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Guidelines for animal-assistedinterventions in health care facilities Writing Panel of the Working Group: Sandra L. Lefebvre, DVM, PhD,a Gail C. Golab, PhD, DVM,b E’Lise Christensen, DVM,cLouisa Castrodale, DVM, MPH,d Kathy Aureden, MS, CIC,e Anne Bialachowski, RN, MS, CIC,f Nigel Gumley, DVM,g JudyRobinson,h Andrew Peregrine, DVM, PhD,a Marilyn Benoit, RN,i Mary Lou Card, RN, CIC,j Liz Van Horne, RN, CIC,k andJ. Scott Weese, DVM, DVSca Schaumburg and Elgin, Illinois; New York, New York; Anchorage, Alaska; Guelph, Burlington, Ottawa, Hamilton,London, and Toronto, Ontario, Canada Many hospitals and long-term care facilities in North America currently permit animals to visit with their patients; however, thedevelopment of relevant infection control and prevention policies has lagged, due in large part to the lack of scientific evidenceregarding risks of patient infection associated with animal interaction. This report provides standard guidelines for animal-assistedinterventions in health care facilities, taking into account the available evidence. (Am J Infect Control 2008;36:78-85.) The popularity of animal-assisted interventions patients and residents. But while the use of AAIs and (AAIs) in human health care has grown to the point the evidence supporting their many benefits for where many hospitals and long-term care facilities in patients/residents has grothe development of North America currently permit animals to visit with applicable infection control policies has lagged. Conse-quently, current practices for animal health screening From the Ontario Veterinary College, University of Guelph, Guelph, and infection prevention and control are highly varia- Ontario, Canada;a American Veterinary Medical Association, Schaum- ble both within and between health care facilities burg, IL;b NYC Veterinary Specialists, New York, NY;c Alaska Depart- (HCFs). Patients’ and others’ pets are not held to the ment of Health and Social Services, Section of Epidemiology, same standards as animals belonging to formal AAI Anchorage, AK;d Sherman Hospital, Elgin, IL;e Joseph Brant Com-munity Health Centre, Burlington, Ontario, Canada;f Canadian Veteri- programs, even though any of these animals can nary Medical Association, Ottawa, Ontario, Canada;g St John interact with patients and health care staff. Although Ambulance Therapy Dogs, Hamilton, Ontario, Canada;h Ottawa Ther- general guidelines for animal visitors have been pub- apy Dogs, Ottawa, Ontario, Canada;i St Joseph’s Health Care, London, lished by several expert groups,a collaborative doc- Ontario, Canada;j and Public Health Division, Ontario Ministry ofHealth and Long-Term Care, Toronto, Ontario, Canada.k ument that captures the interests of most stakeholderswhile providing specific recommendations to mini- Address correspondence to J. Scott Weese, DVM, DVSc, Departmentof Clinical Studies, University of Guelph, Guelph, Ontario, Canada mize both injuries and the transmission of infectious organisms to and from animals is needed.
Other Working Group members include Erica Bontovics, MD, CIC, and To address this demand, a Working Group of stake- Sharon Calvin, DVM, MSc, Ontario Ministry of Health and Long-Term holders in AAI assembled in Toronto, Ontario on Janu- Care; Nora Boyd, RN, CIC, Bluewater Health, Sarnia, Ontario; Renee ary 9, 2007, with the aim of finalizing a draft set of Freeman, RN, CIC, and Michael Hawkes, MDCM, The Hospital forSick Children, Toronto, Ontario; Cindy Plante-Jenkins, MLT, CIC, Tril- guidelines that had been prepared by the project leaders lium Health Centre, Mississauga, Ontario; Joanne Laalo, RN, CIC, Com- (JSW and SL) and circulated for preliminary comments munity and Hospital Infection Control Association of Canada; Robert before the meeting. The participants included 29 indi- Franklin, DVM, Delta Society; Carol Jones, Jan Vallentin, and Don Lap- viduals with expertise in AAI, infection control, public ierre, St John Ambulance Therapy Dogs; Judy Sauve´ and Nancy Trus,Therapeutic Paws of Canada; David Waltner-Toews, DVM, PhD, Univer- health, and veterinary medicine from Canada and the sity of Guelph, Ontario; and Richard Reid-Smith, DVM, DVSc and Rita United States. Led by a professional facilitator, the Finley, MSc, Public Health Agency of Canada.
Working Group reviewed all identified evidence regard- The Working Group meeting was sponsored by the Public Health ing the risks of AAI,then systematically debated Agency of Canada and the Centre for Public Health and Zoonoses, Uni- each point in the draft document for its validity, consid- ering both the evidence and expert opinion. Issues requiring further discussion were delegated to expert Copyright ª 2008 by the Association for Professionals in Infection subcommittees for resolution. Subcommittee recom- mendations were subsequently circulated to all Work- ing Group members for their approval.
that are brought into human HCFs for veterinary diag-nostics and treatment, are not addressed here for the sake of brevity. The guidelines herein are based on available evidence and may require updating in the fu- Rather than recommending a rigorous screening protocol to identify animal carriage of specific patho- gens, the guidelines place a major emphasis on all indi- viduals (patients and staff) practicing hand hygiene before and after handling animals, as well as on other infection prevention and control strategies to minimize the spread of pathogens from or to animals. The need for facilities to delegate a single individual—an animal visit liaison—to be aware of all animals entering the premises is also identified. Similarly, a method to facil- itate contact tracing in the event of potentially zoonotic patient infections (or handler/animal contact with con- and supported by limitedclinical or epidemiologic Because animals may interact with various popula- tions that may be at risk of infection or injury, certain re- strictions on animal species, age, origin, behavior, diet, and health status are recommended for animals in for- mal AAI programs, whether these programs are run bythe HCF itself or by an external agency. For visits by pa-tients’ pets, the emphasis is placed on animals meeting Table 2. Level of consensus agreement among members certain basic health and diet requirements, and also on limiting human contact during the visit to the relevant patient only (ie, no other patients or staff). Animal visi-tors falling outside of these 2 categories (eg, those brought in by well-meaning community members with no training in AAI) should be denied entry.
GUIDELINES FOR ANIMALS VISITING HEALTHCARE FACILITIES The final recommendations were annotated accord- ing to 2 different classifications. The quality of evidence supporting each recommendation was ranked follow- 1. Require that all patients, visitors and health care ing the system used by the Centers for Disease Control workers practice hand hygiene both before and and Prevention in other infection control guidelines after each animal contact.(IB, Consensus) ). In addition, the degree of consensus achieved 2. Require that animal handlers carry an alcohol- by the Working Group, as defined in was noted.
based hand rub product with them, and that This report represents the final product of that meet- they offer the product to anyone who wishes to ing. Its purpose is to provide explicit and, whenever touch the animal. Ideally, this product should be possible, evidence-based guidelines to mitigate risks associated with AAI. The intended audience is human 3. Require that animal handlers practice personal health care workers (including those that provide hand hygiene in accordance with the HCF’s policy AAIs themselves), although the responsibilities for car- for volunteers and employees(II, Consensus) rying out many of the recommendations will rest with II. Facility management of programs for animal animal handlers, as well as external organizations that provide AAI services. Explicit guidelines for veterinar- 1. Recommend that the HCF develop an animal vis- ians, including rationales behind the recommenda- itation program or policies for patient-owned an- tions relevant to animal selection and screening, will be published separately. Special circumstances related 2. Recommend that the HCF designate an animal to resident animals (that also are used in AAI pro- visit liaison (AVL) to provide support and facilita- grams), service animals, laboratory animals, or animals tion to animal handlers visiting the facility. The AVL’s duties should include keeping appraised of behavior of AAI animals under conditions that all animals entering the facility. (II, Consensus) they might encounter when in HCFs. Such an eval- III. Determining suitability of animals by species, age, uation process should assess, among other factors: b. Reactions to loud and/or novel stimuli a. Restrict suitable animal species to domestic c. Reactions to angry voices and potentially companion animals that are household pets.
b. No age restriction is recommended, provided e. Reactions to being patted in a vigorous or that the animal is under the control of a handler other than the patient at all times. (II, c. Do not allow patient-owned animals to visit h. Ability to obey handler’s commands(IC, other patients, visitors, staff, or animals. (II, 3. Require all evaluators to successfully complete a course or certification process in evaluating a. Restrict suitable animal species to domestic temperament and to have experience in assess- companion animals that are household pets.
ing animal behavior and level of training. (IC, (IB, Consensus) Exclude those species identi- fied as being of higher risk of causing human a. Require all evaluators to have experience with animal visiting programs or, at the very least, Reptiles and amphibians (eg, lizards, turtles, appreciate the types of challenges that animals may encounter in the health care environment (eg, startling noises, crowding, rough han- b. If several animals need to be evaluated for be- Hedgehogs, prairie dogs, or any other re- haviors other than reactions to other animals, require that the temperament evaluator as- sess each animal separately, rather than as- sessing several animals simultaneously. (II, 4. Require that animal-handler teams be observed by an AAI program representative at least once in a health care setting before being granted final b. Deny the entry of any animal directly from an animal shelter, pound, or similar facility.
5. Recommend that each animal be reevaluated at least every 3 years (Unresolved issue, Consensus).
c. Require that an animal be in a permanent No recommendation is made regarding whether home for at least 6 months to be considered the reevaluation should consist of a formal temper- ament evaluation in a controlled setting or a spot d. Require that all AAI animals be adults, with check by AAI program representatives or AVLs dur- cats being at least 1 year of age and dogs at ing a routine visit; however, if the latter option is least 1 year but ideally 2 years of age (the age chosen, then annual reevaluation is suggested.
6. Require that a handler suspend visits and have e. Admit an animal only if it is a member of a for- his or her animal formally reevaluated whenever mal AAI program (whether run by the HCF or he or she notices or is apprised (either directly or an external entity) and is present exclusively through the AVL) that the animal has demon- IV. Determining suitability of animals for AAI programs a. A negative behavioral change (as described in IV.2.a to h) since the time it was last tempera- 1. Verify that the AAI program, whether run by the HCF or an external entity, requires a tempera- b. Aggressive behavior outside the health care ment evaluation for all participating animals.
2. Require that every animal pass a temperament evaluation specifically designed to evaluate the d. Loss of sight or hearing and, consequently, an overt inclination to startle and react in an ad- fleas, ticks, or mange (mite infestation) and treat as directed by the animal’s veterinarian 7. Require that any animal be formally reevaluated until the infestation has cleared, as deter- before returning to AAIs after an absence of 6 mined by the veterinarian. (IB, Consensus) b. Routine screening for specific, potentially 8. Requiring that cats be declawed to prevent zoonotic microorganisms, including group A scratches is not recommended. (II, Consensus) streptococci, Clostridium difficile, vancomycin- resistant enterococci, and methicillin-resistant Staphylococcus aureus (MRSA), is not recom- a. Require that dogs and cats be vaccinated against rabies as dictated by local laws. (IC, (1) Special testing may be indicated in situa- (1) Exemption of rabies vaccine-sensitive ani- interacted with a known human carrier, ei- mals may be granted on a case-by-case ba- ther in the hospital or in the community, or when epidemiologic evidence suggests that exposure to rabies is considered very low.
the animal might be involved in transmis- (2) Serologic testing for rabies antibody con- animal’s veterinarian, in conjunction with centration should not be used as a substi- appropriate infection control and veteri- nary infectious disease/internal medicine b. For the protection of both the animal and peo- ple, prevent the animal from entering the HCF (2) Special testing may be indicated if the AAI starting from the onset of and until at least animal is epidemiologically linked to an out- break of infectious disease known to have sion of visitation pending results is recom- (3) Episodes of sneezing or coughing of un- mended in these situations. (II, Consensus) (4) Treatment with nontopical antimicrobials 1. Exclude any animal that has been fed any raw or dehydrated (but otherwise raw) foods, chews, or treats of animal origin within the past 90 VII. Training and management of animal handlers (7) Skin infections or ‘‘hot spots’’ (ie, acute a. Ensure that the animal’s handler has been in- (8) Orthopedic or other conditions that, in the formed of the HCF’s policy for animal visits opinion of the animal’s veterinarian, could and has signed an agreement to comply with result in pain or distress to the animal dur- b. Request that documentation of current rabies immunization be provided to the approving (9) Demonstrating signs of heat (estrus). (II, authority for patient-owned animal visits. (IC, 2. Scheduled health screening of AAI animals c. Ensure that the visitor and the animal are es- a. Require that every animal receive a health corted to their destination, as arranged by the evaluation by a licensed veterinarian at least d. Ensure that every unleashed animal is carried in a clean carrier and not released until reach- (1) Defer to the animal’s veterinarian regard- ing an appropriate flea, tick, and enteric e. Ensure that a dog is leashed if not in a carrier and taken to the patient by the route least likely to ex- be designed to take into account the risks pose other patients to the animal. (II, Consensus) of the animal acquiring these parasites spe- f. Advise the handler of a patient-owned animal cific to its geographic location and living that he or she should expect others (patients, health care workers, or visitors) to notice the animal and want to interact with it. Instruct the b. Limit visits to 1 animal per handler. (II, handler to deny such requests and to avoid c. Keep control of the animal at all times while on a. Require that every handler participate in a for- (1) Keep a dog leashed at all times unless mal training program and an evaluation of that transported within the facility by a carrier (as may be the case with smaller breeds).
(2) Infection control practices (including proper (2) Transport an off-leash animal in a clean cleanup and disposal of animal excrement) (3) Identifying appropriate contacts in the (3) Refrain from using cell phones or partici- pating in other activities that may divert the handler’s attention away from the ani- (5) Reading an animal’s body language to d. Approach patients from the side that is free of any invasive devices, such as intrave- (6) Patient confidentiality. (II, Consensus) b. Require that each handler comply with the from contacting any insertion sites. (II, HCF’s policy for influenza vaccination and any additional human health screening re- e. Prevent the animal from licking or bumping quirements in place for volunteers and em- f. Before entering an elevator with an animal, c. Require that a handler use particular care in di- ask the other passengers for permission, and recting the visit to prevent patients from touch- do not enter if any passenger asks that the an- ing the animal in inappropriate body sites (eg, imal not enter or if a passenger appears to be mouth, nose, perianal region) or handling the animal in a manner that might increase the likelihood of frightening or harming the ani- (1) For a patient’s animal, prevent non–family mal or the animal harming the patient acciden- d. Restrict visiting sessions to a maximum of (2) For an AAI animal, require that everyone 1 hour, to reduce the risk of adverse events as- sociated with animal fatigue. (II, Consensus) hand hygiene before and after contact. (II, (1) Observe the animal for signs of fatigue, stress, thirst, overheating, or urges to uri- g. Do not visit with a patients while he or she is eating or drinking, and do not permit a patient (2) If taking a short break (or taking the animal to eat or drink while interacting with the ani- outside to relieve itself) will not ease the animal’s signs of discomfort, then termi- h. Wear gloves to clean up any animal excreta nate the session for that day. (II, Consensus) (urine, vomitus, or feces), and dispose of the material according to the HCF’s biowaste man- facility-defined restrictions for patient vis- agement policy. Report the incident to health itation and to be familiar with facility- care staff so that the area can be properly dis- specific signage regarding restricted areas i. In the case of a urinary or fecal accident, imme- diately terminate the visit and take appropriate a. Self-screen for symptoms of communicable measures to prevent recurrence during future disease and refrain from visiting while ill.
Such symptoms include, but are not limited to: (1) If submissive urination was involved, this (1) New or worsening coughing or sneezing will require suspending the animal’s visit- ing privileges, having the handler address reevaluating the animal’s suitability before (2) In other situations, requiring that the han- e. Clean the animal carrier before visits. (II, dler be reeducated in attending to the ani- mal’s comfort may suffice. (II, Consensus) f. Maintain animal leashes, harnesses, and collars (3) If repeated incidents of this nature occur, visibly clean and odor-free. (II, Consensus) permanently withdraw the animal’s visit- g. Use only leashes that are nonretractable and 1.3 to 2 m (4 to 6 feet) or less in length. (II, (4) In the case of vomiting or diarrhea, termi- nate the visit immediately and withdraw the h. Do not permit the use of choke chains or prong collars, which may trap and injure pa- 1 week, as discussed in V.1.b.(1). (II, Consensus) j. Restrict the animal from patient lavatories. (II, i. Identify an animal belonging to an AAI program with a clean scarf, collar, harness or leash, tag k. Report any scratches, bites, or any other inap- or other special identifier readily recognizable propriate animal behavior to health care staff immediately so that wounds can be cleaned j. Provide a dog with an opportunity to urinate and treated promptlyLater, report the inci- and defecate immediately before entering the dent to the AVL and to public health or animal control authorities, as required by local laws.
(1) Dispose of any feces according to the pol- (1) The visit should be immediately terminated after any bite or scratch. (II, Consensus) IX. Managing appropriate contact between animals (2) In the case of bites, intentional scratches, or other serious, inappropriate behavior, permanently withdraw the animal’s visit- a. Obtain oral or, ideally, written consent from the patient or his or her agent for the visit. (II, (3) In the case of accidental scratches, con- b. Require the handler to obtain oral permission from other individuals in the room (or their agents) sures to prevent similar injuries from oc- before entering for visitation. (II, Consensus) curring in the future. If measures cannot c. Ensure that people who have been identified be undertaken to reduce the risk of recur- (or have identified themselves) beforehand as rence, then visitation privileges should be being allergic to animals, or resistant to or un- comfortable in the presence of animals, are (4) If it is determined that the handler’s behav- pointed out to the handler, along with instruc- ior was instrumental in the incident, then tions to avoid these individuals. (II, Consensus) the handler’s visitation privileges should be d. Do not allow an animal to visit in rooms shared by people with known or suspected fears of has addressed the situation. (II, Consensus) animals or allergies to animal saliva, dander, l. Report any inappropriate patient behavior (eg, inappropriate handling, refusal to fol- e. Restrict all visiting animals from entering the low instructions) to the AVL. (II, Consensus) 1. Require that every handler do the following: (2) Medication preparation and storage areas a. Brush or comb the animal’s hair coat before a visit to remove as much loose hair, dander, and other debris as possible. (II, Consensus) b. Keep the animal’s nails short and free of sharp (5) Areas of patient treatment where the na- ture of the treatment (eg, resulting in pain c. If the animal is malodorous or visibly soiled, for the patient) may cause the animal dis- bathe it with a mild, unscented (if possible), hypoallergenic shampoo and allow the ani- mal’s coat to dry before leaving for the HCF.
(6) Other areas identified specifically by the d. Visually inspect the animal for fleas and ticks.
f. Restrict all animals from entering dialysis or burn units, except under special circumstances and with the agreement of the patients’ physi- (4) Instruct the patient to present the treat cian(s), the AVL, and the infection control staff.
with a flattened palm. (Unresolved issue, g. Require the handler to prevent the animal from coming into contact with sites of invasive a. Restrict a patient-owned animal from visiting the devices, open or bandaged wounds, surgical patient in a critical care or isolation unit except incisions or other breaches in the skin, or med- under special circumstances, with the agree- ment of the patient’s physician, the AVL, and h. If the patient or agent requests that an animal the infection control staff, and when arrange- be placed on the bed, require that the handler: ments can be made to control the visitation (1) Check for visible soiling of bed linens first.
situation to minimize the risk of transmission (2) Place a disposable, impermeable barrier be- tween the animal and the bed; throw the bar- 1. The facility should develop a system of contact rier away after each patient. (II, Consensus) tracing that at a minimum requires animal han- (3) If a disposable barrier is not available, a pil- dlers to sign in when visiting and ideally provides lowcase, towel, or extra bed sheet can be a permanent record of areas and/or room num- used. Place such an item in the laundry im- bers where the animal has interacted with pa- XI. Determining appropriate visit locations 1. Individual HCFs are in the best position to decide a. Allow the animal to visit only with patients, which locations are appropriate for animals in- visitors, and staff who clearly express an inter- teracting with patients, in consultation with the est, or with patients on whose behalf an agent infection control practitioner. (II, Consensus) has expressed an interest. (II, Consensus) b. Ensure that all potentially immunocompro- 1. Practice routine cleaning of environmental sur- mised patients are assessed by their primary health care providers to determine whether vis-iting with an animal would be appropriate, and The authors thank the many people who provided thoughtful feedback on and sugges-tions for the content of this document, including Steven Kruth, DVM, DACVIM, Phil that this information is conveyed to the AVL, Arkow, BA, Jeff Bender, DVM, MS, Jennifer Calder, DVM, MPH, PHD, Radford Davis, who will indicate to the handlers which patients DVM, MPH, John New, DVM, MPH, DACVPM, Debra Horwitz, DVM, DACVB, BeckyJankowski, RN, MS, Bonnie Beaver, DVM, MS, DACVB, Janice Seigford, DVM, DACVB, are ineligible for visitation. (II, Consensus) Amy Marder, VMD, CAAB, Jacqui Ley, BVSc, MACVS, and Deschler Cameron, DVM.
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