Web Exclusive: Animal-Assisted Therapy and Infection Control

Transmission of MRSA and C. diff through pet therapy dogs? CLICK HERE to read about this new study.

For another recent study on this topic, refer to: Bryden L. CMAJ. 2008 August 12; 179(4): 317.

Eleven-month-old Emma suffered a traumatic brain injury and was in the intensive care unit of Phoenix Children’s Hospital for weeks while her physical and occupational therapists struggled to get her to turn or lean to her left. Nothing worked, until a specialist suggested bringing in a therapy dog team.

A nurse held Emma on her lap and kept all the tubes, lines and wires out of the way as the team led a gentle dog to Emma's left side, says Mary Lou Jennings, animal-assisted therapy program coordinator at Phoenix Children’s Hospital. “Immediately, Emma's eye moved left, then her head, and her arms. She moved more at that moment than the nurse had seen her move in days.”

Animal-assisted therapy (AAT) became a regular part of Emma’s schedule and she recovered quickly. The benefits of AAT and of patients receiving visits from their pets are well documented, but can poorly run visits threaten infection control?

Absolutely.

The good news, however, is that clear, thorough policies and rule-abiding therapy team members and handlers contribute to extremely clean, successful programs that aid patients and staffs without compromising cleanliness. Forming proper policies takes time, but can be worth the trouble.

“AAT is tremendously important in a healthcare setting, and we can see that everyday with our children,” Jennings says. “Animals in the healthcare setting give children a way to cope and be active in a very non-threatening way. Children use AAT to have fun, and do what they need to do, without even knowing they are working at it.”

Phoenix Children's Hospital and many other facilities nationwide provide AAT program for patients and their families. Jennings' program is funded by donations and special events, and the therapy leaders are trained volunteers who are nationally certified.

Research has shown that interaction with an animal can reduce stress and promote well-being.¹ Some specific benefits to kids, in particular, are that animals motivate them to get up, move, leave their room, play, interact, participate in therapy, and focus on something besides their discomfort.¹

AAT is “very important” and so are well established infection control policies and universal precautions, says Dianne Bell, program manager of the Delta Society, an international non-profit human service organization that supports AAT.

While animals of the “household” variety rarely spread infection to humans, it can happen. For instance, research commissioned by the Department for Environment, Food and Rural Affairs from the University of Liverpool Veterinary School, has identified health risks in the interaction between dogs and humans.² However, the risks of infection are low.²

Helpful Hints

Rigorous screening to identify specific pathogens on animals is not necessary if patients, staff and handlers practice hand hygiene before and after touching animals, and follow other infection prevention strategies.³ One way to keep programs consistent is to delegate one or two people to be animal-visit liaisons. The animal-visit liaison should be aware of all animal visits, including who interacted with the animal and where. This is for AAT as well as visitation from patient pets. These records are important for contact tracing in the event of potentially zoonotic patient infections, or for if a handler or animal is showing signs of having caught an affliction from a contagious patient.

Jennings says the following practices are integral to her program:

-Handwashing. “We use hand-sanitizer before and after every patient visit, and we make it a regular practice to have patients, family and staff use the hand sanitizer or wash their hands,” she says.

-Using barrier protection. The Phoenix Children’s Hospital AAT team puts an extra sheet on the bed, and another on the patient before the dog gets next to the patient. 

 -Assigning an escort to every team. Jennings accompanies most teams, or another trained escort goes in her place. “We are the ones who watch for isolation signs on the doors, watch for cleanliness issues, stop problems before they start — like food on the face of a patient that is too close to a therapy dog team, or body fluid on the floor,” she says. 

At Phoenix Children's Hospital, teams do not visit patients who are in isolation for infection control, unless there are special requests from the patient’s doctor. In that case, they take extra-careful precautions. “We see that patient prior to any other patients, we still use PPE on ourselves, and the patient may be required to use the PPE also,” Jennings says.

Guidelines

The use of animal therapy has grown and the evidence that supports this tool is also expanding, but the development of applicable infection control guidelines has not been commensurate.³ In fact, these policies have “lagged,” say the members of the “writing panel of the working group,” a team of AAT and infection control experts who authored “Guidelines for animal-assisted interventions in health care facilities.” As a result of scant national policy, animal health screening and infection control related to animal programs has been “highly variable” in and between healthcare facilities, the authors contend.

“Although general guidelines for animal visitors have been published by several expert groups, a collaborative document that captures the interests of most stakeholders while providing specific recommendations to minimize both injuries and the transmission of infectious organisms to and from animals is needed,”³ they write. 

The panel members are from Canada and the United States and met in 2007 with the goal of finalizing guidelines that could be used in their respective countries and possibly beyond. For information from these guidelines, read the accompanying story, “Guidelines Make Animal Programs Stronger.”

Another group that has released guidelines is Bell’s organization, the Delta Society. This group was founded by professionals and academics from veterinary and human health fields in 1977. The members first focused on funding credible research about whether animals are important to well being. The case of animals as healers has been well documented over the years, so in the 1990s the group shifted its focus from science and education to one that provides direct local service. The group provides comprehensive animal-assisted activities training to volunteers and healthcare professionals.4

The society also developed the book “Standards of Practice in Animal-Assisted Activities and Animal-Assisted Therapy.” This book provides guidance in the administrative structure of animal therapy programs and covers such bases as how to meet health requirements, select animals, evaluate programs, document properly and train personnel.  

Animals as Healers          

One animal-therapy memory Bell recalls is of a little boy who was working on balance and strengthening his muscles. The therapist would hold on to him so he could kick a ball gently to the dog. “The boy enjoyed the session and the therapist was able to achieve the steps needed to reach the goal for that session,” Bell says. “For the young boy it was fun — for the therapist it made her job easier to get him engaged.”

For some people, animal contact can decrease stress and raise immune function. The contact can benefit healthcare staff too. One study measured stress and immune function in 20 healthcare professionals who interacted with a therapy dog and the findings suggest that stress reduction in healthcare professionals may occur after as little as five minutes of interaction with a therapy dog.4 The researchers measured, among other indicators, serum cortisol, epinephrine, and salivary cortisol and lymphocytes.

Other studies have shown that illness, fear, loneliness, and depression may be lessened when patients receive a therapy dog visit, since the interaction is a welcome change in routine and is something to look forward to.6 Patients are often more active and responsive during and after a visit, say the authors of “The healing power of dogs: Cocoa's story” which was published in the Journal of Psychosocial Nursing and Mental Health Services in 2006. “Just stroking and petting a dog requires the use of hands and arms, as well as the motions of stretching and turning,” the authors state.

The benefits of animal therapy and patient pet visitation are promising, but infection control can never be ignored. Overall, is cleanliness a big enough part of AAT? Bell believes so. “As long as universal precautions are being followed and infection control policies are evaluated and assessed on an ongoing basis, with standards of practice for AAA/T being adhered to, yes,” she says.

 Jennings is also confident that AAT programs can be safe and clean. She says her program has sufficient protection. 

“We have strict policies for our therapy dog teams about bathing, grooming, vaccinations and training,” Jennings says. “I do think there will always be human error, which is why we build thoroughness in our processes, review infection control with volunteers often, and let them know about infection control errors that have caused serious harm and death in other places, so we all take it seriously.”               

Thanks to healthcare staff like Jennings taking infection control of animal programs seriously, patients can relax a little, and there’s nothing like a big friendly fuzzy dog to assist in that effort.

References

1. Phoenix Children’s Hospital animal-assisted therapy program. www.phoenixchildrens.com/patients-visitors/aat/

2. Elliott V. Beware of the dog: you may catch MRSA. The Times. April 14, 2008.

3. Lefebvre SL, et all. Writing Panel of the Working Group. Guidelines for animal-assisted interventions in health care facilities. American Journal of Infection Control. March 2008 (Vol. 36, No. 2, Pages 78-85).

4. The Delta Society. www.deltasociety.org

5. Barker SB, et all. Measuring stress and immune response in healthcare professionals

following Interaction with a therapy dog: a pilot study. Psychol Rep. June 2005.

6. Cangelosi PR, Embrey CN. The healing power of dogs: Cocoa's story. Journal of Psychosocial Nursing and Mental Health Services. January 2006.

Guidelines Make Animal Programs Stronger

By Michelle Beaver

There may not be one dominant, nationally accepted set of guidelines for animal-assisted therapy, but the following instructions from a working group of animal-assisted therapy experts and stakeholders can help any facility. The group was sponsored by the Public Health Agency of Canada, and the Centre for Public Health and Zoonoses at the University of Guelph in Ontario, Canada. The guidelines can be used on their own, or with other guidelines, such as those from the Delta Society, an Oregon-based international non-profit human service organization that promotes animal-assisted therapy.

Hand Hygiene:

-All patients, visitors and healthcare workers must cleanse their hands using recommended practices before they touch an animal, and after the visit.

-Healthcare facilities should provide animal handlers with an appropriate supply of alcohol-based handrub products. The handlers should carry these products any time they are in the facility, and should offer them to everyone who touches the animal.

Creating an Animal Visitation Plan:

-Healthcare facilities should develop policies for when animals visit through formal therapy programs, and for when patient pets visit. Some information will overlap.

-Healthcare facility authorities should designate an animal visit liaison (AVL) who can be a “point person” and who will be aware of every animal visit.

-The best length for animal visitation is one hour or less.

Advice Regarding Patients’ Pets:

-Patients of any age can receive visits from their pets, but the pets should always be under supervision of someone besides the patient.

-The pets can not visit other patients, or staff.

Advice Regarding Animals of Formal Programs (Not Patient Pets):

-The animals chosen for a program must be of the “household pet” variety. Animals not acceptable in programs include amphibians, reptiles, primates, hamsters, mice, rats, gerbils, etc. These creatures have a higher risk than a cat or dog, for instance, of causing human infection. 

-Every animal must be in a permanent home for at least six months before it can visit patients. This way, there is time for its health and character traits to become more evident.

-All program animals should be at the age of social maturity, with cats being at least one year old and dogs being more than one but preferably at least two years old.

-Each animal must undergo a temperament evaluation before they are formally accepted into the program. The screening can include reactions toward handlers, strangers, loud noises and being restrained and should be repeated at least every three years. The evaluators must complete a course or certification process.

-It is advisable for animal handlers to be observed by a program representative at least once in a healthcare setting.

-Visits must be suspended and/or an animal should be revaluated if they show aggression, strong fear, or experience loss of sight or hearing. Cats should not be de-clawed.        

Health Guidelines Applicable to All Animals:

-Dogs and cats must be vaccinated against rabies.

-If the animal has vomited, had diarrhea, urinary or fecal incontinence, open wounds, ear infections or skin infections within the last week, they cannot be allowed to visit a healthcare facility. This is also true for if they were treated in the last week with non-topical antimicrobials. Animals who exhibit any type of pain that will be worse during handling cannot visit.

-Therapy animals should be examined by a veterinarian at least once a year. Ask the animal’s veterinarian about appropriate flea, tick, and parasite control programs.

-The handler should brush or comb the animal’s hair before the visit to reduce debris from shedding in the facility. They must also keep the animal’s claws short and dull. Carriers and leashes must be clean.

-It is not necessary to routinely screen for specific, potentially zoonotic microorganisms, including methicillin-resistant Staphylococcus aureus, for example.

-Any animal (including patient pets) that has eaten raw foods of animal origin within the last 90 days cannot visit the facility.

Training for Handlers of Patient Pets:

-The handler must be informed of the facility’s animal visitation policy and sign an agreement that they will comply with the policy. They must bring the animal's rabies immunization documentation.

-Handlers should be escorted to the patient’s room by the AVL along a low-traffic area, and should not release the animal from its leash or cage until they are near the patient.

-The AVL and the facility policy should instruct handlers about the fact that staff, patients, etc., will want to interact with the animal. However, the handler must deny those requests.

Advice for Handlers of Therapy Animals:

-Handlers should undergo formal training that includes information on Zoonoses, infection control practices, and reading the body language of animals.

-Handlers must wear gloves to clean up animal waste, and dispose of it with other biowaste. They must then report the incident so the area can be disinfected. The rest of the visit must be canceled. 

-Handlers must prevent animals from making contact with insertion sites or devices, and should try to prevent patients from touching the mouth, nose or perianal region of the animals.

-Handlers should not visit if they have diarrhea, conjunctivitis, or a rash, or if they are coughing, sneezing, feverish or vomiting.

-Handlers should ask the AVL to tell them who is allergic or fearful of animals, so that the handler can avoid those people.

-Animals cannot enter food or medication storage areas, operating rooms, neonatal nurseries, dialysis or burn units.

-Animals should only be placed on beds if the patient requests it. The handler should then place an impermeable barrier between the animal and the linens. If necessary, a towel, sheet or pillowcase can be used. They must be put in the laundry immediately after the visit.

-In most cases, patients, visitors and healthcare workers shouldn’t feed the animals, but if they do, the treats must not be raw.

If the preceding guidelines are followed, chances are good that there will not be any harmful contagions passed between people and animals. However, visit records must be kept just in case. Handlers should sign in when they arrive and depart, and records should include who came in contact with the animal and where. Lastly, after every visit, staff should clean environmental surfaces that the animal touched.

Source: Lefebvre SL, et. al. Writing Panel of the Working Group. Guidelines for animal-assisted interventions in health care facilities. American Journal of Infection Control (AJIC). March 2008 (Vol. 36, Issue 2, Pages 78-85).