Stranger, Danger!

As children we were taught to shout the phrase “Stranger, Danger!” to alert those around us of unfamiliar people in our surroundings. As a means of infection control, perhaps we should yell “Stranger, Danger” when visitors enter our healthcare facilities.

While visiting a dear friend recently in a skilled nursing facility, I was surprised that I could walk through the facility without any staff intervention and without any posted or verbalized encouragement to wash my hands. Handwashing is critical in preventing the spread of infections¹. 

Studies indicate that visitors do not consistently use good handwashing practices^{2, 3, 4} and these “strangers” could be a source of many illnesses, including norovirus⁵. Norovirus, easily transmitted person-to-person, most frequently impacts at-risk individuals and 64% of outbreaks occur in healthcare facilities⁶ Following the Centers for Disease and Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations⁵ is essential for visitor-related infection control within our acute and long-term health care facilities.

• Stranger, Danger – Just as all visitors should check in at a security desk for a visitor badge, establish and implement policies for visitor health assessment and screening⁵. Visitors with symptoms of acute gastroenteritis and other transmissible illness symptoms should be denied entry.
• Control the Danger – Actively promote visitor hand hygiene by providing readily visible handwashing and/or handcare stations at reception desks and ward entrances⁵. In addition to signs and free-standing hand sanitizer dispensers³, audible⁷ and audio-visual hand hygiene reminders⁸ have been shown to be an inexpensive and successful tool to promote hand hygiene compliance among visitors. In one study, an audible reminder increased visitor compliance from 10.6% to 63.7% (P < .001) and the positive behavior change was also shown to be sustained⁷.
• Wanted Posters – Provide education to visitors on recognizing transmittable illness symptoms and methods for preventing infection⁵. Use culturally appropriate and emotionally impactful flyers and signage⁹ to make a lasting impact. Visitors pose a threat to infection control in the healthcare setting. Minimize your risk by implementing “Stranger, Danger” protocols.

References:

1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002;51(No. RR-16) http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
2. Willison-Parry TA, Haidar EA, Martini LG, Coates AR. Handwashing adherence by visitors in poor: Is there a simple solution? Am J Infect Control. 2013 Oct;41(10):928-9.
3. Birnbach DJ, Nevo I, Barnes S, Fitzpatrick M, Rosen LF, Everett-Thomas R, Sanko JS, Arheart KL. Do hospital visitors wash their hands? Assessing the use of alcohol-based hand sanitizer in a hospital lobby. Am J Infect Control. 2012 May;40(4):340-3.
4. Randall j, Arthur A, Vaughn N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect. 2010 Nov;76(3):252-5.
5. MacCannell T, Umschei C, Agarwal R, Lee I, Kuntz G, Stevenson K and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings . 2011 www.cdc.gov/hicpac/pdf/norovirus/Norovirus-Guideline-2011.pdf
6. Hall AJ, Lopman BA, Payne DC, Patel MM, Gastañaduy PA, Vinjé J, et al. Norovirus disease in the United States. Emerg Infect Dis. 2013:19
7. http://dx.doi.org/10.3201/eid1908.130465
8. Fakhry M, Hanna GB, Anderson O, Holmes A, Nathwani D. Effectiveness of an audible reminder on hand hygiene adherence. Am J Infect Control. 2012 May;40(4):320-3.
9. Taylor RJ, El-Kafrawy U. A simple inexpensive audio-visual reminder of infection control procedures on entry to a neonatal intensive care unit. J Hosp Infect. 2012 Nov;82(3):203-6.  
10. FDA Oral Culture Learner Project http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/Industry…
11. Jamie Stamey, MS, RDN, LDN, CP-FS is food safety and applied nutrition consultant with HealthyAndSafeFood.com.