Emerging Pandemic-Related Evidence on Visitation: Having Someone Matters

In her September President's Message, ARN President Dr. Patricia Quigley examines a recent, first-of-its-kind study that quantifies the impact of visitation restrictions during the COVID-19 pandemic on patient experience and safety outcomes. The article is a must-read for rehab nurses as they continue to face ongoing challenges of limited and eliminated visitation privileges for their patients in the midst of the pandemic.

Around the world, tears were shed and fear resounded as healthcare institutions essentially eliminated visitation privileges for patients' and residents' families, friends, and caregivers. This decision was deemed essential by healthcare executives to protect all persons from inpatients diagnosed with COVID-19 or admitted with the suspected virus. Care practices were reengineered to integrate social media technology and telehealth as solutions to patients' and residents' strict isolation. Specialty areas, such as our rehabilitation units, made some exceptions to visitation restrictions, including allowing one family member receiving discharge education on the day of a patient's discharge and other strategies shared on ARN's Member Circle Open Forum. As rehabilitation nurses, we experience the impact of these restrictions on our patients and residents. But has anyone directly quantified the link between restricted visitation and patient outcomes?

A colleague recently shared a newly published study on this very topic—"The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: A critical role for subjective advocates," from Silvera et al. (2021). This is the first research study I have read that examines the influence of COVID-19 visitation restrictions on patient experience and safety outcomes. I believe this article is a must read for every member and should be shared within and across your organizations.

Little to No Visitation for Patients

Silvera et al. (2021), acknowledging the value of patient engagement and family and caregiver partnerships in care, emphasized that hospital executive leaders' decisions to change visitation policies and practices was very difficult. The pandemic's spread and surges throughout 2020 provided context for the study. They examined the relationship between hospital visitation practices and patient experience and safety outcomes, comparing limited visitation, no visitation, and pre-pandemic open visitation. They selected 32 U.S. hospitals and compared previous publicly reported performance measures in 2019, before the pandemic, with the same measures in 2020, the first year of the pandemic. These measures may be familiar to you: patient perceptions, measured by the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] survey) and patient safety, measured by the Agency for Healthcare Research and Quality's (AHRQ) select patient safety indicators from Patient Safety Indicator (PSI) 90 composite measure for patient safety.

Briefly, the HCAHPS is a survey instrument and data collection methodology to measure patients' perceptions of their hospital experience. Information about this survey is available here. This instrument is divided into eight domains, with each domain including specific questions, and provides an overall rating for the hospital. For this study, the researchers looked at three out of eight patient perception domains and the overall rating of the hospital. The three domains were Responsiveness of Hospital Staff, Communication with Nurses, and Communication with Doctors. For example, the questions for Communication with Nurses pertain to Nurse Respect, Nurse Listening, and Explanation from Nurses. More information on the instrument domains and questions therein is available here.

The AHRQ select PSI 90 is a hospital-level composite measure of 10 adverse events with an assigned PSI score weighted separately for their contribution to overall harm. For the purposes of this study, the researchers selected three adverse events: Pressure Ulcer Rate (PSI 3), In-Hospital Fall with Hip Fracture Rate (PSI 8), and Post-Operative Sepsis Rate (PSI 13). More information about this instrument is available here.

For the purpose of my message, I am only briefly sharing key findings with hopes that you will read the full article and share it widely.

Having Someone Present Matters

At baseline (2019 [which reported analyzed 2017 data]), all hospitals in the study were performing at or above the 50th percentile score for the HCAHPS measures excepting the responsiveness domain. The PSI 90 patient safety outcome measures all outperformed the benchmarks.

During the pandemic, the 32 hospitals reported a no-visitor status for 127 of the collective 384 months in 2020. The no-visitor status aligned with the COVID 19 surges: a surge in March and April, a return to initial 2020 numbers through August and September, and a second surge at the end of the year. At the peak of the crisis, 90% of all facilities had restricted visitors. Based on the researchers' analysis, closed visitation restrictions negatively impacted hospital performance and patient safety outcomes.

The most significant changes were declines in medical staff responsiveness, increased rates of falls that resulted in hip fractures, and increased rates of sepsis. Patient adverse events presented the greatest negative impact of visitation restriction: falls with hip fractures increased by 104%, and sepsis rates also increased by 104%. The rates for open visitation, open/limited visitation, and no visitation are reported for the three adverse events. Sepsis rates of course were always higher that fall-related hip fractures, and are still rare. PSI 90 does not include a fall rate. However, this increase in hip fractures could be related to a decrease in nurse response time and patients trying to get up on their own. Still, the increased rates of hip fractures and sepsis that occurred during closed visitation are alarming and life threatening. Overall, the findings confirm that family members and care partners are important in the care of their loved ones.

This study is the first to quantify the impact of visitation restrictions on two publicly reported measures. The findings confirm that "the presence of a family member or care partner matters" and that "…when no visitation was allowed, things just simply got worse" (Silvera et al., 2021, pp. 36–37).

I imagine you agree with the researchers, as I do, that having someone present matters. Even limited visitation had a positive effect on patient safety outcomes, whereas prohibiting visitation seemed to increase patient harm. The researchers recommend that policy allow for visitors, advocates, and individuals with a vested interest in the well-being of the patient, as this is beneficial for patients, families, and friends and improves quality of care. Their findings provide us with quantifiable observations to guide our future decisions about visitation, enabling us to protect and preserve life, safety, and well-being for all.

Colleagues, I hope that you will read this study with great interest and reflect on the lessons learned that will influence future decisions for patients in isolation, separated from families and caregivers. For researchers, I hope that this study invites replication studies for rehabilitation units and programs that will examine effects of visitation restriction on patient perception, outcomes, and care transitions. We have much to learn from decisions made during the pandemic.

I so look forward to hearing back from you!

Patricia A. Quigley, PhD MPH APRN CRRN FAAN FAANP FARN

ARN President, 2020-2021