Large Animal Isolation Policy

Implementation Date: 4/2013

Date of Last Revision: 7/2022

Next Review Due: 7/2025

 

Reviewed by VTH Administrative Team: N/A

Reviewed by VTH Board: N/A

 

Reviewed by Legal Counsel: N/A

Reviewed by Biosecurity Subcommittee: 6/2019; 7/2022

Subject to modification by the VTH Director and/or Section Heads without approval.

Policy

The objective of this policy is to outline procedures used in the Equine Isolation Unit in the VTH. The goal is to minimize transmission of contagious disease to other horses in the general population and to other horses housed in Isolation.

Guidelines

Isolation Candidates - Any equine patient suspected to harbor contagious disease should be considered as a candidate for Isolation. Horses that should be housed in Isolation include, but are not limited to, those with the following signs or presumed conditions:

1. Infectious respiratory disease -respiratory signs plus fever such as Strangles (Streptococcus equi var. equi) suspects.
2. Any two of the following three criteria: diarrhea, fever, and leukopenia. (Patients with gastrointestinal signs must be examined prior to unloading for evidence and/or fever and admitted directly to Isolation if either is present).
3.  Suspect Equine Infectious Anemia (EIA) patients (characterized by anemia, jaundice, edema, depression and fever) awaiting the results of serologic testing. 
4. Horses with neurologic disease AND fever that are standing at the time of arrival may be admitted to Isolation. Recumbent animals shall be placed in the ‘specially ventilated (DMSO)’ stalls in Ward 4. 
5. Horses originating from a facility with known EHV-1 outbreak must be admitted to isolation even if no neurological clinical signs are present.

Procedure (if applicable)

I. Patient Entry
Equine patients must be admitted to Isolation via individual exterior doors on the west side of the Large Animal Clinic (LAC). These doors shall be closed at all times when a patient is in Isolation. The building’s climate control system has been designed to heat or cool the Isolation Unit despite its western exposure, so doors should not be propped open to allow temperature changes or to allow the patient to see outside. Personnel admitting the patient shall wear PPE and not return to the open wards without changing clothes and shoes after admitting the patient into an Isolation stall. If questions exist about any patient and isolation, the Section Head will make the final determination of location of the patient.

II. Patient Exit
Every effort must be made to minimize exposure of remaining VTH patients to Isolation patients. Isolation patients shall not return to the open wards from Isolation. Equine patients should only leave Isolation to:

• Return home.
• Be transported to necropsy.
• Enter Imaging (see below)
• Go to Surgery.

III. Isolation Hallway

The LAC Isolation stalls are located on the western side of the LAC building running from just south of Ward 1 through just north of Ward 3. The interior Isolation hallway may be entered in street clothes either for observation of Isolation patients through the individual windows, or for entry of personnel or equipment into Isolation stalls. From this hallway, each individual Isolation stall has its own anteroom. Isolation Stall 1 has been designated as the Isolation Stockroom and contains most of the commonly-needed equipment for working on patients in Isolation. Patient records are to be kept in the record room and are not to enter isolation. ICU and walk-by sheets shall never enter the anteroom, but remain on a red cart outside the stall in the main isolation hallway.

IV. Isolation Anteroom

The individual anteroom for each Isolation stall shall be considered semi-clean/semi-isolated. Before entering the anteroom, all equipment (stethoscope, thermometer) and easily removable clothing (i.e., coveralls, hats), which will be worn or used in contact with open ward patients must be removed and remain in the Isolation Stockroom (Stall 1). Equipment which goes into the anteroom shall never be returned to the open wards or to the Isolation stockroom without first being cleaned and sterilized. In the anteroom, the sink shall be used for hand-washing as one both enters and exits the Isolation stall area. A small shelf is available for temporary placement of equipment and supplies to be used in the Isolation stall. The Biohazard trashcan for each stall shall not be located in the anteroom, but shall be placed in the stall area proper, since it is considered biohazardous and should be isolated as much as possible from the open ward traffic (the hallway). The procedure to enter isolation from the anteroom is as follows:

1. Put on a pair of gloves in the anteroom.
2. Stand on the ledge between anteroom and isolation to put isolation suit on. Plastic foot 
   covers may be necessary for those whose shoes do not fit into isolation suits.
3. Once your feet are in the suit, you may step into stall.

V. Isolation Stall
The stall area shall be considered isolated. It may be entered by crossing over the threshold (a small raised tile step) from the anteroom into the stall area, but ONLY once protective clothing has been put on. Each Isolation stall has a smaller area immediately adjacent to the exterior door where the following should be located: Biohazard trash, hooks for hanging disposable coveralls before exiting the stall area, and a hose for providing water to the patient. No extra feed or hay should be stored in this area, since the drain in the center collects feces and urine, potentially contaminating feedstuffs stored here. The stall itself may be entered through the metal gate.

VI. Doctor/Student/Caretaker Exit Isolation Stall
4.6.1. Upon leaving the Isolation stall area, no equipment, feed, or hay shall be left on the floor outside the Isolation stall itself. Disposable trash shall be placed in the red Biohazard bag. Sharps shall be placed in the sharps container on the shelf in the anteroom. When trash or sharps containers are nearly full, caretakers or the EQMS technician shall be notified to allow him/her to properly bag the contents for appropriate disposal. The following procedure should be utilized to exit from the isolation stall to the anteroom:

1.  Disposable boots shall be removed while still wearing gloves and shall be placed in the Biohazard trash. Once the plastic boots have been removed, stand on the top of the threshold step to minimize contamination
2. Unzip isolation suit first. Then remove gloves and place in the Biohazard trash. The hands, without gloves, shall be pulled inside the sleeves of the isolation suit during suit removal. 
3. Stand on the ledge during removal of the isolation suit. If not overly soiled, overalls should be hung on the hooks in the stall area for re-use with the same patient at a later date.

VII. Isolation Anteroom

1. Enter anteroom by stepping into footbath located inside the threshold.
2. Wash and dry hands thoroughly for 20-30 seconds with soap or detergent equivalent in anteroom sink. No equipment or supplies shall leave the anteroom with personnel at this point. 
3. Samples for laboratory analysis (blood samples in vacuum tubes, exudate in tubes or on culture swabs, feces in sealed plastic containers) may leave the anteroom only once properly placed in an additional sealable plastic bag.

VIII. Isolation Hallway
Personnel may then leave the anteroom into the Isolation hallway, taking care again to step into the foot bath provided.

IX. Footbaths
Care and cleanliness of footbaths will be the responsibility of the student who is assigned the case. The bleach (1part bleach: 9 parts water) baths must be changed twice daily: organic material makes them ineffective. Keep them clean and refill as needed. The bleach solution should only be deep enough to cover the bottom of shoes.

X. Equipment Entry
Equipment from Isolation stores or the open wards may enter isolation through the anteroom door. Once in the anteroom, equipment shall be considered semi-contaminated and shall not be returned to the wards without proper disinfection.

XI. Equipment Exit
Disposable equipment and material shall be thrown away in the red Biohazard trash containers found individually in each Isolation stall. Non-disposable equipment should be bagged and tagged for careful return to Central Sterile for proper cleaning and sterilization (steam or gas, where appropriate). The EQMS technician shall be notified immediately to pick up this nondisposable, contaminated trash bag from Isolation stall anteroom.

XII. Caretaker Duties
For cleaning and feeding, one caretaker enters and exits the stall through the normal hallway/anteroom/stall procedure outlined above. A second caretaker does not enter the stall but remains at the open exterior door and carefully hands the inside caretaker feed, hay, or bedding from outside the external door. Carts for removal of bedding and feces shall not be rolled into any Isolation stall. Instead, the cart shall be placed at the opening to the exterior door while the inside caretaker cleans the stall, placing all disposed bedding and feces into the cart. 
Care must be taken NOT TO CONTAMINATE the wheels or the outside of the cart leading to cross-contamination to another Isolation patient. AT NO TIME should a caretaker who has been inside the stall, even wearing protective clothing, move outside the external door to another stall for additional caretaker duties. The inside caretaker shall exit the stall in the manner prescribed above and re-enter the next stall through the manner prescribed above. Once an isolation patient has permanently exited a stall, the stall shall be pressure-washed by the caretakers, who shall still wear protective clothing while pressure-washing and who shall dispose of the protective clothing and remaining Biohazard trash as outlined above. After the isolation area has been disinfected, the anteroom shall also be cleaned and disinfected.

XIII. Imaging of Isolation Patients
If imaging of an isolation patient is desired, then it is important that the Imaging group be notified as soon as possible. Isolation patients should be imaged ONLY as the last patient of the day, when possible, to allow Imaging personnel to wash and disinfect the Imaging suite after the patient has returned to Isolation. In this event, another EQMS student/staff member shall follow any diarrhea patient moving to/from Imaging with a Biohazard bag to remove any feces which may be expelled in open hallways. When possible and practical (for example foot radiographs for laminitis using a portable machine), a patient must be imaged either outside the exterior door to its own stall, or in the hallway corner just south of Ward 1.

XIV. Endoscopy/Electrocardiography/Ultrasound of Isolation Patients
The equipment shall be rolled to the edge of the exterior doorway of the individual Isolation stall. It shall not be plugged into outlets in any occupied Isolation stall. A dedicated Isolation extension cord shall be plugged into the outlet and brought to the doorway for plugging in equipment. The endoscope or electrocardiographic leads shall then be wiped clean with 70% isopropyl alcohol, and the computer unit and rolling table (especially the wheels) shall be wiped clean either with 70% isopropyl alcohol or chlorhexidine solution before the unit is returned to storage in the general population areas of the VMTH.

XV. Surgery of Isolation Patients
Rarely, but occasionally, an Isolation patient may require surgery. Every effort should be made to complete minor surgeries (e.g. draining lymphadenopathies) in the Isolation stall while the horse is under sedation and local blockade. Surgeries under general anesthesia may be completed inside the FAMS or EQMS surgery suites. In the event of surgery inside the surgery suites, every effort shall be made to minimize cross-contamination of the general population: surgery should be the last of the day, in a room used less often for horses (e.g. FAMS room if possible), and then the patient shall be followed to/from surgery with trash bags to collect feces if that horse has had diarrhea.

XVI. Isolation Stockroom

1. Various cabinets in Isolation Stall 1 (Isolation Stockroom) must be stocked at all times with the following equipment:
   

   Disposable gloves Disposable coveralls  Disposable plastic boot covers  Clippers, including spare #40 blades  Kool lube  Flashlight/disposable penlights/batteries  Hand Soap  Chlorhexidine solution

   Bandage material Thermometers Stethoscopes Sprayer bottles Bandage scissors Stainless steel buckets Stomach pumps Nasogastric tubes

2. Additionally, extra lead ropes, muzzles, fluid ropes, a ladder, and the aluminum hook for hoisting fluid ropes can be found in this area. Any equipment taken into an individual Isolation stall must be considered contaminated and must be sterilized, disinfected, or pressure-washed before re-entry into the Isolation Stockroom or another Isolation stall.
3. Catheter set-ups, tracheostomy kits, fluid bags, fluid lines, and surgical scrub and alcohol in smaller disposable bottles are available in Ward 2. When an Isolation case requires catheterization, a complete catheter kit should be taken to the Isolation stall to minimize forgotten equipment and to minimize unnecessary travel between the open wards and the Isolation Unit.
   
   

XVII. Food and Drinks
Food and drinks must never be taken to the Isolation area. Diarrhea in horses is often due to Salmonella spp. or sometimes Cryptosporidium, both of which are zoonotic and easily communicable to people.

Definitions (if applicable)

Personal Protective Equipment (PPE) - Personal protective equipment may include items such as gloves, safety glasses and shoes, earplugs or muffs, hard hats, respirators, or coveralls, vests and full body suits. 

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.