Kia ora

Welcome to our November pānui. In this edition, we have included some timely information about the upcoming World Antimicrobial Resistance (AMR) Awareness Week and what VCNZ is doing to support responsible antimicrobial use amongst veterinarians. We have also shared a change in the management of the Mycoplasma bovis eradication programme, as well as the latest information from New Zealand Food Safety (NZFS) about its work on developing a classification system for animal antibiotics. We have published a new piece of guidance on The Hub about disclaimers and how they relate to veterinary work, which we encourage you to read. It includes information about informed consent which is the theme of this month’s pānui case study. Please feel free to let us know if there are any specific issues you would like to read a case study about.

In memory of Ron Gibson

The Veterinary Council of New Zealand is devastated to hear that Dr Ron Gibson ONZM passed away on 15 November. He was surrounded by family including his wife Jude and his children Jinny, Stephen, Paddy and Sam. Ron’s contribution to the veterinary profession was immense and he will be dearly missed. Ron was raised on a Taranaki dairy farm and received his veterinary degree from Queensland University. He spent 44 years in clinical practice at Anexa/Animal Health Care. Ron joined the practice in Morrinsville in the late 1960s, initially as a dairy vet and was Chief Executive of the business for 22 years. In a newspaper interview covering his retirement from practice in 2011, Ron said: “The aspect of my career I have enjoyed the most is the satisfaction gained from seeing my clients achieve their farming goals.” Ron joined the Veterinary Surgeons Board (later to become the Veterinary Council) in 1994. He was appointed Chair of the Council’s Complaints Assessment Committee in the same year. In 2002 he was elected by his fellow Councillors to chair the Veterinary Council and he remained Chair, being re-elected annually, until December 2013. Ron was pivotal in the development of the Veterinarians Act 2005 and the inclusion in it of new measures to support veterinarians returning to the workforce and to take a rehabilitative and supportive approach to health and competence issues. He oversaw the implementation of our first continuing professional development framework for veterinarians and a major overhaul of the Code of Professional Conduct for Veterinarians. Ron also worked to promote the harmonisation of Australasian standards and he was a strong and respected advocate for global accreditation initiatives, which allow New Zealand trained veterinarians to work in so many other countries overseas. In 2012 Ron was made an Officer of the New Zealand Order of Merit for his services to veterinary science. He was forward-looking and supportive and a great mentor to many in the profession. [ron]

World AMR Awareness Week

Within the next 30 years, resistance to antibiotics and other antimicrobial products is anticipated to kill more people around the world than cancer, according to the World Health Organisation. Antimicrobial resistance (AMR) is one of the top 10 global public health threats and occurs when bacteria, viruses and parasites no longer respond to medicine, making them difficult or impossible to treat. For this year’s World Antimicrobial Awareness Week (WAAW), which runs from 18-24 November, the emphasis will be on the collaboration required to manage the issue as it impacts animals, humans and plants. VCNZ, which regulates veterinarians and sets standards to support responsible antimicrobial use among veterinarians, is about to begin developing a new strategy to minimise the risk of AMR in New Zealand’s animals. VCNZ CEO and Registrar Iain McLachlan says the strategy will complement initiatives in other parts of the sector, including the New Zealand Veterinary Association (NZVA) and Ministry for Primary Industries (MPI). “Veterinarians, as stewards of antimicrobial products and the sole authoriser of their use in animals, have a critical role to play in managing the risks of AMR,” Iain says. “We’re looking forward to getting this work underway and will be consulting right across the sector to ensure a wide range of perspectives are captured.” A steering group has been established, which will review how antibiotics are currently used and antimicrobial stewardship by New Zealand veterinarians. Members of the group will also interview stakeholders and evaluate existing AMR strategies. A discussion document summarising the group’s research and potential strategies will be widely consulted on before a strategy is finalised. The theme of WAAW 2023 is an extension on last year - “Preventing antimicrobial resistance together” - which calls for cross-sector collaboration to preserve the effectiveness of antimicrobials by using them prudently and appropriately; taking preventive measures to decrease the incidence of infections; and following good practices when disposing of antimicrobial contaminated waste. This year the Ministry of Health and the MPI are promoting the importance of documenting the reasons for prescribing antibiotics. The goal is to encourage antibiotic prescribers to review and discuss how prescriptions are documented. A documented rationale behind an antibiotic authorisation enables continuity of care between staff in the clinic and encourages thoughtful decision making. Could recording the following in your notes help patient outcomes and antimicrobial choice?

Suspected infectious agent
Results of cytology or urinalysis
Is culture and sensitivity needed, or could a sample be collected pre-treatment for later use?
If you are following prescribing guidelines or why a different treatment protocol is needed (e.g. adherence to product label directions, NZVA guidelines or your own practice policy on antimicrobial use)
Recording the clinical rationale if using a critically important antibiotic (CIA)
When will the case be reviewed?
Does the animal need to be re-examined to ensure an appropriate therapeutic response?

For more information about AMR, visit https://www.mpi.govt.nz/animals/veterinary-medicines-acvm/antimicrobial-resistance/

M. bovis programme change

From this month, MPI is contracting the surveillance phase of the Mycoplasma bovis (M. bovis) programme to disease management agency OSPRI. OSPRI will manage the day-to-day running of the M. bovis programme, which will include testing, managing any active or newly-detected properties, depopulation and site cleaning, and farmer support. Farmers should not be impacted by the change, and M. bovis programme levies will not increase. The contracting arrangement between MPI and OSPRI will remain in place until a proposed National Pest Management Plan (NPMP) comes into effect. This is likely to be in July 2024. If approved, an NPMP will provide legislative authority for a management agency to carry out the programme’s services, including enforcement. Until this change happens, oversight of the programme will continue to be carried out by the M. bovis Governance Group made up of MPI, DairyNZ, and Beef + Lamb New Zealand. For more information, email [email protected]

Agricultural Compounds and Veterinary Medicines (ACVM) Antibiotic Classification System

New Zealand Food Safety (NZFS) has been developing a classification system for all antibiotics registered for use in animals and plants in Aotearoa. This work has been undertaken as part of an antibiotic reassessment programme. NZFS has recognised the importance of having a specific antibiotic classification system to support decision making on antibiotic use by veterinarians and plant health professionals. The antibiotic classification system will now be prioritised, and tranches two to four of the antibiotic reassessment will be delayed until the classification system is completed. The classification system will outline the importance of each antibiotic based on the potential risks to public health of increased antimicrobial resistance, and the need for their use in veterinary medicine and plant/crop health. Three classifications have been established for antibiotic agricultural compounds: critically important antibiotic, highly important antibiotic, and important antibiotic. Antibiotic agricultural compounds are classed as critically important when they:

have few or no suitable therapeutic alternatives in human and/or animal medicine or horticultural use in New Zealand
are considered critical to the clinical treatment and resolution of disease caused by bacteria in humans, animals, and/or plants
have a scientifically known and significant susceptibility to the development of AMR from either direct use or cross-resistance from another antibiotic or class of antibiotics.

Antibiotic agricultural compounds are classed as highly important when they:

are considered significantly important to the clinical treatment and resolution of disease caused by bacteria in humans, animals, and/or plants
have a recognised and/or demonstrated potential for the development of AMR from either direct use or cross-resistance from another antibiotic or class of antibiotics.

Antibiotic agricultural compounds are classed as important when they:

are considered important to the clinical treatment of disease in humans, animals and/or plants; and
have characteristics that may lead to the development of AMR from either direct use or cross-resistance from another antibiotic or class of antibiotics.

Penicillins, third and fourth generation cephalosporins, and macrolides have already been assigned classifications as part of the reassessment programme. The classifications can be found on the MPI website: https://www.mpi.govt.nz/animals/veterinary-medicines-acvm/antimicrobial-resistance The website will be updated to include the classifications of the remaining antibiotics when the classification system is complete in 2024. The NZVA classification system should be followed until the NZFS classification has been completed. Following completion of the classification system, each product will undergo a reassessment review of appropriate dose rates, indications, and withholding periods. Antibiotic labels will be updated accordingly and will include an importance classification and prudent-use statement. The remaining tranches of antibiotics to be reassessed will be organised as:

Tranche two: Veterinary and horticultural aminoglycosides, fluoroquinolones, lincosamides, and first/second generation cephalosporins
Tranche three: Fusidic acid, tetracyclines, sulphonamides and trimethoprim, and polypeptides (zinc bacitracin and polymyxin)
Tranche four: Amphenicols, nitrofurans, nitroimidazoles, pleuromutilins, and virginiamycin

Case study: Informed consent

These case studies demonstrate how complaints are managed, and what the profession can learn from them. They are a regular feature of this pānui. Please let us know if there are specific issues you would like us to cover.

Background

An 18-year-old cat was taken to a veterinarian by its owners who were concerned about its abnormal breathing. The veterinarian examined the cat and recommended running diagnostic tests, including a bronchoscopy, to assess if it had an upper airway obstruction or another issue. The veterinarian recommended taking a staged approach to the testing to reduce distress to the cat, starting with an echocardiogram, thoracic radiographs and a laryngeal examination, before undertaking the bronchoscopy. The echocardiogram was performed and revealed signs of heart disease but did not explain the cat’s symptoms. The veterinarian spoke with the owners over the phone to relay the findings, and recommended proceeding with a bronchoscopy. Shortly after the bronchoscopy, the cat developed a heart block and became apnoeic, resulting in emergency care. The bronchoscopy results did not reveal any abnormalities. The cat’s owners were called in to the clinic to discuss post-resuscitation care and after being extubated, the cat appeared to be recovering well in the afterhours clinic. However, the next morning, it went into cardiac arrest and could not be resuscitated.

The complaint

The client complained that they were not adequately informed of the risks involved with the diagnostic work or using general anaesthetic, and that they should have been offered the option to withdraw from diagnostic investigations prior to the bronchoscopy. They were also concerned that they were not given a written consent form to sign. The client said their phone conversation with the veterinarian was short and that there was no discussion around what the risks of using general anaesthetic for the proposed bronchoscopy were.

How it was dealt with

Under the Code of Professional Conduct, veterinarians are required to adequately document informed consent. The veterinarian’s practice did not use a consent form to document discussions with the client and their informed consent. There were no entries in the veterinarian’s clinical notes that documented the phone discussion before the proposed bronchoscopy or the discussions held in the initial consultation. The Complaints Assessment Committee (CAC) considered that the veterinarian’s conduct fell short of the expectations set out under the Code but was satisfied that the veterinarian had enough information to confidently, and without any undue risk, use a general anaesthetic to undertake more diagnostics. The CAC determined that the veterinarian failed to document the informed consent process with the client to undertake the proposed course of action. The veterinarian reflected on this situation and accepted that they did not communicate the full risk assessment to the client. The veterinarian demonstrated to the CAC that they have since put a consent form in place. The CAC was satisfied that there was no ongoing risk to the public interest, and that further action under the Act was not warranted.

Learnings for the profession

In its finding, the CAC reminded the profession that informed consent is an ongoing process. Veterinarians are responsible for ensuring clients have and understand all of the relevant information needed to make an informed choice. It is also a requirement that informed consent is adequately documented. For more information about VCNZ’s complaints process, visit https://www.vetcouncil.org.nz/Web/1.Support-and-Information/Vets/Concerns.aspx

Thank you

We hope you found this newsletter interesting and informative. If you’d like to provide feedback or send us a topic or story for next time, please email [email protected] Please also contact us if you have any questions or need support.