Veterinary Times reporter Robin Fearon
reports on efforts by Jill Moss to persuade veterinary practices to introduce better infection control polices following her dog Bella's death from the so-called "superbug" MRSA
WHAT does a pet owner do if his or her animal contracts a serious infection while undergoing surgery at a local, trusted veterinary practice? And how is he or she supposed to react if the pet then dies weeks later, suffering on the surgery floor while the veterinary staff refused to administer suitable treatment?
That's the nightmare situation that dog owner, Jill Moss, claims she faced in August 2004 when her I0-year-old Samoyed, Bella, died after post-operative complications caused by the "superbug" methicillin-resistant Staphylococcus aureas - or MRSA as it is more commonly known.
Glut of information
There has been a glut of information released by the Government and its health agencies about methods to combat the spread of MRSA in hospitals and health clinics. But as of yet there has been no serious governmental consideration of the phenomenon in veterinary hospitals or smaller practices.
It's something Jill Moss is campaigning hard to get recognition for through her website www.pets-mrsa.com, launched in conjunction with her friend Mark Dosher. Both are concerned about the RCVS practice standards scheme, which succeeded the standards adopted by both the British Veterinary Hospitals Association and BSAVA from the beginning of this year.
Their concern relates to the clinical accountability of vets and the lack of response their concerns have had from the RCVS disciplinary committee. But most importantly, they say, the standards will merely serve to raise expectations in pet owners that cannot be met. The net result, they feel, could be a greater degree of alienation between aggrieved pet owners and the veterinary profession.
"I have spoken to the Royal College on this. I asked if this scheme is going to become compulsory and was told 'yes, eventually'," said Mark.
"But the real question is that if there is not going to be any question of real accountability on this, how can those standards ever be made effective?"
It's a question that deserves a credible answer. But it is one that Jill and Mark feel the RCVS is presently reluctant to answer. Jill claims she tried to initiate disciplinary proceedings based on the fact that Bella contracted MRSA at the practice she'd taken her dog to for knee cruciate ligament surgery, but was told it "was not within the current jurisdiction of the RCVS".
This was not a one-off veterinary visit, but the same practice she had attended - and trusted with her pet's health - for the previous four years. When Bella went lame and collapsed due to infection raging throughout her body after surgery, despite regular home visits from her vet, Jill asked to be referred to another veterinary hospital.
They dealt with the infected wound and Bella's condition improved, but after returning home the dog became ill again. And on a second admission to the referral vets, cultures showed that MRSA and Pseudomonas bacteria were present.
Around 30 percent of the UK human population is estimated to be colonised with normal S. aureas bacteria, and an unspecified proportion with MRSA through hospital contacts or through visiting elderly relatives in sheltered accommodation.
Neither Mark nor Jill are colonised with MRSA as both claim to have tested negative. At present there is no research material available to suggest that animals are either colonised with MRSA or are able to pass it to their owners, and the lack of such scientific data creates a vacuum when it comes down to procedures in veterinary practice.
"We will never know if an animal has been colonised because, at present, there's no research being done into healthy animals," said Jill.
"So how do we know if animals are colonised or not? When they get MRSA is it from a member of veterinary staff or could it be that they are colonised and it's living on the skin?"
Mark continued: "Bella's infection has been characterised as 'bad luck'. "I think that getting one serious infection post-operatively might conceivably be thought of as bad luck, but Bella had two.
"To me, to be able to introduce two virulent bacteria into an operating wound in the same procedure takes some doing.
"One of the consequences of having a culture where your clinical actions are never questioned means that you never have to think about the consequences of what you do," he added. Despite their strong feelings, both Mark and Jill insist that they have no intention of becoming an adversarial group attacking the profession. And they say the feedback and opinion they have been getting to their website has so far been almost universally positive.
Jill, however, feels she has got a number of reasons to feel aggrieved following the manner of Bella's sudden death. The principal vet of her local practice was not there to oversee the admission, members of staff were not even aware that they were handling a case caused by MRSA and when they did find out, Jill says, pandemonium ensued. She claims she was put into a consulting room by herself while the nursing staff refused to help because of the possibility of contracting MRSA.
Condition worsened
Bella's condition then worsened until there was no option but to put the dog to sleep.
"I'm not asking for the vet who operated on Bella to be struck-off, but Bella was a healthy animal," said Jill. "From my point-of-view it's about getting veterinary practices to recognise that this infection does exist and infection control policies need to be introduced, such as barrier nursing techniques."
Mark concluded: "We both accept that MRSA is not the most significant infection that can affect a pet.
"But it's a metaphor for the failure to address infection control and to keep up with contemporaneous standards in human medicine. There shouldn't be a difference."
Response
Lynne Hill, chairman of the RCVS practice standards working party, has responded at length to the concerns highlighted by Jill and Mark following the case of Bella.
She iterated the constraints of the current RCVS Guide to Professional Conduct.
She said: "It sets out a veterinary surgeon's responsibilities towards patients, clients, the general public and professional colleagues and makes clear that accessibility, accountability and transparency are fundamental to the regulation of the veterinary profession.
"However, the RCVS, along with other regulatory bodies, can only investigate issues of fraudulent registration, criminal convictions and professional misconduct. "It has no power, currently, to address other issues such as professional negligence, which would be a matter for the civil courts unless the negligence was so serious that it could amount to serious professional misconduct," she added.
Assurance on standards
Mrs Hill said the introduction of practice standards will almost universally provide greater assurance for veterinary clients. She said: "The RCVS practice standards scheme is an amalgamation of a number of former schemes, but with even more benefits for veterinary practices and their clients. "The new scheme's primary objectives are to establish a quality assurance framework to promote and maintain the highest standard of veterinary care and to make more information available about veterinary practices, so giving clients greater choice.
"Far from alienating clients, the additional information provided by the scheme (available on the RCVS website) should help them to understand exactly what services and standards they can expect from their veterinary practice," she added. "The standards are not limited to premises and equipment and are extending to clinical issues. `As the standards are developed and adopted by the profession they will provide a proactive means of voluntary regulation by means of advice and inspections, to supplement the limited powers under the current legislation to react when things go wrong," said Mrs Hill.
As to making practice standards mandatory for veterinary practices, that may well become a political expediency. "With a new Veterinary Surgeons Act on the horizon, aspects of the scheme may indeed become mandatory for all veterinary practices," Mrs Hill continued. "We certainly recognise infection control as an area of veterinary practice standards that needs to be upheld, and that MRSA, albeit but one example of this, is of increasing importance," she said.
"Infection control is addressed in the scheme under 'clinical governance', along with other issues like mortality and morbidity, wound breakdowns and anaesthetic deaths. "It is also covered widely in other sections of the standards including staff, premises and outpatient facilities, in-patient facilities and safety procedures.
All accredited practices must implement a standard operating procedure for the isolation and care of infectious diseases and there are additional requirements for 'Tier three' practices to provide for barrier-nursing." And she concluded: "I am also aware of current research that indicates healthy animals can carry MRSA, so it need not necessarily be passed to an animal from a member of veterinary staff or, indeed, the animal's owner.
"MRSA is a relatively new area for the veterinary profession. However, we will continue to develop the RCVS practice standards scheme as and when new information from research becomes available."
Meanwhile, other organisations are already starting to face up to the potential problems that could be caused in the future by MRSA. Spokesman for the BSAVA, Alistair Gibson, said the association was taking an active role in the discussion surrounding MRSA in domestic and pet animals. He explained: "This interest pre-dates the recent publicity concerning this topic. The association has formulated a position statement on MRSA and this can be accessed on the BSAVA website."
Authoritative paper
Mr Gibson said knowledge on MRSA was increasing. He continued: "An authoritative paper on the subject, written by Dr Tim Nuttall of the University of Liverpool, has recently been published in the Journal of Small Animal Practice.
"Dr Nuttall, a member of the BSAVA's scientific committee, has also been instrumental in producing a series of guidelines to help deal with the MRSA problem in a clinical setting.
"This information, produced for Liverpool University's Small Animal Hospital, should prove of immediate benefit to veterinary hospitals and clinics throughout the country.
Veterinary Times, February 7th, 2005
