Infection Prevention and Control in Residential Facilities for Pediatric Patients and Their Families

Judith A. Guzman-Cottrill, DO; Karen A. Ravin, MD; Kristina A. Bryant, MD; Danielle M. Zerr, MD; Larry Kociolek, MD; Jane D. Siegel, MD


Infect Control Hosp Epidemiol. 2013;34(10):1003-1041. 

In This Article

Executive Summary


The Society for Healthcare Epidemiology of America (SHEA) guideline "Infection Prevention and Control in Residential Facilities for Pediatric Patients and Their Families" is the first infection prevention and control (IPC) guideline to address preventing transmission of infectious agents in "home away from home" residential settings, of which the Ronald McDonald Houses (RMHs) serve as a prototype. These types of facilities provide support services, including overnight lodging, for ill and injured children and their families. Food preparation occurs in common areas, and cleaning of rooms or apartments is performed by the occupants during their stay and before departure. Pediatric patients are frequent guests of the family-centered facilities while receiving or recovering from specialized medical therapy. Examples of high-risk populations served in these facilities include families of patients with cancer, recipients of stem cell or solid organ transplants, surgical and/or very-low-birthweight infants who receive care in neonatal intensive care units (NICUs), those with cystic fibrosis, and women with high-risk pregnancies awaiting delivery in a nearby medical center. Such facilities are located worldwide and vary in their physical structure and the predominant population served.

Development of this guideline began after the presentation of IPC questions that 2 of the authors (J.A.G.-C., K.A.R.) had received from the local RMHs to the SHEA Pediatric Leadership Council in October 2010. There are risks of transmission that may be reduced by following practical IPC procedures, but existing IPC guidelines for hospitals and long-term care facilities are too stringent for a residential family-centered facility. Following discussions with executive leaders of Ronald McDonald House Charities, Inc. (RMHC), a guideline writing group was formed, and a unique collaborative effort began with a needs assessment[1] and establishment of a memorandum of understanding between SHEA and RMHC. While RMHC was involved in establishing this effort, the intention has always been to create a guideline that could be used by any such residential facility. If a family-centered residential facility is located within a medical facility, then the facility's IPC-related policies and procedures will supersede the recommendations contained in this guideline. In most situations, a hospital policy or procedure will contain more detailed and structured instructions than this document provides. This document will not include specific information on food safety, as this is addressed in another RMHC document.

This document differs from other SHEA-endorsed guidelines: (1) The primary audience of this guideline is not healthcare personnel but rather lay staff members and volunteers who are educating and monitoring visitors for illness or exposures in a program providing accommodation to ill and injured children and their families. Thus, the terminology used throughout the document is easily understood by individuals of varying educational backgrounds. (2) Peer-reviewed healthcare epidemiology literature related to this specific pediatric setting is sparse. Recommendations were developed by adapting currently available infection prevention and control evidence to this special setting. Where published evidence does not define the best practices, this guideline provides practical recommendations. Ultimately, management decisions must be individualized for the specific circumstance, and staff members are encouraged to rely on local expertise for complicated problems. Many recommendations for infection prevention and control in day care settings and ambulatory clinics are applicable to RMHs and like facilities. Literature searches were performed by the writing group and recommendations from guidelines published by the Centers for Disease Control and Prevention (CDC), SHEA, the American Academy of Pediatrics (AAP; Red Book 2012), and the World Health Organization (WHO) when applicable to the residential setting. Recommendations were not assigned a "grade" based on quality of evidence and strength of recommendation because of the sparse evidence to support practices in this setting.


The guideline contains several sections that contain background information to enhance the user's understanding of the topics. Recommended practices for the staff of the facility are included immediately following the informational discussions. Sections included in the document are: (1) introduction; (2) background; (3) core principles of infection prevention and control; (4) description of special populations often using the services of residential facilities and their vulnerabilities; (5) alphabetical list of 21 conditions caused by infectious agents or specific infectious agents; (6) background literature cited; (7) Appendix A, which contains 2 documents that may be used by staff; (8) Appendix B, which contains information concerning vaccines used in children and adults to prevent infectious diseases; and (9) Appendix C, which contains a summary table of infections with specific recommendations for (a) exposed healthy guests, (b) guests with specified infections, (c) restrictions needed within the facility, (d) availability of special educational handouts for family members, and (e) miscellaneous comments for each condition.

Three family education guides focusing on hand hygiene, respiratory etiquette, and safe handling of blood and body fluids were also created as part of this guideline but are not contained in this document. These guides are tools to educate families about how to help with minimizing the risk of pathogen transmission. These guides can be found at

Core Principles of Infection Prevention and Control

The core principles of infection prevention and control that form the foundation for recommended practices are (1) Standard Precautions; (2) management of animals that are utilized for animal-assisted therapy, service animals, or "house pets"; (3) protection of highly immune-compromised patients from exposure to mold spores; (4) health screening of house guests and visitors; (5) management of ill staff members and volunteers; (6) safe handling and storage of breast milk and maintenance of breast milk pumps; and (7) understanding what special populations are especially vulnerable to infection and the associated adverse effects. An understanding of these principles and the associated recommendations will assist staff members, volunteers, and families in making safe decisions when faced with a situation that holds a risk of transmission of infectious agents to others.

Standard Precautions are a set of practices aimed at preventing transmission of infectious agents and are based on the principle that all blood, body fluids (eg, material coughed up and saliva), secretions, excretions (eg, urine, stool, and wound drainage but not sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents and, therefore, these body fluids must be contained as much as possible. The various components of Standard Precautions and major recommendations in this document are as follows:

  1. Hand hygiene : Perform hand hygiene before preparing food or eating, before administering medication to a patient, and after changing diapers, toileting or assisting others in toileting, or soiling with body secretions or soil.

  2. Glove use : Use gloves when contact with blood or body fluids is anticipated, always perform hand hygiene after glove removal, and never wash and/or reuse the same gloves more than once.

  3. Respiratory hygiene/cough etiquette : Contain respiratory secretions by covering coughs and sneezes with a tissue, promptly disposing of soiled tissues, and performing hand hygiene afterward. Maintain a distance of 3–6 feet (1–2 meters) from anyone who is coughing or sneezing.

  4. Blood and body fluid precautions : Blood and body fluids may contain transmissible infectious agents (eg, hepatitis viruses, human immunodeficiency virus).

  5. Safe injection practices : Prevent needlesticks and exposure to blood by handling all needles used for injection of medications carefully, not recapping used needles, using needles only once, and disposing used needles separately from all other trash in a rigid, puncture-resistant container.

  6. Laundry management : Do not shake linens and clothing soiled with blood, vomitus, stool, and so on; keep separate in a plastic bag and wash separately in soap and hot water in order to prevent transmission of infectious agents.

  7. Cleaning and disinfection of environmental surfaces : Define and follow routine housekeeping procedures in each house. All items that require disinfection must first be cleaned with a detergent before using a disinfectant. Toileting and diapering areas must always be separate from food preparation areas. Surfaces and items in common areas and playroom should be cleaned and disinfected frequently, and toys that are smooth and scrubbable are preferred to facilitate cleaning.

Notable among the core principles of infection prevention and control is the health screening of house guests and visitors for exposure to infectious diseases and the presence of signs or symptoms of active infectious diseases, especially during seasons when certain infectious diseases are prevalent in the community (eg, influenza, respiratory syncytial virus [RSV], and rotavirus), and management of ill staff members and volunteers. Screening tools are provided in Appendix A.

Specific Diseases and Pathogens

The purpose of this section is to provide guidance for straightforward problems (eg, bed bugs, head lice, conjunctivitis, and diarrhea) and to provide education on recognition of the more complicated conditions (eg, chickenpox, whooping cough, measles, and tuberculosis exposures; infections and colonization with multidrug-resistant organisms; and prevention of influenza). Guidance is provided for the staff of houses for use of local resources (eg, infection prevention and control in referring hospitals, local and state public health departments). While some conditions may be managed by the staff independently, others may require consultation with the referring hospital medical staff.

We recognize that it is not the primary responsibility of the staff of these facilities to assure appropriate immunization status of its staff, volunteers, and guests. However, we encourage these types of facilities to join the many corporations that have found that providing information concerning needed vaccines, especially influenza vaccine, is beneficial to maintaining a healthy environment with reduced absenteeism.


This guideline responds to the evolving changes in the delivery of health care to children worldwide, which frequently includes long-distance travel for specialized medical treatment. Family-centered residential facilities located close to pediatric medical centers serve as bridges to returning home. The primary objective is to improve the health of the dedicated staff members and volunteers and of the vulnerable patients and their families who utilize these family-centered facilities that were developed to meet growing needs and improve the quality of life for children worldwide.