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Infection prevention and control practices among pediatric family caregivers during respiratory viral season and an enteric outbreak

Published online by Cambridge University Press:  03 April 2025

Aparna Darbha ,
Meghan Engbretson Open the ORCID record for Meghan Engbretson [Opens in a new window]  and
Nisha Thampi Open the ORCID record for Nisha Thampi [Opens in a new window]
Aparna Darbha
Affiliation:
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada CHEO Research Institute, Ottawa, ON, Canada
Meghan Engbretson
Affiliation:
Infection Prevention and Control Program, CHEO, Ottawa, ON, Canada
Nisha Thampi*
Affiliation:
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada CHEO Research Institute, Ottawa, ON, Canada Infection Prevention and Control Program, CHEO, Ottawa, ON, Canada
*
Corresponding author: Nisha Thampi; Email: nthampi@cheo.on.ca
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Abstract

We audited family caregivers’ hand hygiene (HH) and masking practices at a pediatric tertiary care center during a period of increased community viral circulation and an enteric outbreak. Observed HH rates were below 5%, whereas masking was above 90%. Awareness of practices can inform strategies in caregiver infection prevention education.

Information

Type
Concise Communication
Information
Infection Control & Hospital Epidemiology , Volume 46 , Issue 6 , June 2025 , pp. 644 - 646
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Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Introduction

Hand hygiene (HH) and source control masking are effective healthcare-associated infection (HAI) prevention measures. Reference Paquette, Shephard, Bedard and Thampi1 Education surrounding HH technique and masking practices in hospitals focus primarily on healthcare personnel, despite the presence of others in the patient environment who likely contribute to HAIs. Reference Paquette, Shephard, Bedard and Thampi1 For pediatric patients, family caregivers (henceforth “caregivers”) are closely involved in their bedside care, entering and exiting rooms often. Alongside healthcare personnel, caregivers play an important role in HAI prevention.

Studies performed prior to the COVID-19 pandemic have demonstrated positive caregiver attention toward infection prevention strategies. Caregivers recognize the importance of HH in preventing HAIs and express interest in receiving infection prevention-related information. Reference Lee, Lo and Luan2–Reference Zahradnik, Tsampalieros and Okeny-Owere4 Nonetheless, audits have shown low caregiver HH rates upon entry and exit of patient rooms. Reference Zahradnik, Tsampalieros and Okeny-Owere4,Reference Lo, Luan, Jacques, Krueckl and Srigley5 Following public health messaging around infection prevention strategies during the pandemic and the introduction of universal masking among hospital personnel and visitors, our objective was to measure caregiver HH and masking practices during a period of high community viral activity at a pediatric tertiary care center.

Methods

Study setting

This study was conducted on two pediatric medicine inpatient units at a pediatric tertiary care center in Ottawa, Ontario, between October and December 2023. During the study period, hospital policy mandated masking across all clinical units for hospital personnel and families and was reinforced through signage upon hospital and unit entry and handouts to caregivers at time of admission. Alcohol-based hand rub (ABHR) stations were available between patient rooms in unit corridors and in every patient room. All patients in isolation received information advising caregivers to wash their hands upon room entry and exit. A sink for handwashing with soap and water was available inside patient rooms and anterooms of isolation rooms. Gloves were available in every patient room.

During the study period, RSV, Influenza A, and SARS-CoV-2 test positivity peaked at 17%, 10%, and 18%, respectively, in the Ottawa region (communication from Eastern Ontario Regional Laboratory Association) and a norovirus outbreak occurred on two inpatient units (November 15–December 5). All caregivers received information from hospital staff regarding the enteric outbreak and HH reminders verbally and through fliers. The kitchen and playroom of the affected units were closed for the duration of the outbreak.

This study was exempt from review by the hospital Research Ethics Board as it was considered a quality improvement initiative with no personal patient or caregiver information collected.

Caregiver hand hygiene and masking audits

Trained study personnel performed audits on each unit over a one-hour period once or twice weekly outside patient rooms with no interaction with caregivers or staff. Audits consisted of observations of caregiver HH (soap and water or ABHR) and caregiver masking (visible or absent at point of entry or exit from room) via the SafetyCulture auditing application. 6

Each recorded observation included the date, moment (entry or exit), action (HH or masking), the presence of additional precautions identified by isolation signage posted outside the room, and room occupancy. Observations were not documented at the caregiver or patient level.

Results

Over the 9-week study period, 274 observations were recorded: 168 (61.3%) were made upon caregiver entry into patient rooms and 106 (38.7%) were made upon caregiver exit. There were 178 (65%) observations before, 54 (19.7%) during, and 42 (15.3%) after the norovirus outbreak.

Overall caregiver HH was observed to be 4.3%; among patients in isolation, caregiver HH was 3.4% (Table 1). In both circumstances, HH was less frequent upon exit from the patient room than upon entry. Compliance with masking was noted among 92% of caregivers overall and above 95% among those with children in isolation.

Table 1.

Hand hygiene and masking compliance upon caregiver entry/exit into patient rooms

During the norovirus outbreak, HH compliance did not improve. Most caregivers were observed to omit HH upon room entry and exit; by the end of the outbreak and following week, no HH was observed (Figure 1). There was no significant change in masking behaviors before, during, and after the outbreak.

Figure 1.

Caregiver hand hygiene and masking compliance upon entry/exit into patient rooms before, during, and after an enteric outbreak. HH = hand hygiene.

Of the 155 caregivers who masked upon entry, 8 individuals (5.16%) also performed HH upon entry; of the 96 who masked upon exit, 3 (3.13%) also performed HH upon exit. Of the 13 caregivers who were not masked upon entry, 0 (0%) performed HH upon entry; among the 10 who were not masked upon exit, 1 (10%) performed HH upon exit.

Interpretation

Fewer than 1 in 20 family caregivers were observed to wash their hands upon entry or exit of their child’s hospital room. Even in the context of increased risk of infection transmission, namely when patients were in isolation or there was a norovirus outbreak declared on the unit, observed caregiver HH rates remained under 5%. Compliance with masking was consistently above 90% during the study in the context of a hospital-wide mandatory masking policy. Yet, caregiver masking did not predict HH practices; among those who masked, only 5% performed HH upon entry and 3% upon exit of patient rooms. This discrepancy may represent knowledge gaps in appropriate HH moments. Given the focus on masking in public health messaging during the COVID-19 pandemic, individuals may have been less likely to engage in other behaviors that could reduce the spread of respiratory and enteric pathogens. Reference Wangchuk, Kinga null, Wangdi, Tshering and Wangdi7,Reference Mantzari, Rubin and Marteau8 Individual caregiver HH education and reinforcement may vary among clinicians. Finally, caregivers experiencing repeat admissions have been shown to be less likely to report HH after room entry and exit, and so may have lower HH rates. Reference Zahradnik, Tsampalieros and Okeny-Owere4 Our findings are consistent with pre-pandemic studies showing low caregiver HH compliance rates between 3.3 and 9%. Reference Zahradnik, Tsampalieros and Okeny-Owere4,Reference Lo, Luan, Jacques, Krueckl and Srigley5

Limitations to the study include frequency of audits and the potential of a Hawthorne effect, with the presence of study personnel near the patient environment influencing HH and/or masking behaviors. Reference Purssell, Drey, Chudleigh, Creedon and Gould9 However, the auditors were not part of clinical teams and did not interact with caregivers or staff, which likely reduced the potential for this effect. Audits were performed outside of patient rooms, so HH may have been performed inside the room before the caregiver touched the patient or after leaving their bedside. While a HH moment in the room would have been missed, families are provided guidance at time of admission to wash their hands before entering and exiting the room. As such, compliance around the guidance is less likely to have been under-reported.

Our study shows low caregiver HH practices during a time of increased community circulation of respiratory pathogens and among those caring for children with infectious syndromes. Notably, additional HH messaging to caregivers on the unit during an enteric outbreak did not improve rates. Building on earlier findings of caregiver HH knowledge and practices, next steps include engaging family advisors to understand HH motivations and barriers and co-design multimodal educational strategies such as pamphlets and videos. As pediatric care partners, caregivers play a central role in infection prevention and can be empowered with strategies to prevent pathogen spread during hospitalization and within healthcare settings.

Financial support

No funding was secured for this study.

Competing interests

The authors have no conflicts of interest relevant to this article to disclose.

References

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Figure 0

Table 1. Hand hygiene and masking compliance upon caregiver entry/exit into patient rooms

Figure 1

Figure 1. Caregiver hand hygiene and masking compliance upon entry/exit into patient rooms before, during, and after an enteric outbreak. HH = hand hygiene.