- Email: [email protected]
Impact of the implementation of a therapy dog program on burn center patients and staff
JBUR 5998 No. of Pages 5
burns xxx (2019) xxx
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Impact of the implementation of a therapy dog program on burn center patients and staff Kaitlin A. Pruskowski a,b, * , Jennifer M. Gurney a,b,c , Leopoldo C. Cancio a a
US Army Institute of Surgical Research, Fort Sam Houston, TX, United States Uniformed Services University of the Health Sciences, Bethesda, MD, United States c Joint Trauma System, Fort Sam Houston, TX, United States b
article info
abstract
Article history:
Animal-assisted interventions have been implemented in both inpatient and outpatient
Available online xxx
settings and have demonstrated positive outcomes on patients and hospital staff. Animalassisted interventions have not been previously reported in any burn center. A therapy dog program was established at our burn center with the intent of improving duration and quality
Keywords:
of rehabilitation sessions and physical therapy. Satisfaction surveys were distributed to
Therapy dog
patients and staff. After one year, 14 patient surveys and 23 staff surveys were collected.
Rehabilitation
Implementation of this program was feasible and patients worked with the therapy dogs in
Integrative therapy
all environments of the burn center: outpatient, ward, and ICU. Most patients reported improved pain and anxiety after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Most reported an improved mood after seeing the therapy dogs and wanted that additional therapy dog visits. One year after the implementation of the therapy dog program, we have demonstrated feasibility, acceptability, and desirability of this type of program at our burn center. Given the paramount importance of rehabilitation in the recovery of burn patients, further investigation into therapy should be performed and longer term outcomes assessed. Published by Elsevier Ltd.
1.
Introduction
The benefits and healing power of the human animal relationship have long been recognized. Animal-assisted interventions, including animal-assisted activities (AAA) and animal-assisted therapy (AAT), have been implemented in both inpatient and outpatient settings. AAA, which includes visits with therapy animals, have been described as using animals to facilitate and empower a patient’s opportunities for motivation, education, or recreation to enhance their quality of life [1]. With AAA, specially trained volunteers
(or professionals) visit a variety of environments with a certified therapy animal. Activities are not ‘fixed’, and there are no specified therapeutic goals for the session [2]. AAT, on the other hand, are goal-directed interventions in which an animal is integrated into a patient’s treatment plan/process [1]. Interactions/activities that occur during AAT are purposeful with a therapeutic intent of helping patients to achieve treatment goals [2]. Both AAA and AAT and have demonstrated positive effects on patients’ moods, anxiety levels, pain scores, and rehabilitation efforts [3 7]. AAA/AAT also has a positive impact on nursing and hospital staff [5]. Given the burnout risk in highly
* Corresponding author at: 3698 Chambers Pass, ATTN: MRMC-SRT-C, JBSA, Fort Sam Houston, TX, 78234, United States. E-mail address: [email protected] (K.A. Pruskowski). https://doi.org/10.1016/j.burns.2019.11.024 0305-4179/Published by Elsevier Ltd.
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
JBUR 5998 No. of Pages 5
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stressful inpatient settings, such as a burn center, AAA/AAT may decrease burnout by improving morale. Healthcare providers have long-recognized the positive impacts animals can have on both patients and staff. The first reported use of animal-assisted interventions was recorded in 1792, when the Quakers used farm animals as a therapy for psychiatric patients in a mental health institution [8]. In 1860, Florence Nightingale noted, “a small pet is often an excellent companion for the sick, for long chronic cases especially” [9]. In 1919, the United States military began incorporating dogs as therapeutic psychiatric interventions in military healthcare facilities [8]. More recently, the US Army used therapy dogs to improve occupational therapy and other rehabilitative efforts of soldiers returning home from the conflicts in the Middle East [10]. Despite the long history of using animals in therapy, use of AAA/AAT has not been previously reported in any burn center. Given the potential of animal-assisted interventions to benefit burn patients and staff, we developed an AAA/AAT program at our burn center. The purpose of this paper is to describe the implementation of such a program and to report patient and staff satisfaction with this program.
2.
Methods
The US Army Institute of Surgical Research (USAISR), the US Army Burn Center, is the sole burn center in the Department of Defense and is located at Fort Sam Houston, San Antonio, Texas. In addition to caring for all military burn casualties, the USAISR also serves as the regional burn center for 49 counties in south Texas, covering an area of 80,000 square miles. Civilian burn accidents include both domestic and occupational injuries. A therapy canine AAA/AAT program was established at the USAISR in November of 2017. Given that the military has precedent within the system for using dogs as therapeutic adjuncts, policy existed supporting the establishment of an AAA/AAT program [11,12]. The US Army Burn Center is located within Brooke Army Medical Center, a Joint Commissionaccredited hospital. Seeking approval to establish a pet therapy program was straightforward utilizing existing hospital and Department of Defense policies governing support animals. At the time the USAISR established the therapy dog program, the only other units in the hospital that had therapy dogs were the inpatient psychiatric units; no medical or surgical units had therapy dog programs. Support from the Burn Center director and the USAISR commander were garnered prior to moving forward with implementation of the therapy dog program. Additionally, buy-in from rehabilitation staff, nursing, and Brooke Army Medical Center’s volunteer services was achieved. The initial intent of the therapy dog program was to improve the duration and quality of rehabilitation sessions. The most feasible location for the initial rollout of this program was in the rehabilitation gym because of space and because of its geographic location outside of the inpatient units. Therapy dog teams made weekly visits, and initially only worked with outpatients during rehabilitation sessions. Over time, as more staff members became comfortable with having the therapy dogs in the burn center, rehabilitation therapists requested
xxx
that therapy dogs work with selected inpatients (as per the therapist’s discretion). After 5 months and secondary to increased demand, the program expanded and therapy dogs were allowed to visit inpatients and staff on the ward and in the ICU (AAA), or in the in-patient therapy gym (AAT). Also, more therapy dog teams were added to meet the increased demand. One of the concerns regarded a potential increased risk of infection. There are no data to support this concern; but with input from the burn center’s infection control nurse, we decided that therapy dogs would not be allowed in patient rooms. However, if a patient was able to leave their room they could visit or work with the therapy dogs. The ability of a patient to leave their hospital room indicated that patients were medically stable, and that there was no concern regarding wound exposure outside the room. Patient and staff participation and interaction with the therapy dogs was voluntary and usually requested. As part of a performance improvement project approved our institution’s Research and Regulatory Compliance division (H-17-028nr), we distributed satisfactions surveys to both patients and staff to evaluate the respondents’ impression and satisfaction with the therapy dog experience. Secondary outcomes were to assess the impact of therapy dog visits on pain, anxiety, and mood. Patient and staff survey questions can be found in Appendices B and C.
2.1.
Animals and handlers
Therapy dogs and handlers were screened by burn center staff prior to their first therapy visit. Initially, 3 therapy dogs visited our burn center, on a rotating schedule: one Great Pyrenees, one Shetland sheepdog, and one collie. Due to handler and canine health reasons, the Great Pyrenees therapy dog team ‘retired’ after a period of several months. At the time of manuscript preparation, 6 dogs were visiting: 2 golden retrievers, one miniature poodle, one labradoodle, 2 Shetland sheepdogs, and one collie. Per hospital policy, all therapy dogs and their handlers were certified with a credible and insured organization, and all attained the American Kennel Club Canine Good Citizen certificate [13]. Therapy organizations represented in our program include: Therapy Animals of San Antonio, Pet Partners (formerly known as the Delta Society), and Alliance of Therapy Dogs. Because of organizational liability insurance purposes, most therapy dogs and handlers were limited to working no more than 2h per day. All therapy dog teams were volunteers; handlers (or their associated organizations) did not receive any monetary compensation for their participation in our program. All dogs were healthy and up-to-date on vaccinations and other preventatives (heartworm prevention, flea prevention). In accordance with hospital policy, all dogs were bathed and brushed within the 24h prior to their visit to the burn center. Information provided to volunteers on our therapy dog program can be found in Appendix A.
2.2.
Rehabilitation activities
Rehabilitation activities incorporating the therapy dogs occurred as part of a patient’s regular physical/occupational
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
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therapy session. Activities were selected by the physical/ occupational therapist and/or therapy assistant as per the patient’s needs. Common occupational therapy activities included gait/stamina activities (walking with the dog), upper extremity activities (brushing, petting, feeding, throwing a toy to the dog, or ‘dressing’ the dog with a bandana), and by providing comfort and emotional support during stretching of burned and/or contracted wounds by being present and close to the patient. During breaks in stretching, patients were able to pet/stroke the dog for emotional support. Therapy dog handlers were instructed to bring a variety of sizes of treats and toys for the dog so that patients could participate (and be challenged) regardless of their injuries and physical limitations. As different dogs have different preferences and/or dietary restrictions, the therapy dog handlers were instructed to provide treats and toys for their dog. Most activities occurred in our burn center’s inpatient or outpatient rehabilitation gyms. However, if a patient working in the gym was afraid of or allergic to dogs, this was respected. The patient not working with the dog was given extra space (i.e. having the patient working with the therapy dog be on the opposite side of the gym from the patient who was afraid or allergic) an alternative space was used for the therapy dog session.
2.3.
Patient selection
Inpatients who were medically stable and able to leave their rooms were asked if they would like to work with a therapy dog prior to the dog’s scheduled visit. If so, rehabilitation staff coordinated a rehabilitation time to coincide with the therapy dog team’s 2-h time slot. Visits with a therapy dog were sometimes used a motivation for patients who frequently declined to work with rehabilitation staff or who were thought not to perform rehabilitation to their fullest potential. Therapy dogs were also used as morale boosters for patients who had been admitted to the burn center for several weeks or months, or those who were having difficulty accepting their injuries and new limitations/realities. The patients needing motivation and/or morale boosts were given priority to work with the therapy dogs. Outpatients who were expected to benefit from the functionality and real-life applications of rehabilitation that the therapy dogs could provide were given priority to work with the dogs. Additionally, patients who were undergoing a prolonged rehabilitation course often considered working with the therapy dogs to be a break from the monotony of their daily rehabilitation sessions.
3.
Results
After one year, 14 patient surveys and 23 staff surveys were completed and returned. A total 48 days included 84 AAT and 249 AAA encounters. Each patient who submitted a survey worked with the therapy dogs during multiple encounters. However, surveys were collected per patient, not per encounter. Table 1 shows patient survey responses. Patients workedwith the therapy dogs in all environments of the burn center: outpatient, ward, and ICU. All patients were satisfied or very
3
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Table 1 – Patient satisfaction. N=14 Satisfied with therapy dog visit Strongly agree Agree Pain is improved after therapy dog visit Strongly agree Agree Neutral Anxiety is improved after therapy dog visit Strongly agree Agree Neutral N/A Want another visit with therapy dog Strongly agree Agree
10 (71.4%) 4 (28.6%) 5 (35.7%) 7 (50%) 2 (14.3%) 6 (42.9%) 6 (42.9%) 1 (7.1%) 1 (7.1%) 9 (64.3%) 5 (35.7)
satisfied with the dogs’ participation during the session. Twelve (85.7%) patients agreed or strongly agreed that their pain was improved and 12 (85.7%) patients reported their anxiety was improved after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. No negative comments were reported. Additional patient comments include: ‘The therapy dog was a fresh breath of air. I loved the idea. Can't wait until the next visit. I had surgery that morning. Knowing the dog was there helped me and motivated me to get out of bed.’ ‘I strongly agree with the therapy dogs. I think they should use them more. It made me feel 100% better because I was missing my dog so much.’ ‘I've been very depressed since the beginning of my situation, and just the interaction with the therapy dog made me not even think or feel any of my pain, inner or physical pain.’ ‘Having the therapy dog with me brightens my day and gives me a little more motivation.’
Table 2 – Staff satisfaction. N=23 Satisfied with therapy dog participation Strongly agree Agree Enjoyed having dog present Strongly agree Agree Improved mood Strongly agree Agree Neutral Want another visit with therapy dog Strongly agree Agree Neutral
17 (73.9%) 6 (26.1%) 18 (78.3%) 5 (21.7%) 17 (73.9%) 5 (21.4%) 1 (4.3%) 16 (69.6%) 6 (26.1%) 1 (4.3%)
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
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Table 2shows staff responses. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Twenty-two (95.7%) staff members reported an improved mood after seeing the therapy dogs. Twenty-two members (95.7%) reported that they would like to see or work with the therapy dogs again. Staff members commented that the therapy dogs were great stress relievers and the visits were very therapeutic and calming. No negative comments were reported. Additional comments from staff members include: ‘Overall, the experience has been good and positive. Different dogs and handlers bring different activities that we can do with the patients. Some dogs are more interactive than others. Some handlers interact more with other people and not just the patient and sometimes this can be distracting.’ ‘The presence of the dog helped with patient motivation, in my opinion.’ ‘All my patients look forward to the pet therapy sessions. They do more without knowing it and their emotions for rehab appear to improve. Patients also report less pain, less discomfort for exercises, and try more activities.’ ‘The patients that participate seem to really enjoy the visits. I believe that pet therapy has a positive effect on patients & staff.’ ‘Amazing program! Instantly improves the moods and lower the stress levels for both the patients and staff. Hope to see it reach more patients & longer visits!’ ‘The dogs really make my day!’
4.
Discussion
Our experience demonstrates 3 components that are necessary for the implementation a new program: feasibility from a logistical, administrative and system standpoint; acceptance by staff members and the leadership of the organization; and desirability from a patient standpoint. The survey responses support these conclusions. Additionally, patients reported decreased pain and anxiety after interventions, and burn center staff reported improved mood after interactions with therapy dogs. There are several theories as to how animal-assisted interventions exert their positive effects. These include the theory that human animal bonds improve physical and psychological health, increase life-satisfaction, promote calmness, and improve coping abilities [2,14]. Proposed mechanisms of animal-assisted interventions also include distraction-based alteration of the patient’s perception of pain. Shen et al. recently published a systematic review exploring possible mechanisms of effectiveness. These mechanisms centered on lessening the patient’s focus on their illness and making them feel more engaged. The proposed mechanisms include: (1) fostering feelings of normalcy; (2) improving behavioral activation (more energy, active, and willing to exercise, which led them to feel stronger, less tired, and more cheerful); (3) enhancement of
xxx
self-esteem; (4) companionship; (5) calming/comforting (helped individuals feel less anxious and depressed); and (6) distraction (from pain, stress, and medical difficulties) [14]. The authors also found that these 6 mechanisms were related to the patient’s contact, interaction, and bond with the therapy animal, and not to the appearance (breed, color, or ‘cuteness’) of the animal. From our experience, all 6 of these mechanisms were at play. In addition to the psychological benefits of animal-assisted interventions, the aim of starting the therapy dog program at our burn center was to enhance physical and occupational therapy rehabilitative efforts. Denzer-Weiler et al. described a case in which AAT was used during physical therapy sessions in an inpatient rehabilitation facility. In this case, a 34-year-old woman was able to meet her rehabilitation goals, including ambulation, stairs, and sitting tolerance, with the addition of the therapy dog to physical therapy sessions [7]. USAISR staff members anecdotally see an improvement in patients’ motivation and rehabilitation efforts, potentially leading to meeting and exceeding rehabilitation goals, with the therapy dog present. There has been a trend in both ICU and acute care delivery to embrace therapies that for years were considered to be unwarranted. The most evident being the importance of early ambulation, but other elements of care such as sleepwake cycle, delirium prevention and daily sedation holidays have been demonstrated to improve morbidity and mortality [15]. Even in patients with severe disease, positive interactive mobility and cognition can be achieved by working with AAT. While there have been no studies demonstrating an increased risk of infection when working with therapy dogs, there have is also not enough experience in the critical care environment to demonstrate that there is not an incremental risk of infection in this highly vulnerable population. This is likely why they has not been a push for AAT in critically ill ICU patients. There is evidence that the presence of a dog can lower anxiety levels in non-ICU patients [6]. Studies using therapy dogs and similar interventions have not yet been done to assess the physiologic effect on the adrenergic response. Infection control or increased risk of infection is a perceived drawback of implementing AAI. However, numerous studies have investigated infection outcomes and have reported no transmission of infection from animal (canine) to patient or no increase in infections during the study period [16]. These studies included a variety of patient populations, including oncology patients undergoing chemotherapy, pediatric patients, and critically ill patients. Additionally, canines do not serve as hosts or vehicles for multidrug resistant organisms commonly encountered in the hospital setting, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or Pseudomonas aeruginosa [16]. In fact, some evidence supports the notion that exposure to canines may be immunoprotective. Charnetski and Riggers reported that subjects who visited with a therapy dog for 18 min had significantly higher IgA levels after their therapy dog encounter, whereas this was not observed in subjects who visited with a stuffed dog or ‘control’ [17]. Higher IgA levels may be immunoprotective, and may provide protection from illness and upper respiratory tract infections [17]. To our
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
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knowledge, this is the first report of using animal-assisted interventions in a burn center. Therapy dogs were able to interact with staff and patients in all levels of care within the burn center (intensive care unit, ward, and outpatient), and patients and staff gave positive feedback on the therapy dog program. Our burn center was able to overcome potential barriers to implementing this program, including perceived infection-control risks, dislike or fear of dogs, and allergy concerns. This report has several limitations. First, we employed satisfaction surveys for both patients and staff, and it is therefore subject to the limitations of all survey-based studies. There was a low response/survey return rate; many of patients or staff members who interacted with the therapy dogs did not turn in surveys. As with all surveys, it is not unreasonable to expect that only patients and staff members who felt strongly (either positively or negatively) returned surveys, which could have skewed our results. Additionally, the survey did not include any questions or information on patient or staff biases toward dogs or specific breeds or sizes of dogs. Lastly, given that this was a performance improvement project to assess the feasibility and acceptability of this sort of program as it relates to perception of rehabilitation in burn patients, our data did not include any objective measures of rehabilitation time, effort, pain, or anxiety during this phase of the program. Objective outcome measures will need to be further studied in order to quantify the effects of this sort of program.
5.
Conclusion
One year after the implementation of the therapy dog program, we have demonstrated feasibility, acceptability and patient and staff satisfaction of this type of program at our burn center. Given these favorable indicators, expansion of the program may be warranted as well as assessment of objective outcome measures. Given the paramount importance of rehabilitation in the recovery of burn patients, further investigation into using animals as a therapeutic intervention should be performed.
Disclaimer The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Conflicts of interest No authors have any conflicts to disclose.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.burns.2019. 11.024. REFERENCES
[1] American Veterinary Medical Association. Animal-assisted interventions; Definitions. 2019 Available from: https://www. avma.org/KB/Policies/Pages/Animal-Assisted-InterventionsDefinitions.aspx. [Accessed 08 May 2019]. [2] Waite TC, Hamilton L, O’Brien W. A meta-analysis of animalassisted interventions targeting pain anxiety and distress in medical settings. Complement Ther Clin Pract 2018;33:49 55. [3] Munoz Lasa S, Ferriero G, Brigatti E, Valero R, Franchignoni F. Animal-assisted interventions in internal and rehabilitation medicine: a review of the recent literature. Panminerva Med 2011;53(2):129 36. [4] Braun C, Stangler T, Narveson J, Pettingell S. Animal-assisted therapy as a pain relief intervention for children. Complement Ther Clin Pract 2009;15:105 9. [5] Marcus DA, Bernstein CD, Constantin JM, Kunkel FA, Breuer P, Hanlon RB. Impact of animal-assisted therapy for outpatients with fibromyalgia. Pain Med 2012;14(1):43 51. [6] Barker SB, Dawson KS. The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatric Serv 1998;49(6):797 801. [7] Denzer-Weiler C, Hreha K. The use of animal-assisted therapy in combination with physical therapy in an inpatient rehabilitation facility: a case report. Complement Ther Clin Pract 2018;32:139 44. [8] Brisson SM, Dekker AH. Staff attitudes regarding the impact of a therapy dog program on military behavioral health patients. J Spec Oper Med 2017;17(4):49 51. [9] Halm MA. The healing power of the human-animal connection. Am J Crit Care 2008;17(4):373 6. [10] Rumayor CB, Thrasher AM. Reflections on recent research into animal-assisted interventions in the military and beyond. Curr Psychiatry Rep 2017;19:110. [11] United States Army Medical Command. Updated guidance on the use of animals in the healthcare setting (service animals, animal assisted therapies, and animal assisted activities). Unpublished internal document. 2014. [12] Department of the Army Brooke Army Medical Center. Use of animals in the healthcare setting. Unpublished internal document. 2012. [13] American Kennel Club, Canine Good Citizen (CGC). What is a canine good citizen? Available from: https://www.akc.org/ products-services/training-programs/canine-good-citizen/ what-is-canine-good-citizen/. [Accessed 30 May 2019]. [14] Shen RZZ, Xiong P, Chou UI, Hall BJ. “We need them as much as they need us”: A systematic review of the qualitative evidence for possible mechanisms of effectiveness of animal-assisted intervention (AAI). Complement Ther Med 2018;41:203 7. [15] Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825 73. [16] Snipelisky D, Burton MC. Canine-assisted therapy in the inpatient setting. South Med J 2014;107(4):265 73. [17] Charnetski CJ, Riggers S. Effects of petting a dog on immune system function. Psychol Rep 2004;95:1087 91.
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
burns xxx (2019) xxx
xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Impact of the implementation of a therapy dog program on burn center patients and staff Kaitlin A. Pruskowski a,b, * , Jennifer M. Gurney a,b,c , Leopoldo C. Cancio a a
US Army Institute of Surgical Research, Fort Sam Houston, TX, United States Uniformed Services University of the Health Sciences, Bethesda, MD, United States c Joint Trauma System, Fort Sam Houston, TX, United States b
article info
abstract
Article history:
Animal-assisted interventions have been implemented in both inpatient and outpatient
Available online xxx
settings and have demonstrated positive outcomes on patients and hospital staff. Animalassisted interventions have not been previously reported in any burn center. A therapy dog program was established at our burn center with the intent of improving duration and quality
Keywords:
of rehabilitation sessions and physical therapy. Satisfaction surveys were distributed to
Therapy dog
patients and staff. After one year, 14 patient surveys and 23 staff surveys were collected.
Rehabilitation
Implementation of this program was feasible and patients worked with the therapy dogs in
Integrative therapy
all environments of the burn center: outpatient, ward, and ICU. Most patients reported improved pain and anxiety after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Most reported an improved mood after seeing the therapy dogs and wanted that additional therapy dog visits. One year after the implementation of the therapy dog program, we have demonstrated feasibility, acceptability, and desirability of this type of program at our burn center. Given the paramount importance of rehabilitation in the recovery of burn patients, further investigation into therapy should be performed and longer term outcomes assessed. Published by Elsevier Ltd.
1.
Introduction
The benefits and healing power of the human animal relationship have long been recognized. Animal-assisted interventions, including animal-assisted activities (AAA) and animal-assisted therapy (AAT), have been implemented in both inpatient and outpatient settings. AAA, which includes visits with therapy animals, have been described as using animals to facilitate and empower a patient’s opportunities for motivation, education, or recreation to enhance their quality of life [1]. With AAA, specially trained volunteers
(or professionals) visit a variety of environments with a certified therapy animal. Activities are not ‘fixed’, and there are no specified therapeutic goals for the session [2]. AAT, on the other hand, are goal-directed interventions in which an animal is integrated into a patient’s treatment plan/process [1]. Interactions/activities that occur during AAT are purposeful with a therapeutic intent of helping patients to achieve treatment goals [2]. Both AAA and AAT and have demonstrated positive effects on patients’ moods, anxiety levels, pain scores, and rehabilitation efforts [3 7]. AAA/AAT also has a positive impact on nursing and hospital staff [5]. Given the burnout risk in highly
* Corresponding author at: 3698 Chambers Pass, ATTN: MRMC-SRT-C, JBSA, Fort Sam Houston, TX, 78234, United States. E-mail address: [email protected] (K.A. Pruskowski). https://doi.org/10.1016/j.burns.2019.11.024 0305-4179/Published by Elsevier Ltd.
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024
JBUR 5998 No. of Pages 5
2
burns xxx (2019) xxx
stressful inpatient settings, such as a burn center, AAA/AAT may decrease burnout by improving morale. Healthcare providers have long-recognized the positive impacts animals can have on both patients and staff. The first reported use of animal-assisted interventions was recorded in 1792, when the Quakers used farm animals as a therapy for psychiatric patients in a mental health institution [8]. In 1860, Florence Nightingale noted, “a small pet is often an excellent companion for the sick, for long chronic cases especially” [9]. In 1919, the United States military began incorporating dogs as therapeutic psychiatric interventions in military healthcare facilities [8]. More recently, the US Army used therapy dogs to improve occupational therapy and other rehabilitative efforts of soldiers returning home from the conflicts in the Middle East [10]. Despite the long history of using animals in therapy, use of AAA/AAT has not been previously reported in any burn center. Given the potential of animal-assisted interventions to benefit burn patients and staff, we developed an AAA/AAT program at our burn center. The purpose of this paper is to describe the implementation of such a program and to report patient and staff satisfaction with this program.
2.
Methods
The US Army Institute of Surgical Research (USAISR), the US Army Burn Center, is the sole burn center in the Department of Defense and is located at Fort Sam Houston, San Antonio, Texas. In addition to caring for all military burn casualties, the USAISR also serves as the regional burn center for 49 counties in south Texas, covering an area of 80,000 square miles. Civilian burn accidents include both domestic and occupational injuries. A therapy canine AAA/AAT program was established at the USAISR in November of 2017. Given that the military has precedent within the system for using dogs as therapeutic adjuncts, policy existed supporting the establishment of an AAA/AAT program [11,12]. The US Army Burn Center is located within Brooke Army Medical Center, a Joint Commissionaccredited hospital. Seeking approval to establish a pet therapy program was straightforward utilizing existing hospital and Department of Defense policies governing support animals. At the time the USAISR established the therapy dog program, the only other units in the hospital that had therapy dogs were the inpatient psychiatric units; no medical or surgical units had therapy dog programs. Support from the Burn Center director and the USAISR commander were garnered prior to moving forward with implementation of the therapy dog program. Additionally, buy-in from rehabilitation staff, nursing, and Brooke Army Medical Center’s volunteer services was achieved. The initial intent of the therapy dog program was to improve the duration and quality of rehabilitation sessions. The most feasible location for the initial rollout of this program was in the rehabilitation gym because of space and because of its geographic location outside of the inpatient units. Therapy dog teams made weekly visits, and initially only worked with outpatients during rehabilitation sessions. Over time, as more staff members became comfortable with having the therapy dogs in the burn center, rehabilitation therapists requested
xxx
that therapy dogs work with selected inpatients (as per the therapist’s discretion). After 5 months and secondary to increased demand, the program expanded and therapy dogs were allowed to visit inpatients and staff on the ward and in the ICU (AAA), or in the in-patient therapy gym (AAT). Also, more therapy dog teams were added to meet the increased demand. One of the concerns regarded a potential increased risk of infection. There are no data to support this concern; but with input from the burn center’s infection control nurse, we decided that therapy dogs would not be allowed in patient rooms. However, if a patient was able to leave their room they could visit or work with the therapy dogs. The ability of a patient to leave their hospital room indicated that patients were medically stable, and that there was no concern regarding wound exposure outside the room. Patient and staff participation and interaction with the therapy dogs was voluntary and usually requested. As part of a performance improvement project approved our institution’s Research and Regulatory Compliance division (H-17-028nr), we distributed satisfactions surveys to both patients and staff to evaluate the respondents’ impression and satisfaction with the therapy dog experience. Secondary outcomes were to assess the impact of therapy dog visits on pain, anxiety, and mood. Patient and staff survey questions can be found in Appendices B and C.
2.1.
Animals and handlers
Therapy dogs and handlers were screened by burn center staff prior to their first therapy visit. Initially, 3 therapy dogs visited our burn center, on a rotating schedule: one Great Pyrenees, one Shetland sheepdog, and one collie. Due to handler and canine health reasons, the Great Pyrenees therapy dog team ‘retired’ after a period of several months. At the time of manuscript preparation, 6 dogs were visiting: 2 golden retrievers, one miniature poodle, one labradoodle, 2 Shetland sheepdogs, and one collie. Per hospital policy, all therapy dogs and their handlers were certified with a credible and insured organization, and all attained the American Kennel Club Canine Good Citizen certificate [13]. Therapy organizations represented in our program include: Therapy Animals of San Antonio, Pet Partners (formerly known as the Delta Society), and Alliance of Therapy Dogs. Because of organizational liability insurance purposes, most therapy dogs and handlers were limited to working no more than 2h per day. All therapy dog teams were volunteers; handlers (or their associated organizations) did not receive any monetary compensation for their participation in our program. All dogs were healthy and up-to-date on vaccinations and other preventatives (heartworm prevention, flea prevention). In accordance with hospital policy, all dogs were bathed and brushed within the 24h prior to their visit to the burn center. Information provided to volunteers on our therapy dog program can be found in Appendix A.
2.2.
Rehabilitation activities
Rehabilitation activities incorporating the therapy dogs occurred as part of a patient’s regular physical/occupational
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therapy session. Activities were selected by the physical/ occupational therapist and/or therapy assistant as per the patient’s needs. Common occupational therapy activities included gait/stamina activities (walking with the dog), upper extremity activities (brushing, petting, feeding, throwing a toy to the dog, or ‘dressing’ the dog with a bandana), and by providing comfort and emotional support during stretching of burned and/or contracted wounds by being present and close to the patient. During breaks in stretching, patients were able to pet/stroke the dog for emotional support. Therapy dog handlers were instructed to bring a variety of sizes of treats and toys for the dog so that patients could participate (and be challenged) regardless of their injuries and physical limitations. As different dogs have different preferences and/or dietary restrictions, the therapy dog handlers were instructed to provide treats and toys for their dog. Most activities occurred in our burn center’s inpatient or outpatient rehabilitation gyms. However, if a patient working in the gym was afraid of or allergic to dogs, this was respected. The patient not working with the dog was given extra space (i.e. having the patient working with the therapy dog be on the opposite side of the gym from the patient who was afraid or allergic) an alternative space was used for the therapy dog session.
2.3.
Patient selection
Inpatients who were medically stable and able to leave their rooms were asked if they would like to work with a therapy dog prior to the dog’s scheduled visit. If so, rehabilitation staff coordinated a rehabilitation time to coincide with the therapy dog team’s 2-h time slot. Visits with a therapy dog were sometimes used a motivation for patients who frequently declined to work with rehabilitation staff or who were thought not to perform rehabilitation to their fullest potential. Therapy dogs were also used as morale boosters for patients who had been admitted to the burn center for several weeks or months, or those who were having difficulty accepting their injuries and new limitations/realities. The patients needing motivation and/or morale boosts were given priority to work with the therapy dogs. Outpatients who were expected to benefit from the functionality and real-life applications of rehabilitation that the therapy dogs could provide were given priority to work with the dogs. Additionally, patients who were undergoing a prolonged rehabilitation course often considered working with the therapy dogs to be a break from the monotony of their daily rehabilitation sessions.
3.
Results
After one year, 14 patient surveys and 23 staff surveys were completed and returned. A total 48 days included 84 AAT and 249 AAA encounters. Each patient who submitted a survey worked with the therapy dogs during multiple encounters. However, surveys were collected per patient, not per encounter. Table 1 shows patient survey responses. Patients workedwith the therapy dogs in all environments of the burn center: outpatient, ward, and ICU. All patients were satisfied or very
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Table 1 – Patient satisfaction. N=14 Satisfied with therapy dog visit Strongly agree Agree Pain is improved after therapy dog visit Strongly agree Agree Neutral Anxiety is improved after therapy dog visit Strongly agree Agree Neutral N/A Want another visit with therapy dog Strongly agree Agree
10 (71.4%) 4 (28.6%) 5 (35.7%) 7 (50%) 2 (14.3%) 6 (42.9%) 6 (42.9%) 1 (7.1%) 1 (7.1%) 9 (64.3%) 5 (35.7)
satisfied with the dogs’ participation during the session. Twelve (85.7%) patients agreed or strongly agreed that their pain was improved and 12 (85.7%) patients reported their anxiety was improved after working with the therapy dogs. All patients reported that they would like more sessions with the therapy dogs. No negative comments were reported. Additional patient comments include: ‘The therapy dog was a fresh breath of air. I loved the idea. Can't wait until the next visit. I had surgery that morning. Knowing the dog was there helped me and motivated me to get out of bed.’ ‘I strongly agree with the therapy dogs. I think they should use them more. It made me feel 100% better because I was missing my dog so much.’ ‘I've been very depressed since the beginning of my situation, and just the interaction with the therapy dog made me not even think or feel any of my pain, inner or physical pain.’ ‘Having the therapy dog with me brightens my day and gives me a little more motivation.’
Table 2 – Staff satisfaction. N=23 Satisfied with therapy dog participation Strongly agree Agree Enjoyed having dog present Strongly agree Agree Improved mood Strongly agree Agree Neutral Want another visit with therapy dog Strongly agree Agree Neutral
17 (73.9%) 6 (26.1%) 18 (78.3%) 5 (21.7%) 17 (73.9%) 5 (21.4%) 1 (4.3%) 16 (69.6%) 6 (26.1%) 1 (4.3%)
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Table 2shows staff responses. All staff members were satisfied or very satisfied with their therapy dog visit and all enjoyed having the therapy dogs present. Twenty-two (95.7%) staff members reported an improved mood after seeing the therapy dogs. Twenty-two members (95.7%) reported that they would like to see or work with the therapy dogs again. Staff members commented that the therapy dogs were great stress relievers and the visits were very therapeutic and calming. No negative comments were reported. Additional comments from staff members include: ‘Overall, the experience has been good and positive. Different dogs and handlers bring different activities that we can do with the patients. Some dogs are more interactive than others. Some handlers interact more with other people and not just the patient and sometimes this can be distracting.’ ‘The presence of the dog helped with patient motivation, in my opinion.’ ‘All my patients look forward to the pet therapy sessions. They do more without knowing it and their emotions for rehab appear to improve. Patients also report less pain, less discomfort for exercises, and try more activities.’ ‘The patients that participate seem to really enjoy the visits. I believe that pet therapy has a positive effect on patients & staff.’ ‘Amazing program! Instantly improves the moods and lower the stress levels for both the patients and staff. Hope to see it reach more patients & longer visits!’ ‘The dogs really make my day!’
4.
Discussion
Our experience demonstrates 3 components that are necessary for the implementation a new program: feasibility from a logistical, administrative and system standpoint; acceptance by staff members and the leadership of the organization; and desirability from a patient standpoint. The survey responses support these conclusions. Additionally, patients reported decreased pain and anxiety after interventions, and burn center staff reported improved mood after interactions with therapy dogs. There are several theories as to how animal-assisted interventions exert their positive effects. These include the theory that human animal bonds improve physical and psychological health, increase life-satisfaction, promote calmness, and improve coping abilities [2,14]. Proposed mechanisms of animal-assisted interventions also include distraction-based alteration of the patient’s perception of pain. Shen et al. recently published a systematic review exploring possible mechanisms of effectiveness. These mechanisms centered on lessening the patient’s focus on their illness and making them feel more engaged. The proposed mechanisms include: (1) fostering feelings of normalcy; (2) improving behavioral activation (more energy, active, and willing to exercise, which led them to feel stronger, less tired, and more cheerful); (3) enhancement of
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self-esteem; (4) companionship; (5) calming/comforting (helped individuals feel less anxious and depressed); and (6) distraction (from pain, stress, and medical difficulties) [14]. The authors also found that these 6 mechanisms were related to the patient’s contact, interaction, and bond with the therapy animal, and not to the appearance (breed, color, or ‘cuteness’) of the animal. From our experience, all 6 of these mechanisms were at play. In addition to the psychological benefits of animal-assisted interventions, the aim of starting the therapy dog program at our burn center was to enhance physical and occupational therapy rehabilitative efforts. Denzer-Weiler et al. described a case in which AAT was used during physical therapy sessions in an inpatient rehabilitation facility. In this case, a 34-year-old woman was able to meet her rehabilitation goals, including ambulation, stairs, and sitting tolerance, with the addition of the therapy dog to physical therapy sessions [7]. USAISR staff members anecdotally see an improvement in patients’ motivation and rehabilitation efforts, potentially leading to meeting and exceeding rehabilitation goals, with the therapy dog present. There has been a trend in both ICU and acute care delivery to embrace therapies that for years were considered to be unwarranted. The most evident being the importance of early ambulation, but other elements of care such as sleepwake cycle, delirium prevention and daily sedation holidays have been demonstrated to improve morbidity and mortality [15]. Even in patients with severe disease, positive interactive mobility and cognition can be achieved by working with AAT. While there have been no studies demonstrating an increased risk of infection when working with therapy dogs, there have is also not enough experience in the critical care environment to demonstrate that there is not an incremental risk of infection in this highly vulnerable population. This is likely why they has not been a push for AAT in critically ill ICU patients. There is evidence that the presence of a dog can lower anxiety levels in non-ICU patients [6]. Studies using therapy dogs and similar interventions have not yet been done to assess the physiologic effect on the adrenergic response. Infection control or increased risk of infection is a perceived drawback of implementing AAI. However, numerous studies have investigated infection outcomes and have reported no transmission of infection from animal (canine) to patient or no increase in infections during the study period [16]. These studies included a variety of patient populations, including oncology patients undergoing chemotherapy, pediatric patients, and critically ill patients. Additionally, canines do not serve as hosts or vehicles for multidrug resistant organisms commonly encountered in the hospital setting, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or Pseudomonas aeruginosa [16]. In fact, some evidence supports the notion that exposure to canines may be immunoprotective. Charnetski and Riggers reported that subjects who visited with a therapy dog for 18 min had significantly higher IgA levels after their therapy dog encounter, whereas this was not observed in subjects who visited with a stuffed dog or ‘control’ [17]. Higher IgA levels may be immunoprotective, and may provide protection from illness and upper respiratory tract infections [17]. To our
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knowledge, this is the first report of using animal-assisted interventions in a burn center. Therapy dogs were able to interact with staff and patients in all levels of care within the burn center (intensive care unit, ward, and outpatient), and patients and staff gave positive feedback on the therapy dog program. Our burn center was able to overcome potential barriers to implementing this program, including perceived infection-control risks, dislike or fear of dogs, and allergy concerns. This report has several limitations. First, we employed satisfaction surveys for both patients and staff, and it is therefore subject to the limitations of all survey-based studies. There was a low response/survey return rate; many of patients or staff members who interacted with the therapy dogs did not turn in surveys. As with all surveys, it is not unreasonable to expect that only patients and staff members who felt strongly (either positively or negatively) returned surveys, which could have skewed our results. Additionally, the survey did not include any questions or information on patient or staff biases toward dogs or specific breeds or sizes of dogs. Lastly, given that this was a performance improvement project to assess the feasibility and acceptability of this sort of program as it relates to perception of rehabilitation in burn patients, our data did not include any objective measures of rehabilitation time, effort, pain, or anxiety during this phase of the program. Objective outcome measures will need to be further studied in order to quantify the effects of this sort of program.
5.
Conclusion
One year after the implementation of the therapy dog program, we have demonstrated feasibility, acceptability and patient and staff satisfaction of this type of program at our burn center. Given these favorable indicators, expansion of the program may be warranted as well as assessment of objective outcome measures. Given the paramount importance of rehabilitation in the recovery of burn patients, further investigation into using animals as a therapeutic intervention should be performed.
Disclaimer The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.
Conflicts of interest No authors have any conflicts to disclose.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.burns.2019. 11.024. REFERENCES
[1] American Veterinary Medical Association. Animal-assisted interventions; Definitions. 2019 Available from: https://www. avma.org/KB/Policies/Pages/Animal-Assisted-InterventionsDefinitions.aspx. [Accessed 08 May 2019]. [2] Waite TC, Hamilton L, O’Brien W. A meta-analysis of animalassisted interventions targeting pain anxiety and distress in medical settings. Complement Ther Clin Pract 2018;33:49 55. [3] Munoz Lasa S, Ferriero G, Brigatti E, Valero R, Franchignoni F. Animal-assisted interventions in internal and rehabilitation medicine: a review of the recent literature. Panminerva Med 2011;53(2):129 36. [4] Braun C, Stangler T, Narveson J, Pettingell S. Animal-assisted therapy as a pain relief intervention for children. Complement Ther Clin Pract 2009;15:105 9. [5] Marcus DA, Bernstein CD, Constantin JM, Kunkel FA, Breuer P, Hanlon RB. Impact of animal-assisted therapy for outpatients with fibromyalgia. Pain Med 2012;14(1):43 51. [6] Barker SB, Dawson KS. The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatric Serv 1998;49(6):797 801. [7] Denzer-Weiler C, Hreha K. The use of animal-assisted therapy in combination with physical therapy in an inpatient rehabilitation facility: a case report. Complement Ther Clin Pract 2018;32:139 44. [8] Brisson SM, Dekker AH. Staff attitudes regarding the impact of a therapy dog program on military behavioral health patients. J Spec Oper Med 2017;17(4):49 51. [9] Halm MA. The healing power of the human-animal connection. Am J Crit Care 2008;17(4):373 6. [10] Rumayor CB, Thrasher AM. Reflections on recent research into animal-assisted interventions in the military and beyond. Curr Psychiatry Rep 2017;19:110. [11] United States Army Medical Command. Updated guidance on the use of animals in the healthcare setting (service animals, animal assisted therapies, and animal assisted activities). Unpublished internal document. 2014. [12] Department of the Army Brooke Army Medical Center. Use of animals in the healthcare setting. Unpublished internal document. 2012. [13] American Kennel Club, Canine Good Citizen (CGC). What is a canine good citizen? Available from: https://www.akc.org/ products-services/training-programs/canine-good-citizen/ what-is-canine-good-citizen/. [Accessed 30 May 2019]. [14] Shen RZZ, Xiong P, Chou UI, Hall BJ. “We need them as much as they need us”: A systematic review of the qualitative evidence for possible mechanisms of effectiveness of animal-assisted intervention (AAI). Complement Ther Med 2018;41:203 7. [15] Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825 73. [16] Snipelisky D, Burton MC. Canine-assisted therapy in the inpatient setting. South Med J 2014;107(4):265 73. [17] Charnetski CJ, Riggers S. Effects of petting a dog on immune system function. Psychol Rep 2004;95:1087 91.
Please cite this article in press as: K.A. Pruskowski, et al., Impact of the implementation of a therapy dog program on burn center patients and staff, Burns (2019), https://doi.org/10.1016/j.burns.2019.11.024