Minimum Requirements for Certification of Veterinary Emergency and Critical Care Facilities
The Veterinary Emergency and Critical Care Society (VECCS) advocates that the following equipment and supplies are the minimum requirements for all Levels (I-III) of Veterinary Emergency and Critical Care Facilities. These minimum requirements allow veterinary emergency and critical care facilities to identify themselves using a certification process endorsed by the VECCS. The certification process is meant to raise the standard of care and increase public and professional awareness in the area of veterinary emergency and critical patient care.
PART 1: OPERATIONS OVERVIEW FOR A VETERINARY EMERGENCY FACILITY
A licensed DVM must be on the premises during operating hours.
A working relationship with a DACVECC and/or other veterinary diplomates with a special interest and experience in emergency and critical care.
A relationship with a DACVR (onsite or via the internet) for the review of diagnostic images when necessary. (Level I and II)
It is recommended that there be at least one veterinarian on duty at all times with at least two years practice experience or one year small animal internship experience. (Level I)
A DACVECC employed full time and available for consultation either on-site or by phone 24/7. (Level I)
Sufficient staff must be available to provide expedient patient care and allow:
- Processing of multiple patients concurrently.
- Performance of a wide range of life-saving procedures to include, but not be limited to, cardiopulmonary resuscitation and emergency surgery. This requires a minimum of two people, one must be a veterinarian and the other can be a veterinary technician or assistant.
- The ability to call-in additional staff as needed.
- Provision of timely and appropriate in-hospital patient care.
- Appropriate and timely consultation with veterinary specialists.
- At least two certified technicians employed full time. (Level I)
- It is recommended that there be at least one certified Veterinary Technician Specialist (Emergency and Critical Care). (Level I)
A complete and thorough medical record for each patient should be kept on file at the emergency and critical care facility. Because of the importance of legibility and availability of medical records, all summary medical records should be computer-generated, digitally stored, and backed up. Additionally, the emergency and critical care facility must comply with state administrative codes for informed consent, patient record keeping and the release of patient records.
The medical record must include but not be limited to:
- Client information
- Phone number
- Referring Veterinarian/Clinic
- Patient identification
- Sex (including reproductive status)
- Patient vaccination status
- Patient history
- Patient weight
- Vital signs
- Heart rate
- Respiratory rate and effort
- Mucous membrane color
- Mental status
- Level of pain
- Physical examination findings
- Clinical pathology tests performed and their results
- Diagnostic imaging performed and their interpretation
- Tentative and/or differential diagnosis
- Procedures performed (including anesthetic and surgical release forms and reports)
- All drugs administered, prescribed, or dispensed to include:
- Dose, frequency and length of treatment
- Route of administration
- Progress notes
- Additional treatment and nursing notes
- Client and referring veterinarian communications
- Discharge instructions, including follow-up instructions
- All entries in the medical records should clearly identify the individual(s) who administered care and entered data with time and date included.
Effective communications must be maintained to allow efficient transfer of patient information between the emergency and critical care facility and primary care veterinarians in a timely manner. It is highly recommended that the emergency and critical care facility maintain an updated list of veterinarians that includes an after-hours contact number and indicates whether or not they are willing to be contacted. A copy of the case summary including discharge instructions should be given to the clients at the time of patient discharge and a faxed or electronic medical record/report should be sent to the primary care veterinarian within 12 hours of patient discharge in order to ensure immediate continuity of care and for inclusion in the patient's permanent record.
Continuing education (CE) must be provided for professional and technical staff and must allow:
- Veterinarians and veterinary technicians to comply with CE requirements for state licensure.
- Veterinary specialists to meet specialty board CE requirements to maintain certification.
- Veterinary technician specialists to meet CE requirements of their respective specialty academy to maintain certification.
All emergency facility staff veterinarians should obtain a minimum of 28 hours of CE every two years in the field of emergency medicine, surgery, and/or critical care medicine. A maximum of six hours per two year period may be obtained via online CE courses.
ACVECC residents must be in compliance with requirements of their training program.
First year interns and new graduates for the first calendar year after graduation are excluded from this requirement.
An in house training program should be provided for all technical staff to assure teamwork and familiarity with current procedures and guidelines.
Credentialed technical staff and non-credentialed technical staff having completed the in-house training program should obtain a minimum of ten hours of CE every two years in the field of emergency and critical care medicine. This CE can be obtained through either enrollment in a college/technical program, attendance of local, state, or national CE events or documented in-house CE.
A comprehensive, written training and continuing education program to include as a minimum the following components: journal club, morbidity and mortality rounds, and wet labs. (Level I)
The emergency and critical care facility must have appropriate and comprehensive references available to the staff at all times. Refer to Part 2 of this document for a list of the required references.
Internet access to online emergency and critical care resource information must be available.
The level of care and maintenance provided in areas of laboratory, pharmacy, medicine, surgery, anesthesiology, diagnostic imaging, infectious diseases control, and housekeeping should be consistent with currently accepted practice standards and comply with state, federal, and provincial directives. Instrumentation, pharmaceuticals, and supplies should be sufficient for the practice of medicine and surgery at a level of care consistent with that expected in the practice of veterinary medicine as directed by the individual country, state, or province practice acts.
All emergency and critical care facilities must have the capacity to:
- Diagnose and manage life-threatening emergencies including cardiovascular, respiratory, metabolic, gastrointestinal, urogenital, neurologic, environmental, hematologic, hemorrhagic, toxicologic and coagulopathic problems.
- Perform procedures to address life-threatening problems including but not limited to:
- Cardiopulmonary resuscitation
- Placement and maintenance of thoracostomy tubes
- Emergency tracheostomy and tracheostomy tube care
- Blood product administration
- Oxygen supplementation
- Assisted ventilation
- Perform emergency surgery including but not limited to:
- Surgical hemostasis, wound debridement, and application of wound dressings
- Stabilization of musculoskeletal injuries
- Aseptic thoracic and abdominal surgery
- Treat circulatory shock using:
- Crystalloid fluids
- Colloid fluids
- Blood products
- Vasoactive drugs
- Allow accurate delivery of fluids using calibrated burettes and infusion pumps.
- Administer natural and/or artificial blood products as well as type and cross match donor and recipient blood.
- Administer analgesic therapy and anesthetic agents including but not limited to:
- Pure agonist opioids
- Non-steroidal anti-inflammatory medication
- Alpha-2 agonists
- Injectable and inhalation anesthetics
- Reversal agents for opiates and alpha-2 agonists
- Sedative medication
- Provide intraoperative monitoring to include but not limited to:
- Body temperature
- Blood pressure
- Pulse oximetry
- Maintain an anesthetic log for all anesthetized patients documenting duration of anesthesia, monitoring parameters and medications administered.
- Decontaminate and administer antidotes when indicated for toxin exposure.
- Perform, in a timely manner, laboratory procedures listed in Part 3 of this document. Additionally the emergency and critical care facility must have laboratory supplies to collect, prepare and preserve samples for analysis at an offsite laboratory.
- Perform diagnostic imaging to include but not limited to:
- Plain film radiography
- Ultrasonography with the minimum requirement that the staff veterinarians have proficiency in the detection of life-threatening clinical problems to include but not limited to fluid in the thoracic, pericardial, and peritoneal spaces.
- Diagnostic abdominal ultrasound and echocardiography or a documented relationship with a DACVR and DACVIM. (Level I)
- To evaluate and stabilize any small mammal, avian and reptile (“exotic”) animals kept as pets. These patients can be referred to a local “exotic” animal expert that sees emergencies, if a documented relationship is present. (Level I)
- Perform volume- or pressure-cycled mechanical ventilation. (Level I)
- Perform invasive blood pressure monitoring. (Level I)
- Perform endoscopy and bronchoscopy. (Level I)
PART 2: MINIMUM REQUIRED REFERENCE LIST
General Physiology - an edition of one of the following published within the previous 15 years
Textbook of Medical Physiology, Boron and Boulpaep
Review of Medical Physiology, Ganong
Textbook of Medical Physiology, Guyton & Hall
Berne & Levy Physiology, Koeppen & Stanton, et al.
Veterinary ECC- an edition of each of the following published within the previous 10 years
Small Animal Critical Care Medicine, Silverstein & Hopper
Manual of Trauma Management in the Dog and Cat, Drobatz, et al
Veterinary ECC Technical Manuals - an edition of one of the following published within the previous 15 years
Veterinary Emergency and Critical Care Manual, Mathews
Veterinary Emergency and Critical Care Procedures, Hackett & Mazzaferro
Manual of SA Emergency & Critical Care Medicine, Macintire, et al.
Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care, Burkitt-Creedon & Davis
Fluid Therapy/Acid-Base/Electrolyte - an edition of the following published within the previous 10 years
Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice, DiBartola
General Veterinary Internal Medicine- an edition of the following published within the previous 10 years
Textbook of Veterinary Internal Medicine, Ettinger & Feldman
Veterinary Surgery - an edition of one of the following published within the previous 15 years
Small Animal Surgery, Fossum
Textbook of Small Animal Surgery, Slatter
Veterinary Anesthesia - an edition of one of the following published within the previous 15 years
Veterinary Anesthesia & Analgesia, McKelvey & Hollingshead
Lumb & Jones’ Veterinary Anesthesia and Analgesia, Tranquilli, et al.
Veterinary Pharmacology - an edition of one of the following published within the last 10 years
Small Animal Clinical Pharmacology and Therapeutics, Boothe
Small Animal Clinical Pharmacology, Maddison, et al.
Veterinary Toxicology - an edition of one of the following published within the last 15 years
Veterinary Toxicology: Basic and Clinical Principles, Gupta
Clinical Veterinary Toxicology, Plumlee
Small Animal Toxicology, Peterson & Talcott
Veterinary Clinical Pathology - an edition of one of the following published within the previous 15 years
Fundamentals of Veterinary Clinical Pathology, Stockham & Scott
Duncan & Prasse’s Veterinary Laboratory Medicine: Clinical Pathology, Latimer et al.
Small Animal Clinical Diagnosis by Laboratory Methods, Willard & Tvedten
Veterinary Hematology and Clinical Chemistry, Thrall, et al.
Specific Topic Areas of Veterinary Medicine published within the previous 15 years
Veterinary Pediatrics, Hoskins
Canine and Feline Endocrinology and Reproduction, Feldman & Nelson
Infectious Diseases of the Dog and Cat, Greene
A Textbook in Veterinary Ophthalmology, (e.g. Gelatt)
Ferrets, Rabbits and Rodents, Quesenberry & Carpenter (Level I)
Avian Medicine and Surgery, Altman (Level I)
Reptile Medicine and Surgery, Mader (Level I)
Exotic Animal Formulary, Carpenter (Level I)
Veterinary Neurology - an edition of one of the following published within the previous 15 years
Fundamentals of Veterinary Clinical Neurology, Bagley
Handbook of Veterinary Neurology, Lorenz & Kornegay
BSAVA Manual of Canine and Feline Neurology, Platt and Olby
Veterinary Neuroanatomy and Clinical Neurology, de Lahunta and Glass
Veterinary Oncology- an edition published within the previous 15 years
Small Animal Clinical Oncology, Withrow & MacEwen
Veterinary Cardiology - an edition of one of the following published within the previous 15 years
Textbook of Canine and Feline Cardiology, Fox, et al
Small Animal Cardiovascular Medicine, Kittleson & Keinle
Cardiovascular Disease in Small Animal Medicine, Ware
Journals (current subscriptions of each)
Journal of Veterinary Emergency and Critical Care
Journal of the American Veterinary Medical Association
PART 3: MINIMUM REQUIREMENTS FOR A CERTIFIED VETERINARY EMERGENCY FACILITY
ER receiving/triage area
Dedicated isolation area with documented infection control plan
Dedicated surgical preparation area for patient (not to be in surgery room) (Level I and II)
Dedicated surgical room
Radiology room that complies with federal and state radiation safety regulations
Oxygen (ER receiving/ICU/ISO/SX/Radiology)
Anesthetic scavenging (ICU/SX/Radiology)
Suction (ER receiving/ICU/SX)
Equipment sterilization capability and quality control
Emergency preparedness plan or onsite backup power supply in case of power outage
System in place to ensure continuous ongoing power in case of power outage (Level I)
Warming support (forced air, circulating warm water blanket or Hot Dog thermal unit)
Small animal blood products
Blood typing capability (canine and feline)
Fresh frozen plasma
Packed red blood cells (Level I and II)
Feline type A
Feline type B or readily available donor (Recommended)
Readily available screened canine and feline donors (onsite or local blood bank with 24 hour service) in lieu of canine and feline packed red cells (Level III)
Red blood cell substitute (if available)
Maintenance (Level I and II)
Intravenous catheter types
Central (Level I and II)
Naso- esophageal or naso-gastric tube feeding
Esophagostomy tube feeding (Level I and II)
Partial parenteral nutrition capability (Level I and II)
Total parenteral nutrition capability (Level I)
Injectable agonist opioids
Nonsteriodal anti-inflammatory agents
NMDA receptor antagonists
Oral analgesic agents
Injectable (Minimum: beta lactam, fluoroquinolone, aminoglycoside, metronidazole)
Drugs for CPR
Magnesium sulfate or magnesium chloride (Level I and II)
Sodium phosphate or potassium phosphate (Level I and II)
Lipid solution (20%)
Propranolol or Esmolol
Diltiazem (Level I and II)
Sodium nitroprusside or hydralazine (Level I and II)
Peritoneal dialysis or hemodialysis (Level I)
Ambu bag/ anesthetic machine
Volume- or pressure-cycled mechanical ventilator (Level I)
Invasive (Level I)
Urinary catheter and closed collection system
300 Ma radiography machine (standard or digital)
Automatic processor (with standard radiography)
Endoscopy (Level I)
Bronchoscopy (Level I)
Laboratory equipment and testing in house
Packed cell volume
Refractometric total solids
CBC with manual differential reading
Dry chemistry analyzer
FIV/FELV antigen testing
Parvoviral antigen testing
APTT activated partial thromboplastin time
CBC complete blood count
CPR cardiopulmonary cerebral resuscitation
D5W 5% dextrose in water
DACVECC Diplomate of American College of Veterinary Emergency and Critical Care
DACVIM Diplomate of American College of Veterinary Internal Medicine
DACVR Diplomate of American College of Veterinary Radiology
DVM doctor of veterinary medicine
ER emergency room
FIV feline immmunodeficiency virus
FELV feline leukemia virus
ICU intensive care unit
PT prothrombin time
NMDA N-methyl d-aspartate