I’m feline good: how to support your patient’s wellbeing through cat friendly hospitalisation

By Andrea Suesskow

Cert IV VN, CIV TAE, AVN, RVN Andrea presented on this topic at the 2022 VNCA Conference

Doesn’t the idea of being ‘cat friendly’ sound lovely? Especially if you are an avid cat lover like me. But what does ‘cat friendly’ mean? The term ‘cat friendly’ has its strongest links with the ‘Cat Friendly Clinic’ program, an international program developed and run by the International Society of Feline Medicine (ISFM). ISFM is a not-forprofit veterinary organisation and a veterinary division of International Cat Care, which is a charity dedicated to improving the health and wellbeing of cats internationally through education. The ISFM Cat Friendly Clinic Standard is an international standard that can be adopted by clinics everywhere, making changes to the clinic ethos, procedures, equipment and infrastructure to demonstrate a clinic’s cat friendly practices to current and new clients. It’s important to note that the ISFM provides a program in which clinics register for accreditation as a Cat Friendly Clinic at 3 various levels; however, you do not need to complete accreditation to implement changes and work towards becoming a more cat friendly clinic. The recommendations provided in this article are formulated following the ISFM recommended guidelines. When it comes to a cat friendly approach, a holistic view is needed to understand cat basics and how this affects our approach to cats as patients. Understanding the behaviour and inherent traits of cats is vital, as this shapes our approach in most areas to ensure we are providing care in a way that meets the needs of the cat and prevents the difficult reactions that can occur when inappropriate care is provided. In simple terms, when we understand more about feline behaviour, we are able to tailor our care to meet their needs, resulting in a happier, stressfree interaction where the cat’s needs are met.

The topic of being cat friendly is enormous, and there are many specific areas we can look at, such as client education and preparation for veterinary visits, reception and waiting areas, consultation techniques, restraint and handling, hospitalisation and enrichment. These are just a few. This article will focus on hospitalisation of the feline patient, looking first at 5 key facts about cats that help us understand and shape our hospitalisation techniques around their needs. FACT #1

Cats are hunters and obligate carnivores who prefer to catch and eat small regular meals. Because cats are predators, they can often defend themselves (fight) when they feel threatened, especially when they do not have the option of flight. Cats do also have two other defence strategies: freeze and appeasement. However, flight and/or fight are the more common responses. This increases the risk of bites, scratches and resulting infection as a handler, so it is ideal to follow protocols that minimise fear and the resulting defensive aggression in the first place. Cats being hunters, this also tells us that cats need an outlet to express their natural hunting behaviours. This can be facilitated through enrichment strategies such as toys. In a natural environment, cats could consume between 10–20 small meals a day, so feeding 1 or 2 big meals a day may not always be ideal. If cats had a choice, the hunting and feeding process would happen in complete solitude with no social interaction (excluding queens and kittens), as food is a survival resource for cats and they prefer to eat alone. Drinking behaviour is important too, as cats may avoid water placed close to their food source due to the instinct to avoid contamination. In the hospital environment, this information can guide us to implement a suitable and individualised feeding and enrichment plan, as well as appropriate cage setup. FACT #2

Cats are territorial.

While cats are fed by their owners so do not need to hunt to survive, cats do still have a strong drive to hunt, and this fuels the need for cats to establish territories. The sex of the cat is also a factor to consider, as the male’s territory can extend 3–10 times that of a queen. Territory marking is an important aspect of feline communication and they use a range of methods including spraying urine, rubbing and scratching. With this information, we can consider the most appropriate ways to house cats within the hospital, recognising that being out of their normal territory is extremely stressful for a cat. (Cats bond more to a territory than they do to owners!) This will enable us to implement strategies of hospitalisation to limit stress and cater to their needs. FACT #3

Cat’s are sensitive to scent.

It’s important to understand that scent is one of the main methods of communication between felines. Have you ever handled a stressed and cranky cat one morning and for the rest of the day your remaining feline patients seemed stressed and cranky too? It’s likely your first stressed patient released an alarm pheromone, and this scent signal was picked up by your next feline patients, resulting in higher stress and fear levels. Cats have scent glands in various locations on the body (as well as release from urine and faeces), where they release pheromones and leave their unique scent as a form of communication. These scent signals can indicate alarm, fear, stress, territorial marking, bonding facilitation, happiness, sexual viability, plus many more. During hospitalisation, there are many key strategies to implement when it comes to scent and managing scents that we must consider for our feline patient’s emotional wellbeing. FACT #4

Cats are clean.

Grooming forms an important aspect of a cat’s instinct and serves many purposes. Being a predator, cats must be in great condition ready to hunt. Grooming ensures they are removing parasites or any contaminants that may cause smells or degradation to the coat. Grooming is important for social bonding and self-comfort too. When cats are unable to maintain cleanliness due to environmental or illness factors, this can negatively impact our patients, and we may even see excessive grooming occur as a displacement behaviour. FACT #5

Cats are independent, emotional and highly aware. Let’s start this section with a key phrase here: It is vital that cats feel in control of their situations. Cats are independent and do not rely on other felines to form social groups. They can (in certain circumstances) live in social groups; however, any assumptions of cats requiring company is a human perception of sociability. When a cat can act on their own terms (i.e. approaching a human), they will be at their most content. While it’s not possible in a hospital environment to let cats run the show, it’s important to remember that when we remove a cat’s control completely, this can result in a cascade of effects that could make handling much more difficult and cause emotional distress to our patients.

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ADMISSION TO THE HOSPITAL Before admitting a cat to the hospital, it can be very helpful to ensure we have some additional information about the individual patient that may not have been covered in the consultation with the veterinarian. Consider asking questions such as: What type of cat litter do you use at home? If your clinic does not stock this type, perhaps consider asking the client to drop some off, as changing litter suddenly could cause a litter tray aversion. What food do you normally feed at home, how often, and from what type of food receptacle? While diet is often required to be changed during hospitalisation, if the situation permits, continuing the patient’s regular diet may help avoid food aversions. In consultation with the veterinarian, they may direct that a new diet is commenced at home once the patient has been discharged, allowing a transition period from their existing diet to the new one. If no special diet is required, it may be helpful to ask the client to provide some of the cat’s normal food to increase patient emotional comfort. Don’t forget these patients are in a brand-new environment where nothing at all is familiar. This is extremely stressful, and if we provide any elements of familiarity, that is a great thing. Utilising the same or a similar style of food receptacle as the cat is used to may assist as well. What activities does your cat normally enjoy? Do they like being groomed or do they enjoy a particular type of toy? Are there any other important behavioural notes for your pet that we should know? This information can be very helpful in assisting with the development and implementation of enrichment strategies that cater to the specific patient. Do you have a blanket, soft bed or toys that have your home scent that you would consider leaving with your pet during their stay? As we remember, scent is extremely important for our felines, and providing a familiar scent in an unfamiliar environment can assist with emotional resilience. It’s best to explain to owners that it’s not always possible to return the items so they can select something suitable. PATIENT TRANSFER TO THE CAT WARD So, now we have a bit more information regarding our patient, we are ready to transfer them into their housing. When transporting the patient from consultation room to the hospitalisation facilities, if possible, ensure this is a direct transfer with no interaction with other patients. It’s best to keep their cages covered with a blanket to reduce visual, auditory and olfactory stimuli. If a direct transfer is not possible, ensure the patient’s cage is always placed in a raised and safe location, away from other patients, and with a covering over the enclosure. Placement on the floor is not acceptable. CAT WARD DESIGN AND CONSIDERATIONS All clinics will have a different layout and individual challenges when it comes to the clinic infrastructure, as there is no one-size-fits-all approach. There are some key considerations we should aim to implement when housing any feline patients. Ideally, cats and dogs should be housed completely separately with a separation of solid walls and doors. If this is simply not possible in your clinic, you may like to consider appropriate scheduling to limit crossover of species and specific cage housing to limit visualisation between species. The use of synthetic dog appeasing pheromones (e.g. Adaptil diffuser) may prevent emotional disturbances such as agitation and barking from the canine patients. Feline facial pheromones i.e. Feliway, can be run concurrently in the same location and each product respectively will not affect the other species. If you do have a cat only ward, there are some additional considerations to have in place where possible and appropriate. Ward location – In addition to separation from the dog ward, where possible, an ideal cat ward should be easily accessible without obstacles through noisy and busy areas of the clinic. Cages should be positioned in a manner so that visibility is reduced or eliminated to other areas of the clinic. It is also ideal that the cat ward position limits exposure to noisy treatment areas where other cats may be vocalising or protesting medical treatment. Ideally, it will also be in an area that is not too isolated from the rest of the clinic, so that cats can be observed frequently without being forgotten and it does not require long distances for the cats to be transported from the ward to the treatment area. Ward specifications – There are a few considerations to make in terms of the ward environment, such as size, ventilation and temperature. Temperature should be controlled and ambient, between 18 to 23 degrees Celsius, and adequate ventilation should be in place. The size of the ward should be taken into consideration, if possible, as staff should have enough space to observe cats from a suitable distance, perform all required tasks and move with ease, as well as transferring patients with the ability to limit exposure to other patients in the room. ENCLOSURE DESIGN AND CONSIDERATIONS Enclosure positioning and layout – There are a few considerations when it comes to the positioning and layout of

the housing within the cat ward. If possible, visual contact between patients should be avoided as this is an additional stressor and may increase the risk of spread of infectious particles between patients. If it is not possible to avoid visual contact with cages facing one another, ensure at least 2 metres remains between cages. A safe height should be considered for staff, so that patients are easily visualised and removed from cages, avoiding strain and injury to the staff. If there are multiple rows of cages together, consider raising the lowest level to at least 20 cm above floor level, if possible, to ensure the patient is not at floor level. An ideal height for the lowest cage is 90–100 cm. Enclosure material – Any cage used should be constructed of a solid material and solid flooring must be used. There are a few options out there, with the two most common enclosure options being: 1. Stainless steel – The advantages of stainless steel are that it is easily cleaned and disinfected, easily accessible and may be a more affordable option for clinic housing. The disadvantages are that they conduct heat away from the patient, are highly reflective (which may scare the patient) and can be noisy. If stainless steel is used, it is necessary to insulate using appropriate flooring and bedding, and it would be ideal to modify the cage door latches with rubber or plastic stoppers to reduce noise. 2. Fibreglass – This is also an excellent option for comfortable feline housing as it can also be cleaned and disinfected easily, it is durable, and compared to stainless steel, it is quieter, warmer and not as reflective. Latches are often still made of metal, so stoppers are also recommended here. Enclosure doors – The front of the cage should also be considered. While toughened glass poses an excellent option for visibility, durability and infection control, this option is not always an accessible or affordable option. If using metal bar doors, it is important to consider the size of any spaces. They should be far enough apart to support visibility into the cage, but close enough together to ensure no injury or escape could occur with smaller patients. Internal enclosure design – When it comes to design of the enclosure, there are small considerations we can make to ensure maximum comfort for the patient.

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Shelves and ledges – As we know, cats often feel more comfortable and safer in higher positions, which is a natural desire we can often accommodate. Cages with built-in shelves or ledges should be considered, particularly for patients hospitalised for longer than 24 hours. However, if this is not available, makeshift shelves can be easily implemented using disposable cardboard boxes turned upsidedown or using the cat’s carrier if it is constructed with a solid and flat roofing. Cage specifications – Often a cat ward will contain cages of varying sizes, with smaller sizes ideal for daystay patients, and larger cages more suitable for hospitalised patients housed for longer than 24 hours. It is important to consider that at a minimum for day-stay surgical patients, the cages must be large enough to facilitate full stretching of the patient with their neck extended to ensure a safe recovery from anaesthesia. ISFM does provide specifications for both cage options, which are the suggested minimum internal measurements. Day patients < 24 hours: 60 x 60 cm (3600 cm2) floor area Longer hospitalisation periods > 24 hours: 90 x 70 cm (6300 cm2) floor area

FURNISHING THE ENCLOSURE With the above in mind, it’s now time to set up and furnish the cage. At this point, we are going to continue reflecting on our 5 feline facts to ensure we are furnishing the cage in a way that meets our cats’ physiological, safety and emotional needs. Before we furnish the cage, we must first ensure our cage is ready for set-up. Scent management – Don’t forget our felines are sensitive to scent and use scent marking due to their territorial nature. Besides the obvious reasons of adequate infection control, previous hospital patients may have also released fear pheromones, which future patients could potentially detect if the cage has not been cleaned appropriately. Before furnishing an enclosure for a new patient, always ensure all surfaces including doors and surrounding catchments have been thoroughly cleaned, using a veterinary grade disinfectant to the correct dilutions and contact time. Ensure any objects entering the cage, such as bedding, litter trays or feeding receptacles, have also been cleaned and disinfected appropriately for infection control. Any toys and enrichment items used should also follow the same protocol. Just as it is important to remove any undesirable scents, it is equally important to implement positive and familiar scents. Familiar scents could include items from home, such as bedding, cat carriers, clothing items of the owners, favourite toys, etc. Another easy step we can take to introduce positive scent is through the use of feline facial pheromones (FFPs) in the form of Feliway diffusers and spray. The FFP is a stress reducing pheromone released from facial glands, which marks an area as safe, and Feliway is the synthetic analogue of this pheromone. When we have constant diffusion of this pheromone in the hospital environment, this can contribute to a sense of safety for the patient. This product can also be sprayed onto bedding 30 minutes before use. Cage flooring and bedding – Here we want to ensure we are applying a base that is not only hygienic, but also comfortable and warm, particularly if our cage is stainless steel material. If underfloor heating is utilised, it is also important to ensure there is bedding to insulate and protect against overheating. There are many options here, some disposable and some reusable. Newspapers only are not enough when it comes to flooring and bedding! Towels are great as a cost and environmentally friendly option as they can be cleaned thoroughly for reuse and are comfortable and warm. It’s important to check towels and

blankets for any loose threads or holes. These should be disposed of to avoid injury or interference with medical paraphernalia such as fluid lines. It is also important to note that towels and blankets absorb moisture, so they must be changed if they become soiled. Disposable absorbent pads are another great option, particularly if a patient is suspected of carrying an infectious disease or is in isolation. The downside to absorbent pads is they are not as cost and environmentally friendly, and often a towel or blanket is still required underneath to have an ideal level of comfort and insulation. There are other purpose-made reusable bedding options available through veterinary suppliers that can be cut to size, are soft and padded, and enable moisture to be drawn away from the surface. While these types of bedding need to be purchased, they are reusable in the long term, which makes them more cost-effective and environmentally friendly than the disposable options. These types of bedding are excellent for recumbent patients or FLUTD patients due to their quick absorbing nature and soft padding. If we reflect on our feline facts, we remember that cats need to feel clean, and bedding and flooring is an important consideration when considering the most suitable option for each individual patient. Litter trays – Litter trays are a necessary addition for all hospitalised cats and it is ideal to have multiple sizes and styles of litter trays available to cater to the individual cat’s needs. For example, if we are housing a geriatric patient with suspected or diagnosed osteoarthritis, it would not be suitable to select a litter tray with elevated sides as this may be difficult and uncomfortable to enter and exit. Some cats may prefer more privacy and in this case using a covered litter tray, or simply placing a large cardboard box over the top, can meet this need. Litter substrate – As discussed earlier, we should aim to ask clients about their cat’s litter preferences at admission. A variety of suitable options should be available, and if necessary, we can request a client brings in some litter if it is a particularly niche type or we feel it is necessary for the patient. Food and water receptacles – As we remember from our feline facts, cats are hunters and obligate carnivores, and because of this they have an instinct to avoid contamination to their water source by consuming food away from their water. It’s important to place food and water apart, which means a big no to the double bowl if we can avoid it. Double bowls are often used in clinic due to them being easily sourced, cost-effective and easily cleaned and disinfected. When double bowls are used this may also increase the likelihood of food aversions. These types of bowls are often deep set with raised sides, which means it is also difficult for a cat to eat and drink without their whiskers touching the side, which can be irritating and uncomfortable. Ideal receptables would be ceramic material, single bowls or dishes with shallow sides to avoid whisker irritation. The ceramic material is also much less permeable than plastic, meaning they do not become tainted with odours like plastic can. The food and water bowls should be placed far apart. Privacy – Privacy is extremely important to cats and we must cater to this physiological need by providing access to a private area where they can hide. As discussed earlier, we know cats are not only solitary predatory hunters, but they are also independent, emotional and highly aware. Hospitalisation for a cat is a huge loss of control and safety, as they cannot retreat from perceived danger. We know that cats will attack if they feel threatened and cannot retreat, which means an increased risk of injury to staff. Ensuring cats have a space where they can hide will help them to regain some feeling of control over their situation and provide some safety and retreat from environmental stimuli. We can make some small changes to introduce a private area to the cage, including a blanket covering half the enclosure door in one corner, an upturned disposable cardboard box that’s an appropriate size for the cage, the patient’s cat carrier with the door removed (remember those familiar scents are important), and enclosed soft bedding igloos can also work very well. FINAL COMMENTS Implementing a cat friendly approach can seem daunting but does not need to be an expensive or complicated process. The core sentiment of these guidelines reflects a positive shift in attitude and culture surrounding the specialised needs of cats and an effort to understand their inherent needs. It’s important to understand that even small steps towards improving feline nursing care is beneficial not only to our misunderstood feline patients and their health outcomes, but also reflects rewarding, skilled and compassionate veterinary care.