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Implementation of respiratory protection measures: Visitors of residential care homes for the elderly
ARTICLE IN PRESS American Journal of Infection Control ■■ (2016) ■■-■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Implementation of respiratory protection measures: Visitors of residential care homes for the elderly Diana T.F. Lee PhD, MSc, RN, FAAN a,*, Doris S.F. Yu PhD, BSc, RN a, Margaret Ip MSc, DTM&H, FRCPath, FRCP(Glasg), FRCPA, FHKCPath(Clin Micro, Infection), FHKAM b, Jennifer Y.M. Tang PhD, MPhil c a b c
The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong Department of Microbiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Sau Po Centre on Ageing, The University of Hong Kong, Pokfulam, Hong Kong
Key Words: Old age homes Nosocomial outbreaks Influenza
To evaluate the implementation of respiratory protection measures for and by visitors of residential care homes for the elderly in Hong Kong, a territory-wide cross-sectional survey was conducted. A total of 87 infection control officers, 1,763 health care workers, and 520 visitors from 87 homes completed the questionnaires. Rules on respiratory protection for visitors were found to vary across residential care homes for the elderly. Uncooperative visitors and inadequate resources were identified as major barriers in the implementation of such measures for visitors. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Residential care homes for the elderly (RCHEs) are homes for older people who require daily assistance with personal and nursing care at various levels. These homes represent a vulnerable community for nosocomial outbreaks of influenza. Various studies have indicated health care workers’ poor compliance with respiratory protection measures in these homes.1-3 Although visitors are important individuals to safeguard these homes against the outbreak of influenza infections, little is known about the implementation of respiratory protection measures for and by the visitors to these homes. A territory-wide cross-sectional survey was conducted September 2014-August 2015 to evaluate the implementation of respiratory protection measures in RCHEs in Hong Kong. This article reports the evaluation of the implementation of such measures for and by visitors.
METHODS Proportional cluster sampling was used to recruit 87 RCHEs using funding mode as the cluster. For each recruited RCHE, 3 target groups
* Address correspondence to Diana T.F. Lee, PhD, MSc, RN, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong. E-mail address: [email protected] (D.T.F. Lee). The Health and Medical Research Fund, Food and Health Bureau, Hong Kong, funded this study (grant number RRG-17). Conflicts of interest: None to report.
were recruited as participants: 1 infection control officer (ICO), all health care workers (nurses, health workers, care workers, and other allied health care staff), and a convenience sample of 10 visitors. Three sets of questionnaires were developed to collect data about the implementation of respiratory protection measures on these 3 groups of participants. Relevant findings from the questionnaires for ICOs, health care workers, and visitors related to the objective of this article will be reported. The questionnaire for the ICOs evaluated 10 perspectives of implementation at the organizational level, such as infection control policies and practices, preparedness of the environment and resources, surveillance and monitoring systems, and outbreak preparedness and management. The questionnaire for the health care workers evaluated their implementation of such measures in areas such as hand hygiene, respiratory hygiene, and etiquette and management of waste. The questionnaire for the visitors focused on evaluating their practice on respiratory protection measures when they visited the residents. The response set for these 3 sets of questionnaires was a 4-point Likert scale with higher scores representing a higher level of implementation. Open-ended questions were included to explore the challenges, facilitators, and barriers for implementing such measures. Descriptive statistics were used to describe the implementation of measures and content analysis was performed on the responses to the open-ended questions. Generalized estimating equations with unstructured working correlation matrices were used to analyze the simultaneous influence of organizational and individual factors on the implementation of such measures.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.07.022
ARTICLE IN PRESS D.T.F. Lee et al. / American Journal of Infection Control ■■ (2016) ■■-■■
2
RESULTS A total of 87 RCHEs (17 nonprivate homes and 70 private homes) were recruited. Private homes had a significantly lower nurse to resident ratio (1:61.2; P = .016) but not health worker to resident ratio (1:22.4; P = .927) when compared with nonprivate homes. A total of 87 ICOs, 1,763 health care workers, and 520 visitors from these homes completed the questionnaires. A majority of the ICOs (93.1%), health care workers (87.6%), and visitors (64%) were women and had attained secondary school education. Their mean age was 47.3, 45.2, and 55.1 years, respectively. A majority of the ICOs were health workers (41%) or registered nurses (37.9%). A health worker is a person who has completed a course of training approved by the government and is responsible for the overall health care of residents in RCHEs in the absence of registered nurses.4 Two-thirds of the homes (46 private and 12 nonprivate) had written regulations on respiratory protection for visitors. One-third of homes (21 private and 10 nonprivate) did not have a restriction on the number of visitors allowed for each resident at one time. Some homes required visitors (21.8%) and volunteers (20.7%) to attend training on respiratory protection measures. Table 1 shows the implementation of rules on some selected respiratory protection measures for visitors. Although it was reported that visitors were not
allowed to visit if they were having influenza-like symptoms (94.3%) and if the resident was having an influenza-like illness (85.1%), 49.4% of the homes either did not or only sometimes required visitors to report influenza-like symptoms. As for the health care workers, rules for visitors were generally implemented more strictly during peak season or influenza outbreak. Among all the rules, “reminding visitors to receive seasonal influenza vaccine annually” and “measuring body temperature for all visitors” were less well implemented both during normal and peak seasons. Uncooperative visitors (72.4%) and inadequate resources (23%) were identified by the ICOs as the main barriers for the homes to implement such measures. In terms of the implementation of rules for visitors, results of the generalized estimating equation analysis found that such implementation was positively associated with the type of home and the total number of residents. Private homes rated higher score for implementation both during normal conditions (P = .014) and during peak season/influenza outbreak (P = .026). Homes with more residents also rated higher scores for implementation both during normal conditions (P < .001) and during peak season/influenza outbreak (P = .005). More than one-third of visitors (36.2%) had received seasonal influenza vaccination. For those who had not received the vaccination, they considered themselves healthy and did not perceive a need to have the vaccination. As outlined in Table 2, most of the protec-
Table 1 Selected items on rules and resources on respiratory protection measures for visitors RCHEs (n = 87) Rules and resources for visitors Visitors having influenza-like symptoms are allowed to visit Visitors are allowed to visit if the resident is having an influenza-like illness Visitors are allowed to visit during an outbreak of influenza Visitors are required to report influenza-like symptoms Asymptomatic visitors are required to wear a mask
None/some of the time
Most/all of the time
82 (94.3) 74 (85.1) 83 (95.4) 43 (49.4) 45 (51.7)
5 (5.7) 13 (14.9) 4 (4.6) 44 (50.6) 42 (48.3) Health care workers (n = 1,763)
Implementing rules for visitors during normal condition Reminding visitors to receive seasonal influenza vaccine annually Measuring body temperature for all visitors Advising visitors to perform proper hand hygiene before visiting Advising visitors to perform proper hand hygiene after visiting
581 (33.0) 633 (35.9) 302 (17.1) 307 (17.4) Health care workers (n = 1,763)
Implementing rules for visitors during peak season/influenza outbreak Reminding visitors to receive seasonal influenza vaccine annually Measuring body temperature for all visitors Advising visitors to perform proper hand hygiene before visiting Advising visitors to perform proper hand hygiene after visiting
1,182 (67.0) 1,130 (64.1) 1,461 (82.9) 1,456 (82.6)
577 (32.7) 520 (29.5) 237 (13.4) 249 (14.1)
1,186 (67.3) 1,243 (70.5) 1,526 (86.6) 1,514 (85.9)
NOTE. Values are presented as n (%). RCHEs, residential care homes for the elderly.
Table 2 Implementation of respiratory protection measures by visitors Visitors (N = 520)
During normal condition I will receive a seasonal influenza vaccine every year. I will wash my hands with liquid soap or apply alcohol-based handrub before visiting I will wash my hands with liquid soap or apply alcohol-based handrub after visiting I will wear a mask if I have respiratory symptoms I will not visit the resident if I have respiratory symptoms I will fill in the visiting records During peak season/influenza outbreak I will receive a seasonal influenza vaccine every year I will wash my hands with liquid soap or apply alcohol-based handrub before visiting I will wash my hands with liquid soap or apply alcohol-based handrub after visiting I will wear a mask if I have respiratory symptoms I will not visit the resident if I have respiratory symptoms I will not visit the resident if there is an outbreak of influenza in the residential care home I will fill in the visiting records NOTE. Values are presented as n (%).
None/some of the time
Most/all of the time
357 (68.7) 173 (33.3) 149 (28.7) 74 (14.2) 191 (36.7) 239 (46.0)
163 (31.3) 347 (66.7) 371 (71.3) 446 (85.6) 329 (63.3) 281 (54.0)
333 (64.0) 121 (23.3) 102 (19.6) 64 (12.3) 161 (31.0) 193 (37.1) 200 (38.5)
187 (36.0) 399 (76.7) 418 (80.4) 456 (87.7) 359 (69.0) 327 (62.9) 320 (61.5)
ARTICLE IN PRESS D.T.F. Lee et al. / American Journal of Infection Control ■■ (2016) ■■-■■
tion measures were implemented by the visitors. In general, most measures were implemented more often during peak season/ influenza outbreak. When asked about why protection measures were implemented or not implemented, “afraid of being infected” (52.5%), “compulsory requirement by the home” (50.3%), and “accessible respiratory protection resources provided by the home” (42.3%) were rated by the visitors as the main reasons. In terms of the barriers to implementing such measures, most visitors (76.9%) indicated that there is no barrier. Some indicated inadequate supplies of resources (10.8%) and inadequate knowledge to implement the measures (10.2%) as barriers. DISCUSSION This study has added knowledge to an area of infection control in old-age homes where very little is known. Although relevant work in this area is scarce, this study in Hong Kong identified that although the rules on respiratory protection for visitors do vary across RCHEs, they are in the main comparable to international guidelines.5,6 It is worthwhile to note that although a majority of homes do not allow visitors to visit if they are having influenza-like symptoms, quite a number of homes do not require visitors to report such symptoms. It remains unclear how RCHEs are to implement this rule. Implementation of respiratory protection measures for and by visitors of RCHEs is found to be generally adequate. The uptake of seasonal influenza vaccine by visitors in this study is also comparatively higher than the 14% in the general population reported by our Centre for Health Protection.7 This may be a result of the intense vaccination promotion work that has been conducted during the past few years. Uncooperative visitors have been identified by RCHE staff as a major barrier in the implementation of such measures. Some visitors themselves have indicated lack of knowledge as a barrier for them to practice such measures. Indeed, provision of education to frequent visitors such as family members and volunteers has been identified as a usual practice in some countries.8 About one-quarter of homes in this study require families and volunteers to attend relevant training. It appears that this practice could be further promoted to empower visitors with the necessary knowledge and skills in respiratory protection. It is also noted that both ICOs and visitors have indicated inadequate resources as a barrier. Indeed, both human and material resources are pivotal to the successful implementation of respiratory protection measures. 9 Continuous efforts in this area are warranted. This study also identified that private homes rated significantly higher scores in the implementation of rules for visitors during
3
both normal conditions and peak season/influenza outbreak. Of all the characteristics between private and nonprivate homes in this study, the only significant difference was that private homes had a significantly lower nurse to resident ratio. In RCHEs in Hong Kong, health workers are the key health care personnel responsible for the overall health care of older residents in the absence of nurses.4 Private homes in this study do not differ significantly in terms of the health worker to resident ratio when compared with nonprivate homes. Findings of this study therefore suggest that empowering health workers with the necessary knowledge and skills in respiratory protection is pivotal in enhancing the implementation of such measures in these homes. A limitation of this study is that it employed self-report to evaluate the implementation of respiratory protection measures. Future studies could use objective competence assessment to provide a broader assessment of the implementation of respiratory protection measures in RCHEs.
Acknowledgments The authors thank the RCHEs and the staff and visitors of the homes who participated in the survey.
References 1. Uchida M, Pogorzelska-Maziarz M, Smith PW, Larson E. Infection prevention in long-term care: a systematic review of randomized and nonrandomized trials. J Am Geriatr Soc 2013;61:602-14. 2. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010;14:e1106-14. 3. Ho M, Seto W, Wong L, Wong T. Effectiveness of multifaceted hand hygiene interventions in long-term care facilities in Hong Kong: a cluster-randomized controlled trial. Infect Control Hosp Epidemiol 2012;33:761-7. 4. Social Welfare Department. Code of practice for residential care homes (elderly persons). Hong Kong: Hong Kong Special Administrative Region; 2013. 5. Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SHEA/APIC Guideline Infection prevention and control in the long-term care facility. Infect Control 2008;36:504. 6. Northern Health and Social Care Trust. Visitor guidelines [Internet]. Antrim: Northern Health and Social Care Trust; 2013 [updated February 8, 2013] Available from: http://www.northerntrust.hscni.net/hospitals/1063.htm. Accessed January 24, 2014. 7. Centre for Health Protection. Seasonal influenza vaccination coverage survey for the 2012/13 season. Commun Dis Watch 2013;10:74-5. 8. Zoutman DE, Ford BD, Gauthier J. A cross-Canada survey of infection prevention and control in long-term care facilities. Am J Infect Control 2009;37:358-63. 9. Mody L, Langa KM, Saint S, Bradley SF. Preventing infections in nursing homes: a survey of infection control practices in southeast Michigan. Am J Infect Control 2005;33:489-92.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief Report
Implementation of respiratory protection measures: Visitors of residential care homes for the elderly Diana T.F. Lee PhD, MSc, RN, FAAN a,*, Doris S.F. Yu PhD, BSc, RN a, Margaret Ip MSc, DTM&H, FRCPath, FRCP(Glasg), FRCPA, FHKCPath(Clin Micro, Infection), FHKAM b, Jennifer Y.M. Tang PhD, MPhil c a b c
The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong Department of Microbiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Sau Po Centre on Ageing, The University of Hong Kong, Pokfulam, Hong Kong
Key Words: Old age homes Nosocomial outbreaks Influenza
To evaluate the implementation of respiratory protection measures for and by visitors of residential care homes for the elderly in Hong Kong, a territory-wide cross-sectional survey was conducted. A total of 87 infection control officers, 1,763 health care workers, and 520 visitors from 87 homes completed the questionnaires. Rules on respiratory protection for visitors were found to vary across residential care homes for the elderly. Uncooperative visitors and inadequate resources were identified as major barriers in the implementation of such measures for visitors. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Residential care homes for the elderly (RCHEs) are homes for older people who require daily assistance with personal and nursing care at various levels. These homes represent a vulnerable community for nosocomial outbreaks of influenza. Various studies have indicated health care workers’ poor compliance with respiratory protection measures in these homes.1-3 Although visitors are important individuals to safeguard these homes against the outbreak of influenza infections, little is known about the implementation of respiratory protection measures for and by the visitors to these homes. A territory-wide cross-sectional survey was conducted September 2014-August 2015 to evaluate the implementation of respiratory protection measures in RCHEs in Hong Kong. This article reports the evaluation of the implementation of such measures for and by visitors.
METHODS Proportional cluster sampling was used to recruit 87 RCHEs using funding mode as the cluster. For each recruited RCHE, 3 target groups
* Address correspondence to Diana T.F. Lee, PhD, MSc, RN, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong. E-mail address: [email protected] (D.T.F. Lee). The Health and Medical Research Fund, Food and Health Bureau, Hong Kong, funded this study (grant number RRG-17). Conflicts of interest: None to report.
were recruited as participants: 1 infection control officer (ICO), all health care workers (nurses, health workers, care workers, and other allied health care staff), and a convenience sample of 10 visitors. Three sets of questionnaires were developed to collect data about the implementation of respiratory protection measures on these 3 groups of participants. Relevant findings from the questionnaires for ICOs, health care workers, and visitors related to the objective of this article will be reported. The questionnaire for the ICOs evaluated 10 perspectives of implementation at the organizational level, such as infection control policies and practices, preparedness of the environment and resources, surveillance and monitoring systems, and outbreak preparedness and management. The questionnaire for the health care workers evaluated their implementation of such measures in areas such as hand hygiene, respiratory hygiene, and etiquette and management of waste. The questionnaire for the visitors focused on evaluating their practice on respiratory protection measures when they visited the residents. The response set for these 3 sets of questionnaires was a 4-point Likert scale with higher scores representing a higher level of implementation. Open-ended questions were included to explore the challenges, facilitators, and barriers for implementing such measures. Descriptive statistics were used to describe the implementation of measures and content analysis was performed on the responses to the open-ended questions. Generalized estimating equations with unstructured working correlation matrices were used to analyze the simultaneous influence of organizational and individual factors on the implementation of such measures.
0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2016.07.022
ARTICLE IN PRESS D.T.F. Lee et al. / American Journal of Infection Control ■■ (2016) ■■-■■
2
RESULTS A total of 87 RCHEs (17 nonprivate homes and 70 private homes) were recruited. Private homes had a significantly lower nurse to resident ratio (1:61.2; P = .016) but not health worker to resident ratio (1:22.4; P = .927) when compared with nonprivate homes. A total of 87 ICOs, 1,763 health care workers, and 520 visitors from these homes completed the questionnaires. A majority of the ICOs (93.1%), health care workers (87.6%), and visitors (64%) were women and had attained secondary school education. Their mean age was 47.3, 45.2, and 55.1 years, respectively. A majority of the ICOs were health workers (41%) or registered nurses (37.9%). A health worker is a person who has completed a course of training approved by the government and is responsible for the overall health care of residents in RCHEs in the absence of registered nurses.4 Two-thirds of the homes (46 private and 12 nonprivate) had written regulations on respiratory protection for visitors. One-third of homes (21 private and 10 nonprivate) did not have a restriction on the number of visitors allowed for each resident at one time. Some homes required visitors (21.8%) and volunteers (20.7%) to attend training on respiratory protection measures. Table 1 shows the implementation of rules on some selected respiratory protection measures for visitors. Although it was reported that visitors were not
allowed to visit if they were having influenza-like symptoms (94.3%) and if the resident was having an influenza-like illness (85.1%), 49.4% of the homes either did not or only sometimes required visitors to report influenza-like symptoms. As for the health care workers, rules for visitors were generally implemented more strictly during peak season or influenza outbreak. Among all the rules, “reminding visitors to receive seasonal influenza vaccine annually” and “measuring body temperature for all visitors” were less well implemented both during normal and peak seasons. Uncooperative visitors (72.4%) and inadequate resources (23%) were identified by the ICOs as the main barriers for the homes to implement such measures. In terms of the implementation of rules for visitors, results of the generalized estimating equation analysis found that such implementation was positively associated with the type of home and the total number of residents. Private homes rated higher score for implementation both during normal conditions (P = .014) and during peak season/influenza outbreak (P = .026). Homes with more residents also rated higher scores for implementation both during normal conditions (P < .001) and during peak season/influenza outbreak (P = .005). More than one-third of visitors (36.2%) had received seasonal influenza vaccination. For those who had not received the vaccination, they considered themselves healthy and did not perceive a need to have the vaccination. As outlined in Table 2, most of the protec-
Table 1 Selected items on rules and resources on respiratory protection measures for visitors RCHEs (n = 87) Rules and resources for visitors Visitors having influenza-like symptoms are allowed to visit Visitors are allowed to visit if the resident is having an influenza-like illness Visitors are allowed to visit during an outbreak of influenza Visitors are required to report influenza-like symptoms Asymptomatic visitors are required to wear a mask
None/some of the time
Most/all of the time
82 (94.3) 74 (85.1) 83 (95.4) 43 (49.4) 45 (51.7)
5 (5.7) 13 (14.9) 4 (4.6) 44 (50.6) 42 (48.3) Health care workers (n = 1,763)
Implementing rules for visitors during normal condition Reminding visitors to receive seasonal influenza vaccine annually Measuring body temperature for all visitors Advising visitors to perform proper hand hygiene before visiting Advising visitors to perform proper hand hygiene after visiting
581 (33.0) 633 (35.9) 302 (17.1) 307 (17.4) Health care workers (n = 1,763)
Implementing rules for visitors during peak season/influenza outbreak Reminding visitors to receive seasonal influenza vaccine annually Measuring body temperature for all visitors Advising visitors to perform proper hand hygiene before visiting Advising visitors to perform proper hand hygiene after visiting
1,182 (67.0) 1,130 (64.1) 1,461 (82.9) 1,456 (82.6)
577 (32.7) 520 (29.5) 237 (13.4) 249 (14.1)
1,186 (67.3) 1,243 (70.5) 1,526 (86.6) 1,514 (85.9)
NOTE. Values are presented as n (%). RCHEs, residential care homes for the elderly.
Table 2 Implementation of respiratory protection measures by visitors Visitors (N = 520)
During normal condition I will receive a seasonal influenza vaccine every year. I will wash my hands with liquid soap or apply alcohol-based handrub before visiting I will wash my hands with liquid soap or apply alcohol-based handrub after visiting I will wear a mask if I have respiratory symptoms I will not visit the resident if I have respiratory symptoms I will fill in the visiting records During peak season/influenza outbreak I will receive a seasonal influenza vaccine every year I will wash my hands with liquid soap or apply alcohol-based handrub before visiting I will wash my hands with liquid soap or apply alcohol-based handrub after visiting I will wear a mask if I have respiratory symptoms I will not visit the resident if I have respiratory symptoms I will not visit the resident if there is an outbreak of influenza in the residential care home I will fill in the visiting records NOTE. Values are presented as n (%).
None/some of the time
Most/all of the time
357 (68.7) 173 (33.3) 149 (28.7) 74 (14.2) 191 (36.7) 239 (46.0)
163 (31.3) 347 (66.7) 371 (71.3) 446 (85.6) 329 (63.3) 281 (54.0)
333 (64.0) 121 (23.3) 102 (19.6) 64 (12.3) 161 (31.0) 193 (37.1) 200 (38.5)
187 (36.0) 399 (76.7) 418 (80.4) 456 (87.7) 359 (69.0) 327 (62.9) 320 (61.5)
ARTICLE IN PRESS D.T.F. Lee et al. / American Journal of Infection Control ■■ (2016) ■■-■■
tion measures were implemented by the visitors. In general, most measures were implemented more often during peak season/ influenza outbreak. When asked about why protection measures were implemented or not implemented, “afraid of being infected” (52.5%), “compulsory requirement by the home” (50.3%), and “accessible respiratory protection resources provided by the home” (42.3%) were rated by the visitors as the main reasons. In terms of the barriers to implementing such measures, most visitors (76.9%) indicated that there is no barrier. Some indicated inadequate supplies of resources (10.8%) and inadequate knowledge to implement the measures (10.2%) as barriers. DISCUSSION This study has added knowledge to an area of infection control in old-age homes where very little is known. Although relevant work in this area is scarce, this study in Hong Kong identified that although the rules on respiratory protection for visitors do vary across RCHEs, they are in the main comparable to international guidelines.5,6 It is worthwhile to note that although a majority of homes do not allow visitors to visit if they are having influenza-like symptoms, quite a number of homes do not require visitors to report such symptoms. It remains unclear how RCHEs are to implement this rule. Implementation of respiratory protection measures for and by visitors of RCHEs is found to be generally adequate. The uptake of seasonal influenza vaccine by visitors in this study is also comparatively higher than the 14% in the general population reported by our Centre for Health Protection.7 This may be a result of the intense vaccination promotion work that has been conducted during the past few years. Uncooperative visitors have been identified by RCHE staff as a major barrier in the implementation of such measures. Some visitors themselves have indicated lack of knowledge as a barrier for them to practice such measures. Indeed, provision of education to frequent visitors such as family members and volunteers has been identified as a usual practice in some countries.8 About one-quarter of homes in this study require families and volunteers to attend relevant training. It appears that this practice could be further promoted to empower visitors with the necessary knowledge and skills in respiratory protection. It is also noted that both ICOs and visitors have indicated inadequate resources as a barrier. Indeed, both human and material resources are pivotal to the successful implementation of respiratory protection measures. 9 Continuous efforts in this area are warranted. This study also identified that private homes rated significantly higher scores in the implementation of rules for visitors during
3
both normal conditions and peak season/influenza outbreak. Of all the characteristics between private and nonprivate homes in this study, the only significant difference was that private homes had a significantly lower nurse to resident ratio. In RCHEs in Hong Kong, health workers are the key health care personnel responsible for the overall health care of older residents in the absence of nurses.4 Private homes in this study do not differ significantly in terms of the health worker to resident ratio when compared with nonprivate homes. Findings of this study therefore suggest that empowering health workers with the necessary knowledge and skills in respiratory protection is pivotal in enhancing the implementation of such measures in these homes. A limitation of this study is that it employed self-report to evaluate the implementation of respiratory protection measures. Future studies could use objective competence assessment to provide a broader assessment of the implementation of respiratory protection measures in RCHEs.
Acknowledgments The authors thank the RCHEs and the staff and visitors of the homes who participated in the survey.
References 1. Uchida M, Pogorzelska-Maziarz M, Smith PW, Larson E. Infection prevention in long-term care: a systematic review of randomized and nonrandomized trials. J Am Geriatr Soc 2013;61:602-14. 2. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010;14:e1106-14. 3. Ho M, Seto W, Wong L, Wong T. Effectiveness of multifaceted hand hygiene interventions in long-term care facilities in Hong Kong: a cluster-randomized controlled trial. Infect Control Hosp Epidemiol 2012;33:761-7. 4. Social Welfare Department. Code of practice for residential care homes (elderly persons). Hong Kong: Hong Kong Special Administrative Region; 2013. 5. Smith PW, Bennett G, Bradley S, Drinka P, Lautenbach E, Marx J, et al. SHEA/APIC Guideline Infection prevention and control in the long-term care facility. Infect Control 2008;36:504. 6. Northern Health and Social Care Trust. Visitor guidelines [Internet]. Antrim: Northern Health and Social Care Trust; 2013 [updated February 8, 2013] Available from: http://www.northerntrust.hscni.net/hospitals/1063.htm. Accessed January 24, 2014. 7. Centre for Health Protection. Seasonal influenza vaccination coverage survey for the 2012/13 season. Commun Dis Watch 2013;10:74-5. 8. Zoutman DE, Ford BD, Gauthier J. A cross-Canada survey of infection prevention and control in long-term care facilities. Am J Infect Control 2009;37:358-63. 9. Mody L, Langa KM, Saint S, Bradley SF. Preventing infections in nursing homes: a survey of infection control practices in southeast Michigan. Am J Infect Control 2005;33:489-92.