The Effect of Hospital Visitor Policies on Patients, Their Visitors, and Health Care Providers During the COVID-19 Pandemic: A Systematic Review

Emergency Nursing and Staff Experiences With Visitation Restrictions During the Coronavirus Disease 2019 Pandemic: A Qualitative Descriptive Study

INTRODUCTION

At the onset of the coronavirus disease 2019 pandemic, visitors were prohibited in the emergency department, leaving patients bereft of their companionship and advocacy. However, little was known about the conflicts and distress of emergency department staff related to this policy. This study aimed to qualitatively explore emergency nursing and staff experiences regarding the no-visitor policy.

METHODS

A qualitative descriptive approach explored short answers to 1 open-ended question. Emergency nurses and assistive personnel (patient care technicians and emergency medical technicians/paramedics) were recruited from 11 participating emergency departments, using convenience sampling and a web-based survey. We followed the 6-step process of reflexive thematic analysis to identify patterns in the data and develop themes that describe the results.

RESULTS

Of 180 respondents, 69 (38%) answered our qualitative question. Participants were typically female (78.3%), White (82.6%), and mostly registered nurses (79.7%), with an average age of 39 years and an average of 10 years' ED experience. Participants offered complex, heartfelt responses, resulting in 3 themes: (1) exposure and risk, (2) experiencing patient and family reactions; and (3) policy enforcement challenges.

DISCUSSION

Although many respondents concluded that the policy was protective against pandemic risk, some saw it as ineffective. They believed exceptions must be made for imminent death. Participants felt that patients/visitors understood, but did not always like, restrictions. Adherence to policy left respondents conflicted, leading to inconsistent enforcement. Visitation policies for patients with infectious diseases must consider patient/visitor needs, moral distress of ED staff, and pragmatic enforcement strategies.

Navigating the trauma-The experiences of significant others supporting patients with severe burn injury: A narrative inquiry

AIM

To explore the experiences of significant others of adult patients with severe burn injury in the Intensive Care Unit. Specifically, this study explored the strategies implemented by significant others and obstacles faced that served to protect or placed them at risk of psychological sequelae during their experience of trauma.

DESIGN

A qualitative study using a Narrative Inquiry approach was undertaken.

METHODS

Individual semi-structured interviews were conducted with 17 participants during 2021-2022, who were a significant other of an adult patient in ICU with severe burn injury. These participants were recruited from the two major severe burns receiving hospitals in New South Wales, Australia. Participants' stories were analysed using a narrative analysis approach informed by Polkinghorne. The COREQ guideline was used in reporting.

RESULTS

As each participant navigated the traumatic experience of supporting a loved one with a severe burn injury, they faced unique obstacles to maintaining their own mental health and well-being. They employed strategies that were likely to protect them on this journey. Psychologically protective factors included taking back control, coexisting in the trauma with the patient and forging a trauma bond. These strategies effectively contained the trauma and protected others (such as children, extended family and friends). While this allowed significant others an element of control, it also effectively isolated them from the support of family and friends.

CONCLUSION

This study shows that significant others may also experience personal trauma and may not recognize this as they focus all their attention on supporting the patient with the burn injury.

IMPLICATIONS FOR PRACTICE

With increased awareness of both protective and risk factors, support can be directed towards enhancing protective factors and addressing risk factors, thereby decreasing their impact and improving support for significant others.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Lessons from COVID-19 patient visitation restrictions: six considerations to help develop ethical patient visitor policies

Patient visitor restrictions were implemented in unprecedented ways during the COVID-19 pandemic and included bans on any visitors to dying patients and bans separating mothers from infants. These were implemented without high quality evidence they would be beneficial and the harms to patients, families and medical personnel were often immediately clear. Evidence has also accumulated finding strict visitor restrictions were accompanied by long-term individual and societal consequences. We highlight numerous examples of restrictions that were enacted during the COVID-19 pandemic, including some that continue to be in place today. We outline six specific concerns about the nature and effects of the visitor restrictions seen during the COVID-19 pandemic. These considerations may help provide both an ethical and science-based framework, through which healthcare workers, families and government entities can work towards safeguarding patient and family rights and well-being.

Optimizing and Sustaining Clinical Outcomes in 88 US Hospitals Post-Pandemic: A Quality Improvement Initiative

BACKGROUND

Optimizing outcomes of hospitalized patients anchors on standardizing processes in medical management, interventions to reduce the risk of decompensation, and prompt intervention when a patient decompensates.

METHODS

A quality improvement initiative (optimized sepsis and respiratory compromise management, reducing health care-associated infection and medication risk, swift management of the deteriorating patient, feedback on performance, and accountability) was implemented in a multistate health system. The primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included health care-associated infections, patient-days with hypoglycemic and severe hyperglycemic episodes, and hospital onset (HO) acute kidney injury (AKI).

RESULTS

A total of 2,015,408 patients were admitted to 88 hospitals over the 36-month study period. Overall mortality improved from the baseline observed/expected (O/E) of 0.97 in 2021 to 0.74 in 2023 (-23.4%; 4,186 fewer deaths, p < 0.001). Controlling for baseline (2021) mortality O/E ratios, the mean mortality O/E ratio for 2023 was 0.74 for system and 0.84 for peers, representing a difference of -0.10 (p < 0.001, 95% confidence interval [CI] 0.12 - -0.07], with 1,807 fewer deaths). The standardized infection ratio declined for central line-associated blood stream infections by 24.8% (0.58; 88 fewer events), catheter-associated urinary tract infections by 30.6% (0.44; 98 fewer events), HO methicillin-resistant Staphylococcus aureus bacteremia by 29.0% (0.72; 67 fewer events), and HO Clostridioides difficile infection by 35.1% (0.36; 311 fewer events) in 2023 compared to 2021. HO AKI episodes dropped by 6.2% (8.6%; 1,725 fewer events), and patient-days with hypoglycemia and severe hyperglycemia decreased by 5.8% (4.0%; 4,840 fewer events) and 22.8% (5.2%; 30,065 fewer events), respectively.

CONCLUSION

This systemwide initiative focusing on standardizing processes, feedback on performance, and accountability was associated with sustainable improvements in mortality and a reduction in infectious and safety events.

"Three Sides to Every Story": Living the Patient, Carer and Staff Experience of COVID

In 2020, the UK's National Health Service (NHS) braced itself for the challenge of the COVID pandemic. Older, frail adults were among those at highest risk for morbidity and mortality. This study aimed to capture the lived experiences of patients, families/carers and staff on a COVID ward. Thirty participants were included, and data collected through in-depth unstructured interviews. The data were analyzed using interpretive phenomenology. Four main themes were constructed, capturing the collective experiences of the participants. The first theme, the changing and uncertain period of time, describes the shared sense of immersion in the chaotic situation, lack of control and resulting fears related to the contagion. Secondly, challenges of care, focuses on shared anxieties and guilt related to shortcomings in care delivery, and efforts to adapt to the new situation. The third theme, communication and keeping in touch, details the effect restrictions had on efforts to maintain contact and its toll on mental health. The last theme of challenging situations in end-of-life care, reflects experiences of grief and loss shared by all three participant groups. This study adds to the growing evidence base around experiences of the COVID pandemic through exploration of the profound triangulated experience of all participants.

Parental and family presence are essential: A qualitative study of children's lived experiences with family presence in pediatric intensive care

OBJECTIVE

To better understand critically ill children's lived experiences with family presence in the pediatric intensive care unit (PICU).

STUDY DESIGN

This qualitative, interpretive phenomenological study is grounded in a Childhood Ethics ontology. We recruited children (aged 6-17 years) admitted to one of four participating Canadian PICUs between November 2021-July 2022 using maximum variation sampling. Data generation methods included participant observation and semi-structured interviews. Field-notes and interview transcripts were analyzed following the SAMMSA (Summary &Analysis coding, Micro themes, Meso themes, Syntheses, and Analysis) approach.

RESULTS

Fourteen participants (7 boys; 7 girls) described parental presence in PICU as essential. Parents contributed to their sense of safety, acted as advocates and interlocuters, and were crucial to participants' belief that their voices would be heard and their needs met. Participants valued the ways in which family and visitor presence mitigated the disruptions that being in PICU caused to their social worlds. Age limits restricted sibling and peer interaction and inadvertently restricting parental presence due to sibling childcare needs.

CONCLUSIONS AND IMPLICATIONS

Parental figure presence in PICU is essential for children. Policies that focus on children as patients instead of whole people discredit childrens' concerns and the ways parental figures mitigate the disruptive nature of PICU admissions. Future policy generation must involve children to ensure that their priorities and concerns are meaningfully recognized.

Nurses' perspectives about end-of-life care when family presence is restricted during a pandemic: A qualitative study

BACKGROUND

To prevent the infection from spreading, patients who were dying from COVID-19 were treated in isolation with restricted family access, which differed from existing end-of-life care procedures. This was a significant change that affected the care provided by nurses.

OBJECTIVES

This study explored nurses' end-of-life care experiences in a limited family visitation setting during the COVID-19 pandemic.

METHODS

A descriptive qualitative study was conducted. Data were collected through individual, in-depth, semistructured interviews with ten critical care nurses who provided end-of-life care to patients with COVID-19 in South Korea. The data were analysed using thematic analysis. The Consolidated Criteria for Reporting Qualitative Research checklist was used to assess the study's rigour.

FINDINGS

Three themes were identified: 'Witnessing patients' and families' heartbreak over separation', 'The gaps between the ideals and realities of end-of-life care', and 'Efforts to provide patients with a comfortable final journey'. Nurses realise the importance of their central role in supporting interactions between patients and families during end-of-life care.

CONCLUSIONS

Family participation, facilitated by nurses' interest and efforts as mediators connecting patients and families, is essential for achieving high-quality care for inpatients facing end of life. This study is significant as it emphasises that the direction of end-of-life care should be family centric, even in a pandemic situation with limited family participation. To improve interaction between patients and families, creating an environment based on family participation that builds trust and strengthens communication is essential. Additionally, hospital support, such as professional education and counselling, should be provided to strengthen nurses' end-of-life care competency.

On a healing journey together and apart: A Swedish critical incident technique study on family involvement from a patient perspective in relation to elective open-heart surgery

BACKGROUND

As family members affect patient outcomes following open-heart surgery, the objective was to provide updated knowledge on family involvement in to guide future interventions facilitating family involvement.

AIM

The aim was to explore and describe the experiences and actions of important situations of family involvement asexpressed by patients who underwent elective open-heart surgery in Sweden.

METHODOLOGICAL DESIGN AND JUSTIFICATION

The critical incident technique (CIT) was used, which is a qualitative research method suitable for clinical problems when a phenomenon is known but the experiences and consequences of it are not.

ETHICAL ISSUES AND APPROVAL

Considerations for patient integrity were made during the recruitment phase by ensuring that voluntary informed consent was obtained in two steps.

RESEARCH METHODS

Individual interviews were conducted with 35 patients who underwent open-heart surgery in Sweden in 2023. Important situations were analysed according to the CIT method.

RESULTS

Two main areas emerged: Patients described important situations of family involvement as experiences of mutual dependency while also being independent individuals. These experiences led to balancing healing and risk-taking activities as a family. The positive consequences of family involvement described by patients included improved recovery through practical help at home and emotional support.

CONCLUSIONS

As complements to preserving the existing positive aspects of family involvement, social support screening, the establishment of individualised visitation policies and the provision of professional and peer support earlier can improve patient recovery following open-heart surgery.

Effects of visit restriction in the COVID-19 pandemic: Experiences and perceptions of intensive care nurses

BACKGROUND

The visit restrictions imposed as a result of COVID-19 precluded the entrance of the patient's family into the confines of the intensive care unit.

AIM

This study evaluated the experiences of intensive care nurses (ICNs) regarding COVID-19 visit restrictions and their opinions on these restrictions.

STUDY DESIGN

From May 2023 to July 2023, semi-structured interviews with 15 ICNs from intensive care units in a tertiary public hospital in Türkiye were conducted. Data were analysed using qualitative content analysis with an inductive approach. Reporting of the study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

The analysis revealed two main themes, 'widespread negative impacts of visit restrictions' and 'adaptive strategies to the visitation ban', and seven sub-themes supporting the main themes. Nurses perceived that the visit restrictions imposed during the COVID-19 pandemic had a severe negative effect on patients, their relatives, themselves and the care environment. They also did not support visit restriction in future pandemics.

CONCLUSIONS

The COVID-19 visitation policy weakened the involvement of family members in patient care and created serious challenges in the intensive care setting. The study revealed an urgent need for patient-centred, family-sensitive and consistently applied protocols in future pandemics.

RELEVANCE TO CLINICAL PRACTICE

In future pandemics, strategies such as the benefit-benefit ratio of the visit, the provision and use of adequate personal protective equipment, and vaccination requirements should be considered in visiting decisions of patients hospitalized because of infection. Participation of nurses responsible for patient care in decisions regarding visitor practices should be supported.

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

COVID-Related Visitor Restrictions and Childbirth Experiences in One US Hospital

OBJECTIVE

The objective of this study was to explore childbirth experiences during COVID-19 visitor restrictions.

METHODS

We used a descriptive phenomenological approach in our study, which took place in a postpartum unit at a level IV birthing hospital in the Mideastern United States, where 3617 births occurred in 2019.

RESULTS

A total of 22 participants who were older than 18 years, who gave birth at 37 weeks gestation or more, and who had at least 1 birth experience in the United States prior to the COVID-19 pandemic participated in this study. We assessed participants' birth experiences before and during COVID-19 visitor restrictions through in-depth interviews. Participant perspectives revealed the following 6 themes after an iterative analysis: A Shared Personal Connection is a Valued Trait, A Female Support Person is Important, Nurses Went the Extra Mile, Support People Help with Decision-Making, Two is an Ideal Number of Support People, and Increased Psychological Burden.

DISCUSSION

These findings are vital to inform hospital visitor policies moving forward in the endemic reality of COVID-19 pandemic.

Validating older adult patient's Medical Treatment Decision Maker's (MTDM). A retrospective observational study with follow-up phone interview transcript

A Medical Treatment Decision Maker (MTDM), also referred to as surrogate decision maker, by law, is to be appointed to make medical treatment decisions on behalf of a person who cannot make such decisions for themselves. In the Emergency Department (ED) and acute healthcare services, the clinicians' (nurses and doctors) ability to contact MTDMs is essential for patient care, particularly in time-critical situations. Our primary objective was to review the verification process and assess the accuracy of MTDM contact numbers in the Health Information System (HIS) to assess compliance with legislation. We used a quantitative method with retrospective observational study design and follow-up phone interview transcript. One hundred and fifty-nine participants were randomly selected of whom 76 % had MTDM. Patient advancing age had statistically significant association with the number of call attempts made to reach the listed MTDM (P = 0.043; CI, -3.541 to -0.057) and the MTDM's consent to participate (p = 0.023).

The effect of visitation restrictions on ED error

EDs restricted visitors during the COVID-19 pandemic on the assumption that the risks of disease spread outweighed the psychological benefits of liberal visitation. But data suggest that beyond providing emotional support, family and caregivers can clarify history, improve patient monitoring, and advocate for patients-actions that can improve quality of care. Our objective was to assess whether removing visitors from the bedside contributed to errors in emergency care. We reviewed a database of medical errors covering visits from 11/15/17 to 7/30/22 at an urban, tertiary-care, academic ED for five types of error amenable to visitor intervention: inadequate history gathering, inadequate monitoring, falls, giving a medication to which a patient is allergic, and inappropriate medication dosing. These records were reviewed by two investigators to determine the likelihood visitor presence could have prevented the error. For those errors judged susceptible to visitor intercession, the number in each category was compared for the period before and after strict restrictions took effect. Our review found 27/781 (3.5%) errors in the pre-pandemic period and 27/568 (4.8%) errors in the pandemic period fell into one of these five categories (p = 0.29). Visitors prevented harm from reaching the patient in three of 27 pre-pandemic errors (11.1%), compared to 0 out of 27 peri-pandemic errors (p = 0.23). On review by two attendings, 17/24 (70.8%) errors that reached the patient in the pre-pandemic period were judged amenable to visitor intervention, compared to 25/27 (92.6%) in the pandemic period (p = 0.09). There were no statistically significant differences in the categories of error between the two groups; monitoring errors came the closest: 1/17 (5.9%) pre-COVID errors amenable to visitor intervention in these categories were monitoring related, whereas 7/25 (28.0%) post-COVID errors were (p = 0.16). While this study did not demonstrate a statistically significant difference in error between lenient and restrictive visitation eras, we did find multiple cases in the pre-COVID era in which family presence prevented error, and qualitative review of post-COVID errors suggested many could have been prevented by family presence. Larger trials are needed to determine how frequent and consequential such errors are and how to balance the public health imperative of curbing disease spread with the harm caused by restricting visitation.

MedT5SQL: a transformers-based large language model for text-to-SQL conversion in the healthcare domain

Introduction

In response to the increasing prevalence of electronic medical records (EMRs) stored in databases, healthcare staff are encountering difficulties retrieving these records due to their limited technical expertise in database operations. As these records are crucial for delivering appropriate medical care, there is a need for an accessible method for healthcare staff to access EMRs.

Methods

To address this, natural language processing (NLP) for Text-to-SQL has emerged as a solution, enabling non-technical users to generate SQL queries using natural language text. This research assesses existing work on Text-to-SQL conversion and proposes the MedT5SQL model specifically designed for EMR retrieval. The proposed model utilizes the Text-to-Text Transfer Transformer (T5) model, a Large Language Model (LLM) commonly used in various text-based NLP tasks. The model is fine-tuned on the MIMICSQL dataset, the first Text-to-SQL dataset for the healthcare domain. Performance evaluation involves benchmarking the MedT5SQL model on two optimizers, varying numbers of training epochs, and using two datasets, MIMICSQL and WikiSQL.

Results

For MIMICSQL dataset, the model demonstrates considerable effectiveness in generating question-SQL pairs achieving accuracy of 80.63%, 98.937%, and 90% for exact match accuracy matrix, approximate string-matching, and manual evaluation, respectively. When testing the performance of the model on WikiSQL dataset, the model demonstrates efficiency in generating SQL queries, with an accuracy of 44.2% on WikiSQL and 94.26% for approximate string-matching.

Discussion

Results indicate improved performance with increased training epochs. This work highlights the potential of fine-tuned T5 model to convert medical-related questions written in natural language to Structured Query Language (SQL) in healthcare domain, providing a foundation for future research in this area.

Frontline nurses' experiences of managing visitor restrictions during the COVID-19 pandemic in a Danish university hospital - Lessons learned

BACKGROUND

Worldwide visitor restrictions forced nurses to separate patients from their relatives. However, the experience of implementing shifting restrictions from the frontline nurses' perspectives in a Danish context has yet to be assessed.

AIM

The aim of this descriptive qualitative study was to explore frontline nurses' experiences of managing shifting visitor restrictions in a Danish somatic university hospital during the COVID-19 pandemic.

METHODS

An online questionnaire, including open-ended questions, was developed. Data were analysed using descriptive statistics and content analysis.

FINDINGS

116 nurses from 29 departments participated; they were informed about restrictions primarily by their charge nurses and hospital intranet. Shifting visitor restrictions compelled the nurses to constantly adjust and negotiate their practices. When deciding to suggest deviating from the restrictions, they shared their decision-making with colleagues. Visitor restrictions left the hospital environment quieter, but they also created a lack of overview and predictability, an emotional burden, and a negative impact on the quality of care.

CONCLUSION

Restricting relatives' access challenged the nurses' professional values, and it seems to have affirmed their appreciation of relatives' role as important partners in contemporary hospital-based health care.

"Like not having an arm": a qualitative study of the impact of visitor restrictions on cancer care during the COVID-19 pandemic

PURPOSE

Visitor restriction policies to prevent the spread of COVID-19 among patients and clinicians were widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision-making. The aim of this study was to explore how visitor restrictions impacted cancer treatment decision-making and care from patient and physician perspectives.

METHODS

Sixty-seven interviews, including 48 cancer patients and 19 cancer and palliative care physicians from four academic cancer centers in the USA between August 2020 and July 2021.

RESULTS

Visitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital care created challenges in cancer care that spanned three domains: practical, social, and informational. We identified eight themes that characterized challenges within the three domains across all three groups, and that these challenges had negative emotional and psychological consequences for both groups. Physicians perceived that patients' negative experiences due to lack of support through the physical presence of caregivers may have worsened patient outcomes.

CONCLUSIONS

Our data demonstrate the tripartite structure of the therapeutic relationship in cancer care with caregivers providing critical support in the decision-making and care process to both patients and physicians. Caregiver absences led to practical, psychosocial, and informational burdens on both groups, and likely increased the risk of burnout among physicians. Our findings suggest that the quality of cancer care can be enhanced by engaging caregivers and promoting their physical presence during clinical encounters.

A qualitative study of leaders' experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services

BACKGROUND

The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services.

METHODS

The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included.

RESULTS

Three main themes emerged from the thematic analysis: "Navigating the role of a leader during the pandemic," "The aftermath - management of COVID-19 in rural primary healthcare services", and "The benefits and drawbacks of being small and rural during the pandemic."

CONCLUSIONS

Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]

BACKGROUND

The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement.

OBJECTIVE

The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany.

MATERIAL AND METHODS

In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis.

RESULTS

Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted.

CONCLUSION

The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

A survey of pediatric intensive care unit clinician experience with restricted family presence during COVID-19

PURPOSE

Limiting family presence runs counter to the family-centred values of Canadian pediatric intensive care units (PICUs). This study explores how implementing and enforcing COVID-19-related restricted family presence (RFP) policies impacted PICU clinicians nationally.

METHODS

We conducted a cross-sectional, online, self-administered survey of Canadian PICU clinicians to assess experience and opinions of restrictions, moral distress (Moral Distress Thermometer, range 0-10), and mental health impacts (Impact of Event Scale [IES], range 0-75 and attributable stress [five-point Likert scale]). For analysis, we used descriptive statistics, multivariate regression modelling, and a general inductive approach for free text.

RESULTS

Representing 17/19 Canadian PICUs, 368 of 388 respondents (94%) experienced RFP policies and were predominantly female (333/368, 91%), English speaking (338/368, 92%), and nurses (240/368, 65%). The mean (standard deviation [SD]) reported moral distress score was 4.5 (2.4) and was associated with perceived differential impact on families. The mean (SD) total IES score was 29.7 (10.5), suggesting moderate traumatic stress with 56% (176/317) reporting increased/significantly increased stress from restrictions related to separating families, denying access, and concern for family impacts. Incongruence between RFP policies/practices and PICU values was perceived by 66% of respondents (217/330). Most respondents (235/330, 71%) felt their opinions were not valued when implementing policies. Though respondents perceived that restrictions were implemented for the benefit of clinicians (252/332, 76%) and to protect families (236/315, 75%), 57% (188/332) disagreed that their RFP experience was mainly positive.

CONCLUSION

Pediatric intensive care unit-based RFP rules, largely designed and implemented without bedside clinician input, caused increased psychological burden for clinicians, characterized as moderate moral distress and trauma triggered by perceived impacts on families.

Relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave: a PREMs study in Valais Hospital, Switzerland

BACKGROUND

During the COVID-19 pandemic, most countries introduced temporary visiting restrictions on the relatives of acute care hospital patients, whether or not they were infected with SARS-CoV-2. This affected relatives' psychological and emotional states and how closely they could be involved in their loved one's hospitalization.

STUDY AIMS

Investigate relatives' experiences of visiting restrictions during the COVID-19 pandemic's first wave and the support offered by Valais Hospital's healthcare staff.

METHODS

Relatives and patients who had been discharged between February 28 and May 13, 2020, were asked to complete a patient-reported experience measures (PREMs) questionnaire, whether or not they had been infected by SARS-CoV-2. Relatives were asked about how visiting restrictions had affected them, their perceptions of the severity of the COVID-19 pandemic, the quality of communication concerning their loved ones' health status during their hospitalization, and the information received from healthcare staff. Descriptive and inferential statistics were computed.

RESULTS

Of 866 PREMs questionnaires returned, 818 were analyzable, and 543 relatives had experienced visiting restrictions to their loved ones: 92 relatives (87%) of COVID-19 patients and 451 relatives (66%) of non-infected patients, with heterogenous effects on their psychological and affective status. Overall, whether or not relatives were subjected to visiting restrictions, they perceived themselves to be well treated, well informed, and that communication with hospital healthcare staff was satisfactory. However, relatives subjected to visiting restrictions reported significantly lower scores on the quality of communication than other relatives. The relatives of patients in gynecology/obstetrics and internal medicine wards were significantly more affected by visiting restrictions than were the relatives of patients in other wards. Numerous relatives subjected to visiting restrictions reported regular communication with their loved ones or with healthcare staff, at least once a day (n = 179), either via videoconferences using FaceTime®, WhatsApp®, Zoom®, or Skype® or via mobile phone text messages.

CONCLUSION

Visiting restrictions affected relatives differently depending on the wards their loved ones were hospitalized. Healthcare institutions should investigate the utility of visiting restrictions on patients, how they affect relatives, and how to improve personalized patient-relative communications. Future research should attempt to develop reliable, validated measurement instruments of relatives' experiences of acute-care visiting restrictions during pandemics.

"It Haunts Me": Impact of COVID-19 Deaths on Frontline Clinicians In Acute Care Settings-A Qualitative Study

BACKGROUND

The COVID-19 pandemic created unprecedented conditions for clinicians providing end-of-life care in acute care settings, yet almost 2 years since the start of the pandemic, little is known about its impact on clinicians.

OBJECTIVES

To qualitatively explore how clinicians experienced their role as they cared for dying patients with COVID-19 during the pandemic and the impact of these experiences on their lives as health care professionals.

METHODS

In-depth, hour-long interviews were conducted by phone in the spring of 2022 at a single time point with 23 physicians and nurses in critical care and emergency department settings from 2 health systems in California. The goal was to elicit perspectives on experiences with end-of-life care and the long-term impact of these experiences. Clinicians were asked to reflect on the different stages of the pandemic, and interviews were analyzed using a thematic analysis.

RESULTS

The interviews highlighted 2 primary themes around provision of end-of-life care during the COVID-19 pandemic. First, clinicians described challenges around their clinical duties of providing care to dying patients, which included decision-making dilemmas and professionalism challenges. Second, clinicians described the emotional aspects around end-of-life care situations they experienced, including communication with family members, "being patients' family members" at the end of life, and various degrees of meaning-making and remembrance of these experiences.

CONCLUSIONS

The findings highlight the sustained and cumulative emotional challenges and burden clinicians are still shouldering more than 2 years after the start of the pandemic.

Disruptions in Sexual and Reproductive Health Care Service Delivery for Immigrants During COVID-19

Purpose

To provide perspectives from heterogenous cisgender immigrant women and service providers for immigrants in New York City (NYC) on how restrictive sexual and reproductive health (SRH) care delivery environments during COVID-19 shape immigrant's access to health care and health outcomes to generate insights for clinical practices and policies for immigrant women's health care needs.

Methods

A qualitative study was conducted in 2020 and 2021, including in-depth interviews with 44 immigrant women from different national origins and 19 direct service providers for immigrant communities in NYC to explore how immigrants adapted to and were impacted by pandemic-related SRH care service delivery barriers. Interviews were coded and analyzed using a constant comparative approach.

Results

Pandemic-related delays and interrupted health care, restrictive accompaniment policies, and the transition from in-person to virtual care compounded barriers to care for immigrant communities. Care delays and interruptions forced some participants to live with untreated health conditions, resulting in physical pain and emotional distress. Participants also experienced challenges within the health care system because of changes to visitor policies that restricted the accompaniment of family members or support persons. Some participants experienced difficulties accessing telehealth and technology, while others welcomed the flexibility given the demands of frontline work and childcare.

Conclusions

To mitigate the health and social implications of increasingly restrictive immigration, reproductive, and social policies, clinical practices like expanding access to care for all immigrants, engaging immigrant communities in health care institutions policies and practices, and integrating immigrant's support networks into care play an important role.

End of life care during the COVID-19 pandemic: A qualitative study on the perspectives of nurses and nurse assistants

AIM

To explore nurses' and nurse assistants' experiences of providing end-of-life care during the COVID-19 pandemic in Austria, Germany and Northern Italy.

DESIGN

A qualitative explorative interview study.

METHOD

Data were collected between August and December 2020 and analysed using content analysis. Healthcare professionals (nurses (n = 30), nurse coordinators (n = 6) and nurse assistants (n = 5)) from hospitals (n = 32) and long-term care facilities (n = 9) in Austria, Germany and Northern Italy were interviewed for this study.

RESULTS

Five main categories were identified as follows: (i) end-of-life care involves love and duty, (ii) last wishes and dignity of the patient, (iii) communication with the family, (iv) organizational and religious aspects and (v) personal emotions. Results indicate that more training and guidelines are needed to prepare nurses and nurse assistants for end-of-life care during pandemics.

PUBLIC CONTRIBUTION

This research can help prepare nurses and nurse assistants for end-of-life care in pandemics and will be of value for improving the institutional and government health policies. Furthermore, it can be of value in preparing training for healthcare professionals patient-relatives.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021.

OUTCOMES AND ANALYSIS

We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts.

RESULTS

We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity.

CONCLUSIONS

Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Companion restrictions in the emergency department during COVID-19: physician perceptions from the Western Cape, South Africa

OBJECTIVES

To determine emergency department (ED) physicians' perceptions regarding hospital companions being prohibited from accompanying the patient during COVID-19.

DESIGN

Two qualitative datasets were combined. Data collected included voice recordings, narrative interviewing and semistructured interviews. A reflexive thematic analysis was conducted and guided by the Normalisation Process Theory.

SETTING

Six hospital EDs in the Western Cape, South Africa.

PARTICIPANTS

Convenience sampling was used to recruit a total of eight physicians working full time in the ED during COVID-19.

RESULTS

The lack of physical companions provided an opportunity for physicians to assess and reflect on a companion's role in efficient patient care. Physicians perceived that the COVID-19 restrictions illuminated that patient companions engaged in the ED as providers contributing to patient care by providing collateral information and patient support, while simultaneously engaging as consumers detracting physicians from their priorities and patient care. These restrictions prompted the physicians to consider how they understand their patients largely through the companions. When companions became virtual, the physicians were forced to shift how they perceive their patient, which included increased empathy.

CONCLUSION

The reflections of providers can feed into discussions about values within the healthcare system and can help explore the balance between medical and social safety, especially with companion restrictions still being practised in some hospitals. These perceptions illuminate various tradeoffs physicians had to consider throughout the pandemic and may be used to improve companion policies when planning for the continuation of the COVID-19 pandemic and future disease outbreaks.

Changes to Birth Plans Due to COVID-19: A Survey of Utah Midwives and Doulas

INTRODUCTION

This study seeks to understand the experiences of Utah midwives and doulas caring for patients during the recent coronavirus disease 2019 (COVID-19) pandemic. Specifically, the goal of the study was to describe the perceived impact on the community birth system and explore differences in the access and use of personal protective equipment (PPE) between in- and out-of-hospital births.

METHODS

This study used a cross-sectional, descriptive study design. A 26-item survey developed by the research team was sent via email to Utah birth workers, including nurse-midwives, community midwives, and doulas. Quantitative data were collected during December 2020 and January 2021. Descriptive statistics were used in the analysis.

RESULTS

Of the 409 birth workers who were sent a link to the survey, 120 (30%) responded: 38 (32%) CNMs, 30 (25%) direct-entry or community midwives, and 52 (43%) doulas. The majority (79%) reported changes to clinical practice during the COVID-19 pandemic. Community midwives (71%) who responded indicated practice volume increased. Survey participants reported an increased patient preference for home births (53%) and birth center births (43%). Among those with one or more patient transfers to the hospital, 61% experienced a change in the process. One participant reported that it took 43 minutes longer to transfer to the hospital. Community midwives and doulas reported poor access to a regular source of PPE.

DISCUSSION

Survey participants reported changes to planned birth locations during the COVID-19 pandemic. When necessary, transfers to hospitals were reported to be slower. Community midwives and doulas reported having insufficient access to PPE and reported limited knowledge about COVID-19 testing resources and resources for educating patients on COVID-19. This study adds an important perspective to the existing literature on COVID-19 by indicating that policymakers should include community birth partners in community planning for natural disasters and future pandemics.

Investigating Epidemiologic and Molecular Links Between Patients With Community- and Hospital-Acquired Influenza A: 2017-2018 and 2019-2020, Michigan

Background

Hospital-acquired influenza virus infection (HAII) can cause severe morbidity and mortality. Identifying potential transmission routes can inform prevention strategies.

Methods

We identified all hospitalized patients testing positive for influenza A virus at a large, tertiary care hospital during the 2017-2018 and 2019-2020 influenza seasons. Hospital admission dates, locations of inpatient service, and clinical influenza testing information were retrieved from the electronic medical record. Time-location groups of epidemiologically linked influenza patients were defined and contained ≥1 presumed HAII case (first positive ≥48 hours after admission). Genetic relatedness within time-location groups was assessed by whole genome sequencing.

Results

During the 2017-2018 season, 230 patients tested positive for influenza A(H3N2) or unsubtyped influenza A including 26 HAIIs. There were 159 influenza A(H1N1)pdm09 or unsubtyped influenza A-positive patients identified during the 2019-2020 season including 33 HAIIs. Consensus sequences were obtained for 177 (77%) and 57 (36%) of influenza A cases in 2017-2018 and 2019-2020, respectively. Among all influenza A cases, there were 10 time-location groups identified in 2017-2018 and 13 in 2019-2020; 19 of 23 groups included ≤4 patients. In 2017-2018, 6 of 10 groups had ≥2 patients with sequence data, including ≥1 HAII case. Two of 13 groups met this criteria in 2019-2020. Two time-location groups from 2017-2018 each contained 3 genetically linked cases.

Conclusions

Our results suggest that HAIIs arise from outbreak transmission from nosocomial sources as well as single infections from unique community introductions.

Predictors of Healthcare Workers' Compassionate Care Amid the COVID-19 Pandemic: A Cross-Sectional Study from Patients' Perspective in Kelantan, Malaysia

Background: Compassionate care served by healthcare workers (HCWs) has been recognized as one of the most critical aspects of high-quality care. Unfortunately, there is still an unmet need for the assessment of compassionate care from the patient’s perspective. During the COVID-19 pandemic, many new rules were enacted to tackle the raging pandemic, which raised concerns about its effect on compassionate care. Methods: A cross-sectional study involving 315 patients from three public hospitals was conducted during the conditional movement control order (CMCO). A self-administered Malay version of the Relational Aspect of Care Questionnaire (RAC-QM) was used to assess compassionate care. Multiple linear regression was used to determine the predictors. Results: More than 90% of the patients were Malays, Muslims, and fell under the B40 household income category. Companions were present for 51.7% of the patients, but 75.2% had no visitors. All hospitals received scores of more than 90%. Occupation (student, p = 0.032), dependency level (total dependent, p < 0.001), and household income level (M40, p = 0.027) were the statistically significant predictors for compassionate care. Conclusions: The current study revealed that compassionate care to patients was not compromised during the pandemic. Patients with disabilities or financial constraints are more likely to experience less compassionate care, while students are generally more satisfied. This study may provide clues for hospital administrators and policymakers regarding the vulnerable group of patients. It also provides opportunities for future research to study the perspective of HCWs.

Relatives Experience More Psychological Distress Due to COVID-19 Pandemic-Related Visitation Restrictions Than In-Patients

Background

The COVID-19 pandemic led to visiting restrictions (VRs) of patients in hospitals. Social contacts between patients' relatives play an important role in convalescence. Isolation may cause new psychological comorbidity. The present study investigated the psychological distress of VR in in-patients and their relatives.

Methods

From April 1, 2020 to May 20, 2020, 313 in-patients (≥14 years) of the University Medical Center Rostock were interviewed by questionnaires and 51 relatives by phone. Subjective psychological distress was assessed by a distress thermometer [0 (not at all)-100 (extreme)]. The study also investigated stressors due to VR, psychological distress in dependence on demographic or disease-related data, currently used communication channels and desired alternatives and support.

Results

Relatives were more psychologically distressed by VR than in-patients (59 ± 34 vs. 38 ± 30, p = 0.002). Loss of direct physical contact and facial expressions/gestures resulted in the most distress. Psychological distress due to VR was independent of demographics and indicates small positive correlations with the severity of physical restriction and the general psychological distress of in-patients. The most frequent ways of communication were via phone and social media. Frequently requested alternatives for patients were other interlocutors and free phone/tablet use, for relatives visiting rooms with partitions.

Conclusion

VRs are a stressor for patients and their relatives. The establishment of visiting rooms with partitions and the free use of phones/tablets could reduce the additional distress.