Abstract
Background
Following updated 2023 guidance from the European Centre for Disease Prevention and Control (ECDC), and in parallel with recommendations from the Swiss Center for Infection Control, a tertiary care centre in Switzerland replaced droplet precautions with ‘respiratory precautions’ on 1 November 2023. A multifaceted strategy was implemented to facilitate the transition to this updated transmission-based precaution. We aimed to describe the implementation of and adherence to respiratory precautions between November 2023 and March 2025.
Methods
From October 2023 to March 2024, a multifaceted, hospital-wide strategy was implemented to introduce changes in infection control policy with updated respiratory precautions, including standardized training, educational materials, a communication campaign, updated signage and prescription orders. Adherence to the updated respiratory precautions was audited during two periods: January–March 2024 and October 2024–March 2025.
Results
A total of 150 training sessions on infection control precautions were conducted for 1967/9410 (21%) healthcare workers and 2913 pocket cards summarizing updated precautions were distributed. Among 793 audits conducted, there was high adherence to recommended patient placement and signage (89–99%). Availability and suitability of placement for FFP2 respirators and eye protection were initially low but improved during the second audit (59% and 36%, respectively). FFP2 use was 76%, while use of eye protection remained low (38%), potentially due to limited availability and suitable placement.
Conclusions
A structured, multifaceted strategy -combining training, audits, and feedback - supported the implementation of a change in respiratory precautions, achieving good adherence overall.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s13756-026-01769-w.
Keywords: Droplet precautions, Respiratory virus, Personal protective equipment, Mask, Healthcare associated infections
Introduction
The COVID-19 pandemic catalyzed a paradigm shift in the conceptual framework of respiratory virus transmission: the traditional dichotomy between droplets and aerosols has evolved into the concept of a turbulent exhalation cloud, composed of respiratory particles spanning a continuum of sizes, with smaller aerosols often predominating [1, 2]. Based on current evidence, transmission may occur through inhalation or mucosal deposition of these particles, as well as through direct or indirect contact [3, 4]. The risk of respiratory transmission is determined by the infectious dose and host susceptibility. Factors that increase infectious dose include the viral load of the source person (especially around symptom onset), the intensity of respiratory emissions (e.g., coughing, sneezing), proximity to the source, duration of exposure, and environmental conditions such as poor ventilation, low humidity, and cold temperatures [2, 5–7]. Host susceptibility depends on virus-specific immunity (from prior infection or vaccination) and general immune competence. Conversely, vaccination, mask use, improved ventilation, hand hygiene, eye protection, and gowns help reduce transmission, though the strength of evidence for some measures varies and uncertainties about optimal protection remain [7–9].
During the COVID-19 pandemic, infection prevention measures evolved to reflect this updated understanding of respiratory virus transmission. However, updated transmission-based precautions for other respiratory viruses often varied, creating challenges for healthcare workers (HCW). Efforts were therefore made to harmonize guidance across respiratory viruses. In February 2023, the European Centre for Disease Prevention and Control (ECDC) updated its transmission-based precautions to reflect current concepts of respiratory virus transmission, adopting a pragmatic approach [10]. In addition to standard precautions and the use of medical masks, the ECDC recommended HCW conduct a risk assessment to guide the appropriate selection of personal protective equipment (PPE), including Filtering Facepiece Respirator class 2 (FFP2) respirators and eye protection in situations involving close and prolonged contact with patients’ airways, as well as gowns when in contact with the patient or his/her close environment. The Swiss National Centre for Infection Control (Swissnoso) and Geneva University Hospitals (HUG), a Swiss tertiary care network, subsequently adapted both national and local guidelines for the prevention of respiratory virus transmission [11]. Consequently, ‘respiratory precautions’ were introduced in HUG on November 1, 2023, replacing droplet precautions for the management of patients with suspected or confirmed viral respiratory infections. The objective of this study was to describe the implementation of and adherence to respiratory precautions at HUG between November 2023 and March 2025.
Methods
Setting
HUG are the largest tertiary care center network in Switzerland and include five rehabilitation and/or palliative care sites, one acute-care, one geriatrics, one pediatrics, one gynecology-obstetrics and one psychiatry site. HUG have a capacity of approximately 2,100 beds and admit on average 60,000 patients per year. HCW accounted for 9,410 of 12,803 employees in 2023 (74%) and 9,137 of 13,086 employees in 2024 (73%).
Respiratory precautions
Following updated 2023 guidance for infection prevention and control (IPC) measures for respiratory viral infections from the ECDC and Swissnoso, HUG replaced droplet-based precautions with respiratory precautions on 1 November 2023 (see Supplementary Material) [10, 11]. The respiratory precautions and their implementation strategy were developed by an interdisciplinary IPC working group and refined through consultations with key stakeholders from various departments, including nursing leadership, frontline staff, physicians, and environmental services. The strategy was formally endorsed by hospital leadership, including both medical and nursing management.
At HUG, respiratory precautions are recommended for patients with suspected or confirmed colonization or infection by respiratory pathogens, particularly viruses, or diseases transmitted through respiratory particles. The recommendation was extended to all pathogens for which droplet precautions were previously indicated, to promote harmonization and facilitate implementation. Distinct airborne precautions continue to be required for suspected or confirmed cases of measles, varicella, or tuberculosis. Whenever possible, patients under respiratory precautions should be placed in a single room; patients with suspected or confirmed COVID-19 require single-room isolation. Alternatively, cohorting of patients with infected with the same pathogen may be considered, provided there is no additional indication for specific transmission-based precautions. In all cases, the sharing of rooms with immunosuppressed patients should be avoided. In addition to standard precautions, HCW must wear a surgical mask upon room entry. To guide the selection of additional PPE, a risk assessment should be conducted by the HCW based on the planned interaction with the patient and the care activities involved: FFP2 respirators and eye protection for close/prolonged airway contact or aerosol-generating procedures, and gowns for contact with the patient or his/her close environment. Finally, under respiratory precautions, patients are required to wear a surgical mask when outside their room.
Transmission-based respiratory precautions are implemented to protect healthcare workers during the care of patients with suspected or confirmed respiratory infection. During the winter season, these precautions operate alongside a seasonal masking policy in clinical areas, which requires the systematic wearing of a medical mask by HCW and visitors in all clinical areas and aims to reduce hospital-wide transmission through source control as well as individual protection. These two approaches are therefore complementary: transmission-based precautions target exposures at the point of care, whereas seasonal masking addresses broader transmission risk during periods of increased respiratory virus circulation. Other infection control measures implemented at HUG to reduce the risk of respiratory virus transmission, including a description of the screening strategies and polices for mask wearing in the hospital, between November 1, 2023, and March 31 2025 are detailed in the Supplementary Material.
Implementation strategy for respiratory precautions
Between November 2023 and March 2024, a multifaceted strategy was implemented to support the introduction of the respiratory precautions for all HCW at HUG. From November to December 2023, this strategy included an update to institutional guidelines, a communication campaign, standardized training, educational materials, revised signage, and an updated prescription order in the electronic health records system. The revised recommendations were prominently posted on the HUG infection control platform (VigiGerme®) which provides resources and guidance for the prevention and management of healthcare-associated infections [12]. The signage that is placed on patients’ doors to indicate the need for infection control precautions was updated (Supplementary Figure S1). A communication campaign was launched that included the dissemination of electronic and printed posters throughout the hospital; direct communication from the Infection Control Program to representatives in each department; hospital-wide emails sent by the head of IPC - reviewed and endorsed by Medical and Nursing Directorates - to inform the implementation of the respiratory precautions; and a prominently featured announcement on the hospital intranet homepage. Physicians and nurses in the Infection Control Program delivered concise, interactive, and standardized training sessions for physicians, nurses, and other HCWs (e.g., physiotherapists, radiology technicians) across all departments, except psychiatry. The first series of sessions reviewed core principles of standard precautions, while the second series focused specifically on respiratory precautions. An updated pocket card summarizing the recommended PPE by type of precaution was distributed to HCW during training sessions, as well as those in clinical units. Finally, on November 1, 2023, the electronic health records system was modified to enable the prescription of respiratory precautions for patients, replacing droplet precautions.
Adherence monitoring of respiratory precautions
Adherence to transmission-based precautions is not routinely monitored at HUG. A structured and standardized audit tool was developed, building on audit frameworks that have been implemented previously (Supplementary Material) [12–14]. The tool assessed the compliance of HCW to both structural components and PPE.
Adherence to respiratory precautions was audited by nurses of the Infection Control Program during two periods: January–March 2024 and October 2024–March 2025. Audits were conducted, either using paper forms or a digital tablet-based format, once per week in each unit across all departments, excluding psychiatry and intensive care. On the day of the audit, all active respiratory precautions were evaluated, unless the precautions had been audited within the previous seven days.
During the first audit period, structural components were assessed, including patient placement, signage on patients’ doors and beds, PPE availability and placement. During the second audit period, structural components were reassessed, as well as compliance to the updated PPE recommendations. It represents a snapshot taken as the auditor enters the room and observes the HCW at work.
Surveillance of respiratory viral infections
The HUG Infection Control Programme conducts routine epidemiological surveillance of respiratory viral infections among hospitalised patients as part of its institutional mandate. This was used as an indirect indicator of the implementation of respiratory precautions. Individuals included in this surveillance were those admitted to HUG for more than 24 h and with a SARS-CoV-2, influenza virus (A/B) or RSV infection detected by RT-PCR between 1 November 2023 and 30 April 2025. Healthcare-associated infections were defined as laboratory-confirmed infections with a positive respiratory sample collected > 72 h after hospital admission for influenza and > 120 h for SARS-CoV-2 and RSV, based on published estimates of median incubation periods [15–17]; all other infections were considered community acquired. The testing strategies for respiratory viruses are detailed in the Supplementary Material.
Monitoring absenteeism in healthcare workers
There is currently no reporting or surveillance of viral respiratory infections among HCW at HUG. Further, there was no routine testing of HCW for viral respiratory infections at the time that respiratory precautions were implemented. However, the HUG Occupational Health Department collects data on staff absenteeism. Absences of permanent medical and nursing staff were used as a second indirect indicator of the effect after the implementation of respiratory precautions. We calculated the monthly proportion of staff absences among permanent medical and nursing staff from November 2023 to March 2025. Absences included only those for medical reasons, excluding pregnancy-related leave or leave due to an accident or trauma.
Statistical analysis
We described the adherence to recommended PPE during the audit periods, expressing categorical variables as counts and percentages. We calculated the incidence rates of community-acquired and healthcare-associated SARS-CoV-2, influenza (A/B), and RSV infections among hospitalized patients at HUG per 1,000 patient admissions and 10,000 patient days, respectively, by season. Analyses were performed with R, version 3.5.2 (R Foundation, Vienna, Austria).
Results
From October to December 2023, a total of 150 training sessions were conducted for 1967/9140 (21%) HCW and 2’913 pocket cards summarizing updated transmission-based precautions were distributed. A total of 793 structural audits were conducted during two periods: January–March 2024 (n = 342) and October 2024–March 2025 (n = 451). Across the two audit periods, there was high adherence to patient placement and signage (Table 1). Availability and suitability of placement for FFP2 respirators and eye protection were initially low (164/342; 48% and 78/342; 23%, respectively), but improved during the second audit (266/451; 59% and 163/451; 36%, respectively). A total of 136 PPE compliance audits were realised during the second period. Adherence to medical mask was high (100/104; 96%); adherence to gown use was 84% (84/100). HCW compliance with FFP2 respirators use was 76% (25/33), while eye protection use remained low (13/34; 38%), potentially due to limited availability and improper placement (163/451; 36% during the second audit).
Table 1.
Observed healthcare worker adherence to respiratory precautions at Geneva University Hospitals during two periods of audit: January to March 2024 and October 2024 to March 2025
| January - March 2024 | October 2024 - March 2025 | |
|---|---|---|
| N (%) | N (%) | |
| Respiratory precautions adherence Number of audits conducted |
342 | 451 |
|
Adequate patient placement - Single room - Shared room with cohorting |
337 (99) 180 157 |
427 (95) 285 142 |
| Adequate signage on patient room doors | 314 (92) | 403 (89) |
|
PPE availability and suitable placement - Medical masks - FFP2 respirators - Eye protection - Gowns |
259 (76) 164 (48) 78 (23) 319 (93) |
373 (83) 266 (59) 163 (36) 399 (88) |
|
PPE compliance Number of situations audited* |
- | 136 |
| Adequate use of PPE ** | ||
| Medical masks | 100/104 (96) | |
| FFP2 respirators | 25/33 (76) | |
| Eye protection | 13/34 (38) | |
| Gowns | 84/100 (84) |
PPE: personal protective equipment
* Situations involving direct observation of HCW entering or caring for patients under respiratory precautions.
** Adequate usage was defined as the correct application of PPE—whether worn or not—in accordance with the specific indication under respiratory precautions.
In 2024–2025, we observed a decrease in the incidence rate of healthcare-associated SARS-CoV-2 infections (18.1 infections per 10,000 patient days in 2023–2024; 4.6 infections per 10,000 patient days in 2024–2025) (Table 2). In the 2024–2025 winter season, the incidence rates of healthcare-associated influenza A and RSV infections were 5.2 and 3.8 per 10,000 patient-days, respectively. The monthly proportion of staff absences remained stable from November 2023 to March 2025 (Fig. 1).
Table 2.
Incidence rates of community acquired SARS-CoV-2, influenza A or B and RSV infections per 1,000 patient admissions and healthcare-associated SARS-CoV-2, influenza A or B and RSV infections per 10,000 patient days at Geneva University Hospitals, by winter season (November 1 - April 30) for 2023–2025 and for the period May 1 - October 31, 2024
| Community acquired infections (per 1,000 patient admissions) | 1 November 2023–30 April 2024 | 1 November 2024–30 April 2025 | 1 May − 31 October 2024 |
|---|---|---|---|
| - SARS-CoV-2 | 30.2 | 9.3 | 15.5 |
| - Influenza A | 16.7 | 19.4 | - |
| - Influenza B | 0.3 | 2.7 | - |
| - RSV | 13.2 | 10.2 | - |
| Healthcare-associated infections (per 10,000 patient days) | |||
| - SARS-CoV-2 | 18.1 | 4.6 | 10.1 |
| - Influenza A | 3.8 | 5.2 | - |
| - Influenza B | 0.1 | 0.3 | - |
| - RSV | 1.3 | 3.8 | - |
Fig. 1.
Monthly proportion of absences among permanent medical and nursing staff at HUG from November 2023 to April 2025 (excluding pregnancies and accidents)
Discussion
In this study, we report on the implementation of and adherence to updated respiratory precautions at a tertiary care center in Switzerland from November 2023 to March 2025. A multifaceted strategy was implemented to support the introduction of updated transmission-based precautions that replaced droplet precautions for suspected or confirmed respiratory infections. During audits of the updated precautions, we found high adherence to patient placement and signage (89–99%), improved availability and suitability of placement for FFP2 respirators and eye protection, high use of FFP2 (76%), and low use of eye protection (38%), likely linked to limited availability.
Our results are of particular interest from an IPC perspective. Since the publication of updated transmission-based recommendations by the ECDC, several professional societies have revised their guidance [18]. However, there is a lack of published studies on how these measures have been implemented and monitored in healthcare settings. Our study contributes practical insights into how these recommendations may be introduced into a tertiary care context.
We found compliance with room placement and appropriate signage to be high, likely reflecting that these general measures are already well established in institutional practice. Similarly, the high adherence to medical mask and gown use likely stems from their longstanding role in droplet precautions and the frequent recommendation to combine droplet and contact precautions for respiratory viruses [19]. Despite increased availability and improved placement of eye protection and FFP2 respirators between the two audit periods, we observed that compliance with their use remained suboptimal. This finding is consistent with previous studies, which have reported variable adherence to eye protection, with some documenting low usage while others have observed higher compliance rates [20–22]. Adherence to indicated FFP2 respirators and eye protection is also influenced by implementation‑ and equipment‑related factors, including ready access to well‑fitting FFP2 respirators in appropriate sizes and a sufficient range of models, supported by fit testing and user acceptability, as well as practical, ergonomically acceptable reusable eye‑protection devices. HUG’s multi-site structure, characterized by diverse architectural and infrastructural characteristics, may have influenced the PPE availability and placement and, consequently, HCW adherence, particularly for eye protection and FFP2 respirators. Although eye protection and FFP2 respirators were recommended during the COVID-19 pandemic, it must be acknowledged that they were only recently included in the updated respiratory precautions. Adherence may also have been impacted by factors such as staff underestimation of risk in specific clinical situations, limited awareness or understanding of the risk assessment, or discomfort associated with PPE use [22–27].
To complement direct adherence monitoring, we assessed two indirect indicators: surveillance of respiratory viral infections among hospitalized patients and absenteeism among HCW. We observed an important decrease in the incidence of healthcare-associated SARS-CoV-2 infections among hospitalized patients during the study period, while there was a modest increase in the incidence of healthcare-associated influenza A and RSV infections among hospitalized patients. However, these trends likely reflect contemporaneous epidemiological trends in the community, and should be interpreted with caution given the limited duration of follow up (two winter seasons) and the absence of a comparator period under previous droplet precautions. Staff absenteeism rates remained stable during the study period, which may indirectly suggest no major impact on infections among the workforce. However, this indicator likely has limited sensitivity for detecting infection-related absences, as it includes non-specific medical leave. In addition, in accordance with institutional guidelines, HCW with respiratory symptoms were permitted to continue working provided that they wore a medical mask. Continued surveillance and further assessments are needed to evaluate the direct and indirect impacts of transmission-based precautions on the incidence of healthcare-associated respiratory infections.
This study has several limitations. First, this study was conducted in a single tertiary care center with substantial IPC resources, and support from the Chief Medical Officer. As such, our findings and implementation strategy may not be generalizable to all healthcare settings. Second, data on the total number of patient-days under respiratory precautions were unavailable for both periods, thereby precluding the calculation of audit percentages relative to the total hospitalized patient population under respiratory precaution. Third, only 21% of HCW directly participated in education and training sessions, suggesting that many audited personnel may not have received information about the updated precautions, which may have impacted adherence. Other modalities—such as e-learning—might have reached a larger proportion of staff, although the relative effectiveness of different educational approaches in improving knowledge and clinical practice remains uncertain [28–30]. Nevertheless, the multifaceted implementation strategy included several forms of communication, and the information related to the introduction of updated precautions likely reached a proportion greater than 21% of all HCW. Fourth, audits to assess PPE compliance were limited in number, covering a relatively small number of HCW-patient interactions, potentially affecting the representativeness of precaution adoption. While the audits used to assess HCW adherence and compliance followed a standardized assessment (combined with a specific training to the IPC team), we cannot exclude that there may have been some inter-operator variability. Fifth, the short timeframe from the development to implementation of the respiratory precautions precluded the identification of implementation barriers and facilitators, or the development of a structured evaluation of determinants of implementation. As a result, implementation outcomes indicators could not be measured [31]. Our experience highlights that future studies would benefit from assessing implementation outcomes together with the contextual determinants that influence them, to better understand which components support compliance. Finally, the implementation of respiratory precautions overlapped temporally with the seasonal masking policy in clinical areas. The design of the study does not allow us to evaluate the relative contributions of these concurrent measures to trends in hospital-onset respiratory viral infections or staff absenteeism.
We acknowledge that this update to respiratory precautions reflects a pragmatic approach, intended to align with evolving concepts of respiratory transmission and to support the harmonization of protective measures across all respiratory viruses. In our setting, the implementation achieved high adherence for structural components, while gaps persisted for certain PPE elements - particularly eye protection - highlighting the continued influence of availability, placement, and usability on real-world uptake. The recent WHO report on revised terminology for transmission through the air represents a recent conceptual milestone, likely to catalyze further studies on respiratory pathogens transmission dynamics, the effectiveness of preventive measures in healthcare settings, and the development of updated recommendations and guidance [32]. As evidence evolves, precautions can be refined to balance practicality and simplicity for HCW with effective protection of both HCW and patients, informed by comprehensive syntheses of respiratory virus transmission and PPE effectiveness [9, 33]. Dedicated studies are needed to assess the specific impact of updates on nosocomial transmission. Dedicated studies are needed to assess the specific impact of this update on nosocomial transmission. It will be necessary to identify precautions measures that appropriately balance practicality, simplicity for HCW, and effectiveness in protecting both patients and staff against the transmission of respiratory viruses [9, 33].
Conclusion
A structured, multifaceted strategy - combining training, audits, and feedback - supported the implementation of a change to transmission-based precautions, with good overall adherence. Continued efforts are needed to sustain and improve adherence particularly in relation to the use of FFP2 respirators and eye protection. The findings of our study may contribute to future interventions to strengthen compliance and help refine novel strategies for the prevention of respiratory pathogen transmission in various healthcare settings.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We sincerely thank Professor Laurent Kaiser, Dr Marie‑José Roulin, and Dr Catherine Chenaud for their leadership, support, and active participation in the project steering committee. We also thank the Infection Prevention and Control team — including Marie-Noëlle Chraiti — for their dedicated involvement in the implementation process and audits. We are grateful to Christine Bergère, Esther Guizado Espichan, and Ghislaine Clerc for their valuable contributions to the audits, as well as to the communication division for their support, the IT colleagues for their efforts in updating the electronic medical record system, and all the healthcare workers at Geneva University Hospitals.
Author contributions
Author’s contributions: AN and MCZ conceptualized the study. AN, RG, VG, MFH, MP, VC, MCZ developed the methodology and conducted the investigation. AN, RG, JS, YK and MCZ curated the data. AN, RG and MCZ performed the formal analysis. AN, RG and MCZ drafted the original manuscript. AN, RG, VG, KMPB, SH and MCZ contributed to data interpretation. SH and MCZ provided supervision. MCZ oversaw project administration. All authors read and approved the final manuscript.
Funding
No funding was received for this study.
Data availability
The datasets generated and analysed during the current study are not publicly available but may be obtained from the corresponding author upon reasonable request.
Declarations
Ethics approval
This study did not require approval by the local ethics committee because it was deemed a quality improvement project.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and analysed during the current study are not publicly available but may be obtained from the corresponding author upon reasonable request.