Hostname: page-component-7b7567c8c-fvjsw Total loading time: 0 Render date: 2026-11-15T00:00:14.711Z Has data issue: false hasContentIssue false
  • English
  • Français

Impact of Infection Prevention and Control Initiatives on Acute Respiratory Infections in a Pediatric Long-Term Care Facility

Published online by Cambridge University Press:  07 April 2016

Meghan T. Murray,
Olivia Jackson,
Bevin Cohen,
Gordon Hutcheon,
Lisa Saiman,
Elaine Larson and
Natalie Neu
Meghan T. Murray*
Affiliation:
Columbia University School of Nursing, New York, New YorkElizabeth Seton Pediatric Center, Yonkers, New York
Olivia Jackson
Affiliation:
Elizabeth Seton Pediatric Center, Yonkers, New York
Bevin Cohen
Affiliation:
Columbia University School of Nursing, New York, New York
Gordon Hutcheon
Affiliation:
Elizabeth Seton Pediatric Center, Yonkers, New YorkDepartment of Pediatrics, New York Medical College, Valhalla, New York
Lisa Saiman
Affiliation:
Department of Pediatrics, Columbia University Medical Center, New York, New YorkDepartment of Infection Prevention and Control, NewYork Presbyterian Hospital, New York, New York
Elaine Larson
Affiliation:
Columbia University School of Nursing, New York, New York
Natalie Neu
Affiliation:
Elizabeth Seton Pediatric Center, Yonkers, New YorkDepartment of Pediatrics, Columbia University Medical Center, New York, New York
*
Address correspondence to Meghan T. Murray, MPH, 617 West 168th Street, Room 355, New York, NY 10032 (mtm2164@cumc.columbia.edu).
Rights & Permissions [Opens in a new window]

Abstract

We evaluated the collective impact of several infection prevention and control initiatives aimed at reducing acute respiratory infections (ARIs) in a pediatric long-term care facility. ARIs did not decrease overall, though the proportion of infections associated with outbreaks and average number of cases per outbreak decreased. Influenza rates decreased significantly.

Infect Control Hosp Epidemiol 2016;37:859–862

Information

Type
Concise Communications
Information
Infection Control & Hospital Epidemiology , Volume 37 , Issue 7 , July 2016, pp. 859 - 862
Copyright
© 2016 by The Society for Healthcare Epidemiology of America. All rights reserved 

Acute respiratory infections (ARIs) are burdensome in pediatric long-term care facilities (pLTCFs). Infection prevention and control (IP&C) interventions such as hand hygiene improvement, hiring IP&C personnel experienced in long-term care, prophylactic administration of oseltamivir, and staff and resident influenza vaccination have reduced outbreaks in adult long-term care.Reference Hota and McGeer 1 However, pLTCFs present additional challenges due to the family-centered approach, on-site schools, age-related vulnerability to infections, high rate of device utilization, and behavioral factors that increase transmission (eg, uncontrolled secretions).Reference Harris 2

Outbreaks in pLTCFs lead not only to morbidity and acute care hospitalizations for infected children but also to school closures and service reductions that affect quality of life for all residents.Reference Murray, Pavia and Jackson 3 Thus, preventing ARIs and limiting outbreaks are uniquely important in these settings. In this study, we implemented several IP&C interventions aimed at reducing ARIs in a pLTCF, and we compared the incidence of ARIs and related outcomes before and after implementation.

METHODS

Study Population

This study was conducted from January 2009 through May 2015 at a 137-bed pLTCF in New York that provides sub-acute, long-term, and rehabilitative services (bed occupancy, 97%–100%). The mean age of residents was 9.7 years (range, 2 months–21 years), and the average length of stay was 477 days (range, 1–7,315 days). Residents were being treated with mechanical ventilation (6%), tracheostomies (36%), and gastrostomy tubes (80%). Most residents had neurological deficits (>90%) including cerebral palsy, brain anomalies, and/or hypoxic ischemic encephalopathy. Most residents (83%) attended an on-site Department of Education school, and a few residents (4%) attended schools in the community. The staff-to-resident ratio was 4:1 and included 7 onsite clinicians. This study was approved by the appropriate institutional review boards.

Infection Prevention and Control Policies

A single IP&C coordinator worked with medicine, nursing, and environmental services to conduct active surveillance and to develop IP&C policies. Resident influenza vaccination and ARI isolation policies remained consistent throughout the study. All residents without a contraindication (>95%) were vaccinated for influenza. Residents with ARIs (index cases) were placed on contact/droplet precautions until 48 hours after symptoms improved or the pathogen’s shedding period passed, if the pathogen had been identified. The IP&C coordinator traced each case’s contacts by reviewing bed locations, school rooms, and group activities. Asymptomatic contacts were placed on contact/droplet precautions until precautions were discontinued for the index case. Beginning in 2009, the facility implemented a series of initiatives aimed at reducing ARIs (Table 1).

TABLE 1

Implementation of Infection Prevention and Control Policies and Procedures at a Pediatric Long-Term Care Facility

NOTE. ARI, acute respiratory infections; IP&C, infection prevention and control; DFA, direct fluorescent antibody; RT-PCR, reverse transcriptase polymerase chain reaction.

a DFA tests for adenovirus; RSV; parainfluenza 1, 2, 3; influenza A and B; and metapneumovirus. Viral culture tests for adenovirus; RSV; parainfluenza 1, 2, 3; and influenza A and B. RT-PCR tests for adenovirus; coronavirus HKU1, NL63, 229E, OC43; human metapneumovirus; human enterovirus/rhinovirus; influenza A; influenza A/H1; influenza A/H3; influenza A/H1−2009; influenza B; parainfluenza viruses 1, 2, 3, 4; respiratory syncytial virus; Bordetella pertussis; Mycoplasma pneumoniae; and Chlamydophila pneumonia.

Data Collection

The IP&C coordinator and a trained researcher collected data regarding the incidence of ARI outbreaks and cases associated with each, incidence of total ARIs and of ARIs unassociated with outbreaks, and number of ARI-related transfers to a separate acute care facility (eg, for respiratory distress). Date of onset, symptoms, and diagnostic testing results were recorded. The proportion of staff who received inactivated influenza vaccination was obtained from the facility’s employee health service.

ARIs were identified using the IP&C coordinator’s line list, medical records, in-house pharmacy database, and outside referral laboratory database. Case definitions were modified from the Society for Healthcare Epidemiology of America 2008 guidelines for adult long-term care.Reference Stone, Ashraf and Calder 4 ARIs were defined as (1) documented clinical diagnosis of upper or lower respiratory tract infection including pneumonia, tracheitis, and respiratory viral infections; (2) ≥2 documented symptoms (eg, abnormal temperature, cough, increased secretions, wheezing, vomiting/diarrhea, increased oxygen need, congestion, desaturation); and/or (3) positive laboratory test for a respiratory tract pathogen.

ARI outbreaks were defined as ≥2 cases of the same laboratory-confirmed pathogen or ≥2 cases on the same unit with the same symptoms.Reference Murray, Pavia and Jackson 3 Cases were considered part of an outbreak if they occurred within the maximum incubation period of the pathogen defined by Red Book. 5

Analysis

To analyze the collective impact of the interventions, we used Poisson regression to compare rates (incidence per 1,000 resident days) of total ARIs, ARIs unassociated with outbreaks, ARI-related transfers to acute care, use of viral diagnostic testing, and influenza before (January 2009–March 2012) and after (April 2012–May 2015) full implementation of the IP&C changes. Cases per outbreak were compared using the Student’s t test. Analyses were conducted using SAS 9.1 (SAS Institute, Cary, NC).

RESULTS

From January 2009 through May 2015, 946 ARIs occurred in 251 residents (3.0 per 1,000 resident days). There were 107 outbreaks, with an average of 3.7 infections per outbreak. Of 549 ARIs, 58% were single infections unassociated with outbreaks. ARI-related transfers to acute care occurred 219 times; 39 of these resulted in hospitalizations. Laboratory testing was performed for 475 ARIs (50%). Tests included direct fluorescent antibody (n=176), viral culture (n=159), and/or reverse transcriptase polymerase chain reaction (n=111). Test type was unknown for 201 samples (42%). Viral pathogens were identified for 267 ARIs (56%) and included parainfluenza (n=75; 28%), rhinovirus/enterovirus (n=56; 21%), influenza (n=47; 16%), human metapneumovirus (n=40; 15%), respiratory syncytial virus (n=34; 13%), coronavirus (n=7; 3%), and 2 cases (1%) had ≥1 virus. One resident died due to adenovirus.

Table 2 describes differences in ARI outcomes before and after implementation of the new policies. While the rates of total ARI and outbreaks increased (P<.01 and P=.20, respectively), the proportion of infections associated with outbreaks and the average number of cases per outbreak decreased (P<.01 and P=.17, respectively). Staff vaccination increased from an average of 65% during 2009–2013 (range, 44%–77%) to an average of 97% during 2013–2015 (range, 96%–98%), and incidence of influenza in residents decreased significantly.

TABLE 2

Acute Respiratory Infections, Outbreaks, and Use of Viral Diagnostic Testing Before and After Implementation of New Infection Prevention and Control Policies

NOTE. ARI, acute respiratory infection.

a Includes data previously reported during an outbreak of human metapneumovirus in 2010.Reference Neu, Plaskett, Hutcheon, Murray, Southwick and Saiman 6

b Incidence per 1,000 resident days. Differences assessed using Poisson regression.

c Mean. Differences assessed using the Student t test.

DISCUSSION

We detected increases in ARIs and outbreaks after implementing IP&C initiatives, including a respiratory illness algorithm, enhanced screening for visitors and staff, mandatory staff influenza vaccination, and an 83% increase in facility size, which increased space between residents. We suspect that the observed increase may be due to greater case detection from improved surveillance and testing. Another contributing factor may be the doubling of mechanical ventilation beds after facility expansion, which elevated the average severity of illness among residents. We detected higher rates of ARI versus adult long-term care, 3.0 versus 1.2 ARIs per 1,000 resident days, respectively.Reference Loeb, McGeer, McArthur, Walter and Simor 7 This result is not surprising considering the immunologic immaturity and behavioral characteristics of pediatric patients. Pathogens identified in our facility are similar to those reported by other pLTCFs, including influenza and adenovirus.Reference DiOrio, de Fijter and Schwartz 8 , Reference James, Vernon and Jones 9

Although ARIs increased overall, the rate of single infections unassociated with outbreaks increased and outbreak size decreased, suggesting that IP&C initiatives successfully curtailed the spread of ARIs. Because complete ARI prevention is likely infeasible, focusing on limiting transmission may have a strong impact on reducing resident morbidity, mortality, and facility-wide disruption of services due to isolation. Influenza rates also decreased significantly, likely due to high compliance with the staff vaccination policy. The respiratory illness algorithm was intended to reduce acute care transfers by providing information to help manage residents within the facility. However, no change was observed, possibly because 44% of the assays performed did not detect viral pathogens.

Because IP&C changes were implemented sequentially during a short period, it was impossible to isolate the effects of any single initiative. Detection bias likely resulted from enhanced surveillance and greater use of more sensitive and specific tests. Furthermore, consistent ARI documentation in this population is challenging due to the lack of pLTCF-specific case definitions.Reference Murray, Neu and Cohen 10 High nursing turnover during facility expansion and turnover in the IP&C coordinator role may also have confounded our results. Nevertheless, our findings support the use of mandatory staff influenza vaccination and suggest that factors such as increased space between residents and heightened ARI symptom monitoring among staff may limit transmission within the facility once a case occurs.

ACKNOWLEDGMENTS

Financial support: This work was funded by a grant from the Agency for Healthcare Research and Quality (grant no. R01 HS021470). DebMed provided the hand hygiene dispensers and a group monitoring system.

Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.

References

REFERENCES

1. Hota, S, McGeer, A. Antivirals and the control of influenza outbreaks. Clin Infect Dis 2007;45:1362–1368.CrossRefGoogle ScholarPubMed
2. Harris, JA. Infection control in pediatric extended care facilities. Infect Control Hosp Epidemiol 2006;27:598–603.CrossRefGoogle ScholarPubMed
3. Murray, MT, Pavia, M, Jackson, O, et al. Healthcare-associated infection outbreaks in pediatric long-term care facilities. Am J Infect Control 2015;43:756–758.CrossRefGoogle ScholarPubMed
4. Stone, ND, Ashraf, MS, Calder, J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965–977.CrossRefGoogle ScholarPubMed
5. American Academy of Pediatrics Committee on Infectious Diseases. Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2012.Google Scholar
6. Neu, N, Plaskett, T, Hutcheon, G, Murray, M, Southwick, KL, Saiman, L. Epidemiology of human metapneumovirus in a pediatric long-term care facility. Infect Control Hosp Epidemiol 2012;33:545–550.CrossRefGoogle Scholar
7. Loeb, M, McGeer, A, McArthur, M, Walter, S, Simor, AE. Risk factors for pneumonia and other lower respiratory tract infections in elderly residents of long-term care facilities. Arch Intern Med 1999;159:2058–2064.CrossRefGoogle ScholarPubMed
8. DiOrio, M, de Fijter, S, Schwartz, M, et al. Severe influenza among children and young adults with neurologic and neurodevelopmental conditions—Ohio, 2011. Morb Mortal Wkly Rep 2012;60(51–52):1729–1733.Google Scholar
9. James, L, Vernon, MO, Jones, RC, et al. Outbreak of human adenovirus type 3 infection in a pediatric long-term care facility—Illinois, 2005. Clin Infect Dis 2007;45:416–420.CrossRefGoogle Scholar
10. Murray, MT, Neu, N, Cohen, B, et al. Developing case definitions for healthcare-associated infections for pediatric long term care facilities. Clin Pediatr (Phila) 2015;54:1380–1382.CrossRefGoogle ScholarPubMed
Figure 0

TABLE 1Implementation of Infection Prevention and Control Policies and Procedures at a Pediatric Long-Term Care Facility

Figure 1

TABLE 2Acute Respiratory Infections, Outbreaks, and Use of Viral Diagnostic Testing Before and After Implementation of New Infection Prevention and Control Policies