Impacts on Quadruple-Aim Metrics of Long-Term Care Facility Visitor Restrictions

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 members 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 long-term care facilities (LTCFs) and the impacts on quadruple-aim metrics of visitor restrictions in LTCFs 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

Effective September 9, 2020, there are visitation restrictions for: 1) essential visitors including caregivers, support workers, and those providing essential services (e.g., any number of support workers may visit, but there is a maximum of two caregivers per resident at a time, or one caregiver per resident during an outbreak); and 2) general visitors (e.g., a maximum of two general visitors per resident are permitted if the resident is not self-isolating or symptomatic and when there is no outbreak). Accompanying public health measures for all visitors include verbally attesting to testing negative for COVID-19 within the previous two weeks, sanitizing hands upon arrival and departure, wearing a mask during the entire visit, and maintaining physical distance.

Implementation Implications

There is limited scientific evidence linking visitors to COVID-19 infection rates in LTCFs, however, many international and Canadian jurisdictions are restricting numbers of visitors along with implementing public health measures and alternative communication modalities (e.g., outdoor visiting).

Supporting Evidence

This section below summarizes the scientific evidence and jurisdictional experiences regarding the risk of COVID-19 transmission in LTCF and the impacts on quadruple-aim metrics of visitor restrictions and exceptions in LTCFs 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, Australia, China, Germany, Italy, the Netherlands, Singapore, South Korea, Spain, Sweden, Switzerland, the United Kingdom (UK), and the United States (US). The following framework was used to organize the findings:

  • 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, language barriers); and other restrictions.
  • Accompanying Public Health Measures: Institutional 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); and
    • Per capita costs or resource consumption more generally (e.g., reduced personal protective equipment [PPE] consumptions, staffing and iPad constraints, reduced sedative use).

Scientific Evidence

  • Risk of Transmission of COVID-19: Limited sources provided evidence about rates of transmission attributable to visitors including overall transmission rates in LTCFs. For example:
    • A systematic review (June 26, 2020) noted that outbreak investigations in LTCFs found COVID-19 incidence rates between 0.0% and 72% among residents and between 1.5% and 64% among staff.
    • Two studies (June 2 and August 17, 2020) yielded conflicting results regarding COVID-19 outbreaks in LTCFs in Ontario and the US. In Ontario, the for-profit status of LTCFs was associated with the extent of COVID-19 outbreaks and the number of deaths, with key factors including older design standards and chain ownership. In contrast, in the US, nursing homes that were not part of a chain were in urban locations and had a greater percentage of African-American residents with an increased probability of COVID-19 infections.
    • One study (July 2020) from the Netherlands noted no new cases of COVID-19 three weeks following the re-opening of 26 nursing homes to visitors with designated guidance. However, the results of this study must be interpreted with caution due to the short time frame and the multitude of factors that could impact COVID-19 transmission risk from visitors in LTC (e.g., prevalence in the community, precautions taken during visits).
  • Visitor Restrictions: Limited information was found relating directly to the quadruple aim, except for 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: Guidelines (May 29, April, and July 2020), a rapid review (no date provided), and a study (March 18, 2020) highlighted the importance of restricting visitors to protect LTCF residents, while also noting the importance of visitors to residents’ well-being, particularly for those nearing end-of life or in other compassionate care circumstances.
    • A rapid review (September 2020) found there is a lack of published research on the psychological and social implications of COVID-19-related isolation measures for residents of LTCFs. Existing research on the effects of isolation in older adults in general has shown that isolation is associated with anxiety, depression, cognitive decline, malnourishment, and increased loneliness. Isolation and loneliness are associated with cognitive decline, the progression of Alzheimer’s disease, and an increased risk for developing dementia.
  • Visitor Restrictions and Accompanying Public Health Measures:
    • Two guidelines (March 21 and June 2, 2020) noted the importance of adjusting LTCF visitor policies based on the active number of COVID-19 cases, trends in local areas, and availability of PPE and testing supplies.
    • Infection Control Measures: Four rapid reviews (September 2, 2020; March 16, 2020; no date provided for two) and one study (April 3, 2020) found the following infection control measures had been put in place in LTCFs:
      • Limiting the number of visitors;
      • Maintaining visitor logs;
      • Screening visitors for temperature and symptoms;
      • Daily cleaning of frequently touched surfaces and weekly deep cleans;
      • PPE wearing for staff and masks for visitors;
      • Diagnostic testing in the case of suspected exposure;
      • Contact tracing for confirmed cases; and
      • Immediate shut down of visitors should a case of COVID-19 be confirmed within the facility
    • Relationship between Policy Responses and Deaths: An analysis (June 2020) comparing Canada to 16 other countries found that countries that implemented LTCF visitor restrictions as part of their policy response had fewer COVID-19 deaths in LTCFs compared to those that did not. The addition of further policy responses in LTCFs (e.g., surge staffing, PPE funding, isolation wards, infection control training and audit) led to even further decreases in COVID-19-related deaths in LTCFs. However, there are limitations to these findings, such as differences in adherence to and implementation of policies, multiple interventions bundled together in different “levels” of policy responses, differences in the baseline prevalence of COVID-19 across countries and regions, and differences in reporting practices.
    • Best Practices for Supporting Staff: A rapid review (September 2020) noted that multiple measures are essential to support staff in re-opening processes of LTCFs during the pandemic:
      • The most prominently recommended measures included adequate PPE and resources, adequate staffing levels, adequate training of infection prevention and control (IPC) protocols, access to IPC specialty teams on site, access to relevant medical staff, financial incentives to limit work between facilities, and policies to promote and enforce sick leave. Employing these strategies, as well as regularly monitoring staff well-being and having transparent communication about COVID-19 updates, supports LTCF staff in continuing their role in a meaningful way, even as visitor restrictions are relaxed.
      • Potential options to improve LTCF environments include investing in electronic devices to streamline visitation protocols and investing in infrastructure (e.g., isolation rooms, separate bathrooms) to support outbreak preparedness.
  • Alternative Communication Modalities: Evidence on measures that can be put in place to mitigate any potential harms associated with LTCF visitor restrictions was identified for video and audio calls, and other communication guidance:
    • A World Health Organization guidance (March 21, 2020) noted that where visitors to LTCFs have been reduced, alternatives to in-person visiting should be explored such as support video and audio calls with family members.
    • A study (June 4, 2020) found that inpatient palliative care electronic meetings were feasible and acceptable during the COVID-19 pandemic.
    • A rapid review (March 31, 2020) advised that those working in LTCFs should plan for frequent communication between residents, caregivers, friends, volunteers, and community organizations providing support and should speak to residents about their preferred means of communicating with friends and family, offering user assistance as needed.

International Scan

  • No Visitors with No Exceptions:
    • In Sweden, there is an ongoing ban on visits to LTCFs, however, as of August 31, 2020, consultations were taking place to develop a program to assess how exemptions can be made.
    • In South Korea, entry of visitors at senior care facilities is restricted.
  • Limited Visitors and Accompanying Public Health Measures:
    • China, Germany, and Italy adjust LTCF visitor policies based on the state of the pandemic in the local community:
      • In China, nursing homes in medium- and high-risk regions are not allowing visitors.
      • In Germany, where active COVID-19 cases are present, visitors are not allowed except for relatives of persons at the end of life.
      • In Italy, allowing external visitors of LTCFs is up to the discretion of the Clinical Director of each organization.
    • In Switzerland, while visits are permitted to LTCFs, they are not recommended; those that wish to visit may set up an arrangement to do so with the individual facility. LTCFs differ in terms of precautions, rules of conduct, and visiting times permitted.
    • In both Spain and Singapore, a staged approach is being used where residents are allowed to designate a limited number of visitors.
    • Common public health practices in place to help mitigate the potential risks of visitors include:
      • Maintaining physical distance (Germany);
      • Washing or disinfecting hands upon entry and exit (Germany and Singapore);
      • Putting in place physical barriers in visiting spaces between residents and their families (i.e., plexiglass or alternative) (Germany);
      • Requiring residents to designate select visitor(s) (Singapore);
      • Screening of visitors for symptoms prior to entry (Singapore);
      • Time limits on visits (Singapore); and
      • Requiring appointment times for visitors (Singapore)
  • Alternative Communication Modalities: No examples identified.

Canadian Scan

  • No Visitors with No Exceptions: No examples identified.
  • Limited Visitors with Specific Exceptions:
    • In Canada, the Yukon has the strictest visitor policies in place, whereby general visitors are not permitted, though two pre-identified visitors are permitted in cases where the resident is nearing the end-of-life or has special needs.
    • Alberta, Manitoba, Ontario, Newfoundland and Labrador, Nunavut, and Prince Edward Island (PEI) are limiting the number of designated visitors to between one and five.
      • In Nunavut, there is a requirement that the visitors are immediate family which includes grandchildren and great-grandchildren.
      • In PEI, all residents are allowed to identify three “partners in care”. One of the selected individuals will be able to visit the resident at all times of the day. Overnight stays may be permitted if the visitor follows infection control protocols. Patients may also leave the facility if they will have limited contact with others.
    • British Columbia and Quebec adjust LTCF visitor policies based on the state of the pandemic in the local community:
      • In British Columbia, social visits are currently allowed in LTCFs, however social visits are no longer permitted if a COVID-19 outbreak is declared within the LTCF or community rates rise significantly.
      • In Quebec, the government relaxed restrictions related to visitors given the reduction in community cases, but these may be tightened should there be a resurgence of COVID-19 cases.
  • Public Health Measures: Common public health practices in place to help mitigate the potential risks of visitors include:
    • Designating one (or two) individuals to be visitors (British Columbia, Ontario, New Brunswick, and Yukon);
    • Washing or disinfecting hands upon entry and exit (British Columbia, Ontario, and Northwest Territories);
    • Assigning social areas to see visitors within the facilities (British Columbia);
    • Maintaining physical distance (British Columbia, Ontario, Yukon, and Northwest Territories);
    • Wearing a mask or other PPE during visit (Ontario, Yukon, and Northwest Territories);
    • Scheduling a visit in advance (Ontario and New Brunswick); and
    • Limiting the number of visitors at a given time and on a given day (New Brunswick)
  • Alternative Communication Modalities: Many provinces have put in place alternatives to visitors on an institutional basis, however, in Nova Scotia, LTCFs across the province are providing virtual options for visits including video calls. In addition, many other provinces are recommending that visitors make use of outdoor space and are increasing visitor limits outdoors as long as physical distancing guidelines are followed. Visitor limits for outdoors differ by province; for example, in Alberta, between two and five visitors are allowed.

Ontario Scan

  • No Visitors, with No Exceptions: No examples identified.
  • Limited Visitors: Effective September 9, 2020, there are distinct visitation restrictions for: 1) essential visitors including caregivers, support workers, and those providing essential services (e.g., food delivery, inspector maintenances, health care service providers, or individuals visiting palliative residents); and 2) general visitors (e.g., who provide non-essential services, or for social reasons such as family members or friends not involved in direct care). Restrictions for essential visitors include:
    • Any number of support workers may visit.
    • Maximum of two caregivers (at least 18 years of age and designated by the resident and/or decision-makers) per resident at a time, or one caregiver per resident during an outbreak or if the resident is self-isolating or symptomatic at a LTCF during an outbreak.
    • A caregiver may not visit any other resident for 14 days after visiting another resident who is self-isolating, symptomatic, or there is an outbreak at the LTCF.
  • A maximum of two general visitors per resident are permitted if the resident is not self-isolating or symptomatic and when there is no outbreak (visitors under the age of 14 years of age should be accompanied by an adult).
  • Public Health Measures: Accompanying public health measures for essential and general visitors include verbally attesting to testing negative for COVID-19 within the previous two weeks, sanitizing hands upon arrival and departure, wearing a mask during the entire visit, and maintaining physical distance (at least two metres). During outbreaks, essential visitors must be screened and wear PPE during the visit (in addition to the measures).
    • LTCFs do not require restrictions for length or frequency of visits by essential visitors; however, general visitors may be required to schedule visits in advance and limit the length or frequency of the visit.
    • LTCFs may temporarily prohibit a visitor due to repeated violations to visiting policies.
  • Alternative Communication Modalities: No information was identified.

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 members of the Network provided evidence synthesis products that were used to develop this Evidence Synthesis Briefing Note:

  • Waddell K, Wilson MG, Moat KA, Wang Q, Gauvin FP, Ahmad A, Alam S, Bhuiya A, Tchakerian N, Lavis JN. (September 24, 2020). COVID-19 rapid evidence profile #19: What is the risk of transmission of COVID-19 in hospital and long-term care settings, and the impacts of hospital-visitor policies? Hamilton: McMaster Health Forum.
  • Canadian Agency for Drugs and Technologies in Health (CADTH) A. (September 2020). CADTH Implementation Support & Knowledge Mobilization Summary: Synopsis of the Evidence on Best Practices for Supporting Staff and Mitigating Concerns during Re-Opening of Long-Term Care Homes.
  • Canadian Agency for Drugs and Technologies in Health (CADTH) B. (September 2020). CADTH Implementation Support & Knowledge Mobilization Summary: Psychological and Social Effects/Implications of Isolation for Long-Term Care Residents: Synopsis of Reference Search Results.
  • Canadian Agency for Drugs and Technologies in Health (CADTH) C. (September 2020). CADTH Implementation Support & Knowledge Mobilization Summary: COVID-19 Infection Risk Related to Visitors in Long-Term Care.