Patients are at risk of hospital-acquired respiratory viral infections (HARVIs) spread from ill healthcare workers (HCWs) and visitors.Reference Danzmann, Gastmeier, Schwab and Vonberg 1 , Reference Sukhrie, Teunis and Vennema 2 We assessed hospital staff sick leave policies and visitor restriction policies. A Society of Healthcare Epidemiology of America Research Network (SRN) survey revealed variability in screening of visitors for symptoms suggestive of respiratory viral infection and staff sick leave policies. Many hospitals had no policy restricting direct patient care for sick visitors or hospital staff.
Methods
A survey was sent to US SHEA Research Network (SRN) members between October 11 and November 11, 2017. The Rhode Island Hospital Institutional Review Board granted our survey exempt status.
Results
Of 99 SRN members, 52 completed the survey (response rate, 53%). The highest percentage of respondents was in the Northeast region (33%), and most worked in academic medical centers (56%) or hospitals affiliated with an academic institution (15%). Pediatric hospitals were the primary affiliation of 21 (40%) survey respondents, including stand-alone children’s hospitals and children’s hospitals within hospitals.
Seven respondents (13%) noted that their hospitals do not have a visitor restriction policy (Table 1). Of the 45 respondents in hospitals with a visitor restriction policy, 30 (67%) were hospital-wide and not limited to specific units. When visitor restriction policies were localized, they were most commonly in the neonatal ICU (12 of 15 localized policies), newborn nursery (8 of 15), pediatric ICU (7 of 15), and adult hematology/oncology units (7 of 15). Of the 45 hospitals with visitor restriction policies, 40 (89%) assessed visitor signs and symptoms, 26 (58%) assessed visitor age, and 1 (2%) assessed influenza vaccine status. In addition to these factors, 31 hospitals with visitor restriction policies (69%) indicated that their policies were put in place seasonally.
Table 1 Visitor Restriction and Staff Sick Leave Policies
a Responses could include >1 answer.
b Visitors are screened; sick visitors encouraged to postpone visit.
c Some hospitals had >1 localized unit with staff restriction policies for respiratory viral symptoms.
d Two institutions indicated that they have on-call policies for sick attending physicians that are contingent on the size of their division; smaller divisions do not have an on-call system with shift coverage.
A total of 33 respondents (63%) noted that they had a staff restriction policy in their hospital system based on the presence of respiratory viral symptoms. Among them, 30 reported hospital-wide policies extending beyond ICUs and locations in the hospital caring for immunocompromised patients. In addition, 26 respondents (50%) noted that their hospital has no requirement for hospital staff with respiratory viral symptoms to be evaluated by employee and occupational health (EOH). If EOH evaluated staff members with respiratory viral symptoms and symptomatology was confirmed, 37 of 40 (93%) of those hospitals restricted direct patient care. Of these 37 hospitals, 23 (62%) required fever in addition to upper respiratory tract infection symptoms before direct patient care was restricted. Of 33 respondents whose hospitals have a policy restricting direct patient care with respiratory viral symptoms, 7 (21%) noted that there was no on-call system to provide shift coverage for such healthcare personnel.
Although the Northeast, Midwest, South, and West regions had similar rates of staff restriction policies for respiratory viral symptoms (65%, 60%, 67% and 63%, respectively), the requirements for staff with respiratory viral symptoms to be evaluated by EOH were highest and lowest in the Northeast region (71%) and the West region (13%), respectively. Also, 20% and 58% of respondents in the Midwest and South regions required evaluation by EOH for respiratory viral symptoms, respectively. The West region had the lowest number of respondents reporting an on-call system to provide coverage when healthcare personnel are ill (25%); the South, Northeast and Midwest regions had rates of 58%, 47% and 47%, respectively. In the South and West regions, all respondents reported the presence of a visitor restriction policy, compared to 80% and 76% in the Midwest and Northeast regions, respectively.
Discussion
Hospital-acquired respiratory viral infections are a source of patient morbidity and mortality and universal implementation of visitor screening and HCW sick leave policies are important in reducing transmission of these infections in the hospital. Nevertheless, our survey results show that many US hospitals have not implemented visitor restriction or staff sick leave policies. Implementation of a universal policy restricting ill HCWs from direct patient care may be challenging to hospitals, especially when extra personnel or financial resources are limited. In these situations, policies may have to be tailored to individual patient care units or services, taking into account their unique environments and resources.Reference Szymczak, Smathers, Hoegg, Klieger, Coffin and Sammons 3 Recent studies suggest that the implementation of such policies, specifically visitor restriction policies, can reduce HARVIs.Reference Washam, Woltmann, Ankrum and Connelly 4
Hospitals should also provide an on-call system with shift coverage for ill HCWs, which should be known to all staff, and adherence should be encouraged by senior leadership. Unfortunately, as many as 23% of respondents reported not having an on-call system with shift coverage for ill HCWs and >30% reported that they did not know whether their institution had such an on-call system. Several survey respondents indicated that their policies are seasonally based, but in a previous study, we showed that HARVIs occurred year-round.Reference Chow and Mermel 5 Hospitals should ensure that these policies are enforced beyond the respiratory viral season.
The implementation of visitor and sick leave policies within the hospital will require the acknowledgment by hospitals that HARVIs can negatively affect patients who are sick and recovering in the hospital.Reference Chow and Mermel 6 Senior leadership and healthcare staff will have to support each other to ensure that these policies are adhered to, and they must provide effective ways to safeguard against these hospital-acquired infections in resource-limited settings. As with any culture shift, behavior change should begin early in the education of healthcare staff through reinforcement in the classroom and during rotations.Reference Tanksley, Wolfson and Arora 7
Because the survey was distributed through the SRN, results may reflect sampling bias. Furthermore, our survey was not previously validated. Despite these limitations, we hope that our survey findings stimulate discussions regarding cultural changes to our healthcare system that prevent ill HCWs and visitors from having direct patient contact.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2018.131
Acknowledgments
The authors thank the Society of Healthcare Epidemiology of America Research Network members who kindly responded to our survey.
Financial support
No financial support was provided relevant to this article.
Potential conflicts of interest
All authors report no conflicts of interest relevant to this article.
