970
Table 2. Reported Types and Timing of Visitor Restrictions in Pediatric Healthcare Facilities Type of Restriction Respondents Reporting Restriction (N=104), No. (%) Timing Age restriction
77 (74) All year Seasonal Symptom restriction 101 (97)
Not stated All year
Seasonal Outbreak restriction 78 (75)
Not stated All year
Seasonal Not stated
Alice L. Pong et al
Respondents Reporting Restriction, No. (% per restriction group) 20 (26) 54 (70) 3 (4)
71 (70) 24 (24) 6 (6)
34 (44) 34 (44) 10 (11)
or family satisfaction assessments were used to assess effectiveness of VRPP. Moreover, 38 respondents (37%) reported that either no mechanism was used to monitor effectiveness (n=12, 12%) or that they were not sure whether the effectiveness of VRPP was monitored (n=26, 25%). Respondents felt that the enforcement of VRPP was the responsibility of the nursing and ancillary staff, including nursing staff or charge nurse (n=82, 80%), registration clerk (n=59, 58%), and unit clerks (n=54, 53%). The infection prevention team was involved in enforcement of VRPP at 32 sites (31%). Furthermore, 16 respondents (16%) identified physicians and other advanced practice providers as enforcers of VRPP. Finally, 35 respondents (34%) did not feel that their VRPP was
ideal. One-third of respondents who were not satisfied with their VRPP stated that their ideal VRPP would consist of fewer age- and symptom-based restrictions, without a change in their facil- ities’ outbreak-associated visitor restrictions.
Discussion
Our study demonstrates that VRPP in place prior to the start of the 2016–2017 respiratory virus season in pediatric healthcare facilities in North America varied with respect to scope, timing, communication, awareness, satisfaction, and monitoring for effectiveness. The rationale for VRPP is based upon theoretical risks of limiting transmission of pathogens in the healthcare setting. Visitor restriction policies are present in most hospitals;14 however, few studies have evaluated the effectiveness of age- based, seasonal, or symptom-based VRPP. Furthermore, many VRPP interfere with components of family-centered care by excluding family members and visitors from being present at the bedside based on presumptive risk factors. Assessment of the effectiveness of VRPP is challenging due to
this variation and to the difficulty associated with monitoring adherence, exceptions, and outcomes. Departure from family- centered care and challenges related to enforcement often result in dissatisfaction by both family and/or visitors and the healthcare team responsible for enforcement. Age-based VRPP may not prevent exposure events in pediatric
healthcare environments, which may be as likely attributable to an adult family member or visitor as to a young child. In addition, chronological age does not always correspond with developmental
age, excluding or including individuals who may present a greater risk for pathogen transmission due to their ability or inability to conform to hygienic practices while in the healthcare environment. The practice of setting a numerical visitor limit, as is often done in adult healthcare facilities, is a more direct way of preventing over- crowding and potentially interference with the delivery of healthcare. Washam et al15 reported a 37% decrease in healthcare-acquired respiratory viral infections following a change in their visitor restriction policy to limit the number of visitors allowed per patient. Although two-thirds of respondents reported that their facil-
ities tracked hospital-acquired respiratory infections, variation in organisms assessed and diagnostic modalities makes interpreta- tion of effectiveness of VRPP in these settings challenging. Tracking identical organisms with comparable laboratory meth- ods and standard definitions of healthcare-associated infections may be a systematic way to measure and compare effectiveness of VRPP. Our results are limited by recall bias inherent to survey- based research as well as the possibility that respondents’ knowledge may not represent actual policy. However, these results reflect the informal surveys regarding VRPP that have been done to guide practice. Because our results included 104 respondents familiar with their VRPP from 74 unique institutions, we performed an analysis of the results including only the first respondent from each healthcare system (n=74). Multiple responses from the same institution were deleted while maintaining the same set of institu- tions represented in the original analysis. This analysis yielded essentially identical proportions and findings related to respondent demographics and survey results. In addition to the variation in VRPP reported by respondents,
the dissatisfaction with VRPP reported by one-third of respon- dents reflects the absence of evidence as a basis for restrictions that are challenging to implement and assess. Support for a multisite evaluation of VRPP components with standardized tracking of outcomes would aid in the development of uniform guidance that could be adapted to inform this challenging aspect of pediatric infectious disease care.
Acknowledgments. The authors thank Dr Natasha Halasa for her invaluable help in reviewing the survey and recommendations.
Financial support. This publication was supported by Cooperative Agree- ment 1 (U50 CK000477) funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not
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