The most critically ill horses at New Bolton Center are those with gastrointestinal conditions or contagious diseases. Our James M. Moran, Jr. Critical Care Center, which opened five years ago, is designed specifically for these patients.
The facility has been very successful, not only making treatment more effective, but also virtually eliminating the spread of disease within the hospital.
The self-contained, climate-controlled building has two separate wings, one for colic patients and one for patients with contagious disease, with a total of 24 stalls. The facility’s many state-of-the-art features are designed to prevent the spread of infectious organisms such as bacteria and viruses.
“A tremendous amount of thought went into the design of the building, considering how to best deliver intensive patient care in a biosecure environment,” said Dr. Raymond Sweeney, New Bolton Center’s Chief of Internal Medicine. “It is a very important part of the hospital, a huge factor in the level of care we can provide.”
Sweeney is quick to point out, however, that the veterinarians, students, and nurses are the most important part of patient care. New Bolton Center has an emergency team available 24 hours a day, 7 days a week, that includes senior, board-certified veterinarians in Emergency/Critical Care, Internal Medicine, and Surgery, who supervise the additional staff of residents, interns, students, and certified veterinary technicians.
One of those veterinarians is Dr. Barbara Dallap Schaer, New Bolton Center Medical Director, and a large animal veterinarian board-certified in both Surgery and Emergency/Critical Care.
“We work as a team to care for our patients, and this facility allows us to give the best possible care,” Dallap Schaer said. “The building and the service go hand-in-hand: the building makes us more efficient and facilitates the excellent care.”
Preventing the Spread of Disease
The Moran facility stands alone, separate from the other buildings at New Bolton Center hospital, to prevent contact between patients considered high infection risks and low-risk healthy patients.
“The main goal is to keep those very sick animals away from other horses in the hospital in case they are carriers, and prevent them from transmitting diseases to another patient,” Sweeney said.
Dr. Helen Aceto is Director of Biosecurity at New Bolton Center, and also an Associate Professor of Veterinary Epidemiology.
“The Moran Critical Care Center has been remarkably successful in containing contagious diseases, while delivering the very best patient care, which usually means very intensive management of cases and a lot of traffic in and out of the patient’s stall,” Aceto said.
The design of the facility itself and the additional biosecurity procedures have virtually eliminated spread of pathogens between patients, she said.
- The self-contained stalls have doors to the outside for animals to enter and exit and for stall cleaning. Interior corridors are only for people, who must follow biosecurity protocols, such as wearing dedicated footwear.
- The air-handling system is designed to prevent the spread of airborne pathogens: the clean central corridor is at positive pressure relative to the stalls so that air flow is from clean to dirty. Each stall is independently ventilated and can be climate controlled, so the air from one stall does not mix with air from another.
- Each stall has dedicated oxygen and fluid administration equipment, and air used for a ventilator and vacuum.
- Cameras located in each stall are connected to the central nursing stations in both wings and can also be viewed remotely for around-the-clock monitoring.
- Special extra-large stalls can accommodate mares and foals with a removable, half-wall barrier so they can be separated, but still in close contact.
- Both wings have their own procedure rooms, equipment cleaning and storage areas, and separate entry areas used to change footwear.
- Pharmacies on each side serve only the facility’s patients. Fluids are stored in separate, climate-controlled rooms in each wing.
- Most interior surfaces are smooth, specifically designed with the least possible nooks and crannies for bacteria to hide in, making them easy to clean. Isolation wing stalls each have a separate anteroom between the clean corridor and the stall. The anteroom is complete with a sink and disinfectant materials. Equipment dedicated to each patient is stored in the anteroom.
Colic, a broad term to describe several gastrointestinal problems, is the number one killer of horses. When a horse has an intestinal condition or parts of the gastrointestinal tract get displaced from their normal position or twist, it can affect the blood supply to the intestine. Bacteria from the gut can leak and be absorbed into the circulatory system, which can lead to septic shock.
Many of these patients need surgery, and are some of the sickest in the hospital. New Bolton Center treats an average of 325 horses for colic each year, 60 percent managed medically, and 40 percent with surgery, Aceto said.
An adult horse with diarrhea can require up to 100 liters of fluids a day, which makes the onsite fluid storage rooms very important.
“They need constant monitoring, fluids, and medication. The Moran building is designed to accommodate that,” Sweeney said. “It allows for our clinicians and nurses to provide around-the-clock attention as efficiently as possible.”
Any patient that comes in with diarrhea immediately goes into the isolation wing of the Moran Center, as does any horse with clinical signs or a clinical history consistent with other contagious diseases, such as strangles, equine coronavirus infection, rotavirus, or Potomac horse fever.
The biosecurity protocol is stricter in the isolation wing than in the colic wing. Anyone working with a patient must dress in surgical scrubs and put on dedicated footwear to enter the isolation wing. Additionally, before entering the anteroom, people must put disposable coveralls over their scrubs and wear disposable plastic boots, disposable gloves, and a disposable cap. Once in the anteroom, they must also put on disinfected rubber boots before entering the stall.
Immediately upon leaving the stall, the rubber boots must be placed in a disinfectant tray. Before leaving the anteroom, all of the protective clothing must be removed and disposed of, and hands washed. And then, before leaving the isolation wing, they must change out of the dedicated shoes. Finally, before leaving the building, they must remove scrubs and change back into their regular clothes. Scrubs are laundered once daily, or more often if necessary.
“It’s expensive and labor intensive, but that’s what we do to make sure we don’t spread anything from the isolation population,” Sweeney said.
The building has more stalls than are needed for “planned vacancies,” to give enough time to thoroughly scrub and disinfect a stall and run culture tests for Salmonella before another patient enters.
Salmonella as a Biosensor
“We use Salmonella as our biosensor because it is, without a doubt, the most prevalent cause of hospital-associated infections in large animal veterinary teaching hospitals,” Aceto said, noting that Salmonella is an effective biosensor because it is easy to detect, survives well, is difficult to kill, and can spread easily. “Salmonella is a good indicator of the effectiveness of an infection control program.”
According to Aceto, surveillance data gathered at New Bolton Center, at other veterinary schools, and by the U.S. Department of Agriculture have shown that, at any point in time, about 1-2% of normal horses might be shedding Salmonella organisms in their feces with no clinical signs. Despite the fact that there are horses in the general population that might be shedding Salmonella, this rarely causes a problem in groups of healthy horses.
However, published data shows that horses with colic are about 8-10 times more likely to shed Salmonella in their feces, should they be harboring it in their gastrointestinal tracts when they become ill, Aceto said.
Additionally, horses with colic are much more likely to become infected with Salmonella or other gastrointestinal pathogens, should they contact them while ill. Logically, this should not be surprising, as the normal bacterial flora in the gut is disrupted when gastrointestinal function is disturbed, and this is compounded by stress, changed diet, medications, and anesthesia, if surgery is required.
In a hospital like New Bolton Center, where there are invariably other sick animals present, the vulnerability of the population to infection is much greater than in the general population, she said, which makes the Moran building such an asset.
Responding to a Crisis
The Moran building could perhaps be considered a silver lining to a challenging crisis. New Bolton Center hospital closed down in 2004 because of an outbreak of salmonellosis. For three months, everyone at the hospital stopped work and pitched in, scrubbing every surface of every building in the hospital, more than 220,000 square feet. Throughout the hospital, surfaces were sandblasted and repainted, floors were ripped out and replaced, and new equipment installed.
“We realized that, because of the prevalence of Salmonella shedding in horses with colic or other gastrointestinal problems, we needed to keep them separate from the general hospital population,” Aceto said, noting that the hospital at that time had an aging, six-stall isolation barn that was unable to support the critical care needs of these often very ill patients. “We also needed an upgraded isolation facility for animals we knew had infections.”
The facility became a reality in June 2010 through a combination of funding from the Commonwealth of Pennsylvania and a generous gift from Elizabeth Moran, given in memory of her son, James M. Moran, Jr.
“We vowed that nothing like the shutdown would happen again,” Sweeney said. “And it hasn’t, in part because of the Moran building.”
New Bolton Center clinicians continue to be vigilant, Aceto said. “We are prepared to adjust protocols to optimize safety and efficiency, or in response to new or emerging threats.”