This document discusses the debate around visitation policies in intensive care units (ICUs). It summarizes evidence from the medical literature on the impacts of open versus restricted visitation on patients, families, staff, and organizations. While open visitation may provide benefits like reducing delirium and increasing family satisfaction, it also presents challenges. These include increased risks of infection, disturbances to patient care and rest, and increased burnout for ICU staff. The document concludes that most hospitals still restrict visits due to these issues. A flexible approach determined on a case-by-case basis may balance the needs of all parties if supported by education, resources, and security measures. However, the medical literature has limitations and may be influenced by non-medical

1. ICU VISITATION SHOULD
REMAIN RESTRICTED
Dr Ghaleb Almekhlafi
CCM CONSULTANT-PSMMC

2. Looks nice

3. The Institute for Family-Centered Care was founded in 1992 to advance family-centered
care in all settings and for all ages. In 2010, the Institute changed its name to the
Institute for Patient- and Family-Centered Care (IPFCC).

4. • Open and flexible visitation
policies are a major component
of many PFCC programs

6. • Open visitation policy is widely
embraced by health care
authorities throughout the US and
Europe

7. Since established
How far implemented?????

11. Italy =99.6 %(0.4%).

12. Why still not widely applied?
• PATIENT
• FAMILY
• ORGANIZATION
• STAFF
OPEN
VISITATION

13. EBM -LITERATURE REVIEW

14. PATIENT

15. 16 studies met the inclusion criteria:
2 RCTs (n = 294) 1 RCT had overall low risk for bias but it
us a before-after study, and 1 had high risk for bias
14 observational studies. 12 studies had low or
moderate risk for bias, and 2 were inconclusive
NO MORTALITY DIFERRENCE

16. JAMA. 2019;322(3):216-228.
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.
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.

17. Conclusion:
This review acknowledged challenges faced in adopting an open visiting policy in adult intensive care units such as
negative staff perceptions and attitudes; patient protection; family and cultural consideration, as well as organisational
challenges. The lack of a clear and consistent definition of open visitation is problematic, and strategies are urgently
needed to support staff to provide holistic patient- and family-centred care

18. Patient protection and Patient safety
Interruptions with care by open visitation may compromise
patient safety especially during high-risk nursing interventions
(Kozub et al., 2017; Tayebi et al., 2014). Tayebi et al. (2014)
open visitation may also expose patients to any ill-purposed
visits from outsiders. (in KSA.H1N1,MERS-COV)
Infection control issues with open visitation was voiced in
several studies
(Athanasiou et al., 2014; Khaleghparast et al., 2016a; Tayebi et al., 2014)

19. Patients’ rights violated by open visitation in that patients may
not always wish to be visited and/or have constant family
presence (Riley et al., 2014).
Open visitation may disturb patients from resting which is
essential for their recovery (Athanasiou et al., 2014; da Silva Ramos et al., 2013;
Noordermeer et al., 2013;
Yakubu et al., 2019; Yakubu et al., 2018)
cause distress to patients (Yakubu et al., 2019; Yakubu et al., 2018).

20. Invasion of Patient privacy
Invasion of patient privacy is another frequently stated
impediment in adopting open visitation in ICU
1. Khaleghparast et al., 2016a;
2. Mitchell and Aitken, 2017;
3. Noordermeer et al., 2013;
4. Yakubu et al., 2019, 2018),
5. Tayebi et al., 2014.
especially during procedures

21. Family &
cultural consideration

22. Family members may
• be particularly demanding and are challenging to work with during open visitation
(Riley et al., 2014).
• Have Unrealistic expectations that present a barrier to open visitation in ICU
(Khaleghparast et al., 2016a).
• misinterpret the activities of the healthcare providers-violence?
Yakubu et al. (2019) reported family members’ reservations
towards open visitation in ICU due to cultural and religious
reasons
Family preference:
• procedures being performed by junior doctors(Rileyet al., 2014).
• Choosing specific nurses and doctors

23. Organizational
challenges

24. Adminstration and Organisational challenges
1-Lack of space as well as the unit layout often discourages increased family presence
1. (Athanasiou et al., 2014;
2. Khaleghparast et al., 2016a;
3. Kozub et al., 2017;
4. Noordermeer et al., 2013;
5. Zaforteza et al., 2015)
2-More training for family and staff in communication is desired including training in PFCC in ICU
settings
(da Silva Ramos et al., 2013;
Giannini et al., 2013
3-open visitation was found to be associated with increased burnout among ICU staff
(Giannini et al., 2013).

26. Organizational obligations for liberal visiting
1. Policy considering all parties
2. Restructuring the icu. create a space and facilities
3. Extensive education for families
4. Staff training
5. Security system: Protection of staff, patients and the data

27. five Dutch ICUs had to change their open
visiting policy back to restricted visiting based
on unacceptable disturbance levels for the
patient and the ICU worker

28. IMPACT ON
STAFF

29. ICU VISITORS

30. Staff perceptions and attitudes
In surveys Four subthemes were
identified:
1.scepticism about benefits
2.perceived loss of control
3.increased workload;
4.interruption with care

31. Interruption with care
Open visiting in ICU impairs organisation of care
as increased family presence causes
disruptions in care planning and delivery
1. Athanasiou et al., 2014;
2. Chapman et al., 2016;
3. da Silva Ramos et al., 2013;
4. Khaleghparast et al.,
5. 2016a,b; Kozub et al., 2017;
6. Tayebi et al., 2014;
7. Yakubu et al., 2018;
8. Zaforteza et al., 2015).

38. BOS

39. burnout increased to 43%.
The situation becomes even worse
when looking just at nurse rate of
BOS: 36% at baseline going to 46%
1 year later.

41. • Care disruption and staff BOS may lead to
paradoxical effect on the quality of care and
increase the CHASM instead
Open or flexible visitation

42. EBM SUMMARY-THE IMPACT OF
OPEN ICU VISIT
PARTY ADVANTAGES DISADVANTAGES
PATIENT may reduce delirium? Violation of patient autonomy and
Privacy, affect decisions and quality
FAMILY Satisfaction
Post discharge care
• trouble decision making
• Interfere with care
• Need education and selection
STAFF • may help improve
care-paediatrics
• May Improve
communication
• burn out,
• workload
• Increased violence
• Leak of staff
ORGANIZATION PFCC-KPI for the quality
requirements
• Demanding and costly
• ICU and hospital restructuring
• Need good security

44. • In summary:
• most hospitals still restrict visiting hours
and the subject remains contentious
• Both restricted and open visiting policies
have benefits and drawbacks

45. Flexible visitation policy – my view
May be applied
• in selected hospital with suitable facilities
• determined on a case-by-case basis. eg.daying patients
• visitation schedule should be determined by all parties,
• Choose the appropriate visitor-ask patient preference
• Teaching and training program for family and staff
• Good security

46. MEDICAL LITERATURE
• the medical literature contains the good and the bad
• the medical media is influenced by other factors
• the medical media is showing us what they like
• we are following the media blindly
• we have no time and experience to dig into the literature
We are MOCKED by medical media

47. Two-month sequences of the 2 visiting policies were randomly alternated
for 2 years in a 6-bed ICU, with 226 patients enrolled
might reduce cardiovascular complications, possibly through reduced
anxiety and more favorable hormonal profile
No measurement of:
• cumulative incidence of delirium
• indicator of stress to staff
• indicator of the satisfaction or
dissatisfaction of patients and visitors
Circulation. 2006
MANY LIMITATIONS
HIGH RISK OF BIAS

48. 37 % of ICUs denied participating, despite several recalls. We can speculate that these ICUs
likely have restricted family’s visiting policies