Establishing Requirements:
AAI Implementation
Clear procedures must be established by your AAI program to maximize patient, staff, visitor, and AAI team safety and to enhance patient satisfaction. Since therapy dog organizations vary in the AAI procedures required of their members, health care facilities are strongly advised to consider the recommended procedures in this manual and included in the available online template (docs.lib.purdue.edu/AAI). These procedures are best communicated to your AAI teams through a hard copy and/or online manual (see Chapter 5, Section 5.4: Manuals for AAI Teams). AAI procedures must also be communicated to health care facility staff to inform them of the process and their roles in contributing to safe and efficient AAI team visits. All policies and procedures recommended in this manual are informed by evidence-based guidance regarding animals in health care settings, including the Society for Healthcare Epidemiology of America (Murthy et al. 2015). As more evidence becomes available, health care administrators are advised to continually revisit current epidemiological literature in order to update policies and procedures for AAI.
4.1Health and Grooming
Policies should be established to ensure that each dog participating in AAI is healthy, well groomed, and bathed within 24 hours of visiting the health care facility. First, such policies minimize the entry of contaminates from the outside environment into the health care facility (thus protecting patients, staff, and visitors). Second, they provide the opportunity for the therapy dog handler to examine the dog for any wounds, sensitive spots, or areas of concern that might prevent them from visiting safely. And third, such policies set an important health and cleanliness standard. Concerns about health and grooming of a dog visiting in the facility should result in the immediate departure of the AAI team from the health care facility. AAI program staff should maintain open communication with health care facility employees, encouraging any staff member with a concern about dog grooming or health to contact AAI program staff immediately.
Table 3 can be used to inform your AAI teams and facility staff of the health and grooming requirements for therapy dog team presence in your facility on any given day. This list was developed to minimize risk of infection or incident, as well as provide guidance on safety, behavior, and appropriate grooming. Such guidelines are formed with input from infection control specialists, veterinarians, and therapy animal organizations in order to better ensure that AAI teams are healthy and prepared to visit, all while posing minimal risk to those in the acute health care facility.
TABLE 3 Previsit Requirements for AAI Teams
| Requirement | Requirement Description |
|---|---|
| Bathing | Dogs must be bathed and groomed within 24 hours of the visit. |
| Health | Dogs must be free of illness and/or infection. |
| Skin and coat | Dogs must be free of wounds/sores and have a healthy coat and skin. |
| Nails | Dogs must have nails trimmed as closely as possible. |
| Obedience | Dogs must be well behaved and firmly under the handler’s control at all times. |
| Flea/tick collars | Dogs must not wear flea collars. |
| Flea/tick medication | Dogs must not be treated with flea medication (e.g., Frontline, Advantix) within 3 days of the visit. |
| Estrus (female dogs) | Female dogs must not visit while in estrus. |
| Raw diets | Dogs must not have been fed a raw diet within at least 90 days of visitation. |
| Pork products | Dogs must not have consumed “pork hide” or “pig ear” treats within at least 90 days of visitation. |
| Wellness check | AAI teams must provide documentation of a yearly wellness check signed by their veterinarian. |
| Vaccination | AAI teams must provide documentation of current immunizations signed by their veterinarian. |
4.2Identification of Animals and Handlers and Security
For patients, staff, and visitors to identify AAI teams approved to enter the health care facility, teams must be easily identifiable. The volunteer AAI handler should wear an approved identification badge on the outermost layer of clothing, readily visible on the chest. A clothing uniform for the handler (this can simply be a designated shirt), and an identifying vest or bandana for the dog are ideal in order to maintain a clear and recognized presence while in a health care facility. The badge, shirt, and vest serve to verify and brand the use of AAI teams within your health care facility (see Figures 6 and 7). Proper identification should be provided for the AAI team, both person and dog, in accordance with your facility rules.
Figure 6 A therapy dog in uniform. (Photo by Rebecca A. Vokes.)
Figure 7 A therapy dog handler and therapy dog in uniform. (Photo by Lucy Stefani.)
Staff, including security, should be made aware of the uniform designating an AAI team, and facilities must determine whether they would like to uniform AAI teams identically to other hospital volunteers. Identifying apparel (see Figures 6 and 7) that may be worn by AAI teams include the following:
Dogs
•Vest or bandana denoting therapy dog status
•Collar with visible rabies vaccination tag and/or therapy dog tag
•Leash denoting therapy dog status
•Identification badge denoting volunteer status
•Uniform shirt (preferably with program name and indication of volunteer status)
Your facility may have areas where restrictions on access will require volunteers to have an access code or be escorted by personnel with access to the area. Your facility must determine the level of clearance for AAI teams, and outfit them with proper security devices that may allow them to access patient areas while volunteering. Any access-related concerns can be explained in the AAI manual for volunteers in order to prevent issues with security and safety in the hospital.
4.3Arrival and Departure at the Facility
A safe parking area is important for AAI teams so that they may easily transport their animals to and from the health care facility. This area may include convenient access to an area where dogs may relieve themselves before entering the facility. Some facilities may offer complimentary parking, street parking, or another area where teams may park their vehicles.
It is important for your AAI program to maintain an active log of the visits made by AAI teams. Not only does this aid in program scheduling and evaluation, but it is also vital for the safety of teams and those individuals in your facility in the case of emergencies or adverse events. The log may be a paper sign-in sheet kept in a central location such as the Volunteer Office, accessible to all teams, or electronic via a computer system designated and accessible by the volunteers. The log provides a record of who is present in the facility at any given time, and enables safe management of the number of AAI teams at your health care facility. Finally, signing in and out is important in order to provide necessary tracking information in the unlikely occurrence of any adverse events or contact tracing needed for infectious disease. These policies should be communicated clearly to AAI teams (see Chapter 5, Section 5.4: Manuals for AAI Teams).
Electronic logs in Microsoft Excel or Access format can easily generate reports on visitation frequency and location. Consultation with health care facility’s technology services department may provide additional solutions for tracking AAI team visitation.
4.4Areas Approved for AAI
Your AAI program should develop clear policies regarding where AAI is permitted and consult with individual units in order to define areas of service and unit staff willing to serve as liaisons to the AAI program. These areas may include specific patient locations (such as the palliative care unit) as well as public areas such as lobbies, general hallways, outdoor areas, and waiting rooms.
Within these approved AAI areas, there may be certain rooms or zones where a therapy dog is not be permitted. For instance, although an AAI team may be allowed to visit patients and staff on a cardiac ICU floor, the kitchen area on that floor should be off-limits to the AAI team. Some AAI areas may include restrictions or limits, such as certain hours or days, or allow AAI only in response to requests from a physician in charge of a patient’s care. AAI teams should always be prohibited in areas where sterility must be maintained (in operating rooms, preoperative suites, etc.), and in isolation rooms. Within all patient rooms, the AAI team should be prohibited from patient lavatories.
While it is important that your AAI program provide clear communication to AAI teams on where visitation is allowed and restricted, it is also important to inform unit staff of where AAI teams are prohibited on their unit. For example, if a nurse is on a lunch break eating a meal in the unit break room, and sees a visiting AAI team in the hallway, the nurse will know to exit the food preparation area in order to interact with the dog rather than inviting the AAI team into this area.
Particularly in large facilities, it is also advisable to provide unit maps to AAI teams identifying areas where they are allowed, restricted, or prohibited. These can be color-coded, such as using green highlighting to designate areas approved for visitation, red highlighting to designate areas restricted from visitation, and yellow highlighting to designate areas needing special permission for visitation, and laminated for ease of use.
4.5Entering and Exiting Patient Areas
Unit staff should always be aware of the presence of a dog in order to maintain safe and orderly interactions with AAI teams. AAI policies and procedures should include instructions regarding appropriate protocol for entering patient areas. For example, when arriving to a unit, it is advisable that the therapy dog handler notify key staff on the unit. This can be as simple as approaching the nurse’s station upon arrival to notify the nurse in charge or unit secretary of the AAI team’s presence.
Unit staff may be readily able to identify patients who might be interested in a visit from the AAI team. Staff can also inform the AAI team of the location of linen and linen disposal in the event a towel or blanket is needed to provide a barrier between the therapy dog and patients requesting the dog be placed on their beds.
Unit staff may at times prohibit visitation with any patient based on the patient’s medical condition or when a unit environment has an unusually high patient acuity level or limited staffing. Additionally, the AAI handler must be instructed to always obtain a verbal consent from the patient or from a responsible party in the patient’s room before entering, as a patient’s willingness to participate in AAI may have changed due to any number of factors including a change in mood, a change in medical condition, an additional family visit, and so on. In semiprivate rooms, permission must be obtained from all other patients in the room as well.
Just as it is important for unit staff to know when an AAI team is on their unit, they also need to be made aware of when the team is leaving. The AAI team can be instructed to simply alert staff at the nurses’ station as they prepare to leave the unit. AAI teams also need to be informed of procedures for notifying staff of any pertinent information from the visit (for example, if a patient was not visited because they were sleeping, or a patient expressed fear of dogs) or of patient requests (for water, food, or any type of assistance).
4.6Interactions With Patients
The key goal of any complementary therapy program in the health care facility is to improve the health and well-being of the patients. While it is important to make AAI enjoyable and comforting for patients, it is vital that patient safety is always maintained. AAI programs must form and enforce policies and procedures that reduce the chance of infection or harm to a patient.
Any patient interacting with an AAI team should first have sanitized hands. This can be achieved by washing hands with warm water and antibacterial soap, or using health care facility approved hand sanitizer. AAI handlers must also sanitize their hands before interacting with a patient. AAI teams need to be informed of procedures for obtaining hand sanitizing products on each unit they visit. If hand sanitation products on a unit are immobile (such as wall dispensers) mobile products should be provided to AAI teams in order to allow them to sanitize the hands of those interacting with their dog. Ideally, multiuse, mobile, health care facility approved hand sanitizer should be provided to each AAI team and replenished as needed.
Unit staff may confer with the AAI team prior to any interactions with patients, especially on units where patients are likely to be injured or have physical areas of concern. Upon initial contact with a patient, the AAI handler should be instructed to visibly scan any exposed skin for scratches, cuts, or areas where any invasive devices are present on the patient. Contact with these areas must be avoided. AAI teams should be instructed to always be aware of patient comfort and the therapy dog’s physical position.
AAI handlers may encourage patients to talk to their dogs and, if interested, pet their dogs, but also be open to having patients simply observe their dogs. At times it may be appropriate to let the dog lie on a patient’s bed. When patients give verbal permission or express a desire for therapy dogs to lie on their beds, a towel or sheet must be used to cover the area where the dog will lie to provide a protective barrier between the dog and bedding. Unit staff should be aware of this policy and provide linens on request during AAI visits and directions for disposing of them after individual use.
The following behaviors illustrated in Table 4 are common in dog and human interactions, but should be discouraged in a health care setting to minimize risk of infection:
TABLE 4 Behaviors to Avoid for AAI Teams
| Behavior | Behavior Description | Example Image of Behavior |
|---|---|---|
| Licking | Licking behavior increases the chance of infection due to contact with the dog’s mouth. Handlers should be particularly aware of sites of injury on a patient where a dog may sniff or lick. |  |
| Pawing | A dog’s pawing behavior increases risk of possible scratching. Paws are also a point on the dog’s body where more contaminants may be found (due to their consistent contact with the ground), and patient contact with paws should be avoided. |  |
| Jumping up on others | Jumping of dogs increases the likelihood of scratching, and also can lead to a fall that could result in injury to the patient. A dog’s jumping may also be seen as disruptive to staff and visitors. |  |
| Touching the nose and mouth of dog | It is important to minimize contact with the mouth and paws of the dog, as these are potential sites of infection transmission from dog to person. Individuals should be encouraged to pet the dog on the back and body. |  |
| Playing in a rough manner | Playing in a rough manner greatly increases the likelihood that a scratch, fall, or even a “mouthing” or “play nip” could occur from the dog. This manner of interaction is not appropriate for an acute health care setting. |  |
Photos by Rebecca A. Vokes.
After any interaction with the AAI team, patients should once again sanitize their hands by washing with warm water and antibacterial soap, or using facility-approved sanitizer. AAI handlers should also sanitize their own hands after interacting with each patient.
4.7Interactions With Families, Visitors, and Staff
There are many additional people present in the health care environment who may benefit from AAI. While interactions with AAI teams naturally occur with families and visitors of patients, the same procedures regarding hand hygiene must be observed during interactions with these individuals. Hands of all visitors and family members should be sanitized before and after interactions with the AAI team. The same interaction procedures appropriate with patients should be followed with families, visitors, and staff to minimize risk to these individuals, and to the patients with whom they come into contact.
4.8Interactions With Staff
Employees of a health care facility often enjoy and benefit from AAI, and have been shown to experience reductions in stress as a result of even brief interactions with a therapy dog (see Figure 8). Some employees have scheduled their work shifts to coincide with when AAI is scheduled on their units.
Figure 8 A nurse pauses during her shift to visit with an AAI team. One study reported that interactions with therapy dogs as brief as 5 minutes may produce a similar physiological stress reduction to a 20-minute break for health care professionals. (Photo by Jordan Vance.)
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