New guidance on contact precautions for hospital visitors

Leading infectious diseases experts have released new guidance for healthcare facilities looking to establish precautions for visitors of patients with infectious diseases. The guidance looks to reduce the potential for healthcare visitors in spreading dangerous bacteria within the healthcare facility and community. The recommendations are published online in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA).

"Visitors have initiated or been involved in healthcare-associated infection outbreaks, but it is unknown to what extent this occurs in the transmission of bacteria in healthcare facilities," said L. Silvia Munoz-Price, MD, PhD, a lead author of the guidance. "The guidance is intended to strike a balance between visitor and patient safety, the potential for pathogen spread in hospitals, the psychosocial implications of isolation and the feasibility of enforcement."

The SHEA Guidelines Committee, comprised of experts in infection control and prevention, developed the recommendations based on available evidence, theoretical rationale, practical considerations, a survey of SHEA members, author opinion and consideration of potential harm where applicable.

Since not all pathogens present the same risk of transmission to and via visitors, the guidance reflects the protections that should be taken for distinct pathogens. The authors caution that visitor precautions should only be implemented by hospitals if they can be realistically enforced and regularly evaluated for compliance. Healthcare facilities should use the guidance as a framework for developing facility policies. Recommendations include:

• Hand hygiene performed prior to entering and immediately after leaving a patient room.
• In areas where they are endemic, methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) do not require contact isolation precautions for visitors given their prevalence in the community. However, special considerations should be made for immunocompromised visitors or those unable to practice good hand hygiene.
• Visitors of patients with gram-negative organisms, such as carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pnemoniae carbapenemase (KPC), should follow contact precautions to help prevent transference of pathogens to guests.
• Intestinal pathogens, such as Clostridium difficile and norovirus, are potentially harmful to visitors and have low prevalence in the community so contact isolation precautions should be in place.
• Visitors to rooms with droplet (i.e., pertussis) or airborne precautions (i.e., tuberculosis) should use surgical masks. This is especially the case for household contacts already exposed to the symptomatic patient. N95 respirators are an alternative best used with training and fit testing. Consideration should be given to limit visitation for those visitors requiring high levels of protection (due to lack of documented exposure to the symptomatic patient). In outbreak situations or when novel pathogens are suspected, isolation precautions should be enforced for all visitors.
• For visitors with extended stays, like parents and guardians, isolation precautions are likely not practical and the benefit of wearing personal protective equipment like gowns and gloves is unclear except if assisting in care delivery. In many cases, these visitors may have had extensive exposure to the patient prior to hospitalization and could be immune to the pathogen or in an incubation period.

A survey of SHEA members showed that the majority of their healthcare facilities have policies for visitation of inpatient isolation rooms and many of these policies mirror healthcare personnel policies. However, most healthcare facilities did not monitor visitors' compliance with policies.

The authors recommend further research on the role of visitors in the transmission of healthcare-associated infections to better define the risk and preventive measures necessary.