To our knowledge, this is the first study to examine nosocomial infection rates in a pediatric residential care facility, and the first among pediatric extended care facilities to calculate incidence rates. The lack of such information makes it difficult for extended care facilities to make external comparisons and judge whether its endemic rate exceeds that of other comparable facilities.
For extended care facilities that predominantly serve the adult population, rates of nosocomial infections have been seen to vary extensively depending on the type of facility, the demographics of the population served, and how nosocomial infections were characterized and reported.3, 14
Based on our extensive literature review, only two studies 9, 10
were found citing period prevalence of infection in pediatric extended care facilities (). Vermaat and coworkers conducted a one-year study in a pediatric long-term care facility and reported similar prevalence of URI and eye infections as the current study. Statistically significant differences were observed for UTI, skin, gastrointestinal and lower respiratory infections (P<0.05). Prevalence of UTI was 73% lower in the current study, while prevalences of skin, gastrointestinal, and lower respiratory infections were 188%, 163%, 359% greater, respectively. Harris and co-workers conducted a two-year study of infection prevalence rates in a pediatric rehabilitation hospital. For comparative purposes, we divided prevalence in half, assuming a uniform distribution of infections over the two-year study period and that infections were quickly resolved. Compared to the current study, statistically significant differences were observed for URI, LRI, skin and gastrointestinal infections (P<0.05). Prevalence of UTI was 31% lower in the current study, while prevalence’s of skin, gastrointestinal, URI and LRI were 900%, 207%, 53% and 164% greater, respectively.
Studies reporting nosocomial infection prevalence in pediatric extended care facilities compared to current study
Based on our results comparing infection rates in a residential care facility to those in a long-term9
facility, we can conclude that significant differences in rates exist among different pediatric extended care facilities. LRIs, skin infections and gastrointestinal infections were all higher in the residential care facility, while eye infections were only slightly higher in this study compared to the long-term care facility. URI was lowest in the rehabilitation hospital and highest in the long-term care facility. UTI was much lower in this study compared to the long-term care facility, but similar to that observed in the rehabilitation hospital. Although it can be suggested that pediatric residential care facilities, such as SMHDC, vary in characteristics of patient population, structure, and scope of practice from other extended care facilities, thus having a different infectious disease burden, these conclusions should be taken cautiously due to the evolution in infection control practices, development of new drugs, and the detection of new organisms. Because of the dearth of data on infection rates in pediatric residential care facilities, it is difficult to discern whether or not SMHDC’s infection rates are standard for this type of facility. Therefore, more studies are needed to examine and validate these distinctions between facility types and investigate the potential factors associated with these disparities in infection profiles.
Current infection prevention and control strategies in pediatric extended care facilities have mostly been derived from acute care hospitals that predominantly serve the adult population, failing to conform to unique child-specific needs. Methods used to control infections in acute and other non-acute care facilities may not be applicable to this or other similar facilities due to the differences in host factors, sources of infection, routes of transmission, and distribution of pathogens. 15
A national surveillance system for hospitals, the National Nosocomial Infections Surveillance (NNIS) system, provides acute care facilities with a standardized method of reporting nosocomial infections and provides hospitals with an external benchmark for comparison.16
This system, only exclusive to participating acute care hospitals, analyzes data from hospital-wide, intensive care unit, high-risk nursery, and surgical patient surveillance components that is voluntarily reported to the Center for Disease Control and Prevention.17
National surveillance systems, similar to the NNIS, would be beneficial for pediatric extended care facilities and should not be exclusive to acute care facilities. Infection control policies and procedures should be developed that are specific to each institution based on infection rates, severity of illness of residents, level of care provided to residents, and the structure of the facility. A panel of members from the Centers for Disease Control and Prevention, the American Practitioners of Infection Control, the Society for Hospital Epidemiology of America, the Joint Commission on Accreditation of Healthcare Organizations, and the Pediatric Infectious Diseases Society developed the fundamental structure of an infection control program in a long-term care facility to include surveillance, policy development, adequate employee health and continuing education.18
Although these elements were developed for all extended care facilities, they provide a good foundation which can be built upon to develop infection control protocols for the pediatric population and for specific facilities. Pediatric residential care facilities, like SMHDC, can develop an ongoing surveillance system to monitor the incidence of infections, and use this data to inform clinicians and to implement new procedures to eliminate suspected causes of infections. Informing clinicians via continuing education is particularly useful in this setting because infections and their etiology can vary by season.
Existing infection control measures implemented at the study facility include an emphasis on good hand hygiene using soap and water or antiseptic hand gel by the display of placards at each wash station, isolation precautions for patients with an infection, encouraged sick time for employees with symptoms, and restricted access to the play area and pool for certain infections, although the compliance rates are not known. Standard precautions, such as the use of gloves, gown, and hang hygiene are known to help keep infection rates down. In addition, we suggest that medical devices such as stethoscopes and thermometers be sanitized after each use. Personal items such as toys should be kept away from other children to eliminate the spread of pathogens. We also encourage active surveillance and continuing education for clinicians on the current infectious trends at the facility on a regular basis.
This study has several limitations. Only one residential care facility was examined for this analysis and hence sample size is small and the data are not generalizable to all extended care facilities. The reliance on a retrospective minimal dataset did not allow for the characterization of credentials for health professionals who made the various diagnoses. Inconsistent availability of laboratory data also precluded the validation of ICD-9-CM codes.
Our data indicate that the prevalence of nosocomial infections in this pediatric residential care facility located in Virginia differs from other pediatric extended care facilities. The brevity of published data on pediatric residential care facility infection rates and the descriptive nature of this study limit the amount of comparative analyses that can be done. Based on these study findings, we would recommend that future studies examining trends in infection rates should not characterize extended care facilities as one entity, given the observed heterogeneity among these facilities suggested by our results. In addition, infectious disease surveillance results should be shared with each facility’s infection control department and clinical employees to further educate them on the importance of primary prevention techniques and implementation of appropriate strategies. This study was intended to serve as a baseline for future studies on pediatric residential care facilities. Further research is needed to expand our knowledge on infections that occur in pediatric residential care facilities in order to develop targeted strategies that can reduce infections.