key: cord-0750579-f5qb9a5b authors: Lo, Alexander X.; Wedel, Logan K.; Liu, Shan W.; Wongtangman, Thiti; Thatphet, Phraewa; Santangelo, Ilianna; Chary, Anita N.; Biddinger, Paul D.; Grudzen, Corita R.; Kennedy, Maura title: COVID‐19 hospital and emergency department visitor policies in the United States: Impact on persons with cognitive or physical impairment or receiving end‐of‐life care date: 2022-01-20 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12622 sha: aba2a4225ef4450feb5e717b6752e93cf24df68f doc_id: 750579 cord_uid: f5qb9a5b OBJECTIVE: To characterize the national distribution of COVID‐19 hospital and emergency department visitor restriction policies across the United States, focusing on patients with cognitive or physical impairment or receiving end‐of‐life care. METHODS: Cross‐sectional study of visitor policies and exceptions, using a nationally representative random sample of EDs and hospitals during the first wave of the COVID‐19 pandemic, by trained study investigators using standardized instrument. RESULTS: Of the 352 hospitals studied, 326 (93%) had a COVID‐19 hospital‐wide visitor restriction policy and 164 (47%) also had an ED‐specific policy. Hospital‐wide policies were more prevalent at academic than non‐academic (96% vs 90%; P < 0.05) and at urban than rural sites (95% vs 84%; P < 0.001); however, the prevalence of ED‐specific policies did not significantly differ across these site characteristics. Geographic region was not associated with the prevalence of any visitor policies. Among all study sites, only 58% of hospitals reported exceptions for patients receiving end‐of‐life care, 39% for persons with cognitive impairment, and 33% for persons with physical impairment, and only 12% provided policies in non‐English languages. Sites with ED‐specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end‐of‐life care (26%). CONCLUSION: Although the benefits of visitor policies towards curbing COVID‐19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end‐of‐life care were predominantly lacking, as were policies in non‐English languages. and only 12% provided policies in non-English languages. Sites with ED-specific policies reported even fewer exceptions for patients with cognitive impairment (29%), with physical impairments (24%), or receiving end-of-life care (26%). Although the benefits of visitor policies towards curbing COVID-19 transmission had not been firmly established, such policies were widespread among US hospitals. Exceptions that permitted family or other caregivers for patients with cognitive or physical impairments or receiving end-of-life care were predominantly lacking, as were policies in non-English languages. COVID-19, dementia, disability, end-of-life, health disparities, older adults, visitor policy 1 INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has inflicted a disproportionately heavier toll on older persons. 1, 2 In the United States, adults ≥ 65 years old accounted for ∼15% of cases but > 80% of deaths in 2020. 1 In many countries, older persons who avoided or survived COVID-19 still faced an increased risk of physical deconditioning, cognitive decline, or increased care needs amid social restrictions and community lockdowns. [2] [3] [4] Several public health and hospital responses to COVID-19, such as social distancing, reductions in community programs, or care rationing, were unduly harmful to older persons. [5] [6] [7] Hospital visitor restriction policies have also been adopted in response to COVID-19, but their prevalence and impact have not been well studied. These policies restrict or prevent caregivers from accompanying dependent older adults in the hospital 8 and may be especially detrimental to patients with cognitive 9,10 or physical impairment 4 or receiving end-of-life care, 11, 12 particularly in times of emergency care or unavoidable hospitalization. Our objective was to determine the scope of COVID-19 hospital visitor policies and exceptions across the United States, as they relate to patients with cognitive or physical impairment or end-of-life care, seeking emergency care or requiring hospitalization, and whether these policies were accessible to non-English speakers. To capture the care experience of patients requiring emergency care and unavoidable hospitalization, we designed our sampling scheme a priori to include only care facilities that comprised both an ED and an attached hospital (in this study, any facility comprising an ED and hospital are referred to as "sites"). Freestanding EDs (emergency facilities that are functionally and physically separated from inpatient services 13 ) and urgent care clinics were excluded. Hospitals without an ED were also excluded from the sample. This study used a stratified random sample of US academic and non-academic sites from the 50 US states and District of Columbia (DC). For academic EDs, we randomly selected a minimum of 50% of all The main outcome measures included any hospital or ED visitor policy related to COVID-19 and any reported exceptions pertaining to patients with cognitive or physical impairment or receiving end-of-life care, and children (ie, patients <18 years of age), with the latter serving as a control measure. Data on the languages in which the policies were reported were also collected. Each site was geographically classified by US Census Bureau Region (Northeast, Midwest, South, or West) 16 were combined and classified as "urban" and the remaining 9 rural categories (3 through 12) were combined and singularly classified as "rural," following prior work by Liu et al. 19 Data on visitor policies at each site were independently abstracted by 2 of 3 study investigators (PT, TW, IS). All data, particularly those where the 2 investigators were discordant, were reviewed and adjudicated by a lead investigator (LKW). Two validation analyses were conducted to account for the theoretical possibility that during the study period, hospitals may revise their visitor policies because of (1) changes in local government regulations, or (2) regional variations in COVID-19 case burden. region-specific analysis across the four U.S. Census regions by examining whether there were significant differences in the proportion of sites with any exceptions. We compared the proportions of visitor policy characteristics across different categories of study site characteristics, such as academic status and geographical factors, using Fisher's exact tests. 21 All statistical analyses including the validation analysis described subsequently, were conducted using IBM SPSS statistics software version 26 (IBM Corporation, Somers, NY). The study sample comprised 352 (146 academic and 206 nonacademic) total sites. The geographic characteristics of study sites are shown in Table 1 . COVID-19 hospital-wide visitor policies were available at 326 (93%) sites and significantly more likely found at academic and urban sites. Separate ED-specific policies were available at 164 sites, although their overall prevalence did not significantly differ between academic and non-academic or between urban and rural sites. The prevalence of hospital-wide or ED-specific visitor policies did not vary significantly across the 4 geographic regions (P = 0.965). Of the 326 sites with a hospital-wide visitor policy, 76% reported exceptions for children, 39% for patients with cognitive impairment (with 14% specific for dementia), 33% for those with physical impairment, and 58% for those receiving end-of-life care. Among sites with ED-specific visitor policies, 48% reported exceptions for children, 32% for patients with cognitive impairment (11% of sites specified demen-tia), 27% for those with physical impairment, and 29% for those receiving end-of-life care. A comparison of individual exceptions between academic and nonacademic sites is shown in Table 2 , where academic sites were more likely to report policy exceptions, although non-academic sites were notably more likely to report exceptions for end-of-life care. Of the 352 sites, 310 (88%) provided information only in English; the remaining 12% also provided information in Spanish, of which 4% included a third language. Academic sites were more likely to provide information in languages other than English (17% vs 8%; P = 0.048). In the validation analysis, every state had at least 1 site that had an explicit exception to their visitor policy, and we observed no significant differences in the prevalence of either hospital-wide or ED-specific visitor policies between geographic regions. One limitation with this study was the reliance on publicly available information, as hospitals may have unpublicized internal policies. For example, only 76% of sites explicitly provided an exception for parents, although the remaining sites likely permitted this exception without explicitly publicizing it. 49 Nonetheless, our approach was intentionally chosen to mimic the expected steps the public would take in search of a hospital's visitor policy. Furthermore, explicit publicly available policies are more relevant to older persons; whereas parents of children were more likely to pursue exemptions when none were explicitly provided, 49 older persons were more likely to identify barriers and be discouraged from seeking care. 50 This suggests that allowances for discretionary exceptions should be explicitly mentioned, as the onus of requesting them should not be placed upon the patient, who are the ones most likely to benefit most but evidently also most reluctant to request them. Second, hospital policies may change over time in response to individual state regulations or be influenced by regional COVID-19 patterns and may also change as knowledge of disease transmission and the vaccinated proportion of the population changes. We anticipated this possibility and therefore intentionally designed this study to capture all data in as narrow a time frame as possible to avoid or minimize such changes. We eschewed a potentially larger sample of sites in order to gain a shorter data collection period. We also addressed this limitation with a validation analysis that found no evidence of either a systematic statewide elimination of visitor exceptions or significant regional variations in the prevalence of visitor policies. Relatedly, we also recognize that a similar study conducted after the availability of the COVID-19 vaccines may produce different findings in regard to visitor restrictions. During the height of the first wave of the US COVID-19 pandemic, nearly all hospitals sampled for this study reported a COVID-19 hospital-wide visitor policy and half also reported an ED-specific TA B L E 2 Comparison of COVID-19 hospital-wide and ED-specific visitor restriction policies and exceptions between academic and non-academic sites Note: Superscript notations indicate where differences in the proportion of sites with particular visitor policy elements, when comparing academic and nonacademic sites, were statistically significant at P < 0.05 (*) or P < 0.001 (**). $ P value 0.0507. Fewer than 5 academic and non-academic sites each did not provide details for policy exceptions nor indicated discretionary exceptions that required visitors to contact the hospital or emergency department to discuss their specific circumstances. policy. Yet, fewer than 60% of hospitals reported exceptions for end-oflife care, fewer than 40% reported exceptions for patients with either cognitive or physical impairment, and fewer than 1 in 8 hospitals publicly posted a visitor policy in a language other than English. To our knowledge this is the first nationally-representative and randomly sampled US study on COVID-19 visitor policies with a focus on 3 clinical conditions highly germane to the older adult population. 4, [9] [10] [11] [12] Exceptions to visitor restrictions for patients receiving obstetric, 22 pediatric, 23, 24 and end-of-life care have been reported 25 ; however, the impact of visitor policies on persons with cognitive impairment or physical impairment is lacking. Jaswaney examined visitor policies using a non-random sample of the 70 largest metropolitan US hospitals from 24 states and similarly found that 93% had visitor policies and 46% had ED-specific policies, and a higher proportion of hospitals with exceptions for end-of-life care (78%) and for patients with any "disabilities" (54%), with that category including cognitive impairment. 26 As the SARS-CoV-2 virus may be transmitted by asymptomatic persons, 27 one logical concern was that visitors could infect patients, hospital staff, and/or other visitors or could themselves be infected while in the hospital. Although these risks could be mitigated by pro- The higher prevalence of policy exceptions for persons with cognitive or physical impairments at academic sites may reflect their higher patient population with severe cognitive or physical impairment, whereas the lower prevalence of exceptions for patients receiving end-of-life care was perhaps explained by the specialized care of immunocompromised transplant and oncology patients at these sites that necessitated more restrictive policies for terminally ill patients. 31 Nonetheless, these observations warrant further research. Our findings underscore the need to distinguish the different roles within the umbrella term of "visitors." This term disregards or minimizes the critical roles of family and other caregivers of dependent older persons, who serve as surrogate decision-makers, provide critical medical information, lend emotional support, and advocate for care quality on their behalf. 32, 33 In the case of persons living with advanced dementia, caregivers serve the invaluable role of interpreting the nonverbal clues of these persons, who otherwise may communicate pain, fear, overstimulation, or an unmet need only through agitation. 34 The roles of caregivers of older adults may practically parallel those of parents of young children, and the fact that parents were most likely to be granted an explicit exemption from visitor policies in our study demonstrates that hospitals recognize the benefit of such critical roles in the care of the patient. Caregiver presence would arguably have been more crucial during the pandemic, as persons with cognitive or physical impairment experienced further functional declines, 3, 9, 35 where the widespread use of face masks potentially exacerbated disorientation in those with advanced dementia, 36, 37 and where constraints in hospital resources or competing demands often limited the hospital staff's ability to attend to patients with special needs or disabilities. 38 In this random sample of US ED and hospitals, the majority of sites did not offer exceptions to COVID-19 visitor restrictions that would have benefited older persons with cognitive or physical impairments or who were receiving end-of-life care. Any potential benefits of visitor restrictions in minimizing viral spread must be weighed against the special needs of older persons with complex care needs and the potential harm of depriving them of caregivers. The lack of multilingual information may widen the existing disparities in access to care and health outcomes between socioeconomic groups. This issue is both critical and timely for older adults seeking emergency care in the United States, particularly given that hospitalizations for older persons in the United States often originate from the ED 51 and the increasing use of the ED as a frequent or primary place of care for older persons in the United States. 52 This study also raises a concern for ageism, where well-intended hospital policies failed to account for the critical needs of, and the potentially harmful consequences to, the more vulnerable and dependent older persons of the community they serve. We recom- Age and frailty are independently associated with increased COVID-19 mortality and increased care needs in survivors: results of an international multicentre study Delayed health consequences of COVID-19 lockdown in an older adult Changes to family caregiving of older adults and adults with disabilities during COVID-19 Ageism is making the pandemic worse. 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Boggs, MPH, and the EMNet Coordinating Center at Massachusetts General Hospital (Boston, MA) for access to the information from the NEDI-USA database. There were no funding sources in support of this work. The authors have no conflicts of interest to report.