Delirium and Anxiety Outcomes Related to Visiting Policy Changes in the Intensive Care Unit During the COVID-19 Pandemic

An integrated review: connecting Covid-era hospital visiting policies to family engagement

Introduction

Family engagement and patient-family-centered care are vitally important to improve outcomes for patients, families, providers, hospitals, and communities. Both constructs prioritize providers forming partnerships with patients and their families. The domains of family-engaged care include presence, communication, shared-decision making, family needs, contribution to care, and collaboration at the institutional level. This integrative review describes the extent to which the domains of family engagement are present in the literature about Covid-era hospital visiting policies.

Methods

A search of four databases resulted in 127 articles and one added through data mining. After review, 28 articles were synthesized and analyzed into an integrative review of family engagement in the hospital with Covid-era visiting policies as the backdrop.

Results

The 28-article review resulted in an international, multidisciplinary perspective of diverse study designs. The review's sample population includes 6,984 patients, 1,126 family members, 1,174 providers, 96 hospitals, 50 health centers, 1 unit, and 257 documents. While all the domains are represented, presence is the prevailing domain, identified in 25 out of the 28 (89%).

Discussion

Presence is recognized as facilitating the other domains. Because the concept of collaboration is largely absent in the literature, it may provide healthcare institutions with a growth opportunity to facilitate and promote family engagement. This review is the first step in operationalizing family engagement in the hospital setting, especially when presence is challenging.

Associations between delirium and SARS-CoV-2 pandemic visitor restrictions among hospitalized patients

OBJECTIVES

Delirium is associated with increased morbidity and mortality, but environmental and behavioral factors may decrease the risk of developing delirium and thus must be considered. To investigate trends in delirium prevalence and examine associations of visitor restrictions with delirium diagnoses among all patients hospitalized during and prior to the novel coronavirus SARS-CoV-2 (COVID-19) pandemic.

STUDY DESIGN

Retrospective epidemiological assessment.

METHODS

The medical records of all patients (n = 33,141) hospitalized within a three-hospital academic medical center system in a large Midwestern metropolitan area from March 20, 2019, through March 19, 2021, were analyzed.

RESULTS

The overall prevalence of delirium during COVID-19 was 11.26% (confidence interval [CI]: 10.79%, 11.73%) compared to 9.28% (CI: 8.82%, 9.73%) before COVID-19. From our adjusted logistic regression analyses, we observed that the odds of delirium among non-isolated patients were significantly higher during COVID-19 visitor restrictions (adjusted odds ratio [aOR]: 1.354; 95% CI: 1.233, 1.488; P < 0.0001) than before. The odds of delirium among isolated patients were not significantly higher during COVID-19 visitor restrictions (aOR: 1.145; 95% CI: 0.974, 1.346; P = 0.1006) than before.

CONCLUSIONS

Medically isolated patients remained at high risk of developing delirium both prior to and during COVID-19 era visitor restrictions. However, non-medically isolated patients had a significantly increased risk of delirium during the social isolation of visitor restrictions compared to prior to visitor restrictions.

Family caregivers' responses to a visitation restriction policy at a Korean surgical intensive care unit before and during the coronavirus disease 2019 pandemic

BACKGROUND

Since the COVID-19 pandemic, restricting family visits in the ICU has increased concerns regarding negative psychosocial consequences to patients and families.

OBJECTIVES

To compare the quality of life, depressive symptoms, and emotions in family caregivers of ICU patients before and during the COVID-19 pandemic, and to explore families' perceptions and suggestions for the visitation.

METHODS

A cross-sectional descriptive survey was conducted in 99 family caregivers of adult surgical ICU patients from an urban academic medical center in South Korea (February to July 2021). The WHO's Quality of Life-BREF, Center for Epidemiologic Studies Depression, and Visual Analogue Scale were used to assess quality of life, depressive symptoms, and emotions, respectively. The Family Perception Checklist was used to assess families' perceptions and suggestions about the visitation restriction. Results were compared with the data from our previous survey (n = 187) in 2017.

RESULTS

Family caregivers were mostly women (n = 59), adult children (n = 43) or spouse (n = 38) of patients with mean age of 47.34 years. Family caregivers surveyed during the pandemic reported worsening sadness (54.66 ± 28.93, 45.58 ± 29.44, P = 0.005) and anxiety (53.86 ± 30.07, 43.22 ± 29.02, P = 0.001) than those who were surveyed in. While majority of families were satisfied with the visitation restrictions (86.9%), only 50.5% were satisfied with the amount of information provided on the patient's condition.

CONCLUSIONS

Visitation restriction is necessary during the COVID-19 pandemic despite sadness and anxiety reported in caregivers. Hence, alternative visitation strategies are needed to mitigate psychological distress and provide sufficient information to ICU family caregivers.

Supportive Care in Patients with Critical Coronavirus Disease 2019

Specific therapies for the treatment of coronavirus disease 2019 (COVID-19) have limited efficacy in the event a patient worsens clinically and requires admission to the intensive care unit (ICU). Thus, providing quality supportive care is essential to the overall management of patients with critical COVID-19. Patients with respiratory failure not requiring intubation should be supported with noninvasive positive pressure ventilation, continuous positive airway pressure, or high flow oxygenation. Use of these respiratory modalities may prevent patients from subsequently requiring intubation. Basic components of supportive care for the critically ill should be applied equally to patients with COVID-19 in the ICU.

Impact of Family Presence on Delirium in Critically Ill Patients: A Retrospective Cohort Study

OBJECTIVE

To assess the effect of family presence on the prevalence and duration of delirium in adults admitted to an ICU.

DESIGN

Retrospective cohort study.

SETTING

Medical-surgical ICUs in Alberta, AB, Canada.

PATIENTS

A population of 25,537 unique patients admitted at least once to an Alberta ICU.

METHODS

We obtained electronic health records of consecutive adults (≥ 18 yr) admitted to one of 14 medical-surgical ICU in Alberta, Canada, from January 1, 2014, to December 30, 2018. Family presence was quantified using a validated algorithm and categorized as: 1) physical presence in ICU, 2) telephone call only, and 3) no presence (reference group). Delirium was measured using the Intensive Care Delirium Screening Checklist (ICDSC) and defined as an ICDSC greater than or equal to 4. Multivariable mixed-effects logistic and linear regression were used to evaluate the association between family presence and prevalence (binary) and duration (d) of delirium, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The association between family presence and delirium prevalence differed according to admission type and admission Glasgow Coma Scale (GCS). Among medical and emergency surgical patients irrespective of admission GCS, physical presence of family was not significantly associated with the prevalence of delirium. In elective surgical patients, physical presence of family was associated with decreased prevalence of delirium in patients with intact Glasgow Coma Scale (GCS = 15; adjusted odds ratio, 0.60; 95% CI, 0.39-0.97; p = 0.02). Physical presence of family (adjusted mean difference [AMD] -1.87 d; 95% CI, -2.01 to -1.81; p < 0.001) and telephone calls (AMD -1.41 d; 95% CI, -1.52 to -1.31; p < 0.001) were associated with decreased duration of delirium in all patients.

CONCLUSIONS

The effects of family presence on delirium are complex and dependent on type of visitation, reason for ICU admission, and brain function on ICU admission.

Therapeutic Approaches to the Neurologic Manifestations of COVID-19

As of May 2022, there have been more than 527 million infections with severe acute respiratory disease coronavirus type 2 (SARS-CoV-2) and over 6.2 million deaths from Coronavirus Disease 2019 (COVID-19) worldwide. COVID-19 is a multisystem illness with important neurologic consequences that impact long-term morbidity and mortality. In the acutely ill, the neurologic manifestations of COVID-19 can include distressing but relatively benign symptoms such as headache, myalgias, and anosmia; however, entities such as encephalopathy, stroke, seizures, encephalitis, and Guillain-Barre Syndrome can cause neurologic injury and resulting disability that persists long after the acute pulmonary illness. Furthermore, as many as one-third of patients may experience persistent neurologic symptoms as part of a Post-Acute Sequelae of SARS-CoV-2 infection (Neuro-PASC) syndrome. This Neuro-PASC syndrome can affect patients who required hospitalization for COVID-19 or patients who did not require hospitalization and who may have had minor or no pulmonary symptoms. Given the large number of individuals affected and the ability of neurologic complications to impair quality of life and productivity, the neurologic manifestations of COVID-19 are likely to have major and long-lasting personal, public health, and economic consequences. While knowledge of disease mechanisms and therapies acquired prior to the pandemic can inform us on how to manage patients with the neurologic manifestations of COVID-19, there is a critical need for improved understanding of specific COVID-19 disease mechanisms and development of therapies that target the neurologic morbidities of COVID-19. This current perspective reviews evidence for proposed disease mechanisms as they inform the neurologic management of COVID-19 in adult patients while also identifying areas in need of further research.