Exploring Clinic Characteristics and Opportunities for Hand Hygiene Among Parents and Patients in Pediatric Ambulatory Settings

Background: Healthcare-associated respiratory infections (HA-RIs) are sources of significant health and financial burden to pediatric patients and health care workers (HCWs). In the U.S., HA-RIs, related to pediatric ambulatory practice exposures account for ~770,000 excess cases of influenza-like illness (ILI) annually. Yet, little is known about factors related to respiratory virus transmission in outpatient care settings. We aimed to explore opportunities for the transmission of HA-RIs in pediatric primary care clinics.

Methods: We conducted 3 hour observation sessions focused on the movement and behaviors of parent-patient dyads in the waiting areas of 14 clinics within a large pediatric ambulatory network. Using an exam and waiting room audit tool, we documented parent-patient dyad and clinic infection control activities including use of alcohol hand rub, dyad wait times, and instances of surface cleaning in waiting areas. Presence of alcohol hand rub in waiting areas represented 1 opportunity for alcohol hand rub use.

Results: Nearly one-third (35.7%) of clinics had separate well and sick waiting rooms, 21% of clinics had hard toys in the waiting room, 79% had books or magazines, and 86% had at least one respiratory etiquette station. During 18 observation sessions, 542 dyads were observed. There were 34 occurrences of parent alcohol hand rub use in 598 opportunities (5.7%) and 32 occurrences of child alcohol hand rub use in 590 opportunities (5.4%). The median observed wait time was 7 mins (iqr: 9 mins). There was 1 occurrence of surface cleaning in a well waiting room (1.9%) and no observed surface cleaning in sick waiting rooms.

Conclusion: We observed potential opportunities for respiratory virus transmission with infrequent infection prevention activities including hand hygiene use among parents and patients. Since the prevention of HA-RI transmission is a shared responsibility among HCWs, parents, and patients, IPC programming in ambulatory practices should include audits of parent-patient compliance to IPC measures. Emphasizing behavioral changes among parents and children in ambulatory practices may also lead to adoption of these behaviors in the community, where unknown rates of transmission occurs.