Fair Is Fair: Just Visiting Hours and Reducing Inequities

The impact of family visitor restrictions on healthcare workers in the ICU during the COVID-19 pandemic

PURPOSE

To obtain information on how family visitor restriction during the COVID-19 pandemic has impacted the workplace experience of physicians and nurses in the medical intensive care unit, and to assess differences by profession.

MATERIALS AND METHODS

We developed a survey containing closed- and open-ended questions, applying both quantitative and qualitative analyses to our results.

RESULTS

Of the 74 respondents, 29 (38%) were nurses and 45 (62%) were physicians. Nurses reported positive changes to daily workflow and the ability to provide medical care, while physicians reported negative changes in these areas. Both groups reported decreased comprehension and increased distress among families, and decreased ability to provide end-of-life care. For the qualitative analysis, eight themes were identified: the patient's room as space, creation of a new space through virtual communication, time, increased complexity of care, challenges around the use of technology, adjustments to team roles and responsibilities, desire for families to return, and internal tension.

CONCLUSION

Intensive care physicians and nurses reported both positive and negative effects of family visitor restriction during the COVID-19 pandemic, with significant differences based on profession. Both groups expressed concern for an overall negative impact of visitor restriction on healthcare workers, patients, and their families.

Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the "well-dying law"

Purpose

The importance of dying with dignity in the intensive care unit (ICU) has been emphasized. The South Korean government implemented the “well-dying law” in 2018, which enables patients to refuse futile life-sustaining treatment (LST) after being determined as terminally ill. We aimed to study whether the well-dying law is associated with a significant change in the quality of death in the ICU.

Methods

The Quality of Dying and Death (QODD) questionnaires were prospectively collected from the doctors and nurses of deceased patients of four South Korean medical ICUs after the law was passed (January 2019 to May 2020). Results were compared with those of our previous study, which used the same metric before the law was passed (June 2016 to May 2017). We compared baseline characteristics of the deceased patients, enrolled staff, QODD scores, and staff opinions about withdrawing LST from before to after the law was passed.

Results

After the well-dying law was passed, deceased patients (N = 252) were slightly older (68.6 vs. 66.6, p = 0.03) and fewer patients were admitted to the ICU for post-resuscitation care (10.3% vs. 20%, p = 0.003). The mean total QODD score significantly increased after the law was passed (36.9 vs. 31.3, p = 0.001). The law had a positive independent association with the increased QODD score in a multiple regression analysis.

Conclusion

Our study is the first to show that implementing the well-dying law is associated with quality of death in the ICU, although the quality of death in South Korea remains relatively low and should be further improved.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06597-7.

Discordant Cardiopulmonary Resuscitation and Code Status at Death

CONTEXT

One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status.

OBJECTIVES

This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors.

METHODS

The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score).

RESULTS

A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year.

CONCLUSION

At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.

Visitor Guidelines in US Children's Hospitals During COVID-19

OBJECTIVES

To examine visitor guidelines among children's hospitals in the United States in response to the coronavirus 2019 (COVID-19) pandemic.

METHODS

A retrospective assessment of visitor guidelines in 239 children's hospitals in the United States.

RESULTS

In this study, we present an analysis of 239 children's hospital visitor guidelines posted to hospitals' Web sites during 1 week in June 2020. Of the 239 hospitals, only 28 did not have posted guidelines for review. The guidelines were analyzed and grouped by how the guidelines were updated in response to COVID-19. Parental visitation was restricted to 1 parent in 116 of the posted guidelines (49%). There were no obvious similarities among guidelines associated with their geographical (eg, state or local) location. As of February 2021, 33 of 55 (60%) randomly selected hospitals had not changed their visitor policy since our initial review.

CONCLUSIONS

The COVID-19 pandemic triggered changes in publicly reported visitor guidelines across the majority of children's hospitals. With our findings, we suggest wide variation in policies and practices in how guidelines were updated. More work is needed to understand how to optimize public safety and preserve family-centered care and parental authority in times of crisis.

The enablers and barriers to children visiting their ill parent/carer in intensive care units: A scoping review

AIM

The aim of the study was to identify the enablers and/or barriers to children visiting their ill parent/carer in intensive care units by examining the visiting policies as practiced or perceived by nurses and experienced or perceived by parents and caregivers.

REVIEW METHOD

This is a scoping review following Joanna Briggs Institute Protocol Guidelines.

DATA SOURCES

An extensive literature search of Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, PsychINFO, PubMed, and Excerpta Medica dataBASE databases, using key terms, was conducted between May 2019 and July 2020; studies published between 1990 and 2020 were considered for inclusion. Double screening, extraction, and coding of the data using thematic analysis and frequency counts were used.

RESULTS

Fifteen barriers, 19 facilitators, nine situationally contingent factors, and six personal judgement considerations were identified that influenced children visiting their ill parent/carer in intensive care units. Most barriers (n = 10) were related to organisational factors including restrictive policies, nurses' level of education, age, working hours, nurses' attitudes, and lack of required skills to promote emotional resilience and/or to communicate with children. Family perception factors relating to parents' perceptions, attitudes and concerns of staff/parents, and anticipated behaviours of children were also identified as both barriers and facilitators.

CONCLUSIONS

There is a lack of consistency in the application of policies and procedures to facilitate children visiting their loved ones in an intensive care unit. Without key involvement from the nurses and healthcare team, there may have been opportunities lost to optimise family-centred care practices in critical care settings.

Racial/Ethnic Disparities in Hospital Admissions from COVID-19 and Determining the Impact of Neighborhood Deprivation and Primary Language

Background Despite past and ongoing efforts to achieve health equity in the United States, persistent disparities in socioeconomic status along with multilevel racism maintain disparate outcomes and appear to be amplified by COVID-19. Objective Measure socioeconomic factors and primary language effects on the risk of COVID-19 severity across and within racial/ethnic groups. Design Retrospective cohort study. Setting Health records of 12 Midwest hospitals and 60 clinics in the U.S. between March 4, 2020 to August 19, 2020. Patients PCR+ COVID-19 patients. Exposures Main exposures included race/ethnicity, area deprivation index (ADI), and primary language. Main Outcomes and Measures The primary outcome was COVID-19 severity using hospitalization within 45 days of diagnosis. Logistic and competing-risk regression models (censored at 45 days and accounting for the competing risk of death prior to hospitalization) assessed the effects of neighborhood-level deprivation (using the ADI) and primary language. Within race effects of ADI and primary language were measured using logistic regression. Results 5,577 COVID-19 patients were included, 866 (n=15.5%) were hospitalized within 45 days of diagnosis. Hospitalized patients were older (60.9 vs. 40.4 years, p<0.001) and more likely to be male (n=425 [49.1%] vs. 2,049 [43.5%], p=0.002). Of those requiring hospitalization, 43.9% (n=381), 19.9% (n=172), 18.6% (n=161), and 11.8% (n=102) were White, Black, Asian, and Hispanic, respectively. Independent of ADI, minority race/ethnicity was associated with COVID-19 severity; Hispanic patients (OR 3.8, 95% CI 2.72-5.30), Asians (OR 2.39, 95% CI 1.74-3.29), and Blacks (OR 1.50, 95% CI 1.15-1.94). ADI was not associated with hospitalization. Non-English speaking (OR 1.91, 95% CI 1.51-2.43) significantly increased odds of hospital admission across and within minority groups. Conclusions Minority populations have increased odds of severe COVID-19 independent of neighborhood deprivation, a commonly suspected driver of disparate outcomes. Non-English-speaking accounts for differences across and within minority populations. These results support the continued concern that racism contributes to disparities during COVID-19 while also highlighting the underappreciated role primary language plays in COVID-19 severity across and within minority groups.

Is Open Visitation Really "Open" in Adult Intensive Care Units in the United States?

BACKGROUND

Evidence indicates that open visitation in adult intensive care units is a best practice for patient- and family-centered care, and nurses substantially influence such visitation patterns. However, it is unclear whether intensive care units in Magnet and Pathway to Excellence (MPE) facilities nationwide implement this in practice.

OBJECTIVE

To describe current national visitation practices in adult intensive care units and determine whether they have changed since the last national study, which used data from 2008 to 2009.

METHODS

From February through April 2018, websites of MPE hospitals were reviewed in order to identify their adult intensive care unit visitation policy. If this information was unavailable online, the hospital was telephoned to obtain the policy. From May through August 2018, follow-up telephone calls were made to hospitals that reported open visitation, during which intensive care unit nurses at the hospitals were asked to verify that the policy did not restrict visiting hours or the number, type, or age of visitors.

RESULTS

Among the 536 MPE hospitals contacted, 51% (n = 274) indicated that they allowed open visitation. Further examination, however, revealed that 64% (n = 175) restricted the number (68.2%), age (59.5%), or type (4.4%) of visitors, or visiting hours (19.8%). Only 18.5% of MPE hospitals (n = 99) allowed unrestricted visitation.

CONCLUSION

This study suggests a lack of progress toward implementing open visitation in adult intensive care units nationwide. Research on MPE hospitals that have adopted truly open visitation policies is needed to identify successful methods for implementing and sustaining open visitation.