Table 1. Selected Diseases Transmitted by Dogs Stratifed by Transmission Route

I. Overview of Management of an Animal-Assisted Activities Program Within a Healthcare Facility

A. Facilities should develop a written policy for animal-assisted activities.

B. An animal-assisted activities visit liaison should be designated to provide support and facilitate animal-assisted activities visits. Often these visits are managed by the facility’s Volunteer Office or Department.

C. Only dogs should be used (ie, exclude cats and other animals).
Cats should be excluded because they cannot be trained to reliably provide safe interactions with patients in the healthcare setting.

D. Animals and handlers should be formally trained and evaluated. Facilities should consider use of certification by organizations that provide relevant formal training programs (eg, Pet Partners, Therapy Dogs Incorporated, Therapy Dogs International).
Alternatively, facilities should designate responsibility for the program elements to an internal department (eg, volunteer department) to verify all elements (see section III).

E. Animals and animal handlers should be screened prior to being accepted into a facility animal-assisted activities program (see section II).

F. Infection Prevention and Control (IPC) should be consulted regarding which locations are appropriate for animals interacting with patients.

G. All clinical staff should be educated about the animal-assisted activities program, its governance, and its policies.

II. Training and Management of Animal-Assisted Activities Handlers. Facilities Should Do the Following

A. Ensure that animal-assisted activities handlers have been informed of the facility’s IPC and human resource policies (similar to volunteers) and have signed an agreement to comply with these policies.

B. Confirm that animal-assisted activities handlers have been offered all immunizations recommended for healthcare providers (HCP) within that facility (eg, measles, mumps, and rubella, varicella, pertussis, influenza). If immunization is required of HCP, it should be required for animal-assisted activities handlers.

C. Require the animal-assisted activities handler to escort the animal to the destination as arranged by the facility’s animal-assisted activities liaison and following hospital policy.

D. Instruct the animal-assisted activities handler to restrict contact of his or her animal to the patient(s) being visited and to avoid casual contact of their animal with other patients, staff, or the public.

E. Limit visits to one animal per handler.

F. Require that every animal-assisted activities handler participate in a formal training program and provide a certificate confirming the training, which includes modules on the following:

1. Zoonotic diseases
2. Training on standard precautions including hand hygiene before and after patient contact
3. Proper cleaning and disinfection of surfaces contaminated by animal waste (urine or feces)
4. Proper disposal of animal waste
5. Visual inspection for ectoparasites
6. Reading of an animal’s body language to identify signs of physical discomfort, stress, fear, or aggression
7. Identification of appropriate contacts in the event of an accident or injury

G. Require that a handler use particular care in directing the visit to prevent patients from touching the animal in inappropriate body sites (eg, mouth, nose, perianal region) or handling the animal in a manner that might increase the likelihood of frightening or harming the animal or the animal accidentally or intentionally harming the patient.

H. Restrict visiting sessions to a maximum of one hour to reduce the risk of adverse events associated with animal fatigue.

1. Handlers must observe the animal for signs of fatigue, stress, thirst, overheating, or urges to urinate or defecate.
   1. If taking a short break (or taking the animal outside to relieve it) does not ease the animal’s signs of discomfort, then the session should be terminated for that day.
2. Handlers must comply with facility-defined restrictions for patient visits and be familiar with facility-specific signage regarding restricted areas or rooms.

I. Require that all animal handlers observe standard occupational health practices. Specifically, they should self-screen for symptoms of communicable disease and refrain from providing animal-assisted activities services while ill. Such symptoms include, but are not limited to the following:

1. New or worsening respiratory symptoms (ie, cough, sneezing, nasal discharge)
2. Fever (temperature >38°C)
3. Diarrhea or vomiting
4. Conjunctivitis
5. Rash or non-intact skin on face or hands

J. Require that handlers keep control of the animal at all times while on the premises, including the following:

1. Keeping a dog leashed at all times unless transported within the facility by a carrier (as may be the case with smaller breeds).
2. Refraining from using cell phones or participating in other activities that may divert his/her attention away from the animal.

K. Require all handlers to manage their animal as follows:

1. Approach patients from the side that is free of any invasive devices (eg, intravenous catheters) and prevent the animal from having contact with any catheter insertion sites, medical devices, breaks in the skin, bandage materials, or other compromised body site.
2. Before entering an elevator with an animal, ask the other passengers for permission, and do not enter if any passenger expresses reluctance or appears apprehensive.
3. Require that everyone who wishes to touch the animal practice hand hygiene before and after contact.
4. Do not permit a patient to eat or drink while interacting with the animal.
5. Restrict the animal from patient lavatories.
6. In the case of an animal’s urinary or fecal accident, immediately terminate the visit and take appropriate measures to prevent recurrence during future visits.
   1. If submissive urination was involved, this will require suspending the animal’s visiting privileges, having the handler address the underlying cause, and then formally reevaluating the animal’s suitability before visiting privileges are restored.
   2. If repeated incidents of this nature occur, permanently withdraw the animal’s visiting privileges.
   3. In the case of vomiting or diarrhea, terminate the visit immediately and withdraw the animal from visitation for a minimum of one week.

7. Report any scratches, bites, or any other inappropriate animal behavior to healthcare staff immediately so that wounds can be cleaned and treated promptly. Report any injuries to the animal-assisted activities liaison as soon as possible and to public health or animal control authorities, as required by local laws.
   1. The visit should be immediately terminated after any bite or scratch.
   2. In the case of bites, intentional scratches, or other serious, inappropriate behavior, permanently withdraw the animal’s visiting privileges.
   3. In the case of accidental scratches, consider the circumstances that contributed to the injury and take appropriate measures to prevent similar injuries from occurring in the future. If measures cannot be taken to reduce the risk of recurrence, then visitation privileges should be withdrawn.
   4. If it is determined that the handler’s behavior was instrumental in the incident, then the handler’s visitation privileges should be terminated until the animal-assisted activities program manager has addressed the situation.
   5. Report any inappropriate patient behavior (eg, inappropriate handling, refusal to follow instructions) to the animal visit liaison.

L. Facilities should maintain a log of all animal-assisted activities visits that includes rooms and persons visited for potential contact tracing.

III. Requirements of Acceptable Animals for Animal-Assisted Activities Programs

A. Allow only domestic companion dogs to serve as animal-assisted activities animals. Cats are not included in the recommendation due to concerns for increased potential allergenicity, potential increased risk of bites and scratches, and lack of data demonstrating advantages over dogs.

1. Allow only adult dogs (ie, dogs of ≥1 year but ideally ≥2 years of age, the age of social maturity).
2. Deny the entry of dogs directly from an animal shelter or similar facility.
3. Require that dogs be in a permanent home for ≥6 months prior to enrolling in the program.
4. Admit a dog only if it is a member of a formal animal-assisted activities program and is present exclusively for the purposes of animal-assisted activities.

B. Require that every dog pass a temperament evaluation specifically designed to evaluate it under conditions that might be encountered when in the healthcare facility. Such an evaluation should be performed by a designated evaluator.

1. Typically, this evaluation will assess, among other factors, reactions toward strangers, loud and/or novel stimuli, angry voices and potentially threatening gestures, being crowded, being patted in a vigorous or clumsy manner, reaction to a restraining hug, interactions with other animals, and the ability to obey handler’s commands.

C. Require all evaluators (either at facility or at the formal certification program) to successfully complete a course or certification process in evaluating temperament and to have experience in assessing animal behavior and level of training.

1. Require all evaluators to have experience with animal visiting programs or, at the very least, appreciate the types of challenges that animals may encounter in the healthcare environment (eg, startling noises, crowding, rough handling).
2. If several animals need to be evaluated for behaviors other than reactions to other animals, require that the temperament evaluator assess each animal separately, rather than assessing several animals simultaneously.

D. Recommend that animal-handler teams be observed by an animal-assisted activities program liaison at least once in a healthcare setting before being granted final approval to visit.

E. Recommend that each animal be reevaluated at least every 3 years.

F. Require that any animal be formally reevaluated before returning to animal-assisted activities after an absence of >3 months.

G. Require that a handler suspend visits and have his or her animal formally reevaluated whenever he or she notices or is apprised (either directly or through the animal visit liaison) that the animal has demonstrated any of the following:

1. A negative behavioral change since the time it was last temperament tested
2. Aggressive behavior outside the healthcare setting
3. Fearful behavior during visitations
4. Loss of sight or hearing and, consequently, an overt inclination to startle and react in an adverse manner

H. Health screening of animals

1. Basic requirements for all animals
   1. Require that dogs be vaccinated against rabies as dictated by local laws and vaccine label recommendations. Serologic testing for rabies antibody concentration should not be used as a substitute for appropriate vaccination.
   2. Exclude animals with known or suspected communicable diseases.
   3. Animals with other concerning medical conditions should be excluded from visitation until clinically normal (or the condition is managed such that the veterinarian feels that it poses no increased risk to patients) and have received a written veterinary health clearance. Examples include episodes of vomiting or diarrhea; urinary or fecal incontinence; episodes of sneezing or coughing of unknown or suspected infectious origin; animals currently on treatment with non-topical antimicrobials or with any immunosuppressive medications; infestation by fleas, ticks, or other ectoparasites; open wounds; ear infections; skin infections or “ hot spots” (ie, superficial folliculitis or pyoderma); and orthopedic or other conditions that, in the opinion of the animal’s veterinarian, could result in pain or distress to the animal during handling and/or when maneuvering within the facility.
   4. Exclude animals demonstrating signs of heat (estrus) during this time period.
2. Scheduled health screening of animal-assisted activities animals

I. Require that every animal receive a health evaluation by a licensed veterinarian at least once (optimally, twice) per year.

1. Defer to the animal’s veterinarian regarding an appropriate flea, tick, and enteric parasite control program, which should be designed to take into account the risks of the animal acquiring these parasites specific to its geographic location and living conditions.
2. Routine screening for specific, potentially zoonotic microorganisms, including group A streptococci, Clostridium difficile, vancomycin-resistant enterococcus (VRE) and methicillin-resistantStaphylococcus aureus(MRSA) is NOT recommended.
   1. Special testing may be indicated in situations where the animal has physically interacted with a known human carrier, either in the hospital or in the community, or when epidemiologic evidence suggests that the animal might be involved in transmission. Testing should be performed by the animal’s veterinarian in conjunction with appropriate IPC and veterinary infectious disease personnel, if required.
   2. Special testing may be indicated if the animal-assisted activities animal is epidemiologically linked to an outbreak of infectious disease known to have zoonotic transmission potential. Suspension of visitation pending results is recommended in these situations.
3. Dietary guidelines for all animals
   1. Exclude any animal that has been fed within the past 90 days any raw or dehydrated (but otherwise raw) foods, chews, or treats of animal origin, excluding those that are high-pressure pasteurized or γ-irradiated.

IV. Preparing Animals for Visits

A. Require that every handler do the following:

1. Brush or comb the animal’s hair coat before a visit to remove as much loose hair, dander, and other debris as possible.
2. Keep the animal’s nails short and free of sharp edges.
3. If the animal is malodorous or visibly soiled, bathe it with a mild, unscented (if possible), hypoallergenic shampoo and allow the animal’s coat to dry before leaving for the healthcare facility.
4. Visually inspect the animal for fleas and ticks.
5. Clean the animal carrier.
6. Maintain animal leashes, harnesses, and collars visibly clean and odor-free.
7. Use only leashes that are non-retractable and ≤1.3–2 m (≤4–6 feet) in length.
8. Do not use choke chains or prong collars, which may trap and injure patients’ fingers.
9. Make an animal belonging to an animal-assisted activities program identifiable with a clean scarf, collar, harness or leash, tag, or other special identifier readily recognizable by staff.
10. Provide a dog with an opportunity to urinate and defecate immediately before entering the healthcare facility. Dispose of any feces according to the policy of the healthcare facility and practice hand hygiene immediately afterward.

V. Managing Appropriate Contact Between Animals and People During Visits

A. Obtain oral or written consent from the patient or his or her agent for the visit and preferably from the attending physician as well. Consider documenting consent in the patient’s medical record.

B. The handler should notify caregiver (eg, nurse or physician) of the animal visitation.

C. The handler should be required to obtain oral permission from other individuals in the room (or their agents) before entering for visitation.

D. All visiting animals should be restricted from entering the following clinical areas at all times, in addition to nonclinical areas outlined below in the Service Animals section:

1. Intensive care units; isolation rooms, neonatal and newborn nurseries, areas of patient treatment where the nature of the treatment (eg, resulting in pain for the patient) may cause the animal distress, and other areas identified specifically by the healthcare facility (eg, rooms of immunocompromised patients).

E. Require the handler to prevent the animal from coming into contact with sites of invasive devices, open or bandaged wounds, surgical incisions, or other breaches in the skin, or medical equipment.

F. If the patient or agent requests that an animal be placed on the bed, require that the handler do the following:

1. Check for visible soiling of bed linens first.
2. Place a disposable, impermeable barrier between the animal and the bed. Throw the barrier away after each animal visit.
3. If a disposable barrier is not available, a pillowcase, towel, or extra bed sheet can be used. Place such an item in the laundry immediately after use and never use it for multiple patients.

G. Instruct the handler to discourage patients and HCP from shaking the animal’s paw. If the dog is trained to shake hands with a patient and this contact is allowed by facility, ensure that the patient performs hand hygiene before and after shaking the animal’s paw.

H. Require the handler to prevent the animal from licking patients and HCP.

I. Prohibit feeding of treats to animals by HCP. However, if the act is believed to have a significant therapeutic benefit for a particular patient, then require that the handler:

1. Ensure that the animal has been trained to take treats gently.
2. Provide the patient with appropriate treats to give, avoiding unsterilized bones, rawhides and pig ears, and other dehydrated and unsterilized foods or chews of animal origin.
3. Ensure that the patient practices hand hygiene before and after presenting the treat to the animal.
4. Instruct the patient to present the treat with a flattened palm.

VI. Contact Tracing

VII. Environmental Cleaning

A. Practice routine cleaning and disinfection of environmental surfaces after visits. Clean and disinfect all areas (eg, floors, chairs) with an a US Environmental Protection Agency (EPA)-registered hospital disinfectant.

B. It is recommended that a clean additional bed sheet be used to cover the bed if the animal has contact with surface of the bed, and this should be removed and laundered after the animal visit. If a separate sheet is not used, replace any bedding that might be contaminated.

I. Each healthcare facility should have a policy regarding the admittance of service animals into the facility.

A. The policy allowing service animals into the facility should be compliant with the ADA, any other applicable state and local regulations (note that federal law pre-empts more restrictive state or local regulations).

B. A policy regarding the entrance of service animals into the facility should include the following information:

1. A clear definition of “ service animals” that should be consistent with the ADA (http://www.ada.gov/service_animals_2010.htm). The facility is not required to permit animals in training to become service animals to enter the facility, but may choose to do so, reserving the right to exclude such animals at its discretion.
2. A statement that only dogs and miniature horses are recognized as service animals under federal law.
3. A statement that service animals are NOT pets and should NOT be approached, bothered, or petted.
4. A statement that the care of the service animal is the responsibility of the patient or his or her designated visitor (ie, it is not the responsibility of the healthcare facility’s personnel). If the patient is unable to arrange for the care of the service animal while in the facility, the animal should not be permitted to remain.
5. Notification of IPC that an inpatient has a service animal, followed by discussion with the patient to make sure the service animal complies with institutional policies.
6. A requirement that service animals be housebroken.

II. Persons with disabilities may be requested but not required to have their service animal wear an identification tag (eg, collar, tag, etc.) that identifies them as a service animal to aid HCP in distinguishing service animals from pets.

III. Situations in which a service animal may be excluded from the healthcare facility include the following

A. The animal exhibits aggressive behavior such as snarling, biting, scratching, or teeth baring.

B. The animal is excessively noisy (eg, howling, crying, or whining).

C. The animal is unable to properly contain bodily excretions (eg, the animal is not housebroken, or has vomiting or diarrhea).

D. If the facility’s personnel reasonably believes that a service animal is infectious or ill (see Animal-Assisted Activities, Section III.H.1.b and c for examples), the animal should not be allowed to remain with the person with a disability until the animal is evaluated by a veterinarian and he/she provides written certification, acceptable to the healthcare facility, that the service animal does not pose an increased risk to patients or staff.

E. The policy should include a list of locations from which service animals are prohibited and reasons for that exclusion.

1. Where exclusion is based solely on risk to the service animal, the patient should be consulted.
2. When the service animal is restricted from accompanying the patient, reasonable accommodation should be made for the person with disability to function without the service animal. Areas from which service animals should be prohibited include the following:
   1. Invasive procedure areas where sterility is required, including but not limited to the operating rooms, recovery rooms, cardiac catheterization suites, and endoscopy suites.
   2. Patient units where a patient is immunocompromised or deemed at particularly high risk for infection, or in isolation for respiratory (droplet or airborne) contact, or compromised host precautions, unless in a particular circumstance a service animal does not pose a direct threat and the presence of the service animal would not require a fundamental alteration in the hospitals’ policies, practices, or procedures.
   3. Food and medication preparation areas where appropriate hygiene is required, including but not limited to kitchen, infant formula preparation room, and central and satellite pharmacies.
   4. Areas where the service animal or equipment may be harmed by exposure (eg, metal is not allowed in a magnetic resonance imaging [MRI] room, and a dog may have metal on a collar or in a surgical implant), after consultation with the patient or his/her authorized representative. When there is potential harm to the service animal (eg, animal present in room during radiation therapy), the patient should be advised of the potential harm and assumes full responsibility for any harm to the service animal.

F. Legal counsel should be consulted prior to exclusion of a service animal from a healthcare facility.

G. Any consideration of restricting or removing a service animal should be done with careful discussion with the patient (and/or his or her designee) to achieve consensus and provide an understanding of the concerns.

H. The policy should include the following regarding the health of the service animal:

1. The person with a disability (or his or her designee) is responsible for ensuring the health and care of the service animal.
2. Visiting or residing in a healthcare facility likely increases the risk of the animal acquiring certain pathogens. The healthcare facility assumes no liability for costs associated with a hospital-associated infection in the service animal.

I. The policy should address a service animal’s accompanying a healthcare facility visitor to a patient room and should include the following:

1. Persons with disabilities who are accompanied by service animals are allowed to visit patients as long as visitation occurs in accordance with the facility’s service animal policy and the facility’s “visiting hours and regulations.”
2. Service animals are not allowed to visit other patients’ rooms, the dining rooms, or other public areas of the facility unless accompanied by the person with a disability.
3. When a person with a disability visits a patient’s room, he or she should check with the patient’s primary care nurse before visiting to assure that no patient in the room has allergies to the service animal or bears other significant medical risks that would contraindicate being near an animal. If another patient in the room has an allergy, other significant medical risk from exposure to an animal, or is fearful of the animal, other arrangements for visiting must be made (eg, visit in day room or waiting room).

J. The policy should address the following for service animals belonging to patients:

1. When patients with a service animal are assigned to a semiprivate room, the roommate must be screened for clinically significant allergies to the service animal and, if such a condition is present, either the patient with the disability or the patient with animal allergies must be moved to another room. Similarly, the patient or roommate must be moved if the roommate is fearful or otherwise disturbed by the presence of the animal.
2. IPC should be notified when patients are admitted with service animals.
3. The patient must be able to make arrangements to have the service animal fed, exercised, and toileted, without the involvement of HCP.

K. The policy should specifically address the use of a miniature horse trained to do work or perform tasks for a person with a disability. Miniature horses generally range in height between 24 and 34 inches measured to the shoulders and generally weigh between 70 and 100 pounds. Factors used to assess whether a miniature horse should be permitted in the healthcare facility include the following:

1. Whether the miniature horse is housebroken.
2. Whether the miniature horse is under the owner’s control.
3. Whether the facility can accommodate the miniature horse’s type, size, and weight.
4. Whether the miniature horse’s presence will not compromise legitimate safety requirements necessary for safe operation of the facility.
5. The policy should clearly state who is assigned to enforce the policy (eg, legal).