Protecting the Veterinary Profession During the COVID-19 Pandemic

The COVID-19 pandemic has impacted industries all over the globe. Veterinary medicine is no exception. Practitioners in Florida, and across the world, have faced new challenges—and risen to meet them by, instituting new protocols and social distancing measures to ensure the safety of their staff, clients and patients.

As the “Voice of Veterinary Medicine in Florida,” the FVMA remains ready to serve the veterinary profession. Even in times of crisis, the FVMA protects the profession and ensures the timely flow of information.

The FVMA received its first notice of mandatory business closures on March 19, 2020, when Miami-Dade County Mayor Carlos A. Gimenez issued Executive Order 07-20. The mayor closed all non-essential businesses in Miami-Dade County to limit the movement of persons and safeguard the lives and health of its citizens. The initial order would have closed veterinary clinics and hospitals in Miami-Dade, Florida’s largest county with a population of more than 2.8 million residents. Immediately upon receiving notification of this order, the FVMA interceded with County Mayor Gimenez's office to designate veterinary practices in the Miami-Dade area as “Essential Businesses.” Within a few hours of the request, Mayor Gimenez issued an Addendum to his Executive Order to clarify which businesses could remain open. Because of the FVMA’s swift intervention, the Mayor’s Addendum included veterinarians and pet boarding facilities as essential businesses.

This victory was key. The FVMA was acutely aware that if the association could get Miami-Dade, the first county in Florida to issue mandatory business closures, to include veterinarians on their list of essential businesses then other counties would follow suit. The inclusion of veterinarians ensured the profession remained able to protect the health and well-being of pets and citizens—a vital community role that must be filled in both ordinary and extraordinary times. With this victory secure, the FVMA’s strategic plan was a success—all subsequent mandatory business closures and stay-at-home orders across the state of Florida considered veterinarians essential, including the statewide executive order issued later by the governor.

Front-line veterinary practitioners and staff are among the healthcare professionals who provide surveillance for diseases deemed reportable by state and federal governments, including zoonotic diseases such as rabies, influenza and Lyme disease. They are also responsible for issuing certificates of veterinary inspection that are required for the movement of animals between states and countries, including those entering the food supply. Veterinarians are an integral part of our nation’s food and fiber industries. Veterinary care is critical to ensure that only healthy animals enter the food supply. While primarily housed on farms, food animals are also present in urban areas.

Why Veterinarians Are Designated as Essential

On April 1, Governor Ron DeSantis issued Executive Order No. 20-91, requiring all persons in Florida to limit their movements and personal interactions outside of their homes to only those necessary to obtain or provide an essential service or conduct essential activities. The order stated that essential services were to include those businesses and activities designated in Executive Order No. 20-89 and its attached list propounded by MiamiDade County in multiple orders. The statewide executive order, citing Miami-Dade’s list of essential businesses, clearly indicated that the FVMA’s swift response in Miami-Dade effected the entire state’s categorization of veterinary practices as an essential service.

As the COVID-19 crisis unfolds, the FVMA continues to stay abreast of potential threats and keep membership informed about key developments. With veterinary practices able to remain in business, new challenges regarding the conservation of PPE, the definition of “medically unnecessary” procedures, the use of telemedicine and ways to keep staff safe, arose as cases of infection in the state, and across the nation, multiplied.

In addition to the topics covered below, the FVMA provides pertinent COVID-19 updates on our website (FVMA.org) in addition to resources and materials that veterinarians can give to their clients.

Veterinary practices provide medical and surgical care daily for critically ill and injured animals. Veterinarians provide care for service and therapy animals, supporting both animal and human welfare. Veterinarians also oversee the care of laboratory animals, which are critical to research that leads to the development of pharmaceuticals and biologics, including vaccines such as those currently being developed to combat COVID-19. Veterinarians care for rare, threatened and endangered animals in zoos, aquaria, wildlife rehabilitation clinics and wildlife facilities. Even if such entities need to be closed to the public for COVID-19 mitigation, veterinarians and animal care staff must continue to care for these animals. Veterinarians and their support staff are trusted professionals involved in disaster situations. While perhaps different from a statutory and regulatory perspective, the training, education and experience that veterinarians and their staff have in dealing with disasters, are clearly transferable skills in whatever COVID-19 risk mitigation is deemed necessary. The veterinary profession in Florida, through the FVMA’s Veterinary Corps and the FVMA’s Disaster Preparedness Committee, play an integral role within the state’s EFS 17 response team through the Florida Department of Agriculture Disaster Response Team.

Medically Necessary or Unnecessary?

In the statewide Executive Order No. 20-91, issued April 1, 2020, Governor Ron DeSantis designated veterinary medicine as an “Essential Service.” However, veterinarians were left out of the preceding Executive Order No. 20-72 issued on March 20. The order prohibited medically unnecessary procedures or surgery.

The order directed: “All hospitals, ambulatory surgical centers, office surgery centers, dental, orthodontic and endodontic offices, and other health care practitioners offices in the State of Florida are prohibited from providing any medically unnecessary, nonurgent or non-emergency procedure or surgery which, if delayed, does not place a patient’s immediate health, safety, or well-being at risk, or will, if delayed, not contribute to the worsening of a serious or life-threatening medical condition. Accordingly, all health care practitioners licensed in the State of Florida, including dentists, shall immediately cease performing these elective services.”

While the governor’s order did not specify veterinary medicine, the FVMA recommended that veterinarians defer elective procedures, that in their judgement are not necessary, in order to reduce human-to-human contact and conserve PPE until the order's expiration. The FVMA recognizes that any services provided are, and should be, at the professional, clinical judgement of the treating veterinarian. To date, there is no list of specific procedures in veterinary medicine that should be deferred. The procedures needed for each patient should be made on a caseby-case basis and are dependent on the professional judgment of the treating veterinarian, as it relates to each individual situation.

The inclusion of veterinarians ensured the veterinary profession remained able to protect the health and well-being of pets and citizens—a vital community role that must be filled in both ordinary and extraordinary times. With this victory secure, the FVMA’s strategic plan was a success—all subsequent mandatory business closures and stay-at-home orders across the state of Florida considered veterinarians essential, including the statewide executive order issued by the governor.

Prioritize appointments.

Communicate new protocols to clients.

Prioritize urgent and sick-pet visits over wellness visits—young animal vaccination schedules not included.

Set appropriate exceptions.

Adjust hours of operation. Shortening hours of operation can allow for additional sanitizing time.

Clients call from the parking lot on arrival.

Team members shuttle pets to the facility and back.

Clients stay in their cars. Conversations happen by phone as needed.

Share new protocols via email, social media and when making appointments.

Consider new euthanasia protocols and offer exceptions (critical cases, young animals or patients with special needs).

• Wear gloves. • Disinfect boxes. • Put all lab samples in a pick-up box, so drivers don't have to come inside.

Prioritize appointments. Some practices now prioritize urgent and sick-pet visits over wellness visits—young animal vaccination schedules not included.

Communicate new protocol to clients. Many practices are shifting to a curbside model where: • Clients call from the parking lot on arrival. • Team members shuttle pets to the facility and back. • Clients stay in their cars. • Conversations happen by phone as needed.

When making this shift: • Explain the change when appointments are made. • Email all clients about the process. • Post on social media about the change. • Reiterate the changes to the clients when they arrive. • Share how the new protocol is working and any adjustments that have been made on social media to keep your clients up to date. Set appropriate exceptions to new protocols that work for you. Consider new euthanasia protocols and offer exceptions (critical cases, young animals or patients with special needs).

When handling deliveries and lab samples, consider:

• Having deliveries left outside. • Wearing gloves to carry and unpack boxes. • Disinfecting boxes. • Putting all lab samples in outside pick-up boxes, so that drivers don’t have to come inside.

Adjust hours of operation. Shortening hours of operation can allow for additional sanitizing time. In these particularly difficult times, it could also help prevent burnout.

In addition to new operating protocols, it is important to do the following:

Practice good hygiene. Review CDC guidelines. ☑ NO HANDSHAKING! Use a fist bump, slight bow, elbow bump, etc. ☑ Use ONLY your knuckle to touch light switches, elevator buttons, etc. ☑ Lift the gasoline dispenser with a paper towel or use a disposable glove. ☑ Open doors with your closed fist or hip – do not grasp the handle with your hand unless there is no other way to open the door. This is especially important on bathroom and office/commercial doors. ☑ Use disinfectant wipes at the stores when they are available, including wiping the handle and child seat in grocery carts. ☑ Wash hands with soap for 20 seconds and/or use a greater than 60% alcohol-based sanitizer whenever you return home from ANY activity that involves locations where other people have been. ☑ If possible, cough or sneeze into a disposable tissue and discard. Use your elbow only if you have to.

Stay home if you are sick. Maintain flexible leave policies and make sure all employees know they need to stay home if they are ill. Ask that clients notify you if they’re experiencing

Stay home if you are sick. Practice social distancing. Clean and disinfect fequently. Prioritize your health and well-being.

Because of COVID-19, many practices have changed the way they operate. To help disseminate useful information to our members, we’ve compiled protocols that your practice may want to consider implementing, if you have not done so already. These protocols are meant to serve as a template, so that you can pick and choose ideas that will work for you — or that can be adapted to your operation. We hope these strategies will help you, your staff and your clients stay as safe as possible during this stressful time.

any symptoms to ensure you can take appropriate protective measures. Avoid close contact and practice social distancing. If you or your staff are able, work remotely. Maintain at least 6 feet between contacts. Clean and disinfect frequently touched surfaces. Prioritize your health and well-being. During this tough time, the stress of being a veterinary professional can be overwhelming. Take your entire veterinary team’s wellbeing into account. Take care of yourself and be sure to ask your family and employees how they’re doing. Additional resources are available on the FVMA’s professional wellness page at FVMA.org.

Basic Points for Veterinary Health Care Providers Treating Companion Animals:

• Everyone, including veterinary health care providers and their clients, should be aware of Florida Executive Order 20-91: senior citizens and individuals with a significant underlying medical condition (such as chronic lung disease, moderate-to-severe asthma, serious heart conditions, immunocompromised status, cancer, diabetes, severe obesity, renal failure and liver disease) shall stay at home and take all measure to limit the risk of exposure to COVID-19. • When scheduling an appointment with a client, the veterinary staff member should ask the client if the pet has been exposed to a known or suspected COVID-19 case. ☑ Telemedicine may be an option in some cases. • If essential veterinary care is needed at the clinic, a healthy friend or family member should bring the animal in. Staff should again ask if the pet has been exposed to a known or suspected COVID-19 case upon intake. Refer to the AVMA’s flowchart “Minimizing COVID-19 Exposure and Social Distancing in Veterinary Practice” to help you and your practice decide how a patient can be best cared for, while also staying as safe as possible. Staff who handle the animal should continue to be diligent with standard infection-control practices including good hand hygiene, avoiding mucous membrane exposure to pet saliva and other bodily fluids. ☑ At minimum, gloves and outerwear are recommended when working with the animal and cleaning the animal’s environment. The use of gloves, gowns, goggles or faceshields with surgical masks, and the minimization of staff numbers is recommended when there is a risk for sprays or splashes. See the National Association of State Public Health Veterinarians (NASPHV) Veterinary Standard Precautions and the

CDC’s recommendations for optimizing PPE. The pet should be kept isolated from other pets while at the practice. ☑ If an animal has a new, concerning illness not attributable to more common medical conditions and resides with a person with COVID-19 or suspected COVID-19, the responding veterinarian should contact the Florida State Public Health Veterinarian (850-245-4117 or 850-245- 4401) or Florida State Animal Health Official (850-410- 0900 or after hours/weekends 800-342-5869). Continue to clean and disinfect all equipment used at your facility, following package instructions including recommended contact time. Non-human primates should be managed at a referral practice that specializes in the care of these animals.

Confusion surrounded FDA guidance published on March 24, 2020. The FDA stated it did not intend to enforce the physical examination or medically appropriate visits to the premises requirement in the federal veterinary-client-patient-relationship (VCPR) definition relevant to the FDA regulations that govern Veterinary Feed Directive (VFD) drugs. The federal definition of the VCPR is similar to Florida’s. The FDA said in its guidance that it did not intend to charge veterinarians with a violation of federal law if they used telemedicine, in lieu of physical exam/ premises visits, but only in extra-label drug use or veterinary feed directive cases.

The FDA’s actions in this regard did not mean that the VCPR requirement was no longer required in the practice of veterinary medicine in Florida.

Department of Business and Professional Regulation Emergency Order on Telemedicine

The State of Florida Department of Business and Professional Regulations (DBPR) issued Emergency Order 2020-04 on March 27, 2020. The order suspended restrictions in the Florida Veterinary Practice Act Chapter 474, Florida Statutes and Rule 61G-18 Florida Administrative Code that prohibit veterinarians from practicing telemedicine on their patients, providing the veterinarian exercises good clinical judgment to assist the patient.

The Emergency Order on telemedicine states:

11.) Any restriction in chapter 474, Florida Statutes, or chapter 61G-18, Florida Administrative Code, which would prohibit active Florida licensed veterinarians in good standing from practicing telemedicine on their patients is suspended provided the attending veterinarian is comfortable assessing the patient remotely and feels able to exercise good clinical judgement to assist the patient.

Points of Clarification Regarding the DBPR's Emergency Order on Telemedicine Usage

• The order does not suspend the VCPR requirement for the practice of veterinary medicine in Florida. We wish to stress that the order suspends restrictions that “prohibit active Florida licensed veterinarians in good standing from practicing telemedicine on their patients.”

• The existing definition of a VCPR in Florida remains in effect (which requires a physical examination of the animal).

• Veterinary telemedicine can be used to provide a diagnosis or treatment recommendations (this includes dispensing medications and authorizing prescriptions) for existing patients where a documented VCPR exists.

• Veterinary telemedicine cannot be used to diagnose or treat a new patient when the veterinarian does not have a valid VCPR.

The subject of veterinary telemedicine has been presented in proposed legislation in Florida for the past three years and has not been enacted into law. Although the existing definition of a VCPR remains in effect (which requires a physical examination of the animal), veterinary telemedicine can be used to provide diagnosis or treatment recommendations on existing patients (this includes dispensing medications and authorizing prescriptions). Veterinarians should consider the spirit of the governor’s emergency order and adopt strategies that will help minimize exposure to COVID-19. The treating veterinarian has the ultimate decision on whether the use of technology (video, phone or internet) to assist certain existing clients/patients is appropriate.

Licensing & License Renewal in the Age of COVID-19: The Board of Veterinary Medicine Defers License Renewal Audits Until January 2021

The Florida Board of Veterinary Medicine met on April 1, 2020 in an emergency session to approve two emergency measures related to licensing and active license renewal for 2020. The Board conducted a telephone conference to consider and approve the emergency rules, which became effective immediately after approval.

Rule regarding 2020 licensure application • This first rule allows applicants who apply for licensure before January 1, 2021 to take an online course in “Florida Laws and Rules Governing the Practice of Veterinary Medicine” in lieu of the laws and rules exam.

Rule regarding CE for license renewal in 2020 • This second rule allows active Florida licensees to obtain all CE hours required in the 2018-2020 biennium license renewal through noninteractive/correspondence/distance learning courses. Veterinarians are required to renew their licenses by May 31 of each even-numbered year, but because May 31 falls on a Sunday this year, the deadline is June 1, 2020.

Board of Veterinary Medicine Defers CE Audits

Because of extraordinary circumstances caused by the COVID-19 pandemic, the FVMA requested that the emergency rule be amended to allow veterinarians until December 31, 2020, to obtain the required 30 hours of CE. The Board was advised that it did not have the authority to extend the license renewal deadline until December 31; however, the Board did announce that it had the authority to decide when to conduct CE audits. As a result of the FVMA’s efforts on behalf of all Florida licensed veterinarians, the Board announced that it will defer CE audits until January 2021. Under the Board’s existing rules, licensees responding to an audit can submit any CE hours taken before the date of the audit. By taking this action, the Board, in effect, announced that any CE hours taken before December 31, 2020, can be used to satisfy the 30 hours required for renewal in the current biennium.

Important Note:

• Veterinarians who take CE after June 1, 2020, to meet the 30 hours required for the 2018-2020 biennium will not be able to count those same hours for the 2020-2022 biennium.

Per 61G18-16.002 Continuing Education Requirements for Active Status License Renewal:

(2) Licensed veterinarians shall complete a minimum of thirty (30) hours of continuing professional education in veterinary medicine every biennium. Beginning on June 1, 2012, no less than one (1) hour of continuing education shall be in the area of dispensing legend drugs and no less than two (2) hours of continuing education shall be in the area of the laws and rules governing the practice of veterinary medicine. For the purposes of this rule, the laws and rules governing the practice of veterinary medicine are Chapters 455 and 474, F.S. and rule Division 61G18, F.A.C. (a) One (1) hour equals a minimum of fifty (50) minutes and a maximum of sixty (60) minutes. Total hours of lecture time cannot be added up and divided into 50-minute intervals to obtain 1 hour credit for each 50 minute interval. (b) Not more than fifteen (15) hours shall be non-interactive, correspondence courses. Computer on-line programs that involve on-line, real time, live or delayed participatory questioning or responses are not correspondence courses. (c) Five (5) hours of continuing education in laws and rules may be obtained once per biennium by attending one full day or eight (8) hours of a Board meeting (whichever is shorter) at which disciplinary hearings are conducted by the Board of Veterinary Medicine by complying with the following: 1. The licensee must sign in with the Executive Director of the Board or designee before the meeting day begins. 2. The licensee must remain in continuous attendance. 3. The licensee must sign out with the Executive Director of the Board or designee at the end of the meeting day or at such other earlier time as affirmatively authorized by the Board. A licensee may receive continuing education credit for attending the Board meeting only if he or she is attending on the date solely for the purpose of obtaining continuing education; he or she may not receive credit if appearing at the Board meeting for another purpose. (d) Not more than five (5) hours in complementary and alternative medicine modalities shall be credited toward the required number of continuing professional education hours referenced above. (e) A licensed veterinarian shall receive credit for no more than five (5) hours of continuing professional education in business or practice management courses during any biennium period. (f) A licensed veterinarian shall receive credit for no more than five (5) hours of continuing professional education in wellness and wellbeing seminars during any biennium period.

Sick Employee Recommendations

Sometimes, even when all precautions are taken, it’s still not enough. In these uncertain times, illness is all the more frightening. In the event that an employee becomes ill, we’ve compiled the following recommendations.

Recommendations if an employee is sick but unable to be tested for COVID-19: • If an employee has a respiratory illness, we recommend they follow CDC recommendations for COVID-19.

Recommendations if an employee tests positive for COVID-19: • No one should work while ill. • The county health department will receive the results from the testing laboratory or the patient’s health care provider and will then follow up with the positive patient. • The patient will either be hospitalized or isolated at home

To be released from isolation, all three of the following are needed: • no fever for at least 72 hours without the use of fever reducing medication • other symptoms have improved • at least seven days have passed since symptoms first started

We encourage members to exercise prudent judgement in establishing protocols to ensure the safety of themselves, their teams, clients and patients. The CDC’s recommendations should be adhered to.

The FVMA website continues to be updated with information related to COVID-19 and your clients, patients, practice and license renewal.

Stay informed by visiting fvma.org