Infection control precautions for visitors to healthcare facilities

Abstract

Infection transmission in healthcare facilities is a growing concern. Visitation to healthcare facilities is very common, though the potential role of visitors in the transmission of infection is unknown. Although transmission-based precautions are generally used to prevent the spread of organisms in healthcare settings by healthcare staff, the applicability of these precautions to visitors is unclear. Decisions regarding whether to implement transmission-based precautions among visitors should take into account the organism of concern and means of transmission as well as factors pertaining to the visitor and the healthcare setting. The role of visitors as vectors for organism transmission in the healthcare setting and the potential benefits and adverse consequences of visitor adherence with transmission-based precautions are important areas for additional research.

Keywords:

• hospital epidemiology
• hospital visitors
• infection control
• multidrug resistant organisms
• nosocomial infections

Background

Infection transmission in healthcare settings has become an increasingly recognized threat to patients and healthcare providers. While visitation to healthcare settings is common, the potential role of visitors in the transmission of healthcare-associated infections (HAIs) remains unclear. Despite the frequency of healthcare setting visitation and heightened awareness and understanding of HAI transmission, little attention has been offered to understanding the significance of visitors in HAI transmission. The emergence of multidrug-resistant pathogens with limited treatment options highlights the need to address infection prevention strategies for visitors to healthcare facilities.

Literature describing situations implicating visitors in the transmission of infections is limited. Guidelines have been issued addressing the prevention of transmission of infectious agents in healthcare, primarily focusing on healthcare staff [1]. The applicability of these guidelines to visitors is uncertain. Expert guidance was recently issued to assist healthcare epidemiology programs in formulating policies and practices focusing on transmission-based precautions for visitors to healthcare facilities [2].

General infection prevention strategies & healthcare visitors

Hand hygiene remains the cornerstone of infection prevention and has been well-demonstrated to reduce organism transmission between individuals, thereby protecting both patients and visitors in healthcare settings [3]. Hand hygiene should be practiced before and after any visitor–patient contact. The use of alcohol-based hand rub has been generally accepted as an appropriate means of hand hygiene in most healthcare settings, excluding situations concerning the transmission of spore-forming organisms such as Clostridium difficile, and potentially norovirus [4]. Ensuring that hand hygiene stations are easily accessible and healthcare visitors are educated regarding the importance of hand hygiene before and after patient contact can improve adherence [5,6].

Visitors who are clinically ill should avoid visiting healthcare facilities, as ill visitors can potentially transmit infection to patients, healthcare staff and other visitors. In outbreak settings, active screening of visitors for acute illness has been efficacious in reducing the spread of influenza [7] and norovirus [8]. During the severe acute respiratory syndrome (SARS) epidemic, all hospital visitors were screened at hospital entry for acute illness using questionnaires and temperature assessment [9]. The optimal strategy and location for screening visitors for acute illness depends on the infectious agent of concern. Healthcare visitors should avoid contact with multiple patients as much as feasible, as this can potentially reduce the role of visitors as potential vectors for HAIs. Additionally, visitors should not be present in situations in which aerosolized secretions may be generated as this process can facilitate the spread of microorganisms that may infect visitors.

Healthcare visitors & contact precautions

Contact precautions are transmission-based precautions used to prevent the spread of pathogens, including multidrug-resistant bacteria in healthcare facilities. These precautions are intended to prevent staff and equipment from serving as potential vectors of organism transmission within the healthcare setting. As the role of visitors in facilitating spread of pathogens is unknown, the impact of use of contact precautions, including gowns and gloves with patient contact, is also uncertain and may not be beneficial. Some organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci, are widely prevalent outside healthcare settings. Given the high rates of colonization of household contacts of patients with MRSA infection [10], many visitors to patients colonized or infected with this organism may be colonized themselves, and their adherence with contact precautions may have limited benefit (Table 1). In determining the utility of contact precautions among visitors of MRSA and vancomycin-resistant enterococci-colonized patients, healthcare facilities should consider the likelihood that visitors may have contact with multiple patients, the immune status of the visitor and the ability of visitors to perform hand hygiene.

Table 1. Transmission-based precautions for visitors.

	Recommendation	Comment
Contact precautions (MRSA/VRE)	May be of limited value for visitors	Benefit of protecting visitors unknown Household members may likely be colonized Could consider use in outbreak settings, among visitors who are immunocompromised, visiting multiple patients or unable to perform hand hygiene
Contact precautions – C. difficile, norovirus, CRE, other MDR pathogens	Generally recommended for visitors	General low prevalence of these organisms in the community Visitors are susceptible to infections caused by these organisms Infection is associated significant therapeutic limitations and high rates of morbidity and mortality
Respiratory precautions	Consider implementation on a case-by-case basis	Household contacts may likely have been exposed Use of respirators limited by challenges with fit-testing visitors
Special pathogens (highly virulent or novel organisms)	Consider implementation on a case-by-case basis	Factors that may influence decision to implement precautions include organism transmissibility and virulence and potential for epidemic spread through an institution

CRE: Carbapenem-resistant enterobacteriaceae; MDR: Multidrug-resistant; MRSA: Methicillin-resistant Staphylococcus aureus; VRE: Vancomycin-resistant enterococci.

Visitors of patients colonized with carbapenem-resistant Enterobacteriaceae may warrant further consideration given the relatively low prevalence of these organisms in most countries [11] and the significant therapeutic limitations and high rates of morbidity and mortality associated with infections caused by these organisms [12]. Contact precautions for visitors should be considered in these settings. Enteric pathogens, including C. difficile and norovirus, are readily transmissible to exposed visitors, have relatively low prevalence and glove use has been demonstrated to reduce transmission [13]. Adherence to contact precautions for visitors of patients infected with these organisms may be appropriate [14,15]. A recent study among hospital epidemiologists acknowledged that many facilities recommend more intensive compliance with contact precautions among visitors to patients with carbapenem-resistant Enterobacteriaceae or C. difficile infection [2].

Healthcare visitors & respiratory protection

Pathogens that may spread through either droplets or aerosolized particles present potential risks to visitors. Prior outbreaks of respiratory pathogens, including the SARS virus outbreak, identified healthcare visitors as vectors in pathogen transmission in healthcare facilities and outside the hospital [16,17]. Prior investigation has implicated a hospital visitor as the source of tuberculosis spread throughout a hospital [18]. The risk of infecting healthcare visitors with respiratory pathogens varies based on pathogen, visitor immune status and extent of exposure. For patients receiving care under droplet precautions, surgical masks are recommended for healthcare staff and would be appropriate for visitors. Protecting visitors of patients who are on airborne precautions remains a challenge. For healthcare staff, the use of respirators (N-95 or higher) is recommended in these circumstances [1]. However, these require fit-testing, which is often impractical for visitors and hospitals. For visitors of patients who are on airborne precautions who have not been previously fit-tested, surgical masks may be adequate, although if the visitor was not previously exposed, then visitation restriction should be considered.

Visitors with symptomatic respiratory illness should not visit patients in healthcare settings. Some visitors, particularly household contacts with prior extensive exposure to the symptomatic patient, may already be immune to the infectious agent or in an asymptomatic incubation phase of illness. The potential adverse consequences of visitor mask use, including concerns regarding bonding between children and caregivers, should be weighed against the potential risk of visitor infection and consequences of infection. Clinicians and healthcare epidemiology staff should be engaged in these decisions and communications with visitors. Decisions on foregoing respiratory protection for visitors should be made on an individualized basis and include visitor education and medico-legal considerations, which should be documented in the medical record.

Special circumstances

Monitoring and enforcing isolation precautions for visitors warrant special consideration in situations when heightened transmission is occurring (outbreak or epidemic settings) or a novel or particularly virulent organism is suspected or identified (e.g. SARS, Ebola virus). In these circumstances, hospitals should collaborate with the local government and public health authorities in designing and implementing infection prevention strategies. These may include restricting or limiting visitors and developing infrastructure to monitor and enforce the implementation of transmission-based precautions among visitors. Guidance for visitors to patients with Middle East Respiratory Syndrome Coronavirus has been recently issued recommending visitor restriction to essential visitors, screening for acute respiratory illness among visitors and educating visitors on personal protective equipment use and monitoring adherence [19].

Visitors who may be visiting multiple patients (e.g., non-hospital employed clergy, volunteers and therapy programs) deserve further consideration. Given their potential to transmit organisms between patients, these individuals may warrant the same transmission-based precautions as healthcare staff. Visitor education and communication between healthcare staff, hospital epidemiology and infection prevention programs and these visitors are essential.

Implementation challenges

Monitoring adherence to transmission-based precautions and implementing policies pertaining to infection prevention among healthcare visitors can be challenging. Small studies have shown low level of adherence with all three components of contact precautions: hand hygiene, gloves and gowns [20,21]. A recent survey of hospital epidemiologists and infection control leadership revealed that while some institutions monitor adherence with hand hygiene and isolation precaution adherence among visitors, many do not have infrastructure or programs to address these challenges [2]. This survey revealed significant variation in how non-adherent visitors are addressed and the repercussions of non-adherence. The challenge of monitoring and enforcing adherence to transmission-based precautions among visitors necessitates support from institutional leadership.

Future directions

Institutional guidance addressing healthcare visitors and infection prevention is grounded in basic infection prevention principles balancing the protection of patients, visitors and healthcare staff and the practicality of implementation. We need to better understand the risk of horizontal transmission of pathogens between patients and healthcare visitors, their variability in different settings and their role in HAI transmission. Research on improving visitor adherence to infection prevention practices, including contact and respiratory precautions, is warranted.

Another area of further study is understanding the short- and long-term psychosocial implications of visitor restriction, and the impact of visitation under transmission-based precautions on relationships between patients and visitors. Prior studies have demonstrated higher rates of anxiety and depression among patients treated in contact precautions, although causality remains unclear [22]. More study on the psychosocial impact of visitor adherence with transmission-based precautions when visiting patients in contact or respiratory precautions is needed.

As healthcare leadership becomes increasingly attentive to the importance of HAI prevention, the potential role of visitors in HAI transmission will gain attention. The optimal use of transmission-based precautions among visitors remains uncertain. Successfully understanding and addressing this challenge will require an ongoing collaborative and multidisciplinary approach involving research, policy development and implementation.

Financial & competing interests disclosure

D Morgan has acted as a consultant for Welch Allyn and has received grant funding from United States Department of Veterans Affairs (HSR&D CRE 12-307) and United States Agency for Healthcare Research on Quality (K08 HS18111). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.