with such a situation. Transfer under appropriate conditions to such a centre can be undertaken by the affiliated ambulance services or professional fire services. Most unlikely of all the scenarios is the third example - onset of the disease during the flight home from the country of deployment.
The management of such a case would need to be organised by a specialist treatment centre in accordance with the specifics of the situation. As a rule, this would mean that the patient would be directly transferred to a specialist treatment centre by the professional fire services or the treatment centre personnel. There would thus be no need for temporary barrier nursing in the strict sense.
Barrier nursing and personal protection At the core of the barrier nursing concept is the need to provide for the protection of the clinical personnel and to prevent the escape of a highly contagious disease into the environment while, at the same time, not neglecting the treatment of the patient.
Problems associated with working while wearing PPE: Extensive physical stress due to transpiration and the use of breathing apparatus Fig. This leads to heat build-up and dehydration, limiting the periods over which personnel can be operationally effective. A further complicating factor is the need to use a breathing apparatus. The manufacturers provide no recommendations with regard to maximum periods for use and the breathing apparatus has yet to be subjected to suitability testing.
Limited tactile sensory abilities during routine work Fig.
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