The Health Care
Overview of AAI
Health care administrators face numerous challenges as they seek to provide the best experience and value for patients, as well as a fulfilling and healthy work environment for their teams. Evaluations of health care facilities once hinged on patient outcomes. However, in the age of pay-for-performance, reimbursements are increasingly based on quality, value, and patient experience. Additionally, health care administrators must recruit and retain a strong health care workforce while managing dissatisfaction and burnout among providers.
Evidence-based medicine supports provision of safe and effective clinical care, and now a new field of research seeks to provide evidence-based complementary therapy, improving patient experience, addressing provider stress, and adding value across the health care continuum. This manual was developed to provide guidance for health care administrators, managers, volunteer coordinators, and their staffs in establishing and coordinating one such complementary therapy, animal-assisted interventions (AAI), in health care facilities.
The manual reflects over a decade of direct experience in coordinating and maintaining an animal-assisted therapy (AAT), animal-assisted activity (AAA), and facility animal program in a major academic medical center; conducting research demonstrating the program’s effectiveness and contributing to the evidence base on the health benefits of animal-assisted interventions; and providing education and consultation on AAI in health care facilities. In addition, current resources relevant to AAI in health care settings were consulted and are listed in Additional Resources.
The recommendations presented are intended to offer program structure, best practices, and guidelines for AAI program evaluation as well as establish policies that maximize patient, staff, and AAI team safety and minimize risk. Since it is not feasible for this manual to cover all types of health care facilities, recommendations are offered for the most restrictive settings, acute care hospitals, with the understanding that these recommendations can be extended to other facilities such as residential and outpatient facilities. Administrators in less acute health care settings may wish to tailor these recommendations based on their specific needs.
Because dogs are the only species recommended for AAI in acute health care settings (Murthy et al., 2015), this manual refers specifically to therapy dogs and their human handlers, referred to throughout as “AAI teams.”
1.1Benefits of AAI
Published studies investigating the potential impact of AAI in health care facilities provide evidence of a number of benefits. However, it is important to point out that not all studies find patient benefits, which may be due to the type of intervention implemented, client population selected, and study design. Most interventions studied are structured or unstructured animal-assisted activities, rather than animal-assisted therapy in which the animals are an active component in a patient’s care plan. The vast majority of AAI studied have been conducted with therapy dogs.
Several studies report benefits for cardiovascular patients, including patients with congestive heart failure (Abate, Zucconi, & Boxer, 2011; Cole, Gawlinski, Steers, & Kotlerman, 2007), with hypertension (Allen, Shykoff, & Izzo, 2001), and post–myocardial infarction (Friedmann, Thomas, & Son, 2011). Published studies also show benefits for orthopedic patients post–joint replacement surgery (Havey, Vlasses, Vlasses, Ludwig-Beymer, & Hackbarth, 2014), as well as for women hospitalized with high-risk pregnancies (Lynch et al., 2014). Studies of AAI with psychiatric patients (Bardill & Hutchinson, 1997; Barker & Dawson, 1998; Nepps, Stewart, & Bruckno, 2014) also report benefits. While some evidence supports benefits for hospitalized children (Calcaterra et al., 2015; Kaminski, Pellino, & Wish, 2002; Sobo, Eng, & Kassity-Krich, 2006; Tsai, Friedmann, & Thomas, 2010), a recent critical review of the literature on AAI in pediatric hospitals cautions about the lack of sound evidence and calls for more rigorous research with this population (Chur-Hansen, McArthur, Winefield, Hanieh, & Hazel, 2014).
AAI has also been found to benefit health care staff. Health care professionals interacting with therapy dogs in an acute care hospital were reported to have reduced stress after these interactions, evidenced from reduced serum and salivary cortisol levels after very brief time spent with a therapy dog (Barker, Knisely, McCain, & Best, 2005).
Finally, AAI has been shown to improve patient perceptions of treatment in a health care facility. A recent study in orthopedic surgery patients found that inclusion of therapy dog visitation resulted in improved scoring in top box Hospital Consumer Assessment of Healthcare Providers and Systems measures including nurse communication, pain management, and overall hospital rating (Harper et al., 2015). Another study found that AAI with a therapy dog produced significant reduction in self-reported anxiety scores of adolescent gynecology patients in an outpatient setting (McCracken, LaJoie, Polis, Hertweck, & Loveless, 2016).
While more rigorous research is needed to confirm preliminary studies documenting benefits of AAI for health care patients (and staff), there is a growing body of evidence supporting AAI as a low-cost, complementary therapy with the potential to benefit many patients. Regardless of the evidence supporting AAI, a major barrier to implementing AAI in health care facilities is negative beliefs and fears about dogs in such facilities. Four of the common myths about AAI are addressed in the following section.
1.2Myths About AAI
There are several widespread myths related to AAI, all of which can be addressed by having appropriate policies and procedures in place. Four of the more common myths are discussed below.
Therapy Dogs Will Spread Infections
With appropriate policies and procedures in place, the risk of zoonotic disease transmission is quite low, with dogs posing the lowest risk (Murthy et al., 2015). Health care facilities with successful AAI programs have strict requirements for therapy animals and their handlers, including appropriate species for their settings, registration, health, temperament, and cleanliness policies along with strict procedures for visitation.
Therapy Dogs Will Be Dirty and Bring Ticks and Fleas Into the Facility
Appropriate policies that address cleanliness ensure that therapy animals are well groomed and recently bathed, most within 24 hours of a visit. Policies that require therapy animals to be on flea and tick prevention programs and that have designated exercise areas for therapy animals minimize the risk of ticks and fleas being introduced to the facility by AAI programs. It is also important to be aware that patients, visitors, staff, and volunteers often have pets at home and may bring fleas and ticks into the facility on their clothes and belongings.
Therapy Dogs Will Be Disruptive—Bark and Jump on People
AAI program policies requiring appropriate training of therapy dogs minimize the chances of disruptive behavior and address any disruptive behavior that may occur. While dogs may occasionally bark in a facility, appropriately trained handlers quickly stop any barking or other potentially disruptive behavior.
Therapy Dogs Will Negatively Impact Productivity and Patient Care
There is no evidence to support the myth that therapy dogs will interfere with productivity and patient care. To the contrary, health care professionals have been found to experience reduced physiological stress after very brief interactions with therapy dogs. In our own experience providing AAI to hospital staff at highly stressful times, we receive consistent positive feedback on the ability of therapy dogs to calm and comfort staff. Appropriately trained therapy dog teams and carefully developed policies and procedures for patient interactions minimize the possibility of any interference in patient care and maximize the potential of AAI playing a complementary role in patient care. Policies and procedures addressing these types of issues will be presented later in this manual.
1.3Limiting Therapy Animals in Acute Health Care Facilities to Dogs
Many species of animals are used in AAI including dogs, horses, cats, birds, alpacas, guinea pigs, and rabbits. Some species may visit at a facility with their handler, and some species must be visited and interacted with at the facility where they are housed. For example, while a therapy dog might be brought by her handler into a physical rehabilitation center to visit with patients, patients might visit an equine therapy center in order to visit and partake in therapeutic horseback riding. All animals (with the exception of fish) pose a risk due to the potential for injury from contact with teeth (accidental or intentional), injury from scratch (accidental or intentional), or general abrasion or bruise from contact.
The Centers for Disease Control and Prevention (2017) defines zoonotic diseases as diseases caused by viruses, bacteria, parasites, and fungi that can be spread between animals and humans. All animals pose the risk of zoonotic disease transmission to humans.
Cats may be appropriate for use in AAI in some settings, but are not appropriate for visitation in an acute health care environment due to their less reliable nature and higher risk of zoonotic disease transmission due to risk of scratching with claws (intentional or accidental). Other animals (such as horses) that primarily live in an outdoor setting are not appropriate for an acute health care setting due to their common contact with contaminant sources common to the outdoors.
It is recommended that exclusively dogs be used in a health care facility, and particularly in an acute care setting. Dogs are easily trainable, have generally predictable behavior, are familiar to most individuals as an accepted animal for therapy and service, and generally enjoy human contact. Dogs can be used widely in any setting (acute care, ambulatory care, home health), and also have wide variation in size (some dogs are small enough to be placed on a patient’s lap, while other dogs are large enough to stand adjacent to a patient’s bed or wheelchair). Finally, dogs carry relatively few communicable diseases.
Health care administrators should have an understanding of basic terminology used in AAI in order to accurately communicate the purpose and activities involved in their AAI programming. Additionally, these definitions should be clearly explained to all AAI teams (see Chapter 5, Section 5.4: Manuals for AAI Teams).
Animal-Assisted Intervention (AAI)
AAI is an encompassing term describing the use of an animal in a capacity beneficial to humans (American Veterinary Medicine Association, 2018). AAI is conducted in many settings, typically using therapy animals. Therapy animals may include any species appropriate to the target setting. AAI in health care settings usually involves therapy animals working with a human handler to provide animal-assisted therapy (AAT) and/or animal-assisted activities (AAA).
Animal-Assisted Therapy (AAT)
AAT is the purposeful incorporation of a therapy animal into an individual’s treatment plan. AAT may include a health care professional involving a therapy animal while working with a patient to achieve a treatment goal (such as brushing a dog to improve eye-hand coordination). Patient responses to AAT are typically documented in the medical record by health care professionals.
Animal-Assisted Activities (AAA)
AAA are less structured than AAT, but evidence suggests they are also beneficial for patients, families, and staff. The goals of AAA may include relaxation, fun, and distraction from pain or discomfort. AAA are not considered part of a formal treatment plan, and thus do not require documentation in the medical record by the professionals caring for the patient. Please note that most therapy animal interactions in acute health care settings consist of patient visitation and are categorized as AAA.
Service animals are defined and protected in the United States under the Americans with Disabilities Act of 1990 (ADA). Service animals are individually trained to perform specific tasks for people with disabilities. Examples of such work or tasks include guiding people who are blind, alerting people who are deaf, pulling a wheelchair, alerting and protecting a person who is having a seizure, or reminding a person with mental illness to take prescribed medications. The only two species defined as service animals under ADA are dogs and miniature horses (horses measuring 24–34 inches to the shoulder, and weighing 70–100 pounds). The following are additional important points regarding service animals:
1.Service animals are working animals, not pets.
2.The work or task a service animal has been trained to provide must be directly related to the person’s disability.
3.A person with a disability has a legal right to enter public places with his or her service animal, including banks, restaurants, stores, and other public venues.
4.Service animals typically perform specific tasks for their owners and are not to engage with those around them.
5.Service animals must be under control and leashed unless the leash interferes with the animal’s tasks.
For more information about service animals, please see the Americans with Disabilities Act of 1990 under the U.S. Department of Justice, Civil Rights Division, Disability Rights Section.
Therapy animals meet health, behavior, and temperament criteria for appropriateness to participate in AAI. A wide variety of animal species may be considered therapy animals. Therapy animals do not have the same legal standing as service animals and are not covered by the Americans with Disabilities Act of 1990. They do not have legal access to public and/or private areas and must receive administrative permission to visit in any facility.
Emotional Support Animals
An emotional support animal is a companion animal that provides therapeutic benefit to an individual with a mental or health-related disability (American Veterinary Medicine Association, 2018). These support animals may provide companionship, relieve loneliness, and sometimes help with depression, anxiety, and certain phobias, but do not have special training to perform tasks that assist people with disabilities. Emotional support animals do not have the same legal standing as service dogs and are not covered by the Americans with Disabilities Act of 1990. Emotional support animals are provided legal protection in the United States under the Fair Housing Act of 1968, Section 504, which states that individuals with a disability may request reasonable accommodation for their emotional support dog. Emotional support animals are also provided legal protection by the Department of Transportation, which requires U.S. airlines to provide transport for emotional support animals when persons with mental health-related disabilities require their emotional support animal be present in order to travel.
For more information regarding regulations related to emotional support animals under the U.S. Department of Transportation please see the Air Carrier Access Act (ACAA) or visit www.transportation.gov.
For more information regarding regulations related to emotional support animals under the U.S. Department of Housing and Urban Development, please visit www.hud.gov.
1.5Zoonotic Diseases and Prevention
While AAI is considered safe in acute health care settings due to availability of evidence-based infection prevention techniques (Murthy et al., 2015), it is essential for administrators to know the risks associated with therapy dog visitation in acute health care settings, and to involve hospital personnel responsible for infection prevention in AAI program planning. The following zoonotic diseases are associated with dogs (Centers for Disease Control and Prevention, 2017):
•Ancylostoma brazilense, A. caninum, A. ceylanicum, Unicinaria stenocephala (Hookworm)
•Brucellosis (bacterial infection causing flu-like symptoms; may sometimes develop into a chronic and difficult to treat condition)
•Campylobacter (gastrointestinal bacteria causing abdominal cramping, diarrhea, and fever)
•Capnocytophaga (bacterial infection that is generally not problematic in healthy humans, but may result in complications in patients with compromised immune systems)
•Cryptosporidiosis (parasitic disease causing severe diarrhea and vomiting; may cause complications in humans with compromised immune systems)
•Dipylidium caninum (Ringworm)
•Echinococcosis (parasitic disease that can result in tapeworms growing on different organs of the body, including the lungs and liver)
•Ehrlichiosis (bacterial disease resulting in possible fever, headache, chills, muscle pain, nausea, vomiting, diarrhea, and rash)
•Giardiasis (parasite causing gastrointestinal issues including diarrhea, abdominal cramps, nausea, and vomiting)
•Leishmaniasis (protozoan causing painful ulcers on the skin; visceral leishmaniasis is less common and is characterized by fever, weight loss, enlarged spleen, and anemia)
•Leptospirosis (bacterial disease that often results in no symptoms for humans, although some may have nonspecific flu-like signs; can result in more serious disease)
•Lyme disease (bacterial disease causing flu-like symptoms; may also result in symptoms such as arthritis and loss of facial muscle tone, and can be fatal)
•Pasteurellosis (bacterial disease that can cause painful wound and skin infections, in severe cases widespread infection, and might affect the nervous system)
•Plague (symptoms include sudden onset of high fever, chills, headache, malaise, and swollen lymph nodes; forms include septicemic, pneumonic, and bubonic)
•Rabies (a viral neurological disease fatal in humans and animals if untreated)
•Rocky Mountain spotted fever (symptoms may include fever, rash, headache, nausea, vomiting, abdominal pain, and muscle pain)
•Salmonellosis (infection causing diarrhea, vomiting, fever, or abdominal cramps)
•Sarcoptic mange (parasitic skin disease that will not infect humans, but may result in bites from the mites that cause the disease)
•Methicillin-resistant Staphylococcus aureus (MRSA bacteria causing skin infections that can range from mild to severe; if left untreated, MRSA can spread to the bloodstream or lungs and cause life-threatening infections)
Many diseases may be prevented with proper vaccination (e.g., rabies), and the risk of transfer of a communicable disease from a dog to an individual in a health care facility can be minimized through proper interaction and procedures that emphasize infection control (see Figure 1). This means that both volunteer AAI teams and frontline staff should be prepared to execute and communicate proper procedures with therapy animals. Administrators should work directly with hospital infection prevention personnel, unit managers, volunteer managers, and any other team members who are responsible for communication of proper infection control procedures to volunteers and staff.
Figure 1 A therapy dog relaxes on a patient bed while lying on a sheet, which acts as a barrier between the underside of the dog and the patient’s linens. Use of cloth barriers is one infection prevention method used in AAI. (Photo by Matt Stanton.)