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Medical SOPs: lifesaving, step by step

Defining standard veterinary procedures can ensure consistency and help you save more lives

From Animal Sheltering magazine September/October 2012

Having medical SOPs in place can help guide staff through the initial diagnostics that can save animals’ lives.

Does the idea of writing medical standard operating procedures (SOPs) give you palpitations? You are not alone! Many of us get the blues when this project comes up, and tend to procrastinate on developing them. As a result, shelters often scramble to put SOPs into place only at the very time they are most needed—when a major problem has already occurred. By then, numerous lives may be affected, and the shelter’s reputation in the community may even be at stake.

Developing a solid set of written protocols to be used from the moment animals enter a shelter until they leave is integral to maintaining shelter health and wellness. SOPs matter because they help prevent widespread problems, allow resource conservation, and can help shelter staff evaluate what is working and what may not be. They also provide a consistent, documented standard of care that is transparent both internally and to the public.

There are many resources available to help shelters in overall SOP development. This article provides specific information about basic medical SOPs, and is designed to underscore their necessity in every shelter health program.

Like a Human ER

It may help to think of each animal coming into the shelter as a “patient,” one needing both immediate care for any existing injuries or illness, as well as protective care during a shelter stay. Shelters are very similar to human hospitals in this regard, and we can learn a great deal by using human hospital operations as a direct framework for shelter medical SOPs.In the check-in area of the emergency room of any hospital, people display a spectrum of health issues. The intake area of most shelters is quite similar. Animals may enter in good health, or may be pregnant, injured, already ill, or otherwise immune-compromised. As in a hospital, each individual coming in needs to be cared for properly and promptly to maximize the patient’s potential for going home healthy, and going home quickly. Without written protocols to guide this process, many things can go awry, making a positive outcome less likely.

Imagine a man who goes to the ER with a broken leg but has an underlying heart arrhythmia. Let’s say he clearly needs surgery for the leg, and the intake nurse routes him up to surgery but does not follow the standard operating protocol that requires listening to the patient’s heart. The patient could die in surgery. This would be a major hospital problem!

Similarly, picture a dog with a fracture entering a shelter where a written intake protocol does not exist. Intake staff may be uncertain whether to vaccinate an injured dog and ultimately elect not to. The dog may be placed in a kennel next to a dog who is incubating distemper or parvovirus, and thus be exposed. This patient may have the fracture repaired, only to later die from a vaccine-preventable disease. For both hospitals and shelters, using written protocols can save lives.

Disease Transmission Stops Here

In most hospitals, administrators are responsible for oversight of the overall SOP process. Ideally, shelter management staff should be in charge of maintaining a master list of current protocols, reviewing new or changed documents, and training and reinforcing use of SOPs. Every agency should have a procedure in place for determining what SOPs are necessary. Shelters can have each department list and prioritize their main tasks, or even brainstorm a list of every procedure possible (it is helpful to identify the key areas where SOPs will be most useful and have the greatest effect). These can then be written as a priority by the individuals or team in the shelter who are subject matter experts, and/or who actually perform the work. For example, adoptions staff would develop the SOPs on the adoption process, and so forth.

Veterinary staff should be called upon to draft pertinent medical SOPs. Although there is no perfect way to develop them, you can avoid getting overwhelmed by deciding which SOPs are a priority and then following that development template as you draft the others. Remember that the initial writing takes the most effort, but once an SOP exists, it is considered a “living document” that can evolve with an organization over time.

One way to get started is to work on protocols sequentially, beginning with the procedures animals require medically at the time of entry and ending with what they’ll need upon their departure. With this approach, protocols for intake examination, vaccination, segregation, etc. are prioritized. Another method starts with consideration of the most significant health problems affecting the shelter, such as commonly encountered infectious diseases. Combining input from medical staff and management, and creating predetermined protocols, can limit the effects of disease on the population, and stave off the need to respond reactively to each disease issue as it occurs.

In the human arena, an emergency room protocol for management of people with influenza virus would be especially important to prevent widespread transmission during seasonal outbreaks; in an animal shelter, protocols for the management of canine parvovirus are equally critical.

Here are six key areas that should be addressed in any disease protocol. (See the Resources box above for an example of one shelter’s parvo protocol.)

General overview of the particular disease threat – Here, factual information about the disease should be concisely and clearly communicated. Writing this section may require some research, but the content is generally not debatable and remains relevant in any shelter. The overview should contain general information about the disease, which animals and/or people it affects, transmission modes, incubation and shedding periods, and shelter preventive measures. There are many fast sources of information for this section, such as shelter infectious disease textbooks and online sources like the Koret Shelter Medicine Program and Iowa State University Center for Food Safety and Public Health.

Shelter policy – This crucial section explains the shelter’s response to animals diagnosed with or suspected to have the disease. Policies must take into consideration the disease agent, shelter philosophy, ease and cost of treatment, and impact upon the individual animal and shelter population. Policies are unique to each agency. This section should outline if animals with the disease will be admitted, whether and with whom they will be placed (with or without treatment), or if they will be euthanized. Team meetings between medical and management staff may help to reach agreement on new policies. (This section provides a clear example of the necessity of treating SOPs as living documents with regular review cycles, as policies may change over time—for example, an organization may become more capable of treating a particular disease.)

Recognition – This section provides information that will help staff recognize signs of the disease. A list of common clinical signs likely to be observed should be in this section. Because many diseases can have similar signs (distemper and parvo can both cause gastrointestinal distress, for example) and some diseases (those in subclinical/carrier states) can cause few to no signs in affected animals, it is important to define exactly what elements/symptoms the individual shelter considers indicative of a potential case.

Diagnosis – This section explains how diagnosis will be confirmed. Although there are often different tests for the same disease, this section should not be an exhaustive list of all possible diagnostics. Instead, it should define exactly what tests (if any) the shelter will use, who will perform them, when they will be performed, and what results indicate a positive case. With some conditions—such as the presence of certain parasites, when visual identification of ticks on the body or worms in the stool might suffice—diagnosis may be based on clinical signs alone and will not require tests. These, too, however, should be described clearly so that there is certainty surrounding case definition.

Response – This section explains, step by step, how the shelter will respond once a diagnosis is confirmed. Response when disease is confirmed in one animal is likely to differ from response in an outbreak situation; each possible circumstance should be described. Important steps—such as isolation measures, sanitation methods, and specific treatment—go here. A flow chart may work well to illustrate response.

Outcome decisions – Finally, the protocol should define how decisions are made regarding disposition. Criteria that establish animal(s) as recovered, ready for placement, or requiring euthanasia should be agreed upon and put in writing.

The Value of Checklists

When people go to any emergency room or doctor’s office, the initial forms they fill out are checklists used to guide the next procedural steps: Are you on any medications? Have you ever had a heart attack? Do you have severe stomach pain? Have you had a tetanus vaccine? The answers help the admitting staff strategize the next steps of patient care.In the shelter, developing simple check sheets can be a similarly powerful tool that simplifies the work involved in following SOPs. Checklists to use in concert with medical SOPs ensure that steps are completed in order, and that no actions are omitted (or unnecessary actions included). Checklists help to ensure that procedures are complete.

Each year, millions of dollars are invested in strategies to reduce patient risk in the human health care setting. It is no secret that people die every day from infections acquired in hospitals—it’s actually the fourth leading cause of death in the United States!

If we extrapolate a bit to the shelter world, we know that annually there are still millions of animals entering shelters who do not make it out alive. We also know that many of these animals, just like human patients, enter our “hospitals” well. While available resources and the current structure of sheltering make an investment equivalent to that of the human health care arena improbable, medical SOPs are a foundation in both settings to establish a means for evaluation. Without clearly documenting the current care being provided, how can we hope to understand what must be changed? Committing to create medical SOPs is one of the most important steps to take to ensure that every day more animals, no what their presenting condition, leave our shelters in increasingly better health.

About the Author

Miranda Spindel, D.V.M., M.S. is senior director of shelter medicine and development at the ASPCA.