We just finished our AAHA American Animal Hospital Association inspection and evaluation. Maybe it stems from my time in the Coast Guard, but we have always strived for excellent or perfect on the AAHA inspections. There are over 900 standards that the AAHA inspector looks at. Forty-six of these are mandatory. Although many of these are required by law, I have seen a lot of veterinary hospitals that do not practice this way and even laugh at me for doing some of them.

There are standards for Anesthesia, Client Service, Contagious Disease, Continuing Education, Dentistry, Diagnostic Imaging, Emergency and Critical Care, Examination Facilities, Housekeeping and Maintenance, Human Resources, Laboratory, Leadership, Medical Records, Pain Management, Patient Care, Pharmacy, Referral Standards, Safety, and Surgery. Mandatory standards are listed by MA and consecutive numbers.

MA01 Anesthetic agents are administered by a veterinarian or trained practice team member under the supervision of a veterinarian on the premises. MA03 A patient assessment is performed by a practice team member before the administration of any premedication, sedation, or anesthetic. MA05 Patients are observed at frequent intervals until fully recovered. Although you would expect this of any hospital that your pet is in, it may not be so. My banker reminded me that you could do any two of service, quality or price, but never all three. High volume, low price hospitals cannot afford to have vets do everything, and post-op monitoring can be very time-consuming. Not at Guardian Animal, but sometimes animals recover in their carriers on the floor.

Germs cannot be seen, but they can cause fatal disease. Better known as cleanliness is next to Godliness. MA10 Practice team members follow infection control policies related to personal hygiene, patient care, and disinfection of equipment and facilities. Frequent hand washing or the use of antimicrobial agents are utilized to prevent the spread of contagious disease to hands and hospital surfaces. MA11 Potentially contaminated materials are contained in impervious containers or bags before transport within the practice.

Dentistry and dental care is important but has been an often ignored health care treatment. MA11.6 All dental procedures are performed under general anesthesia with patients intubated. MA12 Veterinarians perform thorough examinations of the teeth and structures of the oral cavity in patients presented for dental procedures. MA13 Only properly trained practice team members perform dental procedures. (I am in early on a Sunday morning of daylight savings time change to learn more about advanced dental procedures.)

Most practices have radiographs or x-rays, but they all don’t have the same level of quality. MA14 Quality diagnostic images are generated on the premises. While not mandatory points were gained for DG01.1 Radiographs produced within the practice are reviewed by a Diplomate of the American College of Veterinary Radiology. DG02 The practice has a separate room devoted to imaging. DG12.1 Two aprons, two pairs of gloves, and two thyroid shields are available. (We have three of each.) DG15 The integrity of lead aprons, gloves, and collars are verified every six months. DG21 Patients are accurately measured and/or weighed per the manufacturer’s recommendations to reduce the need for repeat exposure due to improper technique. DG24 Reliable technique charts are appropriate for patients usually imaged in the practice. DG25 A reference for positioning and technique is available for practice team members.

Laboratory services are also mandatory. MA22 Services provided by in-house or outside laboratories include the following: Hematology, Serology, Blood chemistry analysis, Urinalysis, Urolith analysis, Microbial culture, Antimicrobial sensitivity testing, Fecal parasite examination, Skin parasite examination, Blood parasite examination, Cytology, Histopathology, Toxicology, Therapeutic medication level monitoring, Hormone assay, Polymerase chain reaction (PCR) testing, Fluid analysis, Coagulation testing, Serum electrolytes and Other specialized testing as deemed appropriate.

There is a whole section on pain assessment alone. MA23 Pain assessment is considered part of every patient evaluation regardless of the presenting complaint. MA24 Pain management is provided for the anticipated level and duration of pain. PM02 Pain management is individualized for each patient. PM03 The practice utilizes preemptive pain management. PM07.1 The practice provides ancillary methods for treating pain – e.g., massage, acupuncture, laser therapy, warm or cold compresses. PM08.1 The client is educated, verbally and in writing, on how to recognize signs of pain including potential benefits and adverse effects of pain management therapy.

MA35 Child-resistant containers are used unless the medication is in a form that precludes it from being dispensed in such a container or the client declines the child-resistant container.

MA36 All surgeries are performed by a licensed veterinarian. MA37 Surgical suites are separate, closed; single-purpose rooms entered only for activities associated with aseptic surgical procedures. MA37.1 Clipping and initial cleaning of the surgical site is performed outside of the surgical suite. MA39 Sterile instruments, towels, and drapes are used when major surgery is performed. MA41 Practice team members within the sterile field during major surgery wear proper attire including MA41a: caps and masks, MA41b Sterile gowns, MA42 Sterile single-use surgical gloves are utilized in all surgeries. MA43 Separate autoclaved or gas sterilized surgical packs are used for each surgical procedure. (There are many examples on TV and YouTube of surgeons without proper attire.)

The inspector was amazed at the equipment, services, and space that we had at Guardian Animal Medical Center. MA20 Client and patient areas of the practice are neat, clean, and well organized.

To be fair, there are hospitals that do a very good job that are not AAHA Accredited. And while we passed without a problem, we always try to do a lot more than pass. We strive to meet all of the standards, but some are not economically or ecologically feasible. But because we always strive to do better, many times we have met the standards before they are published. Indeed, instead of taking a break, I will be looking at the new hospice and oncology guidelines to see if there is anything we can do better.

It started Monday morning at 8:00 a.m. with two black lab/Weimaraner puppies, Tucker and Tank. They were coming from the ER, where they had been diagnosed with parvovirus. Parvovirus is a very common, highly contagious viral disease that is very resistant to the elements, so it is basically everywhere.  The first time an unprotected dog comes in contact with the virus, it gets sick in 3 to 10 days. Some dogs get very sick, others not as much.

Tucker had a very, slight cough in the exam room, so I cautioned the owners about other diseases like canine distemper and influenza in combination with the parvovirus. A CBC (complete blood count test) gives us some idea about prognosis. A standard or only slightly decreased white blood cell count is a good sign. Parvovirus affects all rapidly dividing cells. These are usually the gastrointestinal cells (which turn over every seven days), the bone marrow (which turn over every 3 to 10 days) and in very young puppies heart and other tissues.

The dying gastrointestinal cells are what cause the classic vomiting and diarrhea. The disease usually starts with not eating, then progresses to being sick with vomiting and diarrhea. The diarrhea is secretory diarrhea where the body secretes fluid to make diarrhea. The intestines bleed or slough off chunks of mucosa or inner lining. The bacteria of the GI tract starts to putrefy (rot) the dead intestine and the smell is extremely foul. Parasites just damage the GI tract even more.

La Rue comes in next and is a cute little fluffy German Shepard puppy that is not eating and has diarrhea. La Rue’s parvo test is strongly positive, his CBC is moderately depressed, and his fecal was negative. Like the other two puppies, La Rue is started on IV fluids, IV antibiotics, dextrose, electrolytes, anti-vomiting medicine, and vitamins. He is the third patient to join the intensive care isolation.  Each of our parvo-cages has a separate drain and separate ventilation.  Gowns, gloves are worn in the room and changed between patients.

Poppy arrives on Wednesday morning and is the next patient. Poppy is the little brother to Tucker and Tank. His owner is right on top of Poppy.  Poppy is indeed positive for parvo-virus. (If the test is not enough proof of this, Poppy has a blow out of bloody squirty diarrhea all over Josh’s pants.) Poppy’s diarrhea may be impressive, but his CBC is just moderately depressed.  We now have four puppies in isolation.  Our record is thirteen at one time. There were 6 to 7 in a litter of Dalmatians and then various other dogs. All of these pups now have IV fluids, IV antibiotics, dextrose, electrolytes, anti-vomiting medicine, and vitamins. All are on an IV pump to make sure that they get their fluids promptly. We see them through windows, routine checks and on the security monitor.

(But wait, there is more!) Thor is the next puppy to come in.  He is an older yellow lab pup and cute as a button, but sick.  He looks miserable. Money is an issue, but the owner promises to pay.  It is too soon since Ranger died and I relent on an adequate deposit. Money is often an issue in parvo cases because veterinarian vaccinated dogs rarely get parvovirus. In fact, Tucker, Tank, Poppy, La Rue, and Thor, all have had vaccinations from an over-the-counter place. Sometimes the vaccine is not handled correctly, sometimes it is not given correctly, or the correct schedules and vaccines are not used.  People think they are saving money on the same thing, but it is not the same vaccine, and they are not. Because these pups are not protected, their owners will spend far more on treatment than they would have on veterinary vaccines. Of course, many probably couldn’t afford veterinary vaccines, which is why they try OTC vaccines. Then they really cannot afford parvo-virus treatment.

La Rue is the first to go home. He started looking good and then we slowly introduced bites of special bland prescription food. La Rue and Tank both ate their first bites at the same time, but Tank relapsed and vomited his back up. La Rue and Thor have not been affected nearly as much as Tank and Tucker. Both move out of parvo-isolation-intensive care into step-down isolation-care. Thor can go home on by Thursday, but the owner is unable to be reached at any of the five phone numbers that we have.  It is bad enough that we may not get paid, but to not even answer the phone to find out how Thor is doing seems cold to me.

Caught earlier or not as bad, Poppy will go home on Friday, the same day as Tank. Tucker will be left behind on IV fluids and intensive care. I caution the owner that the greenish snot is not a good sign.  We consider euthanasia, but after force-feeding, he wags his tail. I wish for a crystal ball, so I could know exactly what to do. I fear that we have cured his parvovirus, but his weakened immune system has allowed him to catch an even worse disease. He has enough fluids to last until morning, so we decide to wait until morning to make a decision. By morning, he is dead.  Even without complicating factors, we only save nine out of ten parvovirus dogs.  Some are too sick and do not survive under the best of care. We are proud that Tank, Poppy, La Rue went home. I really wish Thor’s dad would answer our calls. We are all sad about Tucker. It is the way of veterinary medicine that we will always remember Tucker.

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