Our survey contained 48 questions in 5 content areas: demographics (5 questions), occupational information (4 questions), infection control knowledge (13 questions), infection control attitudes (17 questions), and infection control practices (7 questions). Two additional questions were included to better understand staff’s interest: “Would you like to receive additional training on infection control at facility A” and “Describe any suggestions you would like to share regarding ways to improve infection control at facility A.”

A 4-point Likert scale (strongly agree, agree, disagree, and strongly disagree) was used for the knowledge and attitude content area. A 2-point Likert scale (agree and disagree) was used for the practice content area. All 3 knowledge, attitude, and practice content areas contained the following 3 different subsections: general infection control and occupational health risks, hand hygiene concerns, and respiratory hygiene and isolation concerns.

Survey participation was voluntary and anonymous. All staff members that had close interaction with facility A residents were eligible to participate and were given 10 days during the investigation to complete the survey. Surveyed staff included physicians, nurses (nurse practitioners, registered nurses, and licensed practical nurses), therapists (respiratory, speech, physical, and occupational therapists), habilitation assistants (individuals providing daily care to residents and assisting medical staff), daily volunteers, school teachers, and housekeeping service staff. We focused our analysis on staff with direct resident care responsibilities and separated direct care staff into 2 groups according to profession. Clinical direct care staff had close medical interaction with residents and included physicians, nurses, and therapists. Nonclinical direct care staff had close nonmedical interaction with the residents and included habilitation assistants, daily volunteers, and school teachers. Non–direct care staff had no direct resident care responsibilities.

Data were entered into a Microsoft Access database. In order to increase statistical power, all frequencies of agreement (defined as those who answered “strongly agree” or “agree”) were combined. We compared differences between groups providing direct care to residents using χ² tests in SAS (ver. 9.3; SAS Institute).

Two hundred of 248 (81%) distributed surveys were completed. One hundred seventy (85%) survey respondents were female staff members, and the median respondent age was 36 years (range, 18–64 years; Table 1). One hundred eightyfour (92%) respondents were non-Hispanic whites, and 45% had been working at facility A more than 5 years. There were 151 direct care staff and 49 non–direct care staff. Among the direct care staff, there were 50 clinical and 101 nonclinical staff. No statistically significant differences in responses were found between staff who had worked at facility A more than 5 years and those who had worked 5 years or fewer.

To our knowledge, this study is the first to provide information regarding infection control knowledge, attitudes, and practices among staff in a residential care facility caring for children and young adults with neurologic and neurodevelopmental conditions. The survey results demonstrate high levels of agreement to most of the knowledge and attitude statements and somewhat lower levels of agreement for the practice statements among direct care staff. Our findings are similar to those previously reported among nursing personnel in LTCFs.¹³ Our survey results also indicated lower levels in hand hygiene practices by occupational category, as previously reported among LTCFs and nursing homes.^10,12

Not all clinical and nonclinical direct care staff indicated that they were able to identify residents with symptoms of respiratory infection, potentially leading to delays in implementation of transmission-based precautions and increasing the risk for influenza transmission. Although identification of ill residents ultimately remains the responsibility of clinical staff, nonclinical staff often maintain close and consistent interactions with residents at facilities for persons with neurologic and neurodevelopmental conditions. Therefore, training nonclinical staff to alert clinical staff when they notice residents behaving differently from their baseline may be beneficial. Because influenza may appear as a nonspecific respiratory infection, direct care staff in such facilities should be vigilant for any changes in baseline conditions that may indicate respiratory infection in residents who may not be able to communicate their symptoms effectively.

Nonclinical staff showed significantly less agreement than clinical staff regarding handwashing after touching residents. This finding might be due to the manner in which clinical and nonclinical staff perceived their interactions with residents. Although nonclinical staff often had direct and prolonged contact with residents in facility A, they may not have viewed their interactions as medical activities and therefore may not have felt that handwashing was required. In contrast, clinical staff may have been more likely to view direct contact with residents as patient care activity, for which hand hygiene is expected. Given the multiple roles of staff and level of services provided to residents in this type of facility, reinforcement of hand hygiene practices among all direct care staff is important,¹⁴ especially during the influenza season.

Sick leave policies and the use of leave among ill staff highlighted some important issues. Only 70% of direct care staff indicated that when ill with a respiratory infection they stayed home from work, and only 64% agreed that the facility’s administration encouraged them to stay home. Direct care staff should be educated about the risk of transmitting respiratory infections to residents and coworkers if they work when ill. Facility administrators should develop sick leave policies that encourage staff with respiratory illness to stay home until symptoms resolve. Finally, facility administrators should consider implementing an occupational health plan addressing staff absences and other related occupational issues (eg, self-assessing influenza-like illness before reporting to work),¹⁵ especially during the influenza season.

Several staff members reported that cohorting of residents may not be practical in facility A. Respiratory cohorting is an important infection control measure during influenza outbreaks in LTCFs.^6,16 Although most direct care staff believed that separating ill residents from well residents would be beneficial, fewer believed that this would be practical in facility A, and only 72% believed this was routinely done in the area in which they worked. Implementing transmission-based precautions and respiratory cohorting in facilities such as facility A can be challenging for staff and stressful for residents. However, in order to reduce possible disease transmission, modifying resident placement and movement during outbreaks should be considered.

Our study has several limitations. First, this was a self-administered survey and did not include an objective assessment/review of infection control practices within facility A. Second, we classified direct care clinical staff into a single group, but there are likely substantial differences in education, experience, and medical responsibilities among physicians, nurses, and other health professionals, which may have affected survey responses. Third, conducting the survey after a recent outbreak of respiratory illness during which members of staff were reported to be ill and residents were either hospitalized and/or died⁴ might have biased responses. Respondents might have felt that they and the facility were being evaluated by an external investigation team in relation to the outbreak, potentially affecting survey responses.

Our findings suggest that adherence to certain infection control practices among staff with direct resident contact was reported to be high but could be improved in certain areas, especially among nonclinical staff. Many direct care staff have non-healthcare-related interactions with residents, and there may be substantial variation in their infection control training and experience. Thus, it would be beneficial to assess infection control knowledge, attitudes, and practices at other facilities with similar characteristics. Furthermore, since it may be challenging for staff at these facilities to incorporate elements of evidence-based infection control guidelines^{6,9,14,15,17,18} while allowing for the breadth of nonmedical activities they perform, it may be appropriate to develop a set of infection control best practices tailored to facilities caring for children and young adults with neurologic and neurodevelopmental conditions. Finally, it remains important to identify any barriers to infection control best practices at such facilities, implement appropriate training for staff, and encourage adherence to infection control recommendations among all staff having direct contact with residents.