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



Throughout the United States and other countries worldwide, families travel long distances to access specialized pediatric care. Thus, RMH programs and similar facilities have become integral components of pediatric family-centered care. In this guideline, we refer to the RMH as the prototype for such facilities, but it is our intention to develop recommendations that will be applicable to all facilities of this type. These types of facilities provide support services, including overnight lodging, for ill and injured children and their families. Pediatric patients are also frequent guests of the family-centered facilities, while receiving or recovering from specialized medical therapy. Examples include children traveling several hours for a specialty clinic appointment, immune-compromised children recovering from hematopoietic stem cell or solid organ transplantation, children receiving intensive outpatient therapy, or premature infants of a multigestational birth recently discharged from a NICU whose siblings remain hospitalized. Some facilities may also include women with high-risk pregnancies who must be close to the specialty delivery hospital if labor begins early. The patient population may be varied in one facility, while another may serve nearly exclusively families of NICU patients. In 2011, SHEA and RMHC established a formal collaboration to develop an IPC guideline, as both organizations agreed that RMH staff and other organizations operating similar programs would benefit from a standardized approach.

RMH programs, the cornerstone program of RMHC, provide a "home away from home" for families while their children receive medical care. In 1974, the first RMH opened in Philadelphia, Pennsylvania.[2] As of January 2013, 323 RMHs exist across 31 countries; 176 of these are in the United States. More than 6,000 families stay at a RMH per night worldwide; the facilities vary greatly in size, accommodating 4–400 persons per night. Most RMHs are freestanding structures. However, some RMH programs exist within a children's hospital. RMHs provide housing, meals, laundry facilities, and family activities at little or no cost to occupants. Lengths of stay range from 1 night to several months, depending on the child's medical needs. There is no maximum length of stay. The minimum criterion for a patient and/or family to stay includes receiving daily outpatient care or treatment as an inpatient; families are routinely reevaluated to determine their eligibility for continuing stay.

RMHs differ substantially from hospitals and long-term care facilities. RMH staff do not provide medical services, there are no facility requirements to minimize or measure environmental exposures (eg, dust and mold), and standardized policies for environmental disinfection do not exist. While local RMHC Chapters employ staff or service providers to maintain housekeeping and cleanliness standards, RMH also relies on guests and volunteers for routine cleaning and disinfection of common areas. When a family "checks out" of a sleeping room, it is initially cleaned and disinfected by the departing family or a volunteer before the next family "checks in." Chapter staff, volunteers, or a housekeeping service follow with room checks to confirm standards of cleanliness have been met.

In all RMHs with overnight accommodations, meals are prepared and consumed in a common kitchen and dining room, and guests share in the cleanup duties after meals. Kitchens are open 24 hours a day, as a family's meal schedule might be dictated by the child's around-the-clock medical care and changing health status. Each family has a designated area to store their own perishable and nonperishable foods. RMHC staff and volunteers review the refrigerator and freezer contents at least once weekly to discard spoiled food. Some houses have apartments dedicated to high-risk transplant patients that include separate food preparation and dining areas.

The annual incidence of infections acquired in the RMH setting is unknown. Similarly, it is unknown how RMH guests (including patients living at a RMH) influence the affiliated hospital's epidemiology. RMH guests are at risk of exposure to infectious pathogens in common areas, such as family lounges and community kitchens. Many pediatric hospital epidemiologists can anecdotally recall at least 1 hospital outbreak investigation that included their local RMH. However, this has never been formally reviewed, and outbreaks related to stay in a residential facility are not easily identified in the medical literature. In fact, literature review revealed only 1 published report (a hospital varicella outbreak involving a RMH).[3] Despite this direct relationship with healthcare facilities, no standardized RMH IPC guideline exists.

Each RMH is owned and operated by a local Chapter and governed by a locally organized board of directors. However, all Chapters are official licensees of McDonald's Corporation, which is located in Oak Brook, Illinois. This governance structure allows for local flexibility within a framework of policies and practices among individual RMHC Chapters, including the management of IPC issues. Most sites have locally written IPC guidelines, and consultation resources vary,[1] increasing the potential for inconsistency.

Hospital infection prevention and control guidelines do not apply to most RMH settings, since such guidelines are developed to protect patients who are vulnerable when hospitalized, undergoing a variety of procedures, and exposed to medical devices. It is both unnecessary and unrealistic to expect a residential facility to adhere to strict hospital guidelines. Specifically, hospital infection prevention and control policies do not align with the RMHC mission of serving families during a time of crisis in a community setting through its RMH program. It was recognized that development of a guideline would require a strategy appropriate for the spectrum of RMH programs, as they differ in size, amenities, patient populations, and location (freestanding versus a program within a hospital).

The recommendations in this guideline address general and specific topics of infection prevention and control that may be applied to various nonhealthcare settings. The discussions and recommendations will include the concepts of Standard Precautions, screening visitors for exposures to infectious diseases, excluding staff members and visitors with transmissible infections, prevention of outbreaks, and optimizing the health of local RMHC staff members and volunteers through education.

This document differs from other SHEA-endorsed guidelines. First, the primary audience of this guideline is not healthcare personnel; instead, the guideline is a reference for 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 was chosen for that target audience. Second, healthcare epidemiology literature related to this specific pediatric setting is sparse. Recommendations were developed on the basis of adaptation of currently available evidence to this special setting. Where published evidence does not define the best practices, our guideline provides practical recommendations. Ultimately, management decisions must be individualized for the specific circumstance. Many recommendations for infection prevention and control in day care settings and ambulatory clinics are applicable to RMHs and like facilities.

Demography and Definitions

The number of children in the United States is rising. The 2010 census reported 74.2 million children living in the United States, and this population is projected to increase to 87.8 million by 2030.[4] Concurrently, the number of children and youth in the United States with chronic health conditions has increased in the past 4 decades,[5] as survival rates have improved for life-threatening pediatric diseases such as prematurity, cancer, and cystic fibrosis (CF).[6–8] As the need for specialized pediatric care increases, the demand for RMH services also increases; it is projected that more than 350 RMHs will be operating by the end of 2015 (J. Burton at RMHC, personal communication, 2013).

A RMH is a facility operated by a local RMHC Chapter that provides overnight accommodations to families while their child receives medical care. It may be freestanding or housed within a children's hospital. A Ronald McDonald Family Room (RMFR) is a program within the hospital operated by a local RMHC Chapter that provides day and, in many programs, overnight services for families while their children receive medical care. An example of a RMFR is an area near a pediatric day hospital where children receive chemotherapy infusions. A RMH guest is a patient or family member who utilizes RMH services (including overnight stay). A RMH visitor is an individual who enters a House but does not utilize their services, such as someone attending a RMH tour or visiting a RMH guest. A RMH staff member is a person employed by a local RMHC Chapter, and a RMH volunteer is someone who contributes unpaid support to RMH program daily operations. A healthcare provider is defined as an individual permitted by law and by the healthcare facility to provide medical care without direction or supervision within the scope of the individual's license and consistent with individually granted clinical privileges (eg, physician, nurse practitioner, or physician assistant).

IPC Needs Assessment

A needs assessment was a critical first step in guideline development to aid in determining the topics and recommendations included in this document. This assessment sought to identify the populations served and the most frequent IPC situations encountered by RMH staff and to understand the methods and resources used to manage IPC situations as they arise. The survey findings are summarized in detail elsewhere.[3]

Focus Group and Site Visits. Several authors attended the RMHC International Conference in Chicago (August 2011) to learn more about the diversity of the RMHs and their IPC needs. The authors coordinated a stakeholder's group meeting with board members and managers of RMHs both within and outside of the United States to better understand the IPC challenges encountered. In January 2012, 2 authors toured 3 RMH programs in Houston, Texas, with a RMH organizational leader and program managers. During these 2 meetings, greater insight was gained regarding the IPC challenges, the variety of physical structures of RMHs, and the types of questions staff members have about management of patients and families with an infectious condition or a history of exposure to others with infections.

Scope of the Guideline

The scope of this guideline is specifically for family-centered residential facilities that provide accommodation and other services to families with ill and injured children. However, these facilities may vary in the populations served, healthcare services provided (RMH does not provide healthcare services), human and fiscal resources, and governance structure. In such situations, the recommendations should be adapted to meet these specific conditions.

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.