key: cord-0911378-cqjkjkt3 authors: Iness, Audra N.; Abaricia, Jefferson O.; Sawadogo, Wendemi; Iness, Caleb M.; Duesberg, Max; Cyrus, John; Prasad, Vinay title: The effect of hospital visitor policies on patients, their visitors, and healthcare providers during the COVID-19 pandemic: a systematic review date: 2022-04-25 journal: Am J Med DOI: 10.1016/j.amjmed.2022.04.005 sha: c273ffdc55ac3d23c493b3eab1d0e48a7b806281 doc_id: 911378 cord_uid: cqjkjkt3 Healthcare policymaking during the SARS-CoV-2 (COVID-19) pandemic has questioned the precedent of restricting hospital visitors. We aimed to synthesize available data describing the resulting impact on patient, family/visitor, and healthcare provider wellbeing. We systematically reviewed articles from the World Health Organization COVID-19 Global Literature on Coronavirus Disease Database published between December 2019 through April 2021. Included studies focused on hospitalized patients and reported one or more pre-specified main or secondary outcome (COVID-19 disease transmission, global wellbeing, mortality, morbidity, or healthcare resource utilization). Two authors independently extracted data into a standardized form with a third author resolving discrepancies. 1153 abstracts were screened, and 26 final full-text articles were included. Ten studies were qualitative, with seven cohort studies, and no randomized controlled trials. Critically ill patients were the most represented (12/26 studies). Blanket hospital visitor policies were associated with failure to address the unique needs of patients, their visitors, and healthcare providers in various clinical environments. Overall, a patient-centered, thoughtful, and nuanced approach to hospital visitor policies is likely to benefit all stakeholders while minimizing potential harms. In western tradition, only in the early twentieth century did hospitals begin to allow visitors for paying patients. 1 Fifty years later, after establishment of newborn intensive care units (NICU), visitor policies appeared more familiar to those of modern day with limited visiting hours for all patients. 2 Additional restrictions for infection control is an established practice during respiratory syncytial virus and influenza seasons. 3, 4, 5 Although not novel, the efficacy and guidance for visitor restrictions remains inconsistent, especially for the COVID-19 pandemic. The Centers for Disease Control and Prevention (CDC) recommended limiting visitors to inpatient facilities "to only those essential for the patient's physical or emotional well-being and care." 6 It is reasonable to suspect that practical application of this statement may vary across institutions and practices. Lack of clarity leaves the potential for inequities in implementation and raises ethical questions. 7, 8 Restriction of visitors is also discussed as a source of moral distress for healthcare providers who may not agree with hospital policies. 9 ,10 Yet, a Cochrane rapid qualitative evidence synthesis review of barriers to healthcare providers' adherence to infection control measures found an opposing effect. Health care workers experienced strain from being responsible for visitors' adherence to infection control measures. 11 The significance of SARS-CoV-2 transmission from visitors in hospitals, however, is also questionable. 12 Therefore, we sought to critically appraise the evidence relating hospital visitor restrictions and COVID-19 transmission. We aimed to determine the impact of visitor restrictions on the wellbeing of hospitalized patients, their visitors, and healthcare providers during the COVID-19 pandemic. Further details are available in the PROSPERO protocol associated with this study (CRD42021248603) that was developed in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. 13 We searched the World Health Organization (WHO) COVID- 19 Patients")). We included quantitative and qualitative studies as well as conference abstracts from December 2019 to April 2021. Studies must have focused on hospitalized patients, their families/visitors, or health care providers of all ages in the setting of the COVID-19 pandemic. "Hospital" was defined as a public or academic institution in which a patient is admitted for inpatient medical care. Studies were in English and reported at least one of the pre-specified main or secondary outcomes (COVID-19 disease transmission, global wellbeing, mortality, morbidity, or healthcare resource utilization). Reviews of existing literature, editorials, and expert opinions were excluded. Studies that did not fit into the conceptual framework of this systematic review or focused on a population other than hospitalized patients were also excluded. Long-term care and skilled nursing facilities were excluded because they are not considered hospitals, but places of permanent residence. Using a systematic review software, Rayyan, 14 two independent reviewers screened abstracts based on the pre-defined criteria. Discrepancies were discussed with a third reviewer until a consensus was reached. This same process was repeated with full articles. For each included study, two reviewers extracted data independently using a standardized data extraction form (available in appendix files). This process occurred without blinding of study authors, institutions, journals, or results. Discrepancies were resolved by discussion with a third reviewer and the research team, as necessary. We evaluated the risk of bias using The Cochrane Collaboration's tool "Risk Of Bias In Non-randomised Studies of Interventions" (ROBINS-I), Critical Appraisal Skills Programme (CASP) appraisal tool for qualitative studies, and Oxford Centre for Evidence-based Medicine quality scheme. 15, 16, 17 . Two authors ranked each study's risk of bias separately. Disagreements were resolved by discussion with a third reviewer. Given the heterogeneity in methodologies across the literature, we comprehensively tabulated study characteristics, permitting critique of design and enumeration of potential biases. Two authors (ANI and JOA) independently made this determination, with input from a third author in the event of a discrepancy (WS We identified 1153 abstracts which were read in full. 78 articles met criteria for screening of the study report. Of these, 26 studies met prespecified criteria for inclusion (Fig. 1) . Half of the studies were published in 2020, the first year of the pandemic, and half in 2021. Most studies took place in North America (46%), specifically the United States, followed by Europe of studies took place in intensive care units (ICUs) ( Fig. 2A) . Finally, the majority of the included studies were qualitative or survey-based; only 7 of 26 were cohort studies (Fig. 2B) . We found 5 of 26 included studies focused on the inpatient ward setting, and a common theme among them was attention to vulnerable populations with potentially impaired decisionmaking capacity ( Table 1) . Visitors/support persons may serve as patient advocates and aid in decision-making if legally authorized. 18 One common cause of impaired capacity in the inpatient setting is delirium. Some suggest that the presence of hospital visitors may protect against delirium development, but this notion was challenged in recent studies. 19 25 Similarly, a cross sectional survey of 328 next-of-kin of veterans who died in an inpatient unit found themes of "anguish and despair" from not being allowed to see patients. 26 Overall, the COVID-19 pandemic and visitor restrictions were associated with negative emotions among most inpatients and their families in the studies reviewed, especially in the context of end-of-life care. There was evidence of moral distress for healthcare providers caring for dying patients; however, some responded positively to visitor restrictions from the perspective of limiting their occupational exposure to the COVID-19 virus. End of life care and vulnerable population discussions are especially pertinent to the ICU setting ( 29 Another retrospective cohort study of patients lacking medical decision-making capacity found more frequent changes in patient goals of care for in-person meetings than by video (36% vs. 11%, p = 0.0006), implying a potential differential effect of communication modality on outcome. 30 Two studies covered the post-operative patient population ( Table 3) . A retrospective cohort study of 117 post-operative patients who were not allowed visitors found that those in the no-visitor cohort were less likely to report complete satisfaction with the hospital experience In lieu of in-person visits, videos calls are increasingly prevalent in hospitals. A retrospective survey of families (N=24) in the UK who received video calls were more likely to be satisfied with the frequency (83%) and quality (83%) of communication. 34 Qualitative interviews with ICU physicians yielded different results. 38 This study found that telehealth increased clinician workload, technical difficulties limited effective communication, and clinicians struggled to engage family members because of discomfort with technology use and less apparent social cues. Clinicians also were concerned about ability to convey empathy remotely. Family member participants, however, felt empathy was relayed successfully via phone and video. In this same study, respondents viewed phone and video communication as somewhat effective but inferior to in-person communication. 38 Common barriers to virtual visiting included challenges associated with family member ability to use videoconferencing technology or having access to a device. 37 Communication strategies suggested by families and clinicians for productive remote interactions include identifying a family point-person to receive updates, frequently assessing family understanding, positioning the camera so that family can see the patient, and allowing time for the family and patient to interact without clinician presence. 38 Interestingly, this model is in contrast to the study in France which reported high levels of stress among "reference persons" who were to field provider calls/updates. 31 Overall, judicious use of video conferencing may be beneficial in some settings. Optimizing communication strategies is important from the provider standpoint. Technical issues and access to technology may limit effective implementation of video conferencing. The authors found the included studies were of limited quality ( Table 4) . Qualitative studies, of which there were several (Fig. 2B) , were evaluated using the Critical Appraisal Skills Programme (CASP) appraisal tool. 15 Here, the authors found inconsistent use of validated formal assessment measures for coding of subject interviews. Globally, this contributed to substantial heterogeneity, limiting the ability to synthesize data. Furthermore, the nature of the secondary research questions has a tendency toward qualitative studies which, by nature, precludes most quantitative analyses. Given the uncertain potential risks and benefits of allowing hospital visitors, it might be argued that a randomized controlled trial is justified in this situation to provide further clarity, as was done for a study assessing impact of visitor presence on delirium prevalence in ICUpatients. 19 Risk-benefit assessment is the cornerstone of medical and policy decision-making. As The CDC now provides visitor recommendations for a variety of scenarios (e.g. vaccinated versus unvaccinated status, symptomatic versus asymptomatic, and specific facilities, such as dialysis centers); however, end-of-life care is not addressed. 42 The CDC also recommends using alternative methods of staying connected with patients, such as video calls. Although our findings suggest that increasing availability of video conferencing may be beneficial in certain situations, consideration should be given to how this practice may be practically and equitably applied. Exclusive reliance on technology may differentially impact those at an economic or resource disadvantage. The origin of this potential disparity harkens back to the infancy of hospital visitor policies when only paying patients were allowed to have visitors. 1 Finally, there is a paucity of reporting for COVID-19 transmission in the context of altering hospital visitor policies and the body of literature is mostly of limited quality. Further retrospective, but importantly prospective and/or randomized studies, are needed to clarify the risks and benefits associated with limiting hospital visitors. In the meantime, it is prudent to take a patient-centered, and thoughtful approach to hospital visitor policies with freedom given to practicing physicians to grant exemptions as opposed to blanket rulings produced by administrators. Strengths of our study include a systematic investigation of the available literature at a period of high policy turnover during the COVID-19 pandemic. Study parameters were prespecified in the protocol to reduce the risk of bias, in accordance with accepted systematic review guidelines. Multiple authors independently completed each step to reduce noise among the otherwise heterogenous data. The most notable limitation was the inability to assess our primary outcome: the impact of visitor policies on COVID-19 transmission. Only one included study reported COVID-19 transmission, which was in the context of transmission from mother to newborn. 43 Therefore, it is difficult to comment on whether or not restriction of hospital visitors significantly reduced the spread of COVID-19 infection. Second, our analysis was limited by the lack of reporting of COVID-19 status in study participants and pertinent details about the visitor policies in place. This may be due to fluid policies in the face of a rapidly evolving pandemic; however, a few investigators used this as an advantage to perform cohort studies. Notably, these retrospective cohort studies compared groups of patients pre-and post-visitor policy implementation. 21, 29, 30, 32 . Potential downsides to these retrospective studies include biases related to the selection of subjects, recall bias, and confounding factors given lack of randomization. 44 Additionally, two prospective cohort studies had relatively small sample sizes and only one assessed COVID-19 transmission. 31, 43 . Finally, the ROBINS-I tool was used, and all authors agreed that these studies were of low quality. 45 Together, the data reflect an early, developing literature exploring the efficacy of policy changes in the face of a challenging pandemic. implementing strategies to reduce risk of horizontal transmission of sars-cov-2: potential for compromise of neonatal microbiome assemblage. Gastroenterology. Table 2 . Summary of included studies focused on the ICU setting. 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