SCCMPod-560 CCE: Therapy Dogs Ease ICU Anxiety

Dr. Enfield: Hello, and welcome to the Society of Critical Care Medicine's podcast. I'm your host, Kyle Enfield. Today, I'm speaking with Dr. Sumeet Rai, PhD, FCICM, about the article, Positivity Care, Canine-Assisted Intervention for Anxiety in ICU Patients and Family Members, a Single-Centered, Single-Armed Study, published in the May 2025 issue of Critical Care Explorations. To access the full article, ccejournal.org, Dr. Rai is a Senior Intensivist at Canberra Hospital, Canberra Health Services, Canberra ACT Australia. Welcome, and before we get started, is there anything we should disclose to the listener?

Dr. Rai: Hi, Kyle. No, thanks. I don't have any conflict of interest.

Dr. Enfield: Summit, I enjoyed reading this article. It's always great to get an article in Critical Care Explorations or any of our journals that is a little bit off the beaten track, but also really important because we know that patient anxiety and family member anxiety in the ICU is a real issue and really affects the outcomes for the patients. Tell me, what got you and your team interested in doing this project at first?

Dr. Rai: Kyle, to be honest, I mean, you know this as well, and the listeners do, I'm sure, that the ICU is a place of quite intense medical interventions, and fortunately, it's also a place where there's a lot of fear and uncertainty, especially among the patients and the family members as to what their outcomes are going to be. We've had anecdotal experiences with animal therapy in the units, especially long-stay patients, which happens in a lot of intensive care units, and in patients at the end-of-life care. But we thought, you know, if an animal's unconditional companionship could kind of bring this calm into the chaos of ICU, and if a simple visit from a kind of a friendly and trained therapy dog could ease that hidden anxiety that grips patients and families in ICU.

So that's kind of how this started with anecdotal experience, and then we wanted to see if there is a bit more science behind this, and if it actually does significantly affect people, family members, and patients.

Dr. Enfield: So when you all were getting started for this, were there any special considerations within your health system? Most health systems allow for therapy animals, but was there any special considerations considering this was an ICU and concerns that your institutional review board came up with?

Dr. Rai: You're absolutely right. I think we're very lucky as well that our hospital, Canberra Hospital, allows therapy animals in the rest of the hospital, but it had never been done in the intensive care unit. So there were, and I get asked this a lot from other intensive care units and people who've read this article to say, hey, well, what are the challenges?

Well, essentially, we looked at the hospital animal therapy guidelines. We then obviously had to revise those guidelines to include therapy dogs being brought into the intensive care unit. I would say it took over a year to get through all the approvals from policy point of view for the hospital, from an infection control point of view, who we took on board, and we had a discussion on how best to implement this, especially in the scenario of ICU.

And once I think we got through those beats of discussions and consultations, it was actually relatively easier getting through ethics because we had the evidence that we'd gone through those consultations and discussions. I don't think from an ethics point of view, it wasn't that tricky.

Dr. Enfield: That's awesome. And I'm glad your hospital was open to thinking about this in a broader way and changing those policies. You know, when I looked through your article, one of the things that I think a lot of readers will ask themselves about is, this is in some ways a sort of a before and after study.

Can you talk a little bit about the assessments for anxiety and how those were done for the patients and for the family members?

Dr. Rai: Sure. The gold standard assessment for anxiety or depression in ICU is hard to kind of have put on paper or to implement it because there is no gold standard. People often don't assess anxiety and depression when patients are in the intensive care unit.

The only tool that is validated relatively and used commonly in the hospital setting is the hospital anxiety depression scale, which we thought was a little tricky and cumbersome to implement in ICU when patients were ventilated and more than half of our patients were ventilated. So we use a visual analog scale, which we thought was much easier to implement in ventilated ICU patients. It was a zero to 10 scale, which was devised for actually another study, which has been submitted for publication.

But the results of this study preceded the actual development of that tool. So we use that visual analog scale for anxiety and you're right, this was like a before and after study or within study subject design. So what that means is we looked at the anxiety in the patients and the family members of the carers before the therapy dogs and then after the therapy dogs.

In a sense, you could say that each patient or their family member served as their own control, although it was not blinded. So there is obviously, you can get into the limitations later on the study. But using the visual analog scale, we found it quite easy to create that baseline anxiety and then anxiety again after the intervention.

Dr. Enfield: That's an awesome study designed to do this kind of work. I wonder before we get too far along into this, because I was questioning this as I read it is, did you notice any changes in the nurses and the teams taking care of these patients that were having the therapy animals visit?

Dr. Rai: It's interesting you asked this. Whenever I presented this, I get told that this is potentially the only intervention is what anecdotal response I get from the audience, which affects not only patients, family members, but staff. Our staff love it.

And I know other hospitals who have started doing that have the same response. In fact, there's an overwhelming positive response from staff. So yes, they loved it.

I think it has been tricky though, from a study point of view to make sure when you do this intervention that we've had to tell the staff not to show that response to the patient, not be able to bias them. I think we have managed to do that reasonably well in that study design where staff were specifically mentioned and trained not to respond to that in front of the patient. But it is positive for staff.

And I can tell you from the number of years that we've been doing this therapy dog design that our staff at least love the therapy animals and therapy dogs in the ICU.

Dr. Enfield: I was wondering also a little bit, what do the therapy animals do specifically with the patients when they're there? Can you kind of describe what those interactions are like?

Dr. Rai: Sure. It's written in my protocol and the paper as well. So what the therapy animals, these were trained and accredited therapy dogs.

So they weren't my dog that I just brought it in, which I have two lovely dogs, by the way, but they were allowed to interact with patients and family members. We had some strict infection control precautions that the handlers had to abide by. But in that context, therapy animals were allowed to be bedded by the patients and the family members.

They could sit on the patient's bed on a sterile sheet, which was then taken away later. The therapy animals themselves were trained and fairly docile. They wouldn't do anything to the patient because they'd been accredited to make sure their temperament was okay.

It was more, I guess, from a patient and family member's point of view, that companionship that they brought rather than any other physical intervention. Of course, the petting that they were allowed to do. And there were some do's and don'ts.

Patients weren't allowed to kiss the dogs or we made sure that they didn't shake their paws because of potential dirt on their paws. And once before the therapy animal visit and after, the patients had to still wash their hands with alcohol hand rubs. So there were some infection control precautions, but as I said, there was a reasonable flexibility built in.

The dogs could sit next to the patients and the family members. They could sit on the beds with some infection control precautions. They could be petted.

They could be touched. And they generally gave some moments of calm and peace, I guess, among all that chaos.

Dr. Enfield: I mean, honestly, it sounds lovely to be in your ICU with a dog sitting on your bed and able to pet it there. I think that if I was in an ICU, that's what I would want, though. Currently, I think my dogs are wanting to be fed.

So they would not be the best companion dogs for this study. I realize you all had some challenges because the study occurred during the pandemic. I wondered if you could just briefly walk us through those.

And then we can sort of talk a little bit about your findings and some of the limitations.

Dr. Rai: Yes, you're right. I mean, we started in 2019. We wanted to get over 100 patients and family members, although the statistical power calculation we'd done suggested that we could show a reasonable effect, approximately 60 patients or family members.

I think we'd reached around 70, 71 patients or 71 family members when COVID hit. Fortunately, it was slightly delayed in Australia. But by March, we had visitor restrictions.

March of 2020, we couldn't get therapy animals or volunteers to come into the hospital because of the visitor restrictions. And we had to suspend the research program and the therapy dog program. And we always thought that we'd come back to it in a few months.

Unfortunately, that few months dragged on. And with the visitor restrictions going on for over two years, we eventually ended up abandoning the program. We had crossed our statistical sample size.

It would have been nice to have a few more patients or family members just to look at some of the other secondary objectives that we had. So yeah, it was a bit tricky. And unfortunately, I think a lot of our volunteers left, which from a program point of view, we've never really had that extent of the volunteers.

Some of them just didn't want to come back to hospitals after the COVID. So we're still trying to build up that therapy program again, long after COVID actually.

Dr. Enfield: That's unfortunate to hear, particularly after we talk about some of your results. I wondered if you might just tell us some of the high level results and maybe also if there were any results that you found particularly intriguing as you guys went through the analysis.

Dr. Rai: I might briefly just talk about that the intervention was actually the therapy dog sessions, which were around 15 to 20 minutes, but a minimum of 15 minutes. And this was based on previous literature from a non-ICU setting, of course, which suggests that even brief interactions of approximately 10 minutes can show a positive outcome. What we were looking at was a reduction in anxiety and actually also a pain for the patients.

And there were some other secondary outcomes we were looking at, but more importantly, we want to make sure there are no adverse events. So that meant this is done as a bigger study or it's rolled out as an actual therapeutic intervention that we could highlight any of those findings. What did we find?

Well, to be honest, we found that there were significant reductions in anxiety scores after the intervention for both patients and the family members. Over 60% of the patients and over 90% of the family members actually demonstrated a significantly meaningful reduction of more than 2.8 out of 10 reduction in their visual analog scales for anxiety. And with the patients, the pain scores also decreased significantly.

From a primary outcome point of view, we thought we had demonstrated what we had anticipated. We didn't find any adverse safety events due to the intervention. So there were no scratches or bites or any kind of other leaks on wounds or anything like that.

Although we were very careful that anyone with open wounds didn't get a therapy dog visit anyway or immunosuppressed patients. And we didn't find any new infections in patients. Having said that, there were limitations to that we'll talk about later.

Essentially summarizing, there was a significant improvement in anxiety and pain for patients and also anxiety for the carers.

Dr. Enfield: Yeah. Well, this is bordering on a limitation, but I wonder if how you all felt that you could disentangle the anxiety of the patient and the family from each other. Because I often wonder how intertwined those reactions are when the family's anxious, the patient's anxious and vice versa.

Dr. Rai: You're absolutely right. I agree with that. There's a significant interplay of emotions between patients and family members.

To be fair, we had thought about that. And I think in all patients and family members, even though these were done separately, because the family members had the therapy dogs visiting in the visitor's room in the ICU, whereas the patient obviously had that at the bedside or if the patient was in the ICU outdoor space, then it was in the ICU outdoor space. But they were distinctly separate, those interactions.

And then the assessments were separate. Whether, and you're right, this is potentially limitations, whether seeing the patient less anxious that day also clouded the interpretation of the family member. But having said that, we did do a pre and post for the family members as well and the patients.

As I mentioned earlier, they were their own controls and they were independently got the therapy and they independently got the assessments. We tried to separate them at those interventions and assessments.

Dr. Enfield: And I guess in some ways, that relationship may not be that important if the patient and family's anxiety is down, they don't reach the benefits, whether it's direct from feelings of the patient or direct from feelings of the family, it's still a positive outcome. That's right. Yes.

So in your own thinking, what were your major concerns and limitations about this? And what should people be aware of as they think about how this could work in their ICU environment?

Dr. Rai: As the main things that we were worried about, of course, is transmission of infection, not only from the animal to patient or from the patient to the animal, but also from using the animal as a vector to transmit those infections between patients. So those were some of our main concerns. And when we looked at that literature, and unfortunately it's mixed because the literature says that surveys show that animal therapy happens in intensive care units, but there's no kind of safety or adverse event data for this.

So the preamble to the whole research was that discussion with our infection control unit and making sure that the policy had strict hand hygiene and other precautions. So for example, we didn't visit patients who were immunosuppressed, who had burns, who had open surgical wounds, or neutropenic patients, because these were patients who were high risk of developing either a wound infection or a subsequent infection. We didn't see patients with MRSA, VRE or clostridium difficile or other contact precautions for the same reason, because we didn't want this transmitted through the dogs to another patient.

And while we check weekly in ICU for these bugs routinely, it is possible that someone would have caught it in the middle, but highly unlikely based on at least our population and the way we do surveillance on them. So those are some of the infection control precautions that we were really worried about. The other thing, of course, was would there be any adverse event, like would there be dislodgement of devices with the therapy dogs there in that environment, or there would be any kinds of bites or scratches.

I think we were reasonably reassured with the accreditation of the therapy dogs and that had happened with an accredited therapy animal organisation. That was not likely to happen, because the dogs were chosen in that way and accredited in that way as therapy animals. That is something I would definitely highlight, those infection control precautions.

So while it's easy to say that therapy dogs could be introduced, I think there does need to be that built-in safety in that programme to protect not only the patients, but also the dogs to make sure that infection is not transmitted to the other person or to the other animal.

Dr. Enfield: One of the things both of us have sort of danced around is the fact that the patients and their family members function as their own control. This is not a randomised study. But as I was reading your article, I was at a loss for how you would really do a randomised study in this setting.

Have you all thought about that?

Dr. Rai: And what would be your approach to that? I have thought about it before and after. And it's an interesting question, because I think the only way to do this would be to do a cluster randomised control trial.

So you assess the parts of the unit or the unit. I think it'll have to be a different unit where you'd cluster them to a control and then bring on the intervention in a few weeks. So you assess a baseline kind of anxiety in the population and then see.

You're right. I mean, in the ideal world, it should be a randomised control trial, but it is going to be tricky. And I find most of these interventions that we are doing for psychological benefit of patients, or even for long-term follow-up when you're doing interventions, they're a little tricky to do with controls.

Because I, and especially if I know this intervention now, we've seen at least feasibility that it potentially works. It's going to be hard to randomise people to a control arm by giving them that evidence to say, well, you may want dogs, but we're not going to give you dogs. You're going to be randomised to the control.

Yeah.

Dr. Enfield: I can see the benefit of a cluster randomise if you had a large number of ICUs willing to do this and doing a baseline sort of anxiety incidents and then following that with the intervention. But I can also see that being a challenge because yeah, it would be hard to go in and say, we'd like to bring a dog into your room. Would you be okay with that?

Well, now we're going to randomise you to just having some human come in here and put a stuffed animal here. So I can see that being challenging.

Dr. Rai: Yes, you're right. And I think the same thing from a staff point of view, I've been told this a number of times, you should do this with staff. I can't potentially, and I've given this a lot of thought.

I don't think I can randomise staff to therapy animals or not because they're so positively welcomed in the unit. And there's such a positive reaction from staff that it will be near impossible to randomise staff to control and non-control to look at their wellbeing after a therapy animal visit or just with control. Yeah, I'm happy if any of the readers want to guide this ongoing research programme, but happy to take any comments really.

I'm at a loss on how to randomise them.

Dr. Enfield: As we wrap up, one of the things that has also come to mind as I listened to you and also thought about this, we know that both patient and staff wellbeing are an important part of something we should be monitoring in our ICUs and from our patients yet, it still seems to not get a lot of traction within institutions outside of a few subsets. How do we change the culture to recognise this as an important part of the critical care we provide?

Dr. Rai: Okay. I think there's been a reasonable research which is emerging now to show there is a significant burnout and psychological issues, even in staff working in critical care environment due to a number of reasons, of course. And that's a difficult question to answer.

I think at least in our setup, what I can say is that some of those work that we're doing with burnout is doing some more resilience training. We have therapy animals, we have brought in some outdoor spaces to see if this will help in the ICU, to see if this will affect staff wellbeing. But those are tricky because I don't think there's enough research in this area yet.

And I think there's an urgent need to do that because the amount of staff turnover that at least we have seen in the last few years post-COVID in ICU, and I know it doesn't affect just our ICU, it affects a number of ICUs, has been phenomenal. I think there's an urgent need to research this and look at interventions that can help improve staff wellbeing. So I definitely agree that there is more work needs to be done in this area.

Dr. Enfield: Sumeet, that's a great place for us to wrap up this episode. I would encourage all the readers to look at Positive Care. It's a great article.

It's well-needed in the space we're in right now, and I applaud you and your researchers for sticking through it during the challenges that you went through with COVID and other areas, including just getting the policy through. This is going to conclude another episode of the Society of Critical Care Medicine's podcast. If you're listening on your favorite podcast app and you like what you heard, consider rating and leaving a review.

For the Society of Critical Care Medicine podcast, I'm Kyle Enfield. Thank you.

Announcer: Kyle B. Enfield, MD, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

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