Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit

Abstract

IMPORTANCE The effects of intensive care unit (ICU) visiting hours remain uncertain. OBJECTIVE To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. DESIGN, SETTING AND PARTICIPANTS Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. INTERVENTIONS Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. MAIN OUTCOMES AND MEASURES Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). RESULTS Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, −1.7% [95% CI, −6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, −0.8% [95% CI, −2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, −3.8% [95% CI, −4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, −1.6 [95% CI, −2.3 to −0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, −1.2 [95% CI, −2.0 to −0.4]; P = .003) were significantly better with flexible visitation. CONCLUSIONS AND RELEVANCE Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium.

Delirium Incidence, Duration and Severity in Critically Ill Patients with COVID-19

“…Reductions in the prevalence of ICU delirium from a historical high of 80% to rates of 16.5-33% have been reported over the past two years. 13,16,17,19 These reductions CoV-2 has been identified in cerebrospinal fluid as well as brain tissue, the neurotoxic impact of COVID-19 is increasingly plausible. [31][32][33]35 The possible pathways for neuronal damage due to COVID-19 require additional study.…”

“…[9][10][11][12] Prior to COVID-19, the prevalence of delirium in mechanically ventilated patients has been decreasing from a historically high rate of 80% to a range of 16.5-33%. [13][14][15][16][17][18][19] In the setting of the current global health crisis, hospital resources have been stretched to their limits to meet the needs of a large number of critically ill patients. The unintended impact of limited resources on clinical practice has raised concerns that current ICU delirium rates have returned to the historically high levels.…”

Predictors of Delirium Incidence, Time to Onset, and Recurrence in a Mixed Medical-surgical ICU Population: A Secondary Analysis Using Cox and CHIAD Decision Tree Modeling

“…This raises questions about the role that family may play in the care of a critically-ill loved one and presents an opportunity for inquiry as ICU visitation policies have been restricted in many cases during the current COVID-19 pandemic. Current evidence suggests that this may potentially be accomplished in the con nes of traditional visiting hours, rather more exible visitation policies that may contribute to staff burnout [82,83].…”

Association between visitation restriction during COVID-19 pandemic and delirium incidence among emergency admission patients: a single-center retrospective observational cohort study in Japan

“…One of the strengths of this study was that it was the rst to show that total visitation restriction was associated with the incidence of delirium in emergency inpatients during visitation restriction. Although some studies have focused on the association between partial limitation of visitation time and delirium in the intensive care unit setting [28][29][30], an assessment of the intervention of uniform and complete visitation restriction for emergency inpatients have never been performed. Because it is practically impossible to this type of study perform from an ethical standpoint, the association between total visitation restriction and the incidence of delirium has not been examined.…”