Animal-assisted intervention in the ICU: a tool for humanization
© The Author(s). 2018
Received: 25 November 2017
Accepted: 9 January 2018
Published: 12 February 2018
The combination of an aging population and advances in critical care medicine is resulting in a growing number of survivors of critical illness . Survivors’ descriptions of their stay in an intensive care unit (ICU) are frequently filled with traumatic events, and include experiences of confusion, anxiety, sleeplessness, pain, and loneliness [2, 3]. Sedative and anxiolytic medications administered to manage patient symptoms are associated with delirium and worse physical and mental health outcomes . Therefore, there is growing interest in the use of non-pharmacologic interventions and in creating a more humanized environment in the ICU for patients and their families . Such efforts have included a focus on understanding the critically ill patient as an individual and providing comprehensive medical, psychological, and rehabilitation care [6–8]. This publication aims to: 1) suggest a conceptual model for the use of non-pharmacologic interventions to reduce suffering and promote recovery in a more humanized ICU environment; 2) describe animal-assisted intervention (AAI) as an exemplar of a non-pharmacologic intervention and provide a conceptual model for the utility of this intervention; and 3) discuss the basic principles for introducing a non-pharmacologic intervention program in the ICU.
Patient suffering and the humanized ICU: where do non-pharmacological interventions fit?
Interventions in one circle have the potential to influence outcomes in other domains. Equally important is acknowledging that the patients’ experiences at each level are real even if they are difficult to observe and measure. Increased attention to both patient suffering and behavior domains ensures comprehensive care and potentially better long-term outcomes.
AAI: an exemplar of a non-pharmacologic intervention to reduce suffering and encourage recovery behavior
Implementing an AAI program for the ICU
Building new, non-pharmacologic interventions, with the intention to reduce suffering and optimize health behavior change, takes a concerted, multidisciplinary effort. Although we use the exemplar of AAI, the following program building process may apply to other non-pharmacological interventions.
Examples of stakeholders and roles for an AAI program
Role and responsibilities
1. Develops policy and procedures with the healthcare facility stakeholders
2. Provides training for facilitators of AAI interventions and ensures that protocol is adopted/followed
3. Coordinates and/or oversees visits
4. Oversees program evaluation
1. Ensures patient/family appropriateness for visit. Recommended questions when evaluating patient for AAI:
a. Is the patient interested?
b. Is the patient able to benefit (e.g., assess cognitive status)?
c. Is the patient on infection-related contact precautions?
2. Places consult request for AAI
3. Coordinates timing of AAI to fit patient schedule and ICU workflow
1. Ensures patient privacy (HIPAA)
2. Provides guidance about prevention/management of patient injury; recommendations include:
a. Using certified therapy animal teams
b. Limiting length/number of patient visits per animal visit
c. Ensuring liability insurance in place
3. Provides guidance about prevention/management of animal injury or death
1. Protects patients from zoonotic infection;  recommendations include:
a. Mandating annual veterinary examination, fecal test for infection and parasites, up-to-date vaccinations
b. Bathing/grooming the animal before and after each hospital visit
c. Prohibiting animals with any illness within 24 h of visit
d. Prohibiting animals with an open wound
2. Protecting from fomite infection; recommendations include:
a. Washing hands for patients, staff members and visitors before and after touching animal
b. Cleaning animal toys after use
3. Excluding or using special precautions for specific patient groups, including those:
a. Known to be colonized or infected with multi-drug resistance bacteria (e.g., methicillin-resistant Staphylococcus aureus), Clostridium difficile, or tuberculosis
i. Special precaution: animal only visits one patient or visits the infected/colonized patient last (with approval from infection control)
b. Who have open wounds or a wound vacuum
i. Special precaution: cover wound; avoid animal having contact with wound
c. Who are immunocompromised
As critical care medicine is increasingly successful in preventing death, the field is more focused on optimizing patients’ survivorship experience. Through creating humanized ICU environments and implementing non-pharmacologic interventions, patients no longer must wait for hospital discharge before they begin to live again. Non-pharmacological intervention programs, such as AAI, may reduce suffering and help patients take an active role in their recovery.
Mr. Dex Mantheiy, Senior Clinical Program Coordinator of the Johns Hopkins Critical Care Physical Medicine and Rehabilitation Program, helps to coordinate animal-assisted intervention in the medical intensive care unit at Johns Hopkins Hospital. He has helped to build the program structure outlined in the editorial.
Availability of data and materials
MH has expertise in the psychological care of critically ill patients and was the primary writer of this editorial. JJ has expertise in animal-assisted intervention, is the lead developer of the animal-assisted intervention program at Johns Hopkins Hospital, and contributed knowledge about animal-assisted intervention to the writing of this paper. SW is an expert in psychological care and promotion of self-management in patients surviving trauma and illness. He provided knowledge and guidance about the model of non-pharmacological care. LC is an expert in non-pharmacological management of anxiety in critically ill patients and contributed knowledge about humanization of the ICU. DN is the senior author on this editorial. He is an intensivist and expert in early rehabilitation interventions for critically ill patients. He contributed knowledge about the feasibility of non-pharmacologic strategies for managing suffering in the intensive care environment. All authors read and approved the final manuscript.
MH is a clinical psychologist with post-doctoral fellowship training in rehabilitation psychology.
Ethics approval and consent to participate
Consent for publication
All adult patients had decisional capacity and provided written consent to have their images used for educational purposes outside of the institution.
The authors declare that they have no competing interests.
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