CHAPTER 7 Standards of Care in Pediatrics
Puppies and kittens make up a large part of the private small animal practice. Developing and implementing a pediatric wellness program and standard of care are important aspects of ensuring consistent, comprehensive health care for pediatric patients, as well as promoting a long-term, client-practice bond. One of the best ways to begin this process is to establish a pediatric standard of care that is unique to your practice. A properly developed standard of care ensures that all puppies and kittens receive consistent care during their individual office visits and throughout their long-term pediatric care. According to the New England Journal of Medicine, standard of care is defined as a diagnostic or treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.
Having an established standard of care is an excellent reference for anyone (head technician, receptionist, new graduate, or newly hired yet experienced associate) to determine what should be done in almost any situation in a practice. This chapter focuses on the standards of care for pediatric wellness visits. These standards are not intended to be hard and fast rules but rather guidelines to follow in frequently encountered situations. These guidelines allow veterinarians to establish more consistent patient care and practice better medicine as a result of improved client understanding and compliance.
Consistent patient care will better aid clinicians in making sure every client is receiving similar information. Even clinicians within a practice have different interests and practice styles, which lead to similar cases being treated very differently within the same hospital. A written standard of care would ensure that every client, regardless of which doctor is seen, would be leaving the practice with a predictable set of information and recommendations. This is particularly important in pediatric cases because it gives each subsequent veterinarian confidence in what information and treatments were given in the prior visits. In the pediatric wellness examinations, an important part of the veterinarian’s job is to educate the client. A client who hears the same or similar recommendations from different sources within the hospital is much more likely to comply with those recommendations. For example, one veterinarian in a three-doctor practice may feel that strictly indoor cats do not require feline leukemia virus (FeLV) testing. The second veterinarian may recommend testing only in multiple cat households. The third veterinarian may recommend testing for all cats but leave it up to the client to decide. Inconsistencies create confusion with clients, as well as support staff, and the client is much less likely to follow any of the recommendations given.
A pediatric standard of care allows clinicians to practice better overall medicine. Every private small animal practice experiences busy days, juggling multiple patients simultaneously. With an established set of guidelines and protocols, there is less chance of omitting a FeLV test, failing to recommend a fecal flotation, or forgetting to discuss a particular aspect of behavior and training on those busy days. The pediatric visits are more likely to become a complete health care program, both medically and behaviorally, rather than a series of vaccines and deworming.
The most important aspect of establishing a standard of care is that it must be in written form. If it is not written, it does not exist. Everything must be documented within a medical chart, from recommendations (both accepted and declined) and treatments to telephone conversations with clients; thus a hospital must have written standards of care.
The first step is to schedule a doctor’s meeting. Having the meeting outside of the hospital may be a good way to avoid distractions and interruptions. This is a team effort in which all doctors within the practice should contribute to create the pediatric standard of care. If everyone is able to contribute to the plan rather than having it dictated, there will be better success in following the plan that has been created. During the initial meeting, a list of areas that need standards to be developed can be generated and agreed on. The American Animal Hospital Association (AAHA), American Association of Feline Practitioners (AAFP), and Veterinary Information Network (VIN) are good resources for guidelines and can easily be tailored to fit a practice style.
Training the support staff on the newly created plan is a crucial part of the process. Each member of the staff needs to adhere to the plan to make sure the desired message is being delivered to the client at any point in their visit to your practice. Whether it is the receptionist, the veterinary assistant, or the technician delivering the message, the information given to the client should be the same. Regular staff meetings can be used to educate staff on the standards and to review and reinforce the protocols and standards of care. A list should be generated of the top 25 to 50 most frequently asked questions that are fielded by the receptionists and technicians, and the written answers to these questions can serve as a source or script for those staff members. Written protocols and standards of care guidelines aid in standardizing and enhancing the training of new staff members. A test bank of different topics from the pediatric wellness visits (or any other aspect of a practice) can be created, and staff members can be periodically tested on the information. For example, how often are vaccinations given, what are the available canine vs. feline vaccinations, or what are the common internal and external parasites of puppies and kittens? Once these tests are completed and scored, many practices will reward successful staff members. Rewards could be gift certificates, staff parties, or pay raises.
The first pediatric visit generally occurs between 6 to 8 weeks of age. An adequate amount of time should be established for the first pediatric wellness visit. Creating 30- to 40-minute office visits allows doctors and technicians ample time to address all topics identified in the plan, as well as answer any questions the client may have. Some may contend that this amount of time is too much for a busy practice; however, if it ensures that the puppy is well socialized and trained, then the time will be recouped in future visits (instead of having to muzzle or deal with an unruly patient). Generally, there is too much information for the average client to digest on the first visit, especially if this is their first pet. It is recommended that information be divided into smaller sections to be discussed at each of the scheduled pediatric visits, so the client does not become overwhelmed. The pediatric visits are an opportunity to educate the clients, to make sure they understand the plan of care and recommendations, and to make sure their new puppy or kitten is going to be a good fit for their family and lifestyle.
A written handout should be created for the initial and subsequent visits. There are typically 3 to 4 pediatric visits between the ages of 6 to 20 weeks (corresponding with vaccination dates), depending on the age of the pet when it is first seen. Each visit and handout should cover different selected topics. A list of suggested topics can be found in Box 7-1. Since there is a large volume of information to be given to the new puppy or kitten owner and the average client remembers about 25% of what they hear, alternative learning aids are helpful. Systematically transferring information into smaller, easier-to-digest sections in a written format for the client to take home is a significant tool in client education.