Friday, September 29, 2023
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Evidence supports the use of standard and contact isolation precautions of healthcare workers. However, the role of visitors in transmitting or becoming infected in acute care hospitals is not known. Visitors rarely move from room to room, and compliance with isolation precautions can be difficult to enforce. A new guidance statement from the Society for Healthcare Epidemiology of America (SHEA) on isolation precautions for visitors in adult and pediatric acute care hospitals includes recommendations based on a synthesis of limited evidence, theoretical rationale, practical considerations, a survey of SHEA membership and the SHEA Research Network, author opinion, and the consideration of potential harm.
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The recommendations attempt to balance visitor and patient safety, the potential for the spread of pathogens within the hospital, the psychosocial implications of isolation practices, and the feasibility of enforcement of isolation precautions among visitors. The recommendations address endemic situations for which contact isolation measures are often used by healthcare workers, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). In outbreaks or times of increased transmission, practices involving hospital visitation should be considered on a situational basis.
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All visitors should perform hand hygiene before entering and immediately after leaving a patient room. Both hand washing with soap and water and proper use of an alcohol-based hand rub are acceptable means of hand hygiene. Institutions should ensure that sinks and alcohol-based hand rub stations are easily accessible to visitors. Visitors should be educated on the importance of frequent hand hygiene in the hospital setting and on the available options and proper techniques for performing hand hygiene.
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Getting visitors to consistently wash their hands is as difficult as getting staff to do so, and hand hygiene compliance efforts are usually targeted to staff rather than visitors.[1] Educational interventions can improve visitor compliance with hand hygiene but must be continuously repeated and reinforced owing to the dynamic nature of hospital visitation. SHEA's recent membership survey found that almost all hospitals post signs with instructions about how to perform hand hygiene, but only about half of hospitals provide verbal instructions from a nurse or doctor.
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In areas where MRSA and VRE are endemic, visitors might not be required to follow contact precautions. However, special considerations (eg, limiting or precluding visitation, use of gowns/gloves) should be made for immunocompromised (neutropenic) patients or visitors who are unable to practice good hand hygiene. Visitors to patients with MRSA or VRE who are interacting with multiple patients may be at greater risk of transmitting pathogens between patients and should use isolation practices similar to those of healthcare workers. This might be the case for visitors of patients with long inpatient stays, such as after transplantation, in which multiple families and patients have more frequent and closer interactions with each other.
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Intestinal pathogens, such as Clostridium difficile and Norovirus, are potentially harmful to visitors and have low prevalence in the community, so contact precautions for visitors should be in place. Contact precautions should also be considered for visitors to patients with extensively drug-resistant gram-negative organisms (eg, Klebsiella pneumoniae carbapenemase) to help prevent transference of pathogens to visitors. Visitors with extensive documented exposure to the symptomatic patient before hospitalization, such as parents/guardians/family members, may be excluded from contact precautions.
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Most visitors to rooms with droplet precautions (ie, patients with pertussis, influenza, meningococcal pneumonia[2]) should wear surgical masks. However, visitors with extensive documented exposure to the symptomatic patient before hospitalization (parents/guardians/close family members) may be excluded from these precautions; they may either be immune to the infectious agent or already in the incubation period. Isolation requirements should be considered on a case-by-case basis in some circumstances (eg, highly virulent pathogens). Additionally, healthcare facilities should generally restrict visitation by any ill individual or family member (eg, active cough, fever).
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Most visitors to patients on airborne precautions (eg, tuberculosis, varicella, smallpox, severe acute respiratory syndrome [SARS][2]), should wear surgical masks. Visitors with extensive documented exposure to the symptomatic patient before hospitalization (eg, household contacts) may be excluded from these precautions because they may be immune or already in the incubation period of infection. If previous exposure cannot be documented and N95 is recommended, then consideration should be given to restricting visitation to only those who have been fit-tested, which, although logistically difficult, might be possible on a case-by-case basis.[1] Whenever visitation must be restricted, visitors should be educated about the rationale, and this communication should be documented in the patient's record.
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In outbreak situations, times of increased baseline infection rates, or when novel potentially virulent pathogens are suspected or identified (eg, Ebola virus, Middle East respiratory syndrome coronavirus [MERS-coV], SARS), isolation precautions should be enforced for all visitors, including parents, guardians, and siblings. At these times, hospitals should consider restricting nonessential visitors, limiting the number of visitors at one time, and developing policies and infrastructure to monitor and enforce adherence to appropriate isolation precautions among visitors.
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For visitors to patients with extended stays, isolation precautions are probably not practical, and the benefit of wearing personal protective equipment (PPE), including gowns and gloves, is unclear except when assisting in care delivery and contact with blood, body fluids, or non-intact skin is anticipated. In many cases, these visitors may have had extensive exposure to the patient prior to hospitalization and could be immune to the pathogen or already in an incubation period. The risk for infection to parents/guardians/visitors is likely reduced if they practice good hand hygiene, and any additional benefit of wearing gowns and gloves in these scenarios is unclear. In special situations, in which patients acquire new transmissible infections after admission, protection of parent/guardian/visitor by the use of isolation precautions may be considered (for example, a child with hospital-onset colonization/infection with extensively antibiotic-resistant gram-negative bacilli). It is unknown, however, how often PPE should be changed for long-term visitors, and requiring continuous glove use can actually discourage proper hand hygiene.[3]
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Very little evidence is available to guide isolation precautions for parents or guardians of infants and young children who may be staying overnight and/or long term with a hospitalized child. It is important to distinguish parents/guardians and other close household contacts from non-household visitors when evaluating the potential pre-admission exposure of visitors to the child. The decision to use isolation precautions, particularly for parents/guardians, must be weighed against the potential negative psychosocial impact of isolation precautions on the child and family. Isolation precautions can interfere with bonding, breastfeeding, and family-centered care, especially when the parents/guardians are rooming in. The risk for horizontal transmission may be minimal when care is provided in a single room.
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An objective of the SHEA guidance document is to help facilities develop or modify their own policies related to the use of isolation precautions by visitors to acute care hospitals. SHEA's survey of 1520 members (response rate, 21%) asked whether the acute care hospitals with which respondents were affiliated had policies for visitors entering isolation rooms.
The specific requirements for visitors under different isolation levels were assessed. Responses were consistent with respect to requirements for contact isolation, but they differed in requirements for respiratory isolation, especially airborne precautions. Before entering airborne isolation, 68% of respondents' facilities require visitors to wear N95 masks, 38% require surgical masks, and 10% require powered air-purifying respirators.[1] (Percentages do not equal 100% because some respondents selected more than one answer.)
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The guidance document states that "hospitals should only consider writing policies regarding visitors when they can be realistically enforced and regularly evaluated for compliance," and that resources should be allocated to scale up enforcement in settings of heightened horizontal transmission.[1]
SHEA suggests that enforcement be stepped up during times of outbreaks, increased transmission, or identification of a new, potentially virulent pathogen. But how practical is it to monitor visitors for compliance or to dedicate staff to enforce policies?
The SHEA survey asked members whether their hospitals monitored and/or enforced compliance with their visitor isolation policies. Although only 23% of respondents reported enforcing visitor compliance with isolation precautions overall, enforcing compliance is somewhat more common with carbapenem-resistant Enterobacteriaceae (46%) and C difficile (41%). The screening of visitors for signs of illness, especially those visiting immunocompromised patients, is another challenge for acute care hospitals.[1]
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Tell us what you think: Does your facility have a visitor isolation policy? Do you require visitors to follow the same isolation precautions as staff, or do the rules differ? Do you insist that patients follow the rules, or do you relax them under certain circumstances? Who monitors and enforces visitor isolation practices? What impact does isolation have on special populations, such as neonates?
Please add your comments at Voice Your Opinion: Hospital Visitors and Isolation.
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