Association Between Children's Hospital Visitor Restrictions and Healthcare-Associated Viral Respiratory Infections: A Quasi-Experimental Study

Contrasting definitions and incidence of healthcare-associated respiratory viral infections in a pediatric hospital

OBJECTIVE

To determine the difference in the incidence of healthcare-associated respiratory viral infection (HARVI) in a pediatric hospital depending on the definition used.

DESIGN

Descriptive historical cohort study.

SETTING AND PARTICIPANTS

Patients aged 0-21 years old who were admitted between July 2013 and June 2018 to a 490-bed primary to quaternary-care pediatric hospital serving northern Texas.

METHODS

HARVI was defined using microbiologic confirmation, development of new symptoms while hospitalized, and exposure time greater than the minimum incubation period for each specific virus. Events that occurred following the maximum incubation period for that virus were classified as definite, otherwise they were classified as possible. This definition was compared to definitions using alternate timing of onset and symptomatology requirements. Data pertaining to demographics, diagnoses, and illness severity were collected.

RESULTS

In total, 498 HARVIs (320 definite and 178 possible) were identified, with an incidence rate of 0.98 per 1,000 patient days (0.63 and 0.35, respectively). Rhinovirus or enterovirus and respiratory syncytial virus were the most identified viruses (58% and 10%, respectively). The median time from admission until HARVI was 10.5 days (interquartile range [IQR], 5-30 days). When alternate definitions were employed, the incidence of HARVI ranged from 0.96 to 2.00 per 1,000 admitted patient days.

CONCLUSIONS

HARVI remain a common nosocomial infection in pediatric hospitals and the measured incidence is dependent on the definition used. Because of the endemic and pandemic potential of respiratory viruses, standardized definitions are needed to facilitate intra- and interhospital comparisons.

Infection control strategies for patients and accompanying persons during the COVID-19 pandemic in German hospitals: a cross-sectional study in March-April 2021

BACKGROUND

Patients are at risk of nosocomial COVID-19 infection. The role of accompanying persons/visitors as potential infection donors is not yet well researched, but the risk will be influenced by prevention measures recommended by infection control practitioners.

AIM

To collect information about COVID-19 infection control strategies for patients and accompanying persons from infection control practitioners in German hospitals.

METHODS

A cross-sectional questionnaire was developed, ethically approved, pre-tested and formatted as an online tool. Infection control practitioners in 987 randomly selected German hospitals were invited to participate in March and April 2021. For statistical analysis, the hospitals were categorized as small (0-499 beds) or large (≥500 beds).

FINDINGS

One hundred surveys were completed (response rate: 10%). A higher proportion of large (71%) than small (49%) hospitals let patients decide freely whether to wear medical or FFP2 masks. Most hospitals reported spatial separation for COVID-19 patients and non-COVID-19 cases (38%) or additionally for suspected COVID-19 cases (53%). A separation of healthcare teams for these areas existed in 54% of the hospitals. Accompaniment bans were more prevalent in large (52%) than in small hospitals (29%), but large hospitals granted more exemptions.

CONCLUSION

The decision as to whether to separate areas and teams seemed to depend on the hospital's structural conditions, therefore impairing the implementation of recommendations. Accompaniment regulations differ between hospital sizes and may depend on patient numbers, case type/severity and patients' requirements. In the dynamic situation of a pandemic, it can be difficult to stay up to date with findings and recommendations on infection control.

Viral Respiratory Infections in Hospitalized Children With Symptomatic Caregivers

OBJECTIVES

The burden of healthcare-associated viral respiratory infections (HAVRIs) among children is significant. While healthcare workers are often the focus for infection prevention strategies, little is known about the impact of sick caregivers and hospital visitors on the incidence of pediatric HAVRIs. The objective of this descriptive study was to determine the proportion of pediatric HAVRIs following contact with a sick caregiver or visitor.

METHODS

A retrospective chart review was performed of all HAVRIs that occurred between December 2017 and July 2019 in a pediatric tertiary care center. A HAVRI was defined as a laboratory-confirmed respiratory viral illness occurring more than 72 hours after admission.

RESULTS

Forty-four HAVRIs occurred in 37 patients during the study, predominantly among patients aged <24 months (n = 32, 72.7%) and with comorbidities (n = 42, 95.5%). For 9 HAVRIs (20.5%), contact with a sick caregiver (n = 8, 18.2%) or visitor (n = 2, 4.5%) in the 7 days before diagnosis was documented. In the 72 hours before HAVRI onset, 18 of the 44 patients (40.9%) were in a single-bed room and 6 of them (33.3%) were under additional precautions. Twelve patients (27.3%) had new or increased oxygen requirements and 4 (9.1%) were transferred to the ICU. There were no associated deaths.

CONCLUSIONS

Contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. Our study reinforces the importance of engaging family caregivers in infection prevention and control strategies in pediatric care settings.

Epidemiology and Risk Factors for Healthcare-Associated Viral Infections in Children

BACKGROUND

Healthcare-associated viral infections (HA-VIs) are common in hospitalized children and are increasingly recognized as a cause of preventable harm; however, the epidemiology and modifiable risk factors for pediatric HA-VIs are poorly understood.

METHODS

We performed a retrospective case-control study to identify risk factors and outcomes associated with pediatric HA-VIs at a quaternary care children's hospital. HA-VI surveillance was performed hospital-wide using Centers for Disease Control and Prevention (CDC) definitions. We abstracted data from the electronic medical record and conducted semi-structured interviews with patient caregivers to identify potential exposures 4 days before the HA-VI onset.

RESULTS

During the 20-month study period, we identified 143 eligible patients with HA-VIs and enrolled 64 matched case-control pairs. In total, 79 viruses were identified among 64 case patients. During the exposure period, case, as compared with control, patients were more frequently exposed to a sick visitor (odds ratio = 5.19; P = .05). During the 7 days after the HA-VI onset, case, as compared with control, patients had a greater length of antibacterial therapy per patient-days (mean 411 vs 159) as well as greater days of antibacterial therapy per patient-days (mean 665 vs 247).

CONCLUSIONS

The results of this study show that exposure to a sick visitor is a potentially modifiable risk factor for pediatric HA-VIs. Hospitalized children with HA-VIs also have increased exposure to antibacterial agents when compared with matched controls. Our findings suggest that hospital policies may need to be revised, with emphasis on visitor screening and partnership with families, to reduce the incidence of pediatric HA-VIs during hospitalization.

The Impact of Visiting Restrictions During the COVID-19 Pandemic on Pediatric Patients

Visitor restriction policies have been implemented on many hospital units as a result of the Covid-19 pandemic. These policies are integral to the strategies that hospitals are using to limit exposure risks during the pandemic. However, visitor restriction policies disproportionally affect hospitalized children. The trauma caused by lack of family at the bedside of adult patients during the Covid-19 pandemic has been studied but there is a lack of primary research on the impact of the Covid-19 visiting policy restrictions on pediatric patients. Long term studies are needed to understand the effect of this separation on children and their caregivers.

Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review

Background

During the COVID-19 pandemic, visiting restrictions of different extents have been implemented. However, despite the long history of visiting restrictions in health care systems, little is known about their effects.

Objectives

This review sought to explore the consequences of visitor restrictions in health care services during the COVID-19 pandemic.

Methods

A systematic, integrative review was conducted in accordance with the PRISMA guidelines, based on a systematic search in PubMed, CHINAL full plus, Web of Science, PsychInfo, Scopus and the Cochrane Library.

Results

A total of 17 scientific papers covering intensive care, pediatric care, general medical care, hospital care, palliative care and nursing home settings were included. Although appreciation for the technical solutions enabling remote meetings was reported, visiting restrictions had several consequences, mainly negative, for the patient's health, the health and wellbeing of family members and the provision of care. Among physical health consequences, reduced nutrition intake, decreased activities of daily living and increased physical pain and symptoms were reported. Among mental health consequences for the patient, loneliness, depressive symptoms, agitation, aggression, reduced cognitive ability and overall dissatisfaction were observed. For family members, worry, anxiety and uncertainty occurred, and they reported an increased need for information from care providers. Family members of neonatal intensive care unit patients reported less bonding with their child and family relation disturbances due to the restrictions. For care providers, visiting restrictions added the burdens of ethical dilemmas, learning new technical means to enable social interaction and an increased demand for communication with families and providing social support to both family members and patients.

Conclusions

When implementing visiting restrictions in health care services, decision makers and nurses need to be aware of their potential negative effects and adapt the provision of care to compensate for such effects. Nurses in all sectors should be aware that visiting restrictions may affect patients, families, and health care services for longer than the actual pandemic. Since the level of evidence regarding effect from visiting restrictions is low, further studies is strongly needed.

Visitor Guidelines in US Children's Hospitals During COVID-19

OBJECTIVES

To examine visitor guidelines among children's hospitals in the United States in response to the coronavirus 2019 (COVID-19) pandemic.

METHODS

A retrospective assessment of visitor guidelines in 239 children's hospitals in the United States.

RESULTS

In this study, we present an analysis of 239 children's hospital visitor guidelines posted to hospitals' Web sites during 1 week in June 2020. Of the 239 hospitals, only 28 did not have posted guidelines for review. The guidelines were analyzed and grouped by how the guidelines were updated in response to COVID-19. Parental visitation was restricted to 1 parent in 116 of the posted guidelines (49%). There were no obvious similarities among guidelines associated with their geographical (eg, state or local) location. As of February 2021, 33 of 55 (60%) randomly selected hospitals had not changed their visitor policy since our initial review.

CONCLUSIONS

The COVID-19 pandemic triggered changes in publicly reported visitor guidelines across the majority of children's hospitals. With our findings, we suggest wide variation in policies and practices in how guidelines were updated. More work is needed to understand how to optimize public safety and preserve family-centered care and parental authority in times of crisis.

A systems approach to examine hospital-acquired infections in a paediatric CICU

OBJECTIVE

We aimed to apply systems engineering principles to address hospital-acquired infections in the paediatric intensive care setting.

DESIGN

Mixed method approach involving four steps: perform time-motion study of cardiac intensive care unit (CICU) care processes, establish a meaningful schema to classify observations, design a web-based system to manage and analyse data, and design a prototypical computer-based training system to assist with hygiene compliance.

SETTING

Paediatric CICU at the Children's Healthcare of Atlanta.

PATIENTS

Paediatric patients undergoing congenital heart surgery.

INTERVENTIONS

Extensive time-motion study of CICU care processes.

MEASUREMENTS

Non-compliances were recorded for each care process observed during the time-motion study.

RESULTS

Guided by our observations, we introduced a novel categorisation schema with action types, observation categories, severity classes, procedure classifications, and personnel categories that offer a systematic and efficient mechanism for reporting and classifying non-compliance and violations. Utilising these categories, a web-based database management system was designed that allows observers to input their data. This web analytic tool offers easy summarisation, data analysis, and visualisation of findings. A computer-based training system with modules to educate visitors in hospital-acquired infections hygiene was also created.

CONCLUSION

Our study offers a checklist of non-compliance situations and potential development of a proactive surveillance system of awareness of infection-prone situations. Working with quality improvement experts and stakeholders, recommendations and actionable practice will be synthesised for implementation in clinical settings. Careful design of the implementation protocol is needed to measure and quantify the potential improvements in outcomes.

Frequency of asymptomatic and symptomatic respiratory virus detection in pediatric hematopoietic cell transplant patients

Respiratory viral infections are common and can cause significant morbidity and mortality in pediatric patients undergoing hematopoietic cell transplantation (HCT). The prevalence of disease has been primarily identified from retrospective studies using standard-of-care specimens. The incidence of both asymptomatic respiratory viral detection and symptomatic respiratory viral detection in this high-risk population is not well described. We performed longitudinal, active, prospective surveillance in pediatric HCT patients. Subjects underwent weekly midturbinate swabs (MTSs) for the detection of 18 respiratory viruses and subtypes peri-HCT and 100 days post-HCT. Clinical data were obtained from the medical record. From September 2015 to February 2017, 24 children underwent 29 HCT, and 284 MTSs were collected. Forty-two (15%) specimens were virus-positive from 10 (42%) subjects. Specimens from children undergoing allogeneic HCT were more likely to have a virus detected (17% vs 8%, P = .04) compared with specimens from children undergoing autologous HCT. Sixteen (38%) detections were not associated with symptoms. Almost half (8/17) of the unique viral infections occurred during the HCT hospitalization after a negative specimen, suggesting nosocomial acquisition, and preceded detection from a clinical specimen. Rhinovirus, the most common virus detected, was the only virus detected in 33 (81%) virus-positive specimens; only 11 (33%) rhinovirus detections were asymptomatic. Asymptomatic detection of coronavirus and bocavirus occurred. Asymptomatic respiratory virus detection occurred in more than one-third of the children undergoing HCT. The acquisition of respiratory viruses during HCT hospitalization suggests nosocomial acquisition. Early detection of respiratory viruses during asymptomatic periods could have infection prevention and treatment implications.

Beyond personal protective equipment: adjunctive methods for control of healthcare-associated respiratory viral infections

PURPOSE OF REVIEW

Prevention of nosocomial transmission of respiratory viruses is a priority in all healthcare settings and often achieved with the use of personal protective equipment. Several adjunctive infection prevention methods are in common use but their effectiveness in reducing healthcare-associated respiratory viral infections is unclear. In this review, recent advances regarding the effectiveness of several adjunctive infection prevention methods to reduce healthcare-associated respiratory viral infections are discussed.

RECENT FINDINGS

Training and education on hand hygiene guidelines, mandatory influenza vaccination for healthcare personnel, access to paid sick leave to reduce ill presenteeism, cohorting of patients with the same infection or clinical syndrome, neuraminidase inhibitor chemoprophylaxis during influenza outbreaks, and enhanced visitor restrictions in pediatric hospitals all have shown some degree of effectiveness in observational or quasi-experimental studies.

SUMMARY

Most of the studies evaluating the effect of adjunctive infection prevention methods on healthcare-associated respiratory viral infections are observational or quasi-experimental and are often combined with other interventions. Therefore, it is difficult to determine the precise effectiveness or efficacy of these interventions and more controlled trials are needed. Multimodal infection prevention policies are likely to be most effective in reducing healthcare-associated respiratory viral infections.

Hospital Associated Respiratory Virus Infection in Children and Adults: It Does Not Just Occur During Cold and Flu Season

Hospital-associated respiratory virus infections (HARVI) are an underappreciated source of morbidity and mortality. We examined HARVI incidence and clinical respiratory virus testing practices in a cohort of hospitalized patients with acute respiratory illness. HARVI were identified in patients of all ages, both during and outside of the influenza season.