Proposal to enhance the current Starship ’s Pet Programme

By Lindy Lely & Veni Oliveros, ADHB Volunteers Centre 1 September 2017 Updated December 2017

I. Objective a. To gain ADHB approval to enhance the current Pet Programme. b. The proposal is to move the pet visits from the Atrium to a designated room on the wards. A wealth of supporting evidence (please see attached research schedule) for allowing Pet Therapy trained and groomed pets onto the wards and on the beds of patients come from similar (Children’s) in the Western world, i.e. UK, Canada, Australia, Italy, USA and The Netherlands. c. The pets as described in this proposal are especially trained, groomed and monitored therapy pets that belong to Pet Therapy organisations that are contracted by DHB Volunteers Services. d. The therapy pets will initially be a dog. e. If, one year after satisfactory implementation, the Volunteers wish to expand the programme to include small animals other than dogs, a new proposal will be formulated.

II. Timeline & Budget The roll-out of the proposed process is 2018 February and to increase the visits to twice or three times a week, depending on the agreed time with (currently Wednesdays between 13.30 and 15.00 hrs).

III. Background Auckland DHB has had a Pet Programme running at Starship Children’s Hospital in the past six years. It involves an Auckland DHB volunteer and SPCA volunteers who bring their specially trained and groomed therapy dog into the atrium of Starship so patients and families can visit. Both volunteer parties are responsible for making sure that all safety and hygiene requirements are met. Visits occur every Wednesday from 1.30 pm to 3pm with children being accompanied by a nurse (if clinically required) and a family member.

There are problems with the atrium as a venue. The atrium can be cold with draughts and is therefore not a suitable place for sick children. It can be hard, if not impossible, to transport sick children from their ward to the atrium. As a result numbers attending the Pet Programme have been lower than expected, and many of the visits have been from siblings rather than the child who is in hospital.

IV. The proposal for an enhanced programme The proposed process is based on the Pet Programme used by the Children’s Hospital of the Academic Medical Centre (AMC), Amsterdam, Netherlands which has been running since February 2010. The detail of the AMC model is very similar to the work process flow currently used at Starship Hospital.

a. Pet visits are allowed on most wards, excluding (by concession only) Intensive Care Units and the Haematology Unit, with the Clinical Charge Nurse (CCN) or Charge Nurse (CN) or Nurse Unit Manager (NUM) authorisation. b. The signed visit checklist and proof of vaccination are to be submitted by the ADHB volunteer-Pet Manager to the Hospital. The ADHB volunteer has a copy of each document available during the visit. c. The proposal extends the current once-a-week regime to two to three times a week. d. Every child must have CCN or CN or NUM and care giver approval granted for a pet visit. The requests for pet therapy will be as per process. e. Patients with open wounds or burns, allergies to pets, or immune deficiencies or compromise will not be allowed pet visits. f. Pets are supervised at all times by their handler/owner and accompanied by an ADHB Pet Volunteer while being transported through the hospital For individual patient/pet contact, ADHB volunteers can take the role of transport and security guide. g. Each ward has an identified room (see table) which can be used one hour in a day to be used by the pet, its owner and the patient. h. In cases where a patient can’t leave their bed, the pet will be brought to the room. i. The child will wear a disposable gown or the gown and/or one will be placed on the bed while interacting with the animal. j. After the pet visit, ADHB volunteers will tidy up the room and remove the disposable gown from the child.

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k. A nurse (or Healthcare Assistant (HCA)) will wheel the patient back to their room while the volunteer guides the pet and owner out of the hospital. l. Before leaving the family room, everyone will perform appropriate hand hygiene (for both visual and non-visual grease). m. Any child with medical equipment such as an IV stand should be accompanied by a Staff member.

Table: Designated Pet Areas in Starship Hospital

PICU Individual bed spaces Ward 23 Family or teaching room Ward 24A & B Family room between the two wards Ward 25 One of the quiet rooms Ward 26A Quiet room Ward 26B Large Quiet room Ward 27 Adolescent lounge on 27B DSU No room

Recommendations Volunteers_Pet Programme in SSH.doc

V. Roles and Responsibilities a. CCN or CN or NUM  Approval of pet visits to patients on the ward to be decided as per process.  Ensure parental/caregiver’s consent

b. Volunteer Manager  Organisation of pet visitation program  ADHB Pet Volunteer’s performance of duties/tasks

c. ADHB Volunteer  ADHB pet programme volunteers facilitate the visits of SPCA pets into the Starship Hospital.  Support Outreach Therapy Pets volunteers and staff with the coordination of visits  Ensure hospital protocols are followed  Ensure pet enclosure, furniture and all equipment are cleaned before and after pet visits  Escort and signing of pet handler/owner in and out of Starship Hospital  Transport of pet to and from L1 entrance to designated room in the ward  Supervision of pet visit  Preparation and cleaning of designated room before and after visit

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 Conduct hand hygiene procedure (Microshield) for everyone in the Family Room before and after pet visit  Immediate notification of CCN, CN, NUM in cases of bites, scratches or any incident relating to the pet visit which is then noted in DATIX  Submission/return of visitation list to the Volunteer Manager  27B patients who have been granted (through CCN or NUM approval only) a therapy pet visit will have first access to the animals before they are moved on to other wards.

d. Nurse of HCA  Transport of Patient to and from designated areas.  Provision of single use disposable gown for the child.

e. SPCA Outreach Therapy Pets Volunteers (Pet Handlers/Owners) as outlined by SPCA

 Abide by ADHB health and safety regulations and by SPCA Therapy Pets guidelines

o Only ever use our own approved animal for visits at approved establishments that have been allocated to the SPCA volunteer o The approval to use a specific animal as a therapy pet is not transferrable to a different animal owned or handler o All animals are subject to individual assessment which will be maintained at least every two years. Animals must always be humanely handled so as to minimise stress and any risk to the welfare and well-being of the animal and clients o Visits shall not be longer than one hour without a suitable break for the animal in which it can rest or burn off steam as appropriate o Approved animals must be healthy (e.g. not lame, no internal or external parasites), in good condition (e.g. not obese or under- weight), well presented (e.g. clean and well groomed), with up to date training and assessments.

IX Complaints process and managing risks Not every family or staff member will be happy to see animals within an acute hospital facility. Animals may initially be associated with dirt and disease or as dangerous or frightening. For this reason it is essential that people opposed to the Pet Programme or who are fearful of animals be able to discuss their concerns with the CCN, CN or NUM of the area.

The following process will help to manage likely criticisms and complaints:  All families are informed about the Pet Programme on admission during orientation, using the information sheet.  How to provide feedback and how to opt out of The Pet Programme will also be clearly indicated at admission time.  A sheet with Frequently Asked Question may also be useful (see the final page).

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 No child will engage with pets without explicit approval of the medical team and the caregiver.

This proposal has addressed the many risks identified to date. Constant monitoring will be required as the programme expands to identify any risks and ensure these are managed promptly. It is important to note that no scratches or any bites have occurred to date in the current programme available at Starship Hospital.

VI. Benefits of this Proposal

a. More children will have the opportunity to interact with the pets. Bringing the pets to family rooms on the wards will shorten the physical distance between the Pet Programme and its intended beneficiaries. With the current process, only 2-15 children are able to go down to the cold and windy Atrium. The number of children (and families) benefitting from the programme is just a tiny fraction of those eligible, especially considering that the hospital has nine wards and a capacity of 219 beds.

b. There will be a more comfortable space for child-dog interaction. Anyone visiting the Atrium during the cold months will notice the draught in the area. A possible solution involving a sail cover for the enclosure was explored but was not pursued due to its prohibitive cost.

c. Programme continuity. With ADHB’s plan to re-allocate hospital spaces and renovate the Atrium, there is a possibility that the Programme will lose the enclosure. Moving the Programme to the wards will ensure that children will continue to experience the positive effects that dogs have on treatment and recovery.

d. By allowing a patient to have a brief encounter with a small animal (placed on a sheet on the bed) provides even very sick patients to benefit from with this therapy. Pet therapy can be, especially helpful for those children who are too sick to enjoy a playful interaction in the Play rooms or with Radio Lollipop.

VII. Benefits Outweigh Risks from the literature

a. An excerpt from the 2013 report by Corydon Consultants Ltd on the social benefits of outreach therapy pets:

The literature identifies disease transfer from animals to patients as the main perceived risk associated with animal assisted therapy. The transmission of disease between animals and humans, infection control, and safety are considered significant barriers to the introduction of animal assisted therapy into health facilities in particular.

The evidence, however, seems to us to dispel such concerns. For example, Emmett (1997) stated that there had been no documented cases of

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disease transmission in animal assisted therapy programmes (cited in Stanley-Hermanns and Miller, 2002). Follow-up research in 2002 also failed to find any documented cases (Stanley-Hermanns and Miller, 2002). Yamauchi and Pipkin (2008) reviewed over 4,000 interactions between children and dogs in a children’s hospital over an eight-year period and found no evidence of infection or adverse reaction among the children.

One area where concern may be more justifiable is visitation by patients’ own pets. Lefebvre et. al. (2006) reviewed “canine visitation programmes” at hospitals in Ontario and found that while the screening processes for animals associated with formal Animal-Assisted Therapy programmes were generally robust, some hospitals allowed visits by patients’ own pets and screening for these was thought likely to be less rigorous. However, the authors noted very few reports of disease transfer to patients, and could find none that were verifiable.

A significant challenge for animal assisted therapy is the cost associated with screening in response to concerns about health risks. Lefebvre et. al. (2006) noted that “the more thorough a pet-health screening protocol is, the more likely it will be cost-prohibitive to volunteers. Overzealous requirements, such as those based on preventing the transmission of agents unlikely to be present, should be avoided in order to decrease costs and prevent the withdrawal of animals and the unnecessary administration of antimicrobials to colonized animals.”

b. Excerpt from an email sent by Annette Jeanes, Director of Infection Prevention and Control, University College Hospitals, to National Health Service (NHS) UK members:

We believe that the value of animals visiting hospitals largely outweighs the risks. Our ITU is included in the animal visiting scheme we have in the Trust and the feedback from staff, visitors and patients has been very positive. We have had many reports of very good patient experiences. Stressed and busy staff have also fed back that the presence of our regular PAT dogs has been a marvellous contrast to the stress of the day.

Dogs and cats which belong to the Pets as Therapy (PAT) scheme are also welcome with their handlers and should follow the PAT guidelines.

In some instances where clinical staff and infection control agree that a visit from a family pet would benefit a patient, a visit may be negotiated. The area manager should contact the security manager and infection control to facilitate the visit.

The following principles should be followed during a visit: Scrupulous hand hygiene after handling the animal Confine the animal to a defined area and keep on a lead Keep animals out of the kitchens Clean up any animal faeces or urine using the same technique as you would do for humans

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Make sure you have checked that other patients or staff are not allergic to the animal

c. Excerpt from The Use of Dogs in Hospital Settings, Amy McCullough, PhD, Ashleigh Ruehrdanz, MPH, & Molly Jenkins, MSW, HABRI Central, January 18, 2016

One of the risks of Animal-Assisted Interventions (AAIs) in hospital settings is the possible transmission of zoonotic (animal to human) disease, especially for those people who are immunocompromised (Murthy et al., 2015). However, in a 2006 study of existing literature on zoonoses by Hemsworth and Pizer (p. 126), it was concluded that “immuno-compromised people are not at any additional risk by interacting with pets than they would be by interacting with other people and the environment.” Precautionary measures, such as veterinary screening of therapy dogs and human hand-washing after contact with a therapy dog, will aid in preventing transmission of most zoonoses (Friedmann & Son, 2009).

Additionally, a pilot study conducted by Caprilli and Messeri (2006) found no increase in hospital infection rates with the commencement of a therapy dog program. Similarly, a 2008 study by Yamauchi and Pipkin found no evidence of infections or adverse reactions in 4,000 patients exposed to therapy dogs over a period of six years. Finally, Snipelisky & Burton (2014) completed a comprehensive literature review on canines in inpatient hospital settings and found that overall, the risks of these types of interactions, including infection, were very minimal and that they should not prohibit their implementation. Included in their review was a 2012 study (Urbanski & Lazenby) which found that over the course of more than 2,400 animal-assisted therapy sessions spanning many years, there was found to be no increases in infection transmission from these canine visits.

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Although other risks are plausible in Animal-Assisted Interventions , such as animal bites and falls caused by the dog, there is little evidence that Animal-Assisted Interventions are dangerous or have adverse effects (Walter-Toews, 1993). Risks can be minimized through careful selection of animals and adherence to informed policies and procedures (Brodie et al., 2002; DiSalvo et al., 2006). There is also a role for veterinarians to properly communicate to animal owners and handlers about the risks related to zoonotic diseases, how best to minimize these risks, how to identify signs of disease in their pets, best practices for preventative health in pets, and how to safety interact with pets (Stull & Stevenson, 2015; Marsh & Babcock, 2015).

d. Excerpt from the NZ SPCA OTP Corydon Research Health and Benefits:

The literature identifies disease transfer from animals to patients as the main perceived risk associated with animal assisted therapy. The transmission of disease between animals and humans, infection control, and safety are considered significant barriers to the introduction of animal assisted therapy into health facilities in particular.

The evidence, however, seems to us to dispel such concerns. For example, Emmett (1997) stated that there had been no documented cases of disease transmission in animal assisted therapy programmes (cited in Stanley- Hermanns and Miller, 2002). Follow-up research in 2002 also failed to find any documented cases (Stanley-Hermanns and Miller, 2002). Yamauchi and Pipkin (2008) reviewed over 4,000 interactions between children and dogs in a children’s hospital over an eight-year period and found no evidence of infection or adverse reaction among the children.

One area where concern may be more justifiable is visitation by patients’ own pets. Lefebvre et. al. (2006) reviewed “canine visitation programmes” at hospitals in Ontario and found that while the screening processes for animals

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associated with formal AAT programmes were generally robust, some hospitals allowed visits by patients’ own pets and screening for these was thought likely to be less rigorous. However, the authors noted very few reports of disease transfer to patients, and could find none that were verifiable.

A significant challenge for animal assisted therapy is the cost associated with screening in response to concerns about health risks. Lefebvre et. al. (2006) noted that “the more thorough a pet-health screening protocol is, the more likely it will be cost-prohibitive to volunteers. Overzealous requirements, such as those based on preventing the transmission of agents unlikely to be present, should be avoided in order to decrease costs and prevent the withdrawal of animals and the unnecessary administration of antimicrobials to colonized animals.”

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Appendix one: Research on Pet Programmes in Other Countries (see table below)

Comments (Health & Hospital Pet Types Areas Accessed Safety) Dogs Wards and hospital Special visits on other wards Royal beds can be arranged Children’s Hospital Meerkats Enclosed area to view (Australia) Tropical fish 2 story high fish tank Lady Cilento Dogs via Delta Wards and hospital Children’s Hospital Society Australia beds (Australia) Wards and hospital Therapy cat () beds Study that showed that the Meyer Children’s hospital infection rate did not Wards and hospital Hospital Dogs change and no new beds (Italy) infections were developed with the introduction of dogs

Most inpatient units, Boston Children’s certain outpatient clinic Volunteer dogs Hospital (USA) areas, ED and other designated areas

Phoenix Children’s Wards and hospital Volunteer dogs Hospital (USA) beds Dogs via Dallas Children’s PetSmart and Pet Wards and hospital Medical Center Partners beds (USA) programs Johns Hopkins All Wards and hospital Children's Hospital Volunteer dogs Dogs do rounds on wards beds (USA)

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Inpatient floors, surgery areas, select Minnesota Children’s waiting rooms, the Volunteer dogs Hospital (USA) and specialty units Rush University Dogs including Wards and hospital Medical Center patient-owned beds (USA) dogs Constructing separate pet Volunteer dogs Cincinnati Children’s Wards and hospital visiting facility with indoor and patient- Hospital (USA) beds and outdoor space and will owned dogs allow 2 pet visits at a time Alaska Regional Dogs via Pet Wards and hospital

Hospital (USA) Partners program beds

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Appendix two: Frequently Asked Questions (FAQs)

Who can have a visit from a pet? Patients can have a visit if they meet specific criteria and receive approval from both the Charge Nurse and from the parent/guardian. Dog/handler teams visit most inpatient units, certain outpatient clinic areas, the emergency department and other designated areas of the hospital.

Can a patient schedule a dog visit? The patient does not schedule a visit. The Auckland DHB Volunteers services schedules and coordinates the visits with Pet Therapy organization. Patients’ families are informed by their doctor or nurse.

When are the Therapy pets visiting Starship? The proposed time of 13.30-15.00 hrs is based on the current therapy dog- Wednesday schedule but both day(s) and time need to be confirmed by the Charge Nurses / Nurse Unit Managers.

What happens during a pet visit? Pets are assisted to a designated area(s) on the wards. The patient decides how he or she would like to interact with the pet (with approval from doctor or nurse). Pets may sit on the floor, a chair or on a clean sheet on the patient’s bed. The patient may pet, play with, talk to or watch the pet. Siblings and other family members are encouraged to interact with the pet as well.

How long are the visits? The length of each visit varies depending on the number of patients scheduled for a visit that day, the preferences of each patient and any health care needs. Individual patient visits/interactions typically last between 5 and 10 minutes.

Who owns the pets and where do they live? The dogs belong to and live with their owner/handler who is a SPCA Therapy Pets volunteer.

Can my pet visit me? At the discretion of the Charge Nurse and only in special occasions (a last farewell) can the patient’s own pet/s be approved to visit. Refer to current policy.

Can another kind of pet visit me in the hospital? For the health and safety of the patients, families and staff at the hospital only approved therapy animals are permitted in the hospital (such as SPCA Therapy Pets dogs).

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