Congress on Demand 2021: Veterinary Nursing

The practice and vet perspective: There is increasing evidence within the veterinary profession that the use of a surgical safety checklist reduces post-operative complications. In this presentation, we will present the science behind why checklists work and how they can help improve our performance by promoting teamwork and communication and increasing situational awareness. We will also give tips on implementing checklists in your practice.

The vet nurse perspective: Everyone knows that horrible sinking feeling when they realise that they have made a mistake, but to err is human – so how can we prevent error and keep our patients safe? In 1999, Atul Gawande suggested that at least 50% of surgical complications in people could be avoided by improving perioperative routines. The launch of the World Health Organisation (WHO) Safe Surgery Saves Lives campaign and the publication of the WHO Surgical Safety Checklist (SSC) in 2008 inspired veterinary hospitals to modify the WHO SSC for use with their surgical patients. Studies on the success of the World Health Organisation Surgical Safety Checklist reported a 47% reduction in deaths, a 36% reduction in post-operative complications and a 48% reduction in infections. Checklists have also been found to improve communication and teamwork in the operating theatre. Checklists are quick to perform, cheap, easily modified to suit the intended clinical environment and straightforward to implement. The checklist is completed in three stages; sign in (before induction), time out (before skin incision) and sign out (before recovery). By performing each of these stages at the correct time errors which may occur due to slips, lapses, cognitive overload, and distraction can be avoided.

The Covid-19 pandemic has brought infection control into sharp focus. Many of the measures taken to halt the spread of Covid-19 (particularly hand hygiene and personal protective equipment/PPE) will have also been effective against hospital acquired pathogens. However, the risk from hospital acquired infections (HAIs) will still be with us once the pandemic recedes. Practices should therefore take the time to establish effective infection control measures that will protect their patients, owners and staff. It is important to understand the most likely organisms in each practice and how these can spread in the environmental and be transmitted between animals and humans. Essential tasks include establishing an infection control team, using effective hand hygiene, cleaning and disinfection, have high quality facilities and equipment, optimising procedures and care, using clinical audit, and practicing antimicrobial stewardship.

Ernie Ward and Alan Robinson discuss the owner and the team perspective, what does it look and feel like – it’s not just about perks. Team perspective: I’ll bet no-one had ‘Global Pandemic’ on your 3-year plan at the beginning of the year. So far over this Covid lockdown we have had major disruption to all the critical business areas – profitability and financial strategies, team harmony and resilience, clinical care and vet performance and client experience and resilience – managed through the leadership lens of your unique COVID experience. Some of the consequences have been surprising and some down-right paradoxical. There are a lot of lessons to be learned from our experience so far and, I suspect, a lot more to come. That still leaves us, and our teams, in the liminal space of uncertainty and ambiguity. Time for planning, priority and perspective. For some of them it is just a job. But it is their safety and security and most of them (and you maybe) are on the edge of meltdown. From a team perspective we discuss the three fundamental Flow and Trust pillars that you can provide at work: (1) safety – physiological and psychological – and how they are linked – how does our veterinary neuroticism and need for meaning affect our sense of safety?; (2) connection and belonging – how does our innate Social Protection System deal with our particularly strong vet need to belong, to be liked, to be accepted as well as the need for intimacy, mutuality, and relatedness; (3) self esteem – how we balance confidence (self-worth) with competence (mastery). Are we just trying to be useful – or do we actually feel valued?Productivity is more than a number – rewarding and recognising team excellence: To recruit and retain the best staff, you must reward them well. You must also measure their contributions in order to determine if they’re positively contributing to your practice. For most practice owners and managers, this means tracking revenue and financial productivity. Revenue is important, but not the only metric to recognise and reward excellence. This session shares several other key performance indicators you should be tracking for your team.

Cats are masters at hiding their pain, but the clues are there if you look closely. Cats are often given less analgesia than their canine friends, sometimes this is because we don’t think they are painful and sometimes it’s because we are unsure what we can do for them. There are many analgesia techniques out there that can be used for cats as well as dogs, using multi-modal and preventive analgesia ensures that your patient has a good experience throughout their stay with you. This webinar covers preventative analgesia, easy local anaesthetic blocks and how to put together an analgesic constant rate infusion for your feline patients so you can ensure they do not suffer in silence.

What can you do for the nauseated patient? Many in-patients present with anorexia, vomiting and/or diarrhoea, but nausea, in comparison, is a more subtle clinical sign. Veterinary nurses can play a significant role in maximising patient wellbeing, encouraging voluntary food intake, and expediting a patient’s recovery and discharge from the hospital. This session examines what nausea is, the signs we commonly see in our nauseated patients and how we can improve these as nurses, both pharmaceutically and through non-pharmaceutical interventions.

Caring for the pancreatitis patient: Pancreatitis can lead to many other co-morbidities in our patients, in which they can become very critical patients that need intensive nursing care. This presentation discusses what signs of deterioration to look for, analgesia, sepsis, fluid therapy and nutrition.

Cytology of inflammatory lesions with Butty Villiers.

Ergonomics in the dental station for the veterinary surgeon: Ergonomically good positions are very important when doing dentistry, since procedures are often long and numerous in awkward back and head positions. This lecture gives the basic guidelines to sit and work with ergonomically good manners to prevent headache, neck, shoulder and back pain to develop. It covers hand instrument grip, light, units, magnifiers, table and chairs, and give a number of solutions to go home and use immediately or to consider when buying new equipment.

Ergonomics in the dental station for the veterinary nurse: Ergonomics is extremely important in the dental station as the veterinary surgeon may frequently spend significant periods of time operating on individual patients, as well as undertaking multiple procedures per day. This can take its toll on the veterinary surgeon’s health and wellbeing due to the potentially awkward head and neck positions they often adopt throughout these procedures. This lecture provides the veterinary nurse with knowledge pertaining to ergonomics in the dental station to take back and apply in practice immediately, to minimise or eliminate the aforementioned negative impacts on their surgeons. We discuss optimal set up of the dental station considering access to the dental unit, X-ray generator, anaesthetic machine and surgical instrumentation, including the positioning of the table and operating light, and explore the concept of four-handed dentistry.

Common coagulopathies: Coagulopathies are commonly encountered in practice, and the veterinary nurse plays a key role in the triage, diagnostics, treatment and nursing care of the bleeding patient. In order to provide the best possible care for these patients, it is important to understand the types of coagulopathies seen in practice, the patients they commonly affect, the clinical signs we see, and how these conditions are diagnosed. This session discusses how coagulation occurs in the body, the pathways involved, and what happens when these go wrong. Common congenital and acquired coagulopathies that nurses encounter in practice are covered, together with the common diagnostic tests performed.

Nursing the bleeding patient: This lecture discusses how to care for these patients in regards to patient handling, blood sampling and how to preserve these delicate vessels. It also covers monitoring for further deterioration and how to administer blood component therapy safely and what type of blood products to use and when.

Jill Macdonald looks at how to recruit and retain veterinary nurses.

Review of different tools and criteria for selection: I’m a strong believer that very few people intend to be the bad team player, but too often we find ourselves working with others who seem to be pulling in a totally different direction or are just out for themselves. What can you do during the recruitment process to help reduce the chance of selecting the wrong person for the role or for your team? Are you 100% clear with who and what you are looking for in the first place-just a vet, a nurse, someone to fill the gap? Which behaviours are you looking for in your new employee? What values match the values and culture of the team and the practice? Are you even sure of the values and culture in your team? If not, how can you be sure to recruit the right person that will fit and be a ‘good team member’ that you are looking for? These are some fundamental questions to be asked prior to recruiting anyone, skills can be learnt (as long as the relevant qualifications are present), forget the letters after the name and look at the person, the values and think about the match you are making. This session discusses how you can attract and retain the right people for your team.

How I hire – essential attributes of excellent employees: Ernie Ward offers the top attributes his management teams evaluate when hiring team members.

How to approach neurotrauma: a vet’s perspective – diagnosis and management: Neurotrauma, including traumatic brain injury (TBI) and acute spinal cord injury (SCI), is a relatively common emergency in small animal veterinary medicine that requires thorough patient assessment and a systematic approach to case management. Damage to the neuroparenchyma can be divided into primary injury directly associated with the trauma (e.g. contusion, compression, laceration and distraction) and secondary injury that occurs subsequently due to deficiencies in homeostasis and normal metabolic processes. Interventions are directed at addressing primary injury more so in SCI as well as minimizing the effects of secondary injury in both TBI and SCI. Initial investigations should be the same as any acute neurological case with a through history, physical examination and neurological examination. All patients should ideally have a minimum database performed with particular attention to electrolytes and glucose levels. Care must be taken to ensure the patient is systemically supported with a focus on airways, breathing and circulation. The level of intervention is patient dependent but can often be intense and hands-on. Prognosis for neurotrauma patients depends on the severity of injury, the site of the lesion, and the timing and efficacy of treatment, but with an appropriate response to initial management and stabilisation the outcomes of neurotrauma patients can be good.

How to approach neurotrauma: a vet nurse’s perspective – diagnosis and management: What you might expect, what to prepare for and complications in neurotrauma.

How capnography can help you identify problems with your patient: Capnography is arguably the most reliable and least error prone anaesthetic monitoring modality available, and it can contribute significantly to patient safety. Capnography relies on the measurement of inspired and expired carbon dioxide and primarily gives information about respiratory adequacy. Distinctive capnograph trace patterns can also alert the user to breathing system faults, endotracheal tube problems and acute lung pathology. Additionally, capnography is recommended to prognosticate and judge the effectiveness of chest compressions during CPR. This session discusses an approach to using and interpreting the capnograph to diagnose problems under anaesthesia.

What options you have in managing hypotension under anaesthesia if fluids don’t work: This session presents an update on recent advances and controversies in managing hypotension during general anaesthesia. Hypotension is one of the most common adverse effects of general anaesthesia. Options for managing anaesthetic-induced hypotension include: 1. reducing the inhaled anaesthetic requirement: this can be achieved directly or indirectly (e.g. by providing analgesia). 2. fluid administration: the efficacy and duration of crystalloid fluid boluses are limited but a number of tools are available to identify patients that will benefit from a fluid bolus (e.g. pulse pressure variation) 3. vasoactive agents (e.g. dexmedetomidine, dopamine, ephedrine): there are pros and cons to the different agents available. These options and practical approaches are discussed.

This case-based session explores and discusses common but still challenging cytology cases using live cytology slide examination, enabling you to see the step by step process of how we examine a slide and how the findings lead us to a diagnosis or differential diagnoses.

How does the cytologist do it? Although there are some exceptions, benign tumours consist of a uniform population of cells that resemble their normal non-neoplastic counterpart whilst malignant tumours generally show variability. In benign tumours cells are small and uniform, with small nuclei and a low nuclear:cytoplasmic (N:C) ratio. Nucleoli may be absent or nuclei may contain 1-2 small nucleoli. When in aggregates the cell arrangement is orderly and neat. Malignant tumours are recognised by identifying cellular, nuclear and cytoplasmic criteria of malignancy: Abnormal location for that cell type e.g. metastatic carcinoma cells should not be present in a lymph node; macrocytosis and karyomegaly with anisocytosis and anisokaryosis; cell clusters may be chaotic and disordered with cell or nuclear moulding; increased N:C ratio; large nucleus and sparse; bi- and multinucleation – anisokaryosis within one cell is especially significant; multiple nucleoli or a single large nucleolus; coarsely stippled to clumped nuclear chromatin; frequent/ abnormal mitoses; increased cytoplasmic basophilia and/or abnormal cytoplasmic vacuolation or granulation, or excessive secretory product. The shape and arrangement of cells will help identify the ‘family’ of cells: Epithelial cells are columnar, cuboidal, roundish or polygonal and in cohesive clusters. Mesenchymal cells are oval to spindle shaped and seen individually or in loose aggregates, sometimes with a swirling pattern, with poorly defined cell borders. Round cells are discrete. The quantity and appearance of the cytoplasm distinguishes lymphoid cells, plasma cells, histiocytic cells and mast cells.

What else does the oncologist need to know (TNM)? Staging determines the extent of disease in cancer patients, to inform treatment decisions. Recommended staging is strongly influenced by the diagnosis and likely behaviour of the tumour: a diagnosis is essential. Full staging is most appropriate for high grade tumours, and in older patients (identifying comorbidities) or before invasive/expensive treatments. Cytology is particularly useful for superficial masses and those accessible by ultrasound guidance. Carcinomas and round cell tumours tend to exfoliate well, sarcomas not. Primary tumour extent is assessed clinically and by imaging. Carcinomas, mast cell tumours, and malignant melanomas tend to metastasise by the lymphatic route, requiring assessment of locoregional lymph nodes. The closest node (moving from peripheral to central) is often likely to be the draining node, but lymphangiography can identify unexpected draining nodes in high grade tumours. Identifying and sampling these nodes leads to better staging. Imaging of retropharyngeal, axillary, medial iliac and inguinal nodes by ultrasound or CT is useful: CT allows imaging of sacral nodes e.g. in anal sac adenocarcinoma patients. FNA has a variable rate of false negatives in different tumours: in particular, FNA may be insensitive to oral melanoma metastases. For distant metastases, cytology is especially useful for assessing splenic and hepatic nodules.

Although regarded as a routine operation, neutering is probably the most invasive procedure undertaken in the majority of pets in the UK. Anaesthesia should be tailored to each patient to ensure not only anaesthesia adequate depth for the operation, but also to ensure preservation of normal physiology as well as excellent analgesia. This session explores the possible approaches that could be applied in practice. It examines the importance of a thorough clinical examination, benefits of tailored premedication, and outlines best practice in anaesthetic induction, maintenance and recovery. Finally, examples are given of how the approach could be modified when dealing with commonly encountered breed specific and clinical problems.

Nursing of cardiac patients generally falls into two categories, chronic and acute. Chronic nursing may be pre-congestive heart failure (CHF) and post CHF. This means patients may have heart disease without having presented with CHF. Patients also require chronic nursing after an acute onset of CHF. Acute nursing includes presentation, typically to an emergency center, for rapid control of CHF. This session reviews the American College of Veterinary Internal Medicine consensus statement regarding the stages of heart disease, then link nursing schema to each stage of heart disease. Many diagnostics and therapies overlap into different stages. For instance, echocardiography is indicated at all stages of heart disease to monitor progression of cardiac enlargement. Certain therapies have specific indications for their introductions. This overview provides a 10,000 foot perspective of cardiac nursing.

Nutritional therapy, like medical and surgical treatments, is recommended to manage many diseases. It is vital that these recommendations are based on a solid evidence base. In this session, the evidence behind nutritional recommendations to manage kidney disease, including protein restriction, phosphorus restriction and fish oil supplementation, are discussed. This includes ways to assess the evidence behind the recommendations and how to use these nutritional recommendations to improve patient outcome.

Managing expectations – client education: Owners often need help to understand the difference between acute and chronic pain; that often we cannot cure the problem; and that the main priority is to reduce the patient’s suffering (which may include side effects and restricted access to resources). Suffering is assessed by changes in individual behaviour and chronic pain is a chronic stressor. We cannot teach our patients not to feel stressed by the sensation of pain and owners must understand that the treatment of chronic pain necessarily involves more veterinary input because of this. A dynamic approach will usually begin with pharmacological analgesia, but may be followed with more physical treatments to help reduce the amount of medicine required and to maintain the animal’s strength and mobility. The clinician should stay open to discussing any approach and be prepared to explore other avenues if the owner requests them. Medicines often a carry a negative association for many clients and the clinician should be clear in explaining expected outcomes; possible side effects; monitoring; and frequency of review. Getting the owners involved in weight control; physiotherapy exercises; comfort; improved core territory; and replacement of lost resources will help with compliance by giving them a sense of control over their pet’s pain.

Monitoring pain therapies: Chronic pain can seem like trial and error sometimes. Having a firm understanding of the pet’s pain and a baseline pain score is essential for judging the efficacy of any future therapies. The identification of pain behaviours is recommended. When asked what they want for their pet, most owners will reply that pain reduction and maintenance of quality of life is their goal. I do ask this directly to owners so we can establish common ground and start to manage expectations. However, when asked to rate quality of life as a direct question in the Canine Brief Pain Inventory owner response can vary according on the message they wish to convey to you. We will discuss this point in the session. Questioning across health domains associated with quality of life can give us vital information and this is the basis of the Vetmetrica scoring system. I adapt the pain/HRQL scoring system I use according to the owner – which can help with the spectrum of pain presentations – another point for discussion. Writing down treatment goals and pain behaviours helps owners recall the consultation and draws focus to each aspect of management. Highlighting the importance of each intervention is valuable to the owners understanding.

Post-operative complications commonly seen in veterinary practice range from wound healing difficulties to multiple organ failure and death. Regardless of their severity, whenever post-operative complications arise, they are never welcome; let’s face it, the last thing you want to hear when reaching for your coat, after mopping the floor, hungry and tired after a long day, is that the bitch spay from this morning is not doing well and needs to return to theatre as a bleed is suspected. To reduce the rate of post-op complications, clinical audits are used to support quality improvement in clinical settings. Clinical audits enable patient care to be improved by assessing and evaluating current processes in a systematic way. By selecting the correct type of audit, getting the whole practice team on board, and ensuring a blame-free culture is embraced improvement strategies can be identified and implemented. The surgical safety checklist (SSC) is an example of a tool that has been proven to reduce the rates of post-operative complications. By involving the whole practice team in tackling post-operative complications though adoption of audits and checklists the benefits quickly become obvious and real improvements in patient care can be seen.

This session considers how we can help owners to recognise acute and chronic pain. Both chronic and acute pain recognition are enormous topics in themselves so the session will focus on ‘how, what and how’ and cover key points relating to each of these areas. Assessing a subjective, multi-dimensional experience such as pain in non-verbal species is a challenge yet there are inextricable links between pain – a negative affective state, welfare and quality of life. Recently, research has resulted in us having a range of pain scoring tools that can be applied to assess both acute and chronic pain in dogs and cats, as well as quality of life. Owners are uniquely placed to observe dogs and cats in their home environment where animal behaviour can be observed in wider contexts and over time, enabling the dynamic nature of pain to be tracked. A combination of Client Specific Outcome Measures and pain assessments can be used to evaluate the animal and assess response to interventions; these can be incredibly useful tools for working in partnership with owners, motivating and actively engaging them in the management of their animal’s pain.

RCVS and BVA data suggest career satisfaction for vets ‘ain’t what it used to be’. The most obvious symptom of this is seen in the difficulty practices face in hiring and retaining clinical team members. But underlying the recruitment issue is a deeper fundamental failing. We are simply not meeting the needs of the next generation of clinical staff who are voting with their feet and leaving not just our practice, but also the general practice arm of the profession. Wage stagnation, poor support and chronic mental health issues were all problems before COVID-19 showed up and raised the stakes and pushed demand for vet services higher than ever before. If you are a leader in practice, then you should be paying attention because this is an existential threat to practice as we know it. This session shines a spotlight on the causes of the issue and options available to leaders to make the changes needed so everyone has the chance to thrive in their clinical career.

This session covers the nursing care of commonly managed devices in the critical patient including vascular catheters, urinary catheters, chest drains, tracheostomy tubes and nasal oxygen catheters. Many nurses will be placing some of these indwelling devices and so it is important that the RVN understands the indications and contraindications to placement in addition to the placement technique. Most importantly nurses need to be familiar with how to manage the tube/drain once in situ, how to troubleshoot problems and prevent complications arising.

Establishing pain through owner questioning: Where to start can depend on whether the consultation was booked to specifically discuss pain or whether pain was detected as part of a routine examination. Validated pain scores are an essential resource to provide a structure to owner questioning. For the planned consultation these can be emailed to the owner prior to the consultation or where pain is noted in a routine consultation can be given to the owner for completion after the consultation. Pain scores are really useful not only for providing a baseline prior to initiating treatment, but as a basis for discussion and further history taking. I find they stimulate owners to mention additional information that can be useful. Options to consider are: Canine Brief Pain Inventory (CBPI); Liverpool Osteoarthritis in Dogs (LOAD); Helsinki Chronic Pain Index (HCPI); Feline Musculoskeletal Pain Index (FMPI); Vetmetrica Health Related Quality of Life System. During history taking I aim to establish 3-5 pain behaviours to use as a baseline. These may be new behaviours associated with pain or behaviours that the pet doesn’t do anymore where the change could be attributed to pain. This introductory session covers the different attributes of these pain scoring systems and when you may choose one over another.

What can be achieved in a 10 minute consult? Chronic pain takes time to develop and will take time to resolve or manage, therefore the first thing to emphasise to the client is that this initial consultation (or from wherever the clinician is picking up the case) is just that: initial, and that there will be a plan to progress the treatment. The first consultation should identify the owner’s concerns; try to establish the sources and classifications of pain present; identify some clear, initial outcome measures; and begin the process of reducing the patient’s suffering. Owner concerns include: their pet’s suffering; inability to exercise; withdrawal and reduced interaction (especially cats); unwanted changes in behaviour (including toileting irregularities; restlessness at night; fearful behaviours); possible side effects of medication; absence of a firm diagnosis; and a potential misunderstanding of what can be achieved with chronic pain problems (i.e. management versus cure). The clinician should observe movement, gait and postural abnormalities. The examination should be performed on as relaxed a patient as possible; aim to establish the presence or absence of secondary sensitisation; and minimise pain and fear. From the history and the examination, the sources and classification of pain may be established; the clinician should aim to identify at least one sign of suffering and/or physical outcome measure, start on appropriate analgesia and arrange a review.