Damian Sendler: When a patient is hospitalized, their family members play an important role in helping them get around, providing emotional support, and informing the health care team about the person they are caring for. There is no such thing as a passive bystander when it comes to family members and patient care [2]. A patient’s primary care provider may be the first to notice subtle changes in the patient, help provide a sense of familiarity for the patient, and assist in improving the processes associated with transitions of care [3, 4]. The presence of family members at the patient’s bedside has been shown to enhance communication and foster a sense of mutual trust [5].
Damian Jacob Sendler: At times of public health crises like the COVID-19 pandemic, visitors may be restricted from visiting patients in acute care facilities [6]. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has been controlled, personal protective equipment (PPE) has been reduced, and care has been organized by policies mandating limited family visits in acute care settings throughout the COVID-19 pandemic [7, 8]. The effects of these limitations on patients and their families have been documented, and include distress [9], grief [10], impaired coping [10], and a decrease in quality of life [11]. Medical professionals’ mental health and well-being has also been shown to be negatively impacted by policies restricting their access to their loved ones, including peritraumatic dissociation [12], moral distress (the feeling that the ethically correct action is different from what one is doing) [13, 14], burnout (exhaustion from excessive, prolonged stress and general stressors in the work environment), and compassion fatigue (triggered by continuous use of empathy and emotional empathy).)
Dr. Sendler: As a result of the COVID-19 pandemic, there is a growing body of evidence suggesting restrictions on patient and family visits in acute care settings have unintended consequences that deserve further investigation [16–20]. Scoping reviews like this one aim to compile information on the impact of COVID-19 pandemic-related restrictions on visiting hours in acute care facilities, as well as patient, family, and healthcare professional perspectives and mitigation strategies for the inconvenience.
Primary research (66, 43 percent) comprised 66 of the 155 records (Additional file 1: Table S3), including case reports or case series (n = 29, 44 percent) and cohort studies (n = 26, 39 percent). No. 29, a 19-percent share, included literature reviews and expert recommendations (a total number of 21, 72 percent [n = 1 systematic review, 5 percent] and 8 per cent), respectively, in the secondary records. Unpublished, non-research records (n = 60) comprised 90% (n = 54) of the 60 (39%) records retrieved; 10% (n = 6) were online web articles or blog posts; all non-research records (100%) reported primary, relevant data. As depicted in Additional file 1: Figure S2 and Additional file 1: Figure S3 of the included records, countries and acute care settings are depicted. Restricted visitation policies implemented hospital-wide or in palliative care settings were reported on in the records, which were mostly from the United States (72%), the United Kingdom (8%) or Italy (11%). The records were published or posted in January through December 2020 and mostly came from these three countries: the US (72%), the UK (8%) and Italy (11%). Restricted visitation policies in hospitals have a significant impact on healthcare professionals (n = 14, 47%), but there are few records assessing the impact on patients (n = 8, 27%) and their families (n = 7, 23%), according to a review of 30 records. Most records (90 percent) contained information about restricted visitation policies.
Restricted visitation policies had an impact on neurocognitive (e.g., delirium) and mental health outcomes (e.g., depression) (n = 23/30, 77 percent), quality of life and well-being (e.g., life satisfaction) (n = 22/30, 73 percent), and coping and daily function (e.g., disabilities, access to support) (n = 23/30, 77 percent) outcomes, according to 155% of the records (Table 1). No visitors were allowed without exceptions (n = 13/30, 43 percent), no visitors except for end-of-life care were allowed (n = 3/30, 13 percent), or one visitor at a time (n = 1/30, 3 percent) in 18 of the 30 records (n = 18/30, 60%). A total of 12 records (n = 12/30, 40%) lacked details about visitation restrictions. According to the data included in Figure 2a, the effects of restricted visitation policies are shown by type of policy restriction. The effect of not having any visits was different for each participant group. 3/13 (23%) included mental health outcomes for patients, coping and daily functioning for families (n = 6/13, 46%), and quality of life and well-being for healthcare professionals (n = 6/13, 46%), respectively.
Consistency and clarity in communication (n = 70/140, 50 percent), coping and accessing support (n = 68/140, 49 percent), as well as a state of well-being (n = 61/140, 44 percent) were the most common perspectives. Only a small percentage of records (n = 45/140, 32 percent) reported feelings of overwhelming grief (e.g., complicated grief) or loss of touch and physical connection. 46 (57%) of the 81 records (specifying enacted policies) required no visitors without exceptions, while the remaining 81 Patients’ views on well-being (n = 5/46, 11 percent) and coping and accessing support (n = 5/46, 11 percent) were the most common from this group. Policy restrictions are shown in Figure 2b by type of policy limitation. Touch and physical presence, coping, and accessing support were the most common themes in the perspectives of family members who had no visitor restrictions (n = 3/46, 7 percent). In addition, the most common themes were connection and communication (n = 3/46, 7 percent). Healthcare professionals mainly commented on intentional practices to facilitate [virtual] connection and communication [for isolated patients] to sustain personalized patient care (n = 30/46, 65%).
Stakeholders frequently reported negative effects on mental health, well-being, and ability to cope with day-to-day tasks. Well-being, connection, communication, and coping, as well as how to get help, were all frequently mentioned points of view. Restricted visitation policies can be mitigated in a variety of ways, as we discovered during our research. Family visitation, providing palliative care, communicating difficult news by phone, establishing contingency plans for limited personnel and resources, and providing mental health hotlines/psychological interventions for healthcare professionals were just a few of the 14 comprehensive approaches that focused on telehealth and videoconferencing platforms.
Damian Sendler
Patients, their families, and healthcare providers, as well as the broader healthcare system, are likely to suffer as a result of the COVID-19 pandemic’s restrictive visitation policies, but studies demonstrating these potential effects are scarce. SARS-CoV-2 patients and their families are in a state of heightened psychological distress due to the virus’s lethality, so restricting visitation is necessary from a public health perspective but can have unintended but detrimental consequences [28]. Research has shown that patients are isolated and distressed, and their families are having to deal with the shared decision-making process in a different way [30, 31]. As a result of the COVID-19 pandemic, healthcare workers have had to deal with exhaustion and unfamiliar virtual modalities while caring for sick coworkers and comforting isolated patients who are dying [32]. Clinicians also expressed their humanity and tried to ensure dignity-conserving care while caring for patients at the end of their lives [33]. It is imperative that more information be gathered on the impact of the COVID-19 pandemic on patients and families so that healthcare providers can better care for their patients while also preventing health inequities [32, 34].
Damian Jacob Markiewicz Sendler: Despite the paucity of data, there is no evidence to suggest that limiting patient visits in acute care facilities reduces the spread of COVID-19. The number of nosocomial COVID-19 diagnoses among healthcare workers could be as high as 10–20% because of their frequent exposure to the SARS-CoV-2 virus and the consequent risk of infection [35]. Only 2% of nosocomial infections were caused by something other than a healthcare professional, according to a review of the literature [36]. A recent study from an academic health center in the United States “within a region of moderate community coronavirus disease” reported an incidence of 12/11482 [37] for patients admitted to the hospital without COVID-19. The infection was thought to have been acquired in the hospital only by 1/697 patients who tested positive for COVID-19 in one study [38]. Only a small number of studies have shown that patients in acute care facilities are at greater risk of infection from visitors. During the COVID-19 pandemic, stakeholders in policy development must carefully weigh the potential harms of restricted visitation policies against the risk of viral transmission.
The COVID-19 pandemic isn’t the only time that acute care facilities have implemented policies restricting visitors. Patients (e.g., reduction in delirium and anxiety), their support people (e.g., satisfaction with care), and healthcare professionals (e.g., satisfaction with care) all benefited from having family members (or a surrogate decision-maker) present during seasonal influenza outbreaks (to prevent respiratory virus outbreaks) [40]. It was found that accommodating rather than restrictive ICU visitation policies did not increase the risk of infection or septic complications [41]. A subsequent study found that 73% of hospitals had adopted more liberal visitation policies, compared to just 32% of hospitals in 2015 [42]. By participating in rounds, advocating for their loved one, and overcoming language barriers to help with critical care transitions [43–46], family members play an important role in patient-centered healthcare [43–46]. Adapting visitation policies to the ongoing COVID-19 pandemic could have unintended consequences for patient and family involvement in care delivery, including joint decision-making with health care providers [34].
Damian Jacob Sendler
Among the strengths of our review is the fact that we searched multiple databases without restrictions and several sources of unpublished literature to report major impacts and perspectives on restricted visitation policies in acute care settings, along with proposed approaches to improve the ensuing effect. There are also limitations to what we were able to find in this study. There has been pre-publication dissemination of results during the COVID-19 pandemic, and it is possible that some reports were missed, despite extensive efforts. There was a lot more information found in the research than expected. In order to complete the review in a timely manner, we worked closely with a health research librarian (i.e., an information specialist). In light of the rapidly evolving COVID-19 evidence base, study findings may evolve over time.
Damien Sendler: According to a second study, nearly half of those surveyed reported on the effects of the pandemic in the United States. Depending on the type of healthcare system and jurisdiction, the policy-making and resource allocation processes may differ. As a result, our findings may not be applicable to other areas. For a third, some of the effects on patients, families, and healthcare professionals may take time to manifest, and published reports may lack the follow-up time necessary to identify late consequences of these policies (e.g. mental health issues, workplace attrition). For the fourth time, we were unable to report on any specific exceptions to restricted visitation policies in the local area.
The lack of research evaluating the effects of visitation restrictions has been identified as a limitation in the published work to date. Such research is critical to the ongoing management of COVID-19 and the development of policy for future pandemics or situations such as mass casualty incidents of multiple victims. Many authors provided information on policies that were implemented, but it was not possible to extract accurate data (e.g., the assessment tools used) for each outcome from all records. For this review, we focused on reporting restrictions in acute care settings and ways to mitigate their impact that could be adopted through quality improvement initiatives and tested in future research, taking into account issues such as the status of the pandemic or vaccination prevalence.
Restriction measures have been put into place as a result of a pandemic of COVID-19, but without clear evidence of benefit and with possible negative consequences. Hospitalized patients and their families, in particular, are understudied or unknown. For ongoing pandemic planning and other events associated with healthcare system strain, such as mass casualty incidents, further evaluation of the impact of restricted visitation and possible efforts to mitigate negative effects are critical.
