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Doi:10.1016/j.ajic.2005.06.005

Who let the dogs out? Infection controldid: Utility of dogs in health caresettings and infection control aspects Heidi DiSalvo, MPH,a Donna Haiduven, BSN, MSN, PhD,a,b Nancy Johnson, BSN, MSN,b Valentine V. Reyes, BSN,bCarmen P. Hench, BSN,b Rosemary Shaw, OT,b and David A. Stevens, MDb Research has substantiated that animals improve human health, both psychologically and physiologically. Therefore, healthcarefacilities have begun to implement programs, such as the ‘‘Furry Friends Foundation,’’ that bring animals into the facility toimprove the quality of life of patients. When implementing these programs, consideration must be given to potential adverseevents such as phobias, allergies, and particularly the possibility of zoonotic disease transmission. Santa Clara Valley MedicalCentre (SCVMC), a 600-bed county teaching hospital with specialized units (e.g., for burns, rehabilitation, and pediatric care), hasimplemented programs that incorporate animals into the healthcare setting. This facility allows three categories of dogs to interactwith their patients: service dogs, therapy dogs, and pet visitation dogs by the ‘‘Furry Friends Foundation.’’ A blurring of the roles ofthe three categories of dogs occurred when these programs were put into place at SCVMC. The American with Disabilities Act (ADA)states that service animals cannot be prohibited from any area. For example, a ‘‘no pet allowed’’ policy could not apply to theseanimals. Proof of a person’s disability or proof of the service animal’s health or training cannot be required. The purpose of thisproject was to maintain these programs by clarifying the policies regarding animals, specifically dogs, in the healthcare setting.
This had to take place to provide a safe and enjoyable environment for the patients and the staff. A comprehensive table wasdeveloped to delineate the three categories of dogs and the corresponding policies. Therapy dogs and the visitation animals aremore restricted than service dogs. Both therapy dogs and visitation dogs require identification and certification of health and areexcluded from certain areas of the facility, including intensive care units and isolation rooms. By complying with the currentpolicies and regulations, the risks from these programs can be minimized. Staff should be educated on the proper terminology andprocedures to prevent a blurring of the categories and roles of these animals. (Am J Infect Control 2006;34:301-7.) It has been known for a long time that pets are Disease Control and Prevention (CDC) guidelines emotionally beneficial for humans. Recent research regarding hygienic consequences of contact with has indicated positive effects of pets on human physiology, eg, blood pressure.These findings, among Santa Clara Valley Medical Center (SCVMC) was others, have led to animals being incorporated into one such facility that chose to incorporate animals, health care settings. One must take into consideration specifically dogs, into the lives of their patients. The the potential risks of incorporating animals into this 3 categories of dogs included therapy dogs, service type of setting, a setting that includes individuals with dogs, and visitation dogs. A blurring of the roles of the altered immune systems. Not only are phobias and categories of dogs initially occurred. Therefore, SCVMC allergies prospective problems for these programs, defined the 3 categories of animals found in a health but also there is a potential for zoonosis transmission.
care setting and implemented specific policies regard- If proper measures and policies are put in place to prevent these risks, these programs can be verysafe and effective. This subject has become verytimely because of the issuance of relevant Centers for THREE CATEGORIES OF DOGS IN A HEALTHCARE SETTING From the University of South Florida,a Tampa, FL, and the Santa Clara The dogs are divided into 3 categories: service dogs Valley Medical Center,b San Jose, CA.
(eg, seeing-eye dogs), therapy dogs, and visitation dogs.
Reprint requests: Donna Haiduven, PhD, RN, CIC, Assistant Professor, A service dog is defined in the Americans with University of South Florida, College of Public Health, 13201 Bruce B.
Disabilities Act (ADA) as ‘‘an animal individually Downs Blvd MDC 56, Tampa, FL 33612-3805. E-mail: trained to perform tasks for people with disabilities.’ The service animal provides essential assistance to the individual with the disability to compensate for his/her Copyright ª 2005 by the Association for Professionals in Infection limitationsAlthough the ADA does not restrict the definition to only canines, dogs are usually the animals A service animal and a therapy animal serve 2 that interactions with animals positively contributes to different functions. Therapy animals are defined in the the patients overall health and happiness.
Standards of Practice for Animal Assisted Activities and Carmack and Fila’s (1989) study (as cited in Animal Assisted Therapy as ‘‘personal pets that provide Jorgenson 1997) found that these programs not only supervised, goal-directed intervention to individuals in benefit the patients but also the Nurses felt that hospitals, nursing homes, special-population schools, the experience was positive and that it allowed them to and other treatment facilities.’’As with service ani- spend more time with the patients. According to the mals, dogs are probably the most commonly chosen study, the nurses also reported that it helped improve animals for pet therapy.Therapy dogs must be trained the nurse-patient relationship and reduced their own in obedience and must be able to respond to com- mands given by the handler to provide controlledinteractions between the dog and the patients. The handler must be trained in skills and concepts of dog management and understand how the dog can beutilized in a therapeutic role.
Few studies have been conducted regarding the Therapy dogs are used to stimulate cognitive func- negative impact of bringing animals into the health tions and communication, increase movement, in- care setting. The majority of the literature that has been crease self-esteem and motivation, and increase published regarding animals in a health care setting participation in treatment. The ADA has no regulations has involved the positive aspects. Some studies have regarding therapy animals. Several organizations are examined the potential risks and disadvantages asso- involved with using pet therapy in hospitals, nursing ciated with animal use in a health care setting.These homes, and other health care facilities. One such include patient phobias, allergies, bites, and the organization is the ‘‘Furry Friends Foundation.’’ This potential risks for zoonoses.Other detrimental organization is made up of volunteers that bring their aspects includes the risks of animal-caused injuries, pets to health care facilities to improve the quality of such as scratches or other trauma that can occur and life of the patientsBefore the animal is allowed to affect infection control and risk management.
participate in the program, the organization requires Allergies can occur in both the patients and staff in that these animals pass both a physical and behavioral the health care facilities. Individuals may be allergic to the saliva, dander, or excretions of the animalsThe Visitation animals allow patients to spend time with coordinators of these animal programs need to be pets in a designated area of the facility. The animal aware of the potential allergies and which patients are visitation program at SCVMC is a cooperative program sensitive. Appropriate action should be taken (ie, between the hospital’s therapeutic recreation division grooming and bathing the animal) before arrival at and the ‘‘Furry Friends Foundation.’’ These animals the health care facility to minimize allergic reactions in have numerous restrictions within the health care facility. SCVMC only allows visitation animals in the Although bites are a potential for concern when day rooms of the facility. The visitation animals are working with animals, they do not usually pose a major only used for entertainment and recreational therapy threat. One potential concern after an animal bite is the for the patients. Classifying the dogs in this way has possibility of the transmission of the rabies virus (a allowed the development of policies and guidelines rhabdovirus of the genus Lyssavirus), a disease that is that can be utilized by facilities involved with patient- almost invariably fatal without appropriate treat- ment.An immune globulin is available as postexpo-sure prophylaxis but must be given as soon as possibleafter the animal biteAccording to Hoff et al,most animal bites only produce minor injury. However, infection of the wound with numerous types ofbacteria is a potential complOf particular Animals are beginning to be used in health care concern is the potential for a high mortality rate from settings to improve the well-being of patients. Many an infected animal bite among the immunocompro- long-term care facilities, such as nursing homes and assisted-living facilities, are also adopting these pro- A zoonosis refers to an infectious disease that can be grams. Animals are being utilized in health care transmitted from animals to humans under normal settings for pet visitation and pet therapy programs.
circumstances.There are more than 200 zoonotic These programs are used to increase patient respon- diseasesFor example, tinea, a fungal infection of the siveness and communication. It has been documented skin, can be spread from dogs or cats to humans. This infection is caused by species of Microsporum and amebiasis.’’A list of potential bacterial, viral, para- Trichophyton and also by Epidermophyton floccosum sitic, and fungal disease agents that can be transmitted Those at high risk of contracting a zoonosis include from dogs to humans are listed in . With careful elderly adults, pregnant women, young children, and planning, risk of transmission of zoonotic diseases and immunocompromised individuals. Pregnant women are extremely susceptible to certain zoonotic infec-tions, one of which is caused by Toxoplasma gondii. If the woman becomes infected, the organism may crossthe placenta and infect the fetus. This may have Policies regarding therapy dogs were developed According to one group of researchers, children and implemented at SCVMC. These policies are listed seem to be at higher risk for animal-related illnesses because of a combination of immunologic reasons andbehavioral factorsFor example, children are likely 1. The handler must successfully complete training to forget to wash their hands after contact with the that meets the ‘‘Minimum Standards for Training animal. This could potentially spread a zoonotic dis- Service Dogs’’ set by Assistance Dogs International, ease. Infants, because of their naı¨ve immune systems, are also very susceptible to zoonotic diseases. In Japan, 2. The therapy dog must be supervised by the handler it was demonstrated that household dogs were able to or left in a secure and controlled environment.
pass Salmonella to an infant on multiple occasions.
3. The use of a therapy dog with a specific patient Immunocompromised individuals must be careful requires a written order from the patient’s physician.
when in contact with animals because they are more 4. The therapy dog is utilized only with patient/family susceptible to certain agents, such as Salmonella permission and based on a therapist’s evaluation of species, Campylobacter species, Giardia lamblia, and the patient’s needs, as well as the patient’s physical many othersCampylobacter species can be passed and mental ability to use the dog appropriately.
from infected puppies and kittens to susceptible 5. The therapy dog is permitted or excluded from the individuals through contact. Animals that have diar- rhea are particularly important in the transmission 6. The handler must use appropriate hand hygiene of Campylobacter species. Pets with diarrhea can be treated with erythromycin to rid the animal of the 7. The therapy dog and handler should enter the infection.Domestic animals, including dogs, can also hospital and go directly to the area in which therapy carry strains of other enteric pathogens that are is to be delivered. When the therapy is completed, the therapy dog and handler should directly exit Although zoonotic diseases can be passed by many areas in which patients are housed or circulate.
different animals, dogs are the main concern in a 8. The Therapy Dog Program is a cooperative venture health care setting. However, according to a survey between selected SCVMC divisions (eg, therapy performed by Grant and Olsen, dogs were viewed as services, geriatrics clinic) and programs such as having the lowest risk of transmitting a disease to Canine Companions for Independence (CCI). Each humans by both physicians and veterinarians.
SCVMC division maintains the right to terminate the There are many ways to reduce the risk of trans- mission of a zoonotic disease. Implementing effective 9. The dog’s health is cleared as follows: hygienic measures to prevent transmission (such as (a) Physical exams: The dog’s health must be eval- handwashing) is a key way to avoid the transmission of uated by a veterinarian on an annual basis. The a zoonotic disease. Early detection of a zoonotic disease veterinarian must provide proof of the physical is essential in preventing transmission of the agent to exam to SCVMC. The handler is responsible for humans, demonstrating the importance of regular ensuring that the physical exams are current.
(b) Vaccinations: The handler is responsible for According to Khan and Farrag, animals can become documented proof that all vaccines are current.
carriers (or vectors) of potentially infectious human (c) Fecal exams: The handler must provide docu- pathogens and may be responsible for cross infec- mented proof to SCVMC that the dog has had an tion.Therefore, ‘‘animals should not be allowed to annual fecal exam. If the test is positive, the dog visit with patients who are infected or colonized with will not be permitted to visit the hospital and tuberculosis, Salmonella, Campylobacter, Shigella, must be cleared by the veterinarian before any Streptococcus group A, methicillin-resistant Staphylo- future visits are allowed. Fecal exams include the coccus aureus (MRSA), dermatophytes, Giardia, or test for parasites (Giardia, Coccidia, roundworm, Contact with infected animals especially aborted fetuses, fluids or membranes, or urine. Possibly airborne.
Fecal-oral route, through contamination of food or water, or by direct contact with infected fecal material. Infected children may transmitinfection to puppies or kittens, which may then expose other childre Handling affected animals, contaminating hands, or abrasions with urine or aerosol exposure during cage cleaning are most Indirect. Tick is brought into contact with humans on Indirect. Tick is brought into contact with humans on Fecal-oral route. Ingestion of organisms in food derived from infected animals or contaminated by feces of an infected From bite or scratch of a dog whose mouth or paw is contaminated by Saliva containing the rabies virus is introduced via a bite or scratch or into a Penetration of intact skin by larvae deposited in soil or sand via dog Ingestion of the flea that contain larvae.k Ingestion of ova from contaminated materials.y *Information from Linville yInformation from Guay 2001.zInformation from Brodie et al 2002.§Information from Heyman.kInformation from Roberts et al 2 tapeworm, whipworm) and bacteria (Salmonel- be allowed to enter the hospital or work with patients and must be cleared of such conditions (d) Cleanliness: The dog must be clean and free from any fleas or skin problems, and the handler 10. The therapy dog must carry identification, service is responsible for inspecting the dog before pack, or other clearly visible sign that identifies it entering the hospital. If the dog does not pass the inspection, the dog will not be permitted toenter the hospital or visit with patients. Addi- tionally, the handler must groom the dog andtrim the nails.
Policies for service animals cannot, by law, be (e) Social behavior: The therapy dog is previewed readily put into place. ‘‘No pets allowed’’ policies do and handled by a qualified veterinarian and not apply to service animals. Any facility that serves the trainer to assure adequate human socialization.
public, including hospitals, must allow service dogs Antisocial behavior by the dog, provoked or not, into the facilityA business can inquire verbally if the during any visit will immediately disqualify the dog is a service animal, but the ADA prohibits public accommodations from requiring ‘‘certification’’ or (f) Illness: Upon any sign of illness (eg, diarrhea, proof of an animal’s training or of a person’s disability vomiting, running nose or eyes, skin lesions, There is also no legal requirement that a service animal excessive scratching/chewing), the dog will not wear special equipment or tags. Numerous states have Table 2. Areas in a health care facility at which therapy Table 4. Santa Clara Valley Medical Center policy Skilled nursing facilities (with approval) Table 3. Areas at Santa Clara Valley Medical at which Excluded in multibed rooms if any other patients therein or excluded in single-bed rooms if patient’s physician objects on grounds of allergy,fear, or other medical or psychologic problems.
Excluded in rooms of patients on isolation.
yThe ADA prohibits public accommodations from requiring ‘‘certification’’ or proof Excluded in the intensive care units, with the exception of the of an animal’s training, or proof of a person’s disability, for the purposes of access.
rehabilitation trauma center and the burn center.
There is no legal requirement that a service animal wear special equipment or tags.
Excluded in any area in which patient wounds are not dressed.
owner must also be trained to appropriately managethe animal.
‘‘White Cane Laws.’’These laws allow the police to becalled if a service animal is prohibited from entering an The policies regarding visitation animals also re- criminal charges against an establishment if admission quire that the animals undergo a physical exam by a veterinarian. The handler must provide proof that Even though service animals are not normally the animal has current vaccinations, a negative stool restricted, there are some exceptions. A business culture, and a physical exam. The animal must also owner may lawfully prohibit a service animal from be friendly, and the handler must be properly trained.
entering the facility if the animal is a direct threat to the These animals have considerable restrictions within occupants of the facility or if the animal is being the health care facility. At SCVMC, visitation animals are disruptive.‘‘Allergies or fears of animals are not normally only permitted in the day rooms of the health generally valid reasons for denying service animals’ care facility and are used only for entertainment.
access or refusing service.’’Duncanstates that A summary comparison of policy components for ‘‘the ADA requires that all places of public accommo- the 3 categories of dogs can be found in . It is dation, including health care facilities, modify their important to note that handlers of all 3 of the policies and practices to permit the use of a service categories of animals must be conscientious of hygiene animal.’’ However, there are certain situations that while handling the animals. Handlers must be properly must be taken into consideration. If allowing the trained and competent to control the animals. Such service animal requires ‘‘alteration of the nature of standards are necessary to minimize risks to client and the business,’’ the service animal may be excluded staff populations. It is also important to note that such from that facility or area.For instance, in health care policies must be communicated to all hospital staff facilities, there are many ill people, including those involved in these programs at the health care facility.
who are immunocompromised. Therefore, restrictionsmay be placed on service animals entering particular The dog owner must assure that the service animal The benefits of animal involvement in the health is free of disease. The animal must have undergone care setting are greater than the risks. Animals can training and be current with all veterinary visits, perform useful functions in hospital and clinical including physical exams, stool cultures, and vaccina- settings, and risks can be minimized while complying tions. The animal must also have a temperament with legal requirements. This was apparent to the conducive to working in a health care setting. The infection control department at SCVMC when policy changes were undertaken to delineate the different purposeful range of motion movements by distracting animal programs within its facility. The changes in from pain caused during movements, thus reducing the policy were a response to concerns about pet-assisted need for analgesics, among many other interventions.
therapy terminology merging with service dogs (dogs This is especially important in therapy for burned for the blind, deaf, wheelchair-bound, and others) children with contractures and constrictions. The terminology and applying it uniformly, allowing pet- handlers educate patients because the patients may assisted therapy animals (primarily dogs) the same be candidates for utilizing therapy dogs in the future. It liberties as service dogs. This ambiguity was of concern is important to reemphasize that handlers of non- to infection control because it was a possible impinge- service animals must be properly trained, but, at this ment on the health and safety of the patients and time, there are no specific requirements.
The new policy was implemented with satisfaction Because the Americans with Disabilities Act of 1990, of both the patients and the employees. The attention Public Law 101-336 (42 USC Sec. 12102), and the given to delineation of pet therapy programs appeared California Civil Code, section 54-55.1, already set the to have improved the legitimacy of therapy dogs within standards for the use of service dogs and their handlers the facility. The uniqueness of the entire process was in the hospital setting, and there were no set provisions enhanced partly because of the support from infection for pet-assisted therapy animals, the focus for changing control appreciation of a pet therapy program in the the policy was primarily placed on pet therapy animals facility and willingness to assist therapy services to to include therapy dogs and visitation animals. The basics for the pet-assisted therapy program policychanges were clarified in discussions involving perti- nent individuals, including those in infection control, With careful planning and well-constructed policy therapy services and administration. These discussions guidelines, SCVMC has successfully incorporated well- led to changes in the pet therapy policies that were trained and healthy dogs to perform useful functions in acceptable to all. Although the dog therapy programs specific therapy programs. Because of the success with occurring in the facility had no known incidences of therapy dogs in the hospital setting, some patients have communicated disease or safety issues, the policy obtained their own dogs to assist with activities of daily needed to emphasize differentiating, defining, and living and provide constant accepting companionship.
surveying the 3 animal programs within the facility, We believe if guidelines are well-defined and followed, with greater regulation of pet-assisted therapy animals.
dogs can perform useful functions in hospital settings.
In part, this put greater restriction on locations at It is important to point out that the revised JCAHO which pet-assisted therapy could occur in the hospital, guidelines effective in 2005 are now directly applicable restricting pet therapy animals from specific parts of to this issue. Standard 1C.4.10 requires organizations to the hospital to include ICUs. Changes also stressed ‘‘Plan and effectively implement infection prevention animal health and hygiene. The policy also included and control processes and strategies to meet identified the requirement for hand hygiene for employees and goals.’’ To accomplish this, core interventions must be patients interacting with the animals.
done throughout all organizations, with one directly Today, much of the success of the SCVMC pet applying to animals as follows: reduction of risks therapy program’s policy implementation is due to the associated with animals brought into the hospital.’’ strong involvement of professional handlers (thera- Thus, this intervention applies to therapy animals and pists). However, it is strictly a volunteer contribution to pets brought by individuals receiving care.
the facility. The handlers assure the quality of the The psychological benefits of visitation animal participating therapy dogs that contributes to the programs are also a successful extension of the therapy program’s success. The handlers and their 5 pet programs. Other health care facilities can use these therapy dogs provide goal-directed interventions to policies as a guide to develop similar strategies. With approximately 30 patients daily in the hospital and careful planning and implementation of these policies, clinics. SCVMC’s large rehabilitation center, burn cen- any potentially negative aspects of bringing animals ter, and geriatric clinic benefit greatly from the use of into health care settings can be substantially dimin- therapy dogs. Therapy dogs have many uses in patient ished. Other health care facilities may benefit from therapy, such as improving motivation and participa- ‘‘letting the dogs out’’ to show how they can earn their tion, and increasing purposeful movements (eg, grooming a dog can improve arm range of motionand strength). The handlers continuously demonstrate the use of the therapy dog to the patient, and the 1. Edney ATB. Companion animals and human health: an overview.
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6. Brodie SJ, Biley FC, Shewring M. An exploration of the potential risks 18. Sato Y, Mori T, Koyama T, Nagase H. Salmonella virchow infection in associated with using pet therapy in healthcare settings. J Clin Nurs an infant transmitted by household dogs. J Vet Med Sci 2000;62:767-9.
19. Grant S, Olsen CW. Preventing zoonotic diseases in immunocom- 7. Furry Friends Pet Assisted Therapy Services. Furry friends fact sheet.
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