Impacts On Quadruple-Aim Metrics of Hospital Visitor Restrictions During COVID-19

Last Updated: September 24, 2020

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This Briefing Note was completed by the Research, Analysis, and Evaluation Branch (Ministry of Health) in collaboration with a member of the COVID-19 Evidence Synthesis Network. Please refer to the Methods section for further information.

Purpose

This note examines the risk of COVID-19 transmission in hospitals and the impacts on quadruple-aim metrics of visitor restrictions in hospitals based on public health measures, the state of the pandemic, and alternative communication modalities.

*The full version of the Briefing Note including the Appendix can be accessed in the PDF file at the top of the page*

Key Findings

Analysis for Ontario

As of June 15, 2020, the Ministry of Health recommended that public and private hospitals resume allowing visitors (e.g., family, caregivers) in acute care settings, and institutional public health measures have been put in place (e.g., limits on the number of visitors or time of visit, designation of care partners, mask wearing). The Ontario Hospital Association also issued guidance on the length and frequency of visits and alternative communication modalities (e.g., virtual care, outdoor visits).

Implementation Implications

There is limited scientific evidence on the benefits or harms of visitors for COVID-19 patients in hospitals, but jurisdictional experiences reflect permissible visitor policies with accompanying public health measures and alternative communication modalities.

Supporting Evidence

  • This section below summarizes the scientific evidence and jurisdictional experiences regarding the risk of COVID-19 transmission in hospitals and the impacts on quadruple-aim metrics of visitor restrictions and exceptions in hospitals based on public health measures, the state of the pandemic, and alternative communication modalities. In terms of jurisdictional experience, information is presented on all Canadian provinces and territories, China, Germany, South Korea, Spain, Taiwan, and United States (US) in general and New York City. The following framework was used to organize the findings:
    • Hospital Settings: General and priority settings, including general medicine, intensive care unit (ICU), labour and delivery, mental health and addictions, and palliative care.
    • Rate of Transmission: Rate of transmission of COVID-19.
    • Visitor Restrictions and Exceptions: No visitors, no exceptions; limited visitors with specific exceptions (e.g., end of life, ICU, labour and delivery, and language barriers); and other restrictions.
    • Accompanying Public Health Measures: Institution and in the community (but only when intersecting with visitor policies for institutions).
    • Alternative Communication Modalities: Video calls, telephone calls, and others.
    • Quadruple Aim Metrics:
      • Health-related benefits to patients, families, and caregivers of visitors (e.g., reduced infections in facility or in community, reduced delirium);
      • Health-related harms to patients, families, and caregivers from restriction of visitors (e.g., worsened mental health);
      • Experiences of patients, families, and caregivers (e.g., help with care and support, help with translation, less worry, less sedatives/constraints);
      • Experiences of providers (e.g., many stressful calls with families);
      • Per capita costs or resource consumption more generally (e.g., reduced PPE consumptions, staffing and iPad constrains, reduced sedative use).

Scientific Evidence

  • Risk of Transmission of COVID-19: None of the identified sources provided evidence about rates of transmission attributable to visitors, but rather focused on overall transmission rates in hospitals.
    • A World Health Organization guideline (last updated July 9, 2020) described the routes of transmission of COVID-19, which occurs primarily through direct, indirect, and close contacts with infected people through infected secretions (e.g., saliva, respiratory) or respiratory droplets (e.g., coughing, sneezing, talking, singing).
    • One systematic review (March 31, 2020) provided estimates of transmission rates in hospitals, where the proportion of nosocomial infections in patients with COVID-19 was found to be 44% in the early outbreak.
    • Three studies were identified that discussed transmission rates of COVID-19 in hospitals:
      • A study (September 11, 2020) found that the rate of nosocomial SARS-CoV-2 infection in an orthopaedic and traumatology department in Spain was 6.5%.
      • A study (September 9, 2020) found that the overall risk of hospital-acquired COVID-19 was low in a cohort study of 9,149 patients admitted to a large US academic medical centre over a 12-week period where 697 COVID-19 cases were identified.
      • A study (July 3, 2020) found a total of 303 hospital staff members and patients were exposed to 29 confirmed COVID-19 patients in a South Korean hospital, of which three were found to have COVID-19 which were largely as a result of poor adherence to public health measures.
  • Visitor Restrictions: Limited information was found relating directly to the quadruple aim, with the exception of findings relating to the health-related benefits of public health measures (e.g., preventing transmission of COVID-19).
    • No Visitors with No Exceptions: No information identified.
    • Limited Visitors with Specific Exceptions: Two studies examined visitor restrictions in Taiwan, noting that hospice units, in general, maintained their visiting policies as did other wards where less vulnerable patients were admitted. Instead of restricting access, hospitals in Taiwan used approaches such as limiting the number of visitors, limiting the length of visits, and checking identification and screening for symptoms.
  • Visitor Restrictions and Accompanying Public Health Measures:
    • No evidence documents were identified that addressed adjusting visitor policies based on the active number of COVID-19 cases, trends in local areas, and availability of PPE and testing supplies.
    • A rapid review (September 2, 2020) highlighted the importance of ensuring visitors had no suspicion of having been in contact with someone with COVID-19, limiting the number of visitors allowed to be at the hospital, and requiring visitors to wear PPE. Moreover, three studies (May 4, May 8, and July 30, 2020) highlighted the following strategies:
      • Protecting medical staff through PPE and tracking of possible exposure;
      • Restricting visitors to select areas;
      • Taking a detailed history of all visitors;
      • Implementing temperature and symptom screening;
      • Enhancing hand hygiene;
      • Prohibiting the wearing of PPE leaving a contaminated area;
      • Disinfecting work areas; and
      • Enhancing ventilation.
  • Alternative Communication Modalities: Evidence on measures that can be put in place to mitigate any potential harms associated with visitor restrictions was only identified for video calls, and not for telephone calls or other modalities:
    • A rapid review (April 2, 2020) noted that with strict visitor policies having been put in place, many hospitals in Australia are making use of Skype, WhatsApp, and Facetime to connect patients with families and friends. However, studies included in the rapid review documented bacterial contamination of mobile handheld devices used for this purpose, and advised that strict infection-prevention and control programs accompany the use of these devices.

International Scan

  • No Visitors with No Exceptions: No examples identified.
  • Limited Visitors and Accompanying Public Health Measures: Though early in the pandemic many countries began with strict enforcement of no-visitor policies, those restrictions have since loosened as COVID-19 cases have decreased. These jurisdictions include in China, Germany, South Korea, and New York, all of whom took a regional approach to regulation, whereby more permissible visitor policies were allowed based on regional COVID-19 rates. Institutional public health measures that have been put in place to mitigate the potential risks of visitors include:
    • Conducting symptom and temperature checks for visitors at the entrance (China, South Korea, and New York);
    • Having visitors sign-in using a visitors log (China and South Korea);
    • Requiring visitors to wear masks while in the hospital (China, South Korea, and New York);
    • Limiting the number of visitors at any given time (China and New York);
    • Limiting visiting times (New York);
    • Restricting visitors to specific locations within hospitals (China);
    • Maintaining physical distancing (South Korea); and
    • Disinfecting hands upon entrance and exit to the hospital (New York).

Alternative Communication Modalities: No examples identified.

Canadian Scan

  • No Visitors with No Exceptions: No examples identified.
  • Limited Visitors with Specific Exceptions:
    • British Columbia, Manitoba, New Brunswick, Nova Scotia, Newfoundland and Labrador, and Northwest Territories have strict policies in place whereby general visiting is not permitted or may be limited to one individual where deemed medically necessary. Common exceptions to this are for exceptional circumstances including palliative care units, for pediatric patients, and in labour and delivery suites.
    • Alberta and Saskatchewan have asked that patients designate two visitors who, so long as they adhere to public health measures, are permitted to see the patient throughout their admission.
    • Quebec and the Yukon are both allowing general visitors in most areas of the hospital but have designated specific areas where additional restrictions apply, including the emergency department, oncology department, and ICU, as well as for select patients such as those receiving bone marrow transplants.
  • Public Health Measures: Institutional public health measures that have been put in place to mitigate the potential risks of visitors include:
    • Maintaining physical distance (British Columbia, Quebec, New Brunswick, Nova Scotia, and Newfoundland and Labrador);
    • Washing or disinfecting hands upon entry and exit (British Columbia, Saskatchewan, Nova Scotia, and Newfoundland and Labrador);
    • Wearing a mask and other PPE (British Columbia, Saskatchewan, New Brunswick, and Nova Scotia);
    • Pre-screening for symptoms, including temperature checks (Saskatchewan, Nova Scotia, Newfoundland and Labrador, and Nunavut);
    • Registration of visitors for contact tracing (Manitoba);
    • Not permitted to eat or drink while visiting (New Brunswick); and
    • Must stay in a patient’s room when visiting (Nova Scotia).
  • Alternative Communication Modalities: Many provinces (British Columbia, Alberta, Saskatchewan, and Manitoba) are recommending that inpatients should make use of outdoor hospital space to see visitors if they are able to. Visitor limits for outdoors differ by province, but are capped at between two and five.

Ontario Scan

  • No Visitors, with No Exceptions: No examples identified.
  • Limited Visitors: As of June 15, 2020, the Ministry of Health recommended that public and private hospital resume allowing visitors (e.g., family, caregivers) in acute care settings with public health measures set in place. For example:
    • The University Health Network allows inpatients to have one essential care partner visit the hospital per day (with a few exceptions).
    • London Health Sciences Centre is limiting family/caregiver visits and provides guidance on number of allowable visitors and length/duration of visits for specific patient populations (e.g., children, women in labour, palliative, major surgery, stays longer than seven days, and emergency department) and situations (e.g., patients experiencing a mental health crisis, actively dying, outpatient appointments).
    • The Ottawa Hospital permits patients to identify two visitors, but they can only have one visit with one person each day for one hour.
    • Guidance has been issued from the Ontario Hospital Association related to length and frequency of visits.
  • Public Health Measures: Institutional public health measures that have been put in place to mitigate the potential risks of visitors include:
    • Limits on the number of visitors and/or time of visiting;
    • Designation of care partners;
    • Maintaining physical distance;
    • Washing or disinfecting hands upon entry and exit; and
    • Wearing a mask and other PPE.
  • Alternative Communication Modalities: Guidance from the Ontario Hospital Association recommends using care partner identification badges, virtual care, and outdoor visits to connect care partners and patients.

Methods

The COVID-19 Evidence Synthesis Network is comprised of groups specializing in evidence synthesis and knowledge translation. The group has committed to provide their expertise to provide high-quality, relevant, and timely synthesized research evidence about COVID-19 to inform decision makers as the pandemic continues. The following member of the Network provided an evidence synthesis product that was used to develop this Evidence Synthesis Briefing Note: