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The Open Practice & Client Presence During Procedures

Kenichiro Yagi, RVT, VTS (ECC, SAIM), Adobe Animal Hospital, Los Altos, California

November / December 2017|Web-Exclusive

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The Open Practice & Client Presence During Procedures

Allowing a client to watch the veterinary team perform a procedure on his or her pet takes courage. Using venipuncture as an example:

  • What if the sampling is unsuccessful? 
  • What if the patient cries in pain?
  • What if the patient struggles and blood splatters?
  • What if the owner gets scratched or bitten while trying to calm his or her pet?

Much can happen in a split second that can lead to disaster. So, why do some veterinary practices use the “open hospital” concept that allows clients to stay with their pets and watch procedures? (See Figure 1.)

 A practice design decision includes glass walls that allow owners to observe surgeries.

Figure 1  A practice design decision includes glass walls that allow owners to observe surgeries.

The Bad

Veterinary professionals often voice concerns about this policy. Here are some of the reasons:

  • Anxious pets and owners can feed off each and create a negative cycle that keeps getting worse.
  • A fearful patient is at risk of running loose and could also harm a veterinary team member or the owner.
  • Owners may risk exposure to occupational hazards (eg, needles, anesthetic gases, radiation).
  • Owners may faint and even fall and injure themselves when they witness traumatic scenes during a surgical procedure.
  • Owners may react inappropriately when they do not understand a situation (eg, grabbing the towel clamp and contaminating the sterile field because he or she thinks clamping the skin was accidental and the patient was being hurt).
  • A human medical professional intently observing a surgery may cause stage fright for the veterinary team members. (See Figure 2).
  • Owners may cause privacy concerns when they peruse another patient’s chart or become upset when they overhear another owner in the ICU being given grave news.
  • The practice can be liable for injuries (eg, an owner falls and is injured, an owner is wounded by an animal). 
 An owner looking over the veterinary team’s shoulder can be intimidating.

Figure 2 An owner looking over the veterinary team’s shoulder can be intimidating.

Meeting the Challenges

Despite these challenges, practices believing in the benefits and embracing the open hospital concept are not unheard of. Fortunately, many challenges can be minimized. (See Table 1.)

Table

Challenges & Solutions to the Open Hospital Policy

ChallengesSolutions
Occupational hazardsSetting ground rules and ensuring regulations are followed
Obstruction of procedure from lack of understandingExplaining procedures and warning about tasks that seem unusual to owners without a medical background
Delay of a scheduled procedure because the owner cannot be contactedSetting strict policies and obtaining agreement to start procedures on schedule
Maintaining privacySetting and enforcing policies to cover charts, and dictating that team members use discretion
Fearful or anxious ownersGiving owners the option of staying without ever forcing them, and encouraging them to leave if they are negatively affected
Patients that are fearful or anxious only when owners are presentEncouraging owners to leave on a case-by-case basis, depending on what works best for the patient
Team member stage frightUsing only experienced, confident team members to perform procedures in the owners’ presence
  • Use the open hospital concept to let the owner know exactly where the patient is, which leads to transparency and trust. An owner left alone to wait in the examination room for his or her pet may hear animals vocalizing, raised human voices, and commotion and begin to imagine his or her pet is suffering and wonder What is happening with my pet? That fear can be dispelled with an open hospital policy.
  • Allow the owner to see the facility, instruments, and monitoring equipment, and to witness the team’s expertise during a procedure (eg, foxtail probe, dental procedure). Seeing the difference in the pet’s teeth before and after a dental procedure helps the owner not only appreciate the value of the veterinary service but also understand the cost of the service, which may even minimize invoice disputes.
  • Allow the owner to listen to the veterinary team as they formulate a treatment plan (eg, for a pet’s wound to heal). Incorporating the owner into the care team can help the owner connect with the team and understand the healing process and may improve compliance.

The Good

Allowing clients to stay with their pets does have benefits.

The veterinary team will gain understanding of and competence in the various procedures as well as improve their communication and listening skills when they regularly explain procedures to owners.

With owners frequently present, the practice culture will shift toward team members consistently presenting themselves as professionals in their work ethic, their own cleanliness and that of the practice, and during patient care and client interactions. Owner absence should not affect any of these factors; however, owner presence will better ensure accountability.

Veterinary team‒client interactions help make veterinary care personal (eg, a veterinary nurse who introduces him- or herself and explains his or her role will make an individual connection that will allow the owner to better recognize the various team roles).

Owners will become familiar with team members and become more invested in their pet’s care when they feel part of the team, and the transparency, competence, and confidence will solidify trust. 

Initiatives focusing on alleviating patient stress (eg, Fear Free) advocate that owner presence in the practice promotes better medicine. 

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Making the Change

Implementing an open hospital policy may seem difficult or even impossible, but many practices actually already practice openly to a certain degree. (See Table 2). Practices are encouraged to gradually expand on areas in which the team can accept owner presence to steadily change the culture. 

Table

Degrees of Openness Within a Practice

LowLow-MidMid-HighHigh
  • Physical examinations
  • Light restraint
  • Vaccinations
  • SQ/IM injections
  • Minimally invasive tests
  • Examination
  • Blood draw
  • Simple sample collection
  • SQ fluids
  • Oral medication administration
  • Radiography
  • Ultrasound
  • Noninvasive monitoring
  • Sedation procedures
  • Short visits
  • IV injections
  • IV catheter
  • Invasive procedures
  • Routine anesthetic procedures
  • Extended visiting hours
  • Postadmission or stabilization
  • Tube placements
  • Paracentesis for evacuation
  • Nonroutine anesthetic procedures
  • Open visiting hours
  • Admission
  • Emergency procedures
  • CPR

Suggestions to start on this path:

  • Commit to a culture change, because it is one.
  • Survey the team and address and alleviate their hesitations.
  • Gather input from clients to gauge demand. 
  • Develop client-friendly treatment areas.
  • Train team members on low-stress techniques and client education.
  • Maintain a presentable practice environment at all times.
  • Implement open areas in stages, with a clear policy for when client presence is acceptable. (See Table 2.) 
  • Periodically survey the team and clients to gauge progress and evaluate any new hesitations that may need to be addressed.

Conclusion

Many human and veterinary medical professionals believe family presence causes physiologic and mental stress to the patient,1 but research in human medicine shows visitation decreases patient anxiety, confusion, agitation, cardiovascular complications, and hospitalization duration, and improves patient satisfaction and sense of security.2 (See Figure 3.) Evidence also shows that family members experience less anxiety, better communication, and greater understanding of the patient’s situation when they are allowed to be present with the patient.1,3 Even in traumatic events (eg, CPR, death), families allowed to be present experience less emotional distress and faster recovery through the grieving process.4

 An ICU patient rests comfortably in the owner’s arms.

Figure 3  An ICU patient rests comfortably in the owner’s arms.

Owner presence in the practice is about carefully considering the pros and cons and creating trust. Parents would not accept their children being taken “to the back” when seeing a pediatrician, so why this is normal in veterinary medicine should be questioned. 

Editor’s note: The author dedicates this article to David Roos, DVM, who cofounded Adobe Animal Hospital in Los Altos, California, and has been using the open hospital concept for more than 50 years, and the Adobe team that continues to carry out the philosophy after his retirement.

References and Author Information

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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