A muti-informant national survey on the impact of COVID-19 on mental health symptoms of parent-child dyads in Canada.

The COVID-19 pandemic negatively impacted the mental health of children, youth, and their families which must be addressed and prevented in future public health crises. Our objective was to measure how self-reported mental health symptoms of children/youth and their parents evolved during COVID-19 and to identify associated factors for children/youth and their parents including sources accessed for information on mental health. We conducted a nationally representative, multi-informant cross-sectional survey administered online to collect data from April to May 2022 across 10 Canadian provinces among dyads of children (11-14 years) or youth (15-18 years) and a parent (> 18 years). Self-report questions on mental health were based on The Partnership for Maternal, Newborn & Child Health and the World Health Organization of the United Nations H6+ Technical Working Group on Adolescent Health and Well-Being consensus framework and the Coronavirus Health and Impact Survey. McNemar's test and the test of homogeneity of stratum effects were used to assess differences between children-parent and youth-parent dyads, and interaction by stratification factors, respectively. Among 933 dyads (N = 1866), 349 (37.4%) parents were aged 35-44 years and 485 (52.0%) parents were women; 227 (47.0%) children and 204 (45.3%) youth were girls; 174 (18.6%) dyads had resided in Canada < 10 years. Anxiety and irritability were reported most frequently among child (44, 9.1%; 37, 7.7%) and parent (82, 17.0%; 67, 13.9%) dyads, as well as among youth (44, 9.8%; 35, 7.8%) and parent (68, 15.1%; 49, 10.9%) dyads; children and youth were significantly less likely to report worsened anxiety (p < 0.001, p = 0.006, respectively) or inattention (p < 0.001, p = 0.028, respectively) compared to parents. Dyads who reported financial or housing instability or identified as living with a disability more frequently reported worsened mental health. Children (96, 57.1%), youth (113, 62.5%), and their parents (253, 62.5%; 239, 62.6%, respectively) most frequently accessed the internet for mental health information. This cross-national survey contextualizes pandemic-related changes to self-reported mental health symptoms of children, youth, and families.

Exploring the influence of behavioural, normative and control beliefs on intentions to adhere to public health guidelines during the COVID-19 pandemic: a qualitative interview based study.

BACKGROUND: Perceived severity and susceptibility of disease are predictors of individual behaviour during health crises. Little is known about how individual beliefs influence intentions to adhere to public health guidelines during periods of health crises, and how access to and consumption of information influence these intentions. This study investigated behavioural beliefs, normative beliefs, and control beliefs, and their influence on behavioural intentions to adhere to public health guidelines during the COVID-19 pandemic. METHODS: Participants were recruited from a related COVID-19 study conducted by our team, and through snowball sampling in subsequent. Using a maximum variation sampling technique, we recruited a diverse group of participants representing six major regions in Canada. Participants took part in one-on-one semi-structured interviews from February 2021 to May 2021. Data were analyzed independently in duplicate by thematic analysis. The Theory of Planned Behaviour (TPB) was the conceptual framework used to organize dominant themes. RESULTS: We conducted a total of 60 individual interviews (137 eligible individuals contacted, 43.8% response rate) and identified six themes organized according to the three constructs of behavioural, normative and control beliefs as described in the TPB: (1) Behavioural: My "New Normal," Individual Rights and Perceived Pandemic Severity, Fatigue with COVID-19, (2) Normative: COVID-19 Collective, (3) Control: Practicality of Public Health Guidelines, and (6) Conflicting Public Health Messages. Most (n = 43, 71.7%) participants perceived individuals in their geographic community to be following public health guidelines adequately. Several participants (n = 15, 25.0%) commented on the unequal impact of restrictions based on socioeconomic factors (i.e., class, race, age). CONCLUSION: Individual perceptions of risk, loss of control, access to resources (i.e., childcare), and societal expectations, shaped intentions to engage in disease preventative behaviours (i.e., social distancing) during the COVID-19 pandemic.

Interventions to improve well-being among children and youth aged 6-17 years during the COVID-19 pandemic: a systematic review.

BACKGROUND: The COVID-19 pandemic is an example of a global infectious disease outbreak that poses a threat to the well-being of children and youth (e.g., physical infection, psychological impacts). The consequences of challenges faced during COVID-19 may be longstanding and newly developed interventions are being deployed. We present a narrative synthesis of available evidence from the first 2 years of the COVID-19 pandemic on the feasibility, accessibility, and effects of interventions to improve well-being among children and youth to inform the development and refinement of interventions relevant to post-pandemic recovery. METHODS: Six databases were searched from inception to August 2022. A total of 5484 records were screened, 39 were reviewed in full text, and 19 studies were included. The definition of well-being and the five domains of well-being as defined by the Partnership for Maternal, Newborn & Child Health and the World Health Organization in collaboration with the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being were used. RESULTS: Nineteen studies (74% randomized controlled trials) from 10 countries were identified, involving a total of 7492 children and youth (age range: 8.2-17.2 years; 27.8-75.2% males) and 954 parents that occurred during the COVID-19 pandemic (March 2020 to March 2021). Nearly all interventions (n = 18, 95%) targeted health and nutrition, followed by connectedness (n = 6, 32%), while fewer studies targeted agency and resilience (n = 5, 23%), learning and competence (n = 2, 11%), or safety and support (n = 1, 3%). Five interventions (26%) were self-guided while 13 interventions (68%) were guided synchronous by a trained professional, all of which targeted physical and mental health subdomains within health and nutrition; one intervention (5%) was unclear. CONCLUSIONS: Studies deploying synchronous interventions most often reported improved well-being among children and youth largely in the domain of health and nutrition, specifically physical and mental health. Targeted approaches will be crucial to reach sub-groups of children and youth who are most at risk of negative well-being outcomes. Further research is needed to determine how interventions that best supported children and youth early in the pandemic are different from interventions that are required now as we enter into the post-pandemic phase.

Perspectives from designated family caregivers of critically ill adult patients during the COVID-19 pandemic: A qualitative interview study.

BACKGROUND: Family visitation in intensive care units (ICU) has been impacted by the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic. While studies report on perceptions of families completely restricted from ICUs, little is known about the burden experienced by designated family caregivers allowed to visit their critically ill loved one. This study sought the perspectives of family caregivers of critically ill patients on the impact of one-person designated visitor policies mandated in ICUs during the COVID-19 pandemic. METHODS: Throughout the study period a restricted visitation policy was mandated capturing the first (April 2020) and second (December 2020) waves of the pandemic that allowed one designated family caregiver (i.e., spouses or adult children) per patient to visit the ICU. Designated family caregivers of critically ill patients admitted to ICU September 2020 to November 2020 took part in individual 60-minute, semi-structured interviews at 6-months after discharge from the index ICU admission. Themes from family interviews were summarized with representative quotations. RESULTS: Key themes identified following thematic analysis from six participants included: one visitor rule, patient advocate role, information needs, emotional distress, strategies for coping with challenges, practicing empathy, and appreciation of growth. CONCLUSION: Designated family caregivers of critically ill patients admitted to ICU during the COVID-19 pandemic perceived a complex and highly stressful experience. Support from ICU family liaisons and psychologists may help ameliorate the impact.

Strategies to mitigate the impact of the COVID-19 pandemic on child and youth well-being: a scoping review protocol.

INTRODUCTION: Children and youth are often more vulnerable than adults to emotional impacts of trauma. Wide-ranging negative effects (eg, social isolation, lack of physical activity) of the COVID-19 pandemic on children and youth are well established. This scoping review will identify, describe and categorise strategies taken to mitigate potentially deleterious impacts of the COVID-19 pandemic on children, youth and their families. METHODS AND ANALYSIS: We will conduct a scoping review following the Arksey-O'Malley five-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. Well-being will be operationalised according to pre-established domains (health and nutrition, connectedness, safety and support, learning and competence, and agency and resilience). Articles in all languages for this review will be identified in CINAHL, Cochrane CENTRAL Register of Controlled Trials, EMBASE, ERIC, Education Research Complete, MEDLINE and APA PsycINFO. The search strategy will be restricted to articles published on or after 1 December 2019. We will include primary empirical and non-empirical methodologies, excluding protocols, reports, opinions and editorials, to identify new data for a broad range of strategies to mitigate potentially deleterious impacts of the COVID-19 pandemic on child and youth well-being. Two reviewers will calibrate screening criteria and the data abstraction form and will independently screen records and abstract data. Data synthesis will be performed according to the convergent integrated approach described by the Joanna Briggs Institute. ETHICS AND DISSEMINATION: Ethical approval is not applicable as this review will be conducted on published data. Findings of this study will be disseminated at national and international conferences and will inform our pan-Canadian multidisciplinary team of researchers, public, health professionals and knowledge users to codesign and pilot test a digital psychoeducational health tool-an interactive, web-based tool to help Canadian youth and their families address poor mental well-being resulting from and persisting beyond the COVID-19 pandemic.

Evidence-informed consensus statements to guide COVID-19 patient visitation policies: results from a national stakeholder meeting.

PURPOSE: Hospital policies forbidding or limiting families from visiting relatives on the intensive care unit (ICU) has affected patients, families, healthcare professionals, and patient- and family-centered care (PFCC). We sought to refine evidence-informed consensus statements to guide the creation of ICU visitation policies during the current COVID-19 pandemic and future pandemics and to identify barriers and facilitators to their implementation and sustained uptake in Canadian ICUs. METHODS: We created consensus statements from 36 evidence-informed experiences (i.e., impacts on patients, families, healthcare professionals, and PFCC) and 63 evidence-informed strategies (i.e., ways to improve restricted visitation) identified during a modified Delphi process (described elsewhere). Over two half-day virtual meetings on 7 and 8 April 2021, 45 stakeholders (patients, families, researchers, clinicians, decision-makers) discussed and refined these consensus statements. Through qualitative descriptive content analysis, we evaluated the following points for 99 consensus statements: 1) their importance for improving restricted visitation policies; 2) suggested modifications to make them more applicable; and 3) facilitators and barriers to implementing these statements when creating ICU visitation policies. RESULTS: Through discussion, participants identified three areas for improvement: 1) clarity, 2) accessibility, and 3) feasibility. Stakeholders identified several implementation facilitators (clear, flexible, succinct, and prioritized statements available in multiple modes), barriers (perceived lack of flexibility, lack of partnership between government and hospital, change fatigue), and ways to measure and monitor their use (e.g., family satisfaction, qualitative interviews). CONCLUSIONS: Existing guidance on policies that disallowed or restricted visitation in intensive care units were confusing, hard to operationalize, and often lacked supporting evidence. Prioritized, succinct, and clear consensus statements allowing for local adaptability are necessary to guide the creation of ICU visitation policies and to optimize PFCC.

RéSUMé: OBJECTIF: Les politiques hospitalières interdisant ou limitant les visites des familles à des proches à l'unité de soins intensifs (USI) ont affecté les patients, les familles, les professionnels de la santé et les soins centrés sur le patient et la famille (SCPF). Nous avons cherché à affiner les déclarations de consensus fondées sur des données probantes afin de guider la création de politiques de visite aux soins intensifs pendant la pandémie actuelle de COVID-19 et les pandémies futures, et dans le but d'identifier les obstacles et les critères facilitants à leur mise en œuvre et à leur adoption répandue dans les unités de soins intensifs canadiennes. MéTHODE: Nous avons créé des déclarations de consensus à partir de 36 expériences fondées sur des données probantes (c.-à-d. impacts sur les patients, les familles, les professionnels de la santé et les SCPF) et 63 stratégies fondées sur des données probantes (c.-à-d. moyens d'améliorer les restrictions des visites) identifiées au cours d'un processus Delphi modifié (décrit ailleurs). Au cours de deux réunions virtuelles d'une demi-journée tenues les 7 et 8 avril 2021, 45 intervenants (patients, familles, chercheurs, cliniciens, décideurs) ont discuté et affiné ces déclarations de consensus. Grâce à une analyse descriptive qualitative du contenu, nous avons évalué les points suivants pour 99 déclarations de consensus : 1) leur importance pour l'amélioration des politiques de restriction des visites; 2) les modifications suggérées pour les rendre plus applicables; et 3) les critères facilitants et les obstacles à la mise en œuvre de ces déclarations lors de la création de politiques de visite aux soins intensifs. RéSULTATS: En discutant, les participants ont identifié trois domaines à améliorer : 1) la clarté, 2) l'accessibilité et 3) la faisabilité. Les intervenants ont identifié plusieurs critères facilitants à la mise en œuvre (énoncés clairs, flexibles, succincts et hiérarchisés disponibles dans plusieurs modes), des obstacles (manque perçu de flexibilité, manque de partenariat entre le gouvernement et l'hôpital, fatigue du changement) et des moyens de mesurer et de surveiller leur utilisation (p. ex., satisfaction des familles, entrevues qualitatives). CONCLUSION: Les directives existantes sur les politiques qui interdisaient ou limitaient les visites dans les unités de soins intensifs étaient déroutantes, difficiles à mettre en oeuvre et manquaient souvent de données probantes à l'appui. Des déclarations de consensus hiérarchisées, succinctes et claires permettant une adaptabilité locale sont nécessaires pour guider la création de politiques de visite en soins intensifs et pour optimiser les soins centrés sur le patient et la famille.

Non-COVID outcomes associated with the coronavirus disease-2019 (COVID-19) pandemic effects study (COPES): A systematic review and meta-analysis.

BACKGROUND: As the Coronavirus Disease-2019 (COVID-19) pandemic continues, healthcare providers struggle to manage both COVID-19 and non-COVID patients while still providing high-quality care. We conducted a systematic review/meta-analysis to describe the effects of the COVID-19 pandemic on patients with non-COVID illness and on healthcare systems compared to non-pandemic epochs. METHODS: We searched Ovid MEDLINE/EMBASE/Cochrane Database of Systematic Reviews/CENTRAL/CINAHL (inception to December 31, 2020). All study types with COVID-pandemic time period (after December 31, 2019) with comparative non-pandemic time periods (prior to December 31, 2019). Data regarding study characteristics/case-mix/interventions/comparators/ outcomes (primary: mortality; secondary: morbidity/hospitalizations/disruptions-to-care. Paired reviewers conducted screening and abstraction, with conflicts resolved by discussion. Effect sizes for specific therapies were pooled using random-effects models. Risk of bias was assessed by Newcastle-Ottawa Scale, with evidence rating using GRADE methodology. RESULTS: Of 11,581 citations, 167 studies met eligibility. Our meta-analysis showed an increased mortality of 16% during the COVID pandemic for non-COVID illness compared with 11% mortality during the pre-pandemic period (RR 1.38, 95% CI: 1.28-1.50; absolute risk difference: 5% [95% CI: 4-6%], p<0.00001, very low certainty evidence). Twenty-eight studies (17%) reported significant changes in morbidity (where 93% reported increases), while 30 studies (18%) reported no significant change (very low certainty). Thirty-nine studies (23%) reported significant changes in hospitalizations (97% reporting decreases), while 111 studies (66%) reported no significant change (very low certainty). Sixty-two studies (37%) reported significant disruptions in standards-to-care (73% reporting increases), while 62 studies (37%) reported no significant change (very low certainty). CONCLUSIONS: There was a significant increase in mortality during the COVID pandemic compared to pre-pandemic times for non-COVID illnesses. When significant changes were reported, there was increased morbidity, decreased hospitalizations and increased disruptions in standards-of-care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020201256 (Sept 2, 2020).

Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial.

Importance: The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19. Objective: To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19. Design, Setting, and Participants: Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021. Intervention: Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195). Main Outcomes and Measures: The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events. Results: Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group. Conclusions and Relevance: In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit. Trial Registration: ClinicalTrials.gov Identifier: NCT04350723.

Lived experiences of Asian Canadians encountering discrimination during the COVID-19 pandemic: a qualitative interview study.

BACKGROUND: Asian Canadians have experienced increased cases of racialized discrimination after the first emergence of SARS-CoV-2 in China. This study examined how the COVID-19 pandemic has affected Asian Canadians' sense of safety and belonging in their Canadian (i.e., geographical) communities. METHODS: We applied a qualitative description study design in which semistructured interviews were conducted from Mar. 23 to May 27, 2021. Purposive and snowball sampling methods were used to recruit Asian Canadians diverse in region, gender and age. Interviews were conducted through Zoom videoconference or telephone, and independent qualitative thematic analysis in duplicate was used to derive primary themes and subthemes. RESULTS: Thirty-two Asian Canadians (median age 35 [interquartile range 24-46] yr, 56% female, 44% East Asian) participated in the study. We identified 5 predominant themes associated with how the COVID-19 pandemic affected the participants' sense of security and belonging to their communities: relation between socioeconomic status (SES) and exposure to discrimination (i.e., how SES insulates or exposes individuals to increased discrimination); politics, media and the COVID-19 pandemic (i.e., the key role that politicians and media played in enabling spread of discrimination against and fear of Asian people); effect of discrimination on mental and social health (i.e., people's ability to interact and form meaningful relationships with others); coping with the impact of discrimination (i.e., the way people appraise and move forward in identity-threatening situations); and implications for sense of safety and sense of belonging (i.e., people feeling unable to safely use public spaces in person, including the need to remain alert in anticipation of harm, leading to distress and exhaustion). INTERPRETATION: During the COVID-19 pandemic, Asian Canadians in our study felt unsafe owing to the uncertain, unexpected and unpredictable nature of discrimination, but also felt a strong sense of belonging to Canadian society and felt well connected to their Asian Canadian communities. Future work should seek to explore the influence of social media on treatment of and attitudes toward Asian Canadians.

Exploring the impact of media and information on self-reported intentions to vaccinate against COVID-19: A qualitative interview-based study.

BACKGROUND: The World Health Organization declared vaccine hesitancy a top threat to global health following resurgence of vaccine-preventable diseases close to eradication in many countries (e.g. measles). Vaccines are effective in preventing severe illness, hospitalization, and death from COVID-19, yet there remains a small proportion of the eligible population who choose not to vaccinate. Social media and online news sources are opportunities for targeted public health interventions to improve vaccine uptake. This study reports the results of a semi-structured interview study that explored the influence of media and information on individuals' self-reported intentions to vaccinate against COVID-19. METHODS: A qualitative descriptive study was employed to gain insight from a diverse group of individuals. Adult participants were recruited through a related COVID-19 study; we used a maximum variation sampling technique and purposively sampled participants based on demographics. Interviews were conducted from February 2021 to May 2021. Themes from interviews were summarized with representative quotations according to the 3C Theoretical Framework (Confidence, Complacency, Convenience). RESULTS: Key themes identified following thematic analysis from 60 participants included: vaccine safety, choice of vaccine, fear mongering, trust in authority, belief in vaccinations (Confidence); delaying vaccination (Complacency); confusing information, access to vaccines and information (Convenience). While most participants intended to vaccinate, many expressed concerns and hesitancy. CONCLUSIONS: COVID-19 vaccine hesitancy prevents universal immunization and contradictory messages in media are a source of concern and fear. The success of future vaccine campaigns will depend upon authorities' ability to disseminate accessible, detailed, and consistent information promoting public confidence.

Impact of Restricted Visitation Policies during the First Wave of the COVID-19 Pandemic on Communication between Critically Ill Patients, Families, and Clinicians: A Qualitative Interview Study.

Rationale: Restricted visitation policies during the first wave of the coronavirus disease (COVID-19) pandemic have had a major impact on the ways that intensive care unit (ICU) clinicians communicated with patients and their families, requiring the use of innovative strategies to adapt to new communication structures. Objectives: The purpose of this study is to describe the impact of restricted visitation policies on communication and to identify strategies that could be used to facilitate better communication within Canadian ICUs from the perspective of those affected. Methods: We conducted semistructured individual interviews with critically ill patients, their families, and clinicians from 23 Canadian ICUs during the first wave of the COVID-19 pandemic between July 2020 and October 2020. We used inductive thematic analysis to identify relevant themes and subthemes. Results: Forty-one interviews were conducted with 3 patients, 8 family members, 17 nurses, and 13 physicians. Five themes were identified from the analysis: 1) patient and family psychosocial and information needs; 2) communication tools; 3) quality of communication; 4) changing roles and responsibilities of patients and nurses/physicians; and 5) facilitators or barriers to implementing alternative communication. Participants identified strategies to leverage new videoconference technology and communication structures to preserve the quality of communication. Conclusions: Our study identified challenges and opportunities related to communication between critically ill patients, families, and ICU clinicians due to the restricted hospital visitation policies during the first wave of the COVID-19 pandemic. The use of videoconference technology and changes to communication structure were important strategies to facilitate effective communication within the ICU.

A Modified Delphi Process to Prioritize Experiences and Guidance Related to ICU Restricted Visitation Policies During the Coronavirus Disease 2019 Pandemic.

To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics. DESIGN: Three rounds of a remote modified Delphi consensus process. SETTING: Online survey and virtual polling from February 2, 2021, to April 8, 2021. SUBJECTS: Stakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic. MEASUREMENTS AND MAIN RESULTS: During Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies. CONCLUSIONS: We have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.

Restricted visitation policies in acute care settings during the COVID-19 pandemic: a scoping review.

BACKGROUND: Restricted visitation policies in acute care settings because of the COVID-19 pandemic have negative consequences. The objective of this scoping review is to identify impacts of restricted visitation policies in acute care settings, and describe perspectives and mitigation approaches among patients, families, and healthcare professionals. METHODS: We searched Medline, Embase, PsycINFO, Healthstar, CINAHL, Cochrane Central Register of Controlled Trials on January 01/2021, unrestricted, for published primary research records reporting any study design. We included secondary (e.g., reviews) and non-research records (e.g., commentaries), and performed manual searches in web-based resources. We excluded records that did not report primary data. Two reviewers independently abstracted data in duplicate. RESULTS: Of 7810 citations, we included 155 records. Sixty-six records (43%) were primary research; 29 (44%) case reports or case series, and 26 (39%) cohort studies; 21 (14%) were literature reviews and 8 (5%) were expert recommendations; 54 (35%) were commentary, editorial, or opinion pieces. Restricted visitation policies impacted coping and daily function (n = 31, 20%) and mental health outcomes (n = 29, 19%) of patients, families, and healthcare professionals. Participants described a need for coping and support (n = 107, 69%), connection and communication (n = 107, 69%), and awareness of state of well-being (n = 101, 65%). Eighty-seven approaches to mitigate impact of restricted visitation were identified, targeting families (n = 61, 70%), patients (n = 51, 59%), and healthcare professionals (n = 40, 46%). CONCLUSIONS: Patients, families, and healthcare professionals were impacted by restricted visitation polices in acute care settings during COVID-19. The consequences of this approach on patients and families are understudied and warrant evaluation of approaches to mitigate their impact. Future pandemic policy development should include the perspectives of patients, families, and healthcare professionals. TRIAL REGISTRATION: The review was registered on PROSPERO (CRD42020221662) and a protocol peer-reviewed prior to data extraction.

Impact of restricted visitation policies in hospitals on patients, family members and healthcare providers during the COVID-19 pandemic: a scoping review protocol.

INTRODUCTION: Flexible visitation policies in hospitals are an important component of care that contributes to reduced stress and increased satisfaction among patients and their family members. Early evidence suggests restricted visitation policies enacted in hospitals during the COVID-19 pandemic are having unintended consequences on patients, family members and healthcare providers. There is a need for a comprehensive summary of the impacts of restricted visitation policies on key stakeholders and approaches to mitigate that impact. METHODS AND ANALYSIS: We will conduct a scoping review as per the Arksey-O'Malley 5-stage scoping review method and the Scoping Review Methods Manual by the Joanna Briggs Institute. We will search relevant electronic databases (eg, CINAHL, MEDLINE, PsycINFO), grey literature and preprint repositories. We will include all study designs including qualitative and quantitative methodologies (excluding protocols) as well as reports, opinions and editorials, to identify the broad impact of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members or healthcare providers of hospitalised patients, and approaches taken or proposed to mitigate this impact. Two reviewers will calibrate the screening criteria and data abstraction form and will independently screen studies and abstract the data. Narrative synthesis with thematic analysis will be performed. ETHICS AND DISSEMINATION: Ethical approval is not applicable as this review will be conducted on published literature only. This scoping review will identify, describe and categorise impacts of restricted hospital visitation policies due to the COVID-19 pandemic on patients, family members and healthcare providers of hospitalised patients, and approaches that have been taken to mitigate impact. We will provide a comprehensive synthesis by developing a framework of restricted visitation policies and associated impacts. Our results will inform the development of consensus statements on restricted visitation policies to be implemented in future pandemics. PROSPERO REGISTRATION NUMBER: CRD42020221662.

An environmental scan of visitation policies in Canadian intensive care units during the first wave of the COVID-19 pandemic.

PURPOSE: In response to the rapid spread of SARS-CoV-2, hospitals in Canada enacted temporary visitor restrictions to limit the spread of COVID-19 and preserve personal protective equipment supplies. This study describes the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic. METHODS: We conducted an environmental scan of Canadian hospital visitation policies throughout the first wave of the pandemic. We conducted a two-phased study analyzing both quantitative and qualitative data. RESULTS: We collected 257 documents with reference to visitation policies (preCOVID, 101 [39%]; midCOVID, 71 [28%]; and lateCOVID, 85 [33%]). Of these 257 documents, 38 (15%) were ICU-specific and 70 (27%) referenced the ICU. Most policies during the midCOVID/lateCOVID pandemic period allowed no visitors with specific exceptions (e.g., end-of-life). Framework analysis revealed five overarching themes: 1) reasons for restricted visitation policies; 2) visitation policies and expectations; 3) exceptions to visitation policy; 4) patient and family-centred care; and 5) communication and transparency. CONCLUSIONS: During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life, patients requiring assistance, or COVID-19 positive patients (varying from not allowed to case-by-case). Further studies are needed to understand the consistency with which visitation policies were operationalized and how they may have impacted patient- and family-centred care.

RéSUMé: OBJECTIF: En réponse à la propagation rapide du SRAS-CoV-2, les hôpitaux du Canada ont adopté des restrictions temporaires pour les visites afin de limiter la propagation de la COVID-19 et de préserver les stocks d'équipements de protection individuelle. Cette étude décrit l'ampleur, les variations et fluctuations des politiques canadiennes concernant les visites aux unités de soins intensifs (USI) pour adultes avant et pendant la première vague de la pandémie de COVID-19. MéTHODE: Nous avons réalisé une étude de milieu des politiques hospitalières canadiennes concernant les visites tout au long de la première vague de la pandémie. Nous avons mené une étude en deux phases analysant des données quantitatives et qualitatives. RéSULTATS: Nous avons recueilli 257 documents faisant référence aux politiques de visites (pré-COVID, 101 [39 %]; mid-COVID, 71 [28 %]; et COVID-tardif, 85 [33 %]). Sur ces 257 documents, 38 (15 %) étaient spécifiques aux USI et 70 (27 %) faisaient référence aux USI. La plupart des politiques au cours de la période pandémique mid-COVID/COVID-tardif ne permettaient aucune visite sauf exception spécifique (p. ex., fin de vie). L'analyse du cadre a révélé cinq thèmes généraux : 1) les raisons des restrictions des politiques de visites; 2) les politiques et attentes en matière de visites; 3) les exceptions aux politiques de visites; 4) les soins aux patients et centrés sur la famille; et 5) la communication et la transparence. CONCLUSION: Au cours de la première vague de la pandémie de COVID-19, la plupart des hôpitaux canadiens avaient des politiques de restriction des visites s'appliquant au public avec des catégories d'exception spécifiques, le plus souvent pour les patients en fin de vie, les patients nécessitant de l'aide ou les patients COVID-positifs (variant d'une interdiction au cas par cas). D'autres études sont nécessaires pour comprendre l'uniformité avec laquelle les politiques de visites ont été mises en œuvre et comment elles ont pu avoir une incidence sur les soins centrés sur le patient et la famille.

A qualitative study of physician perceptions and experiences of caring for critically ill patients in the context of resource strain during the first wave of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has led to global shortages in the resources required to care for critically ill patients and to protect frontline healthcare providers. This study investigated physicians' perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain during the COVID-19 pandemic, and explored implications for the healthcare workforce and the delivery of patient care. METHODS: We recruited a diverse sample of critical care physicians from 13 Canadian Universities with adult critical care training programs. We conducted semi-structured telephone interviews between March 25-June 25, 2020 and used qualitative thematic analysis to derive primary themes and subthemes. RESULTS: Fifteen participants (eight female, seven male; median age = 40) from 14 different intensive care units described three overarching themes related to physicians' perceptions and experiences of caring for critically ill patients during the pandemic: 1) Conditions contributing to resource strain (e.g., continuously evolving pandemic conditions); 2) Implications of resource strain on critical care physicians personally (e.g., safety concerns) and professionally (e.g. practice change); and 3) Enablers of resource sufficiency (e.g., adequate human resources). CONCLUSIONS: The COVID-19 pandemic has required health systems and healthcare providers to continuously adapt to rapidly evolving circumstances. Participants' uncertainty about whether their unit's planning and resources would be sufficient to ensure the delivery of high quality patient care throughout the pandemic, coupled with fear and anxiety over personal and familial transmission, indicate the need for a unified systemic pandemic response plan for future infectious disease outbreaks.

Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice.

BACKGROUND: The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS: We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS: From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS: This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

Characteristics and outcomes of patients with COVID-19 admitted to hospital and intensive care in the first phase of the pandemic in Canada: a national cohort study.

BACKGROUND: Clinical data on patients admitted to hospital with coronavirus disease 2019 (COVID-19) provide clinicians and public health officials with information to guide practice and policy. The aims of this study were to describe patients with COVID-19 admitted to hospital and intensive care, and to investigate predictors of outcome to characterize severe acute respiratory infection. METHODS: This observational cohort study used Canadian data from 32 selected hospitals included in a global multisite cohort between Jan. 24 and July 7, 2020. Adult and pediatric patients with a confirmed diagnosis of COVID-19 who received care in an intensive care unit (ICU) and a sampling of up to the first 60 patients receiving care on hospital wards were included. We performed descriptive analyses of characteristics, interventions and outcomes. The primary analyses examined in-hospital mortality, with secondary analyses of the length of hospital and ICU stay. RESULTS: Between January and July 2020, among 811 patients admitted to hospital with a diagnosis of COVID-19, the median age was 64 (interquartile range [IQR] 53-75) years, 495 (61.0%) were men, 46 (5.7%) were health care workers, 9 (1.1%) were pregnant, 26 (3.2%) were younger than 18 years and 9 (1.1%) were younger than 5 years. The median time from symptom onset to hospital admission was 7 (IQR 3-10) days. The most common symptoms on admission were fever, shortness of breath, cough and malaise. Diabetes, hypertension and cardiac, kidney and respiratory disease were the most common comorbidities. Among all patients, 328 received care in an ICU, admitted a median of 0 (IQR 0-1) days after hospital admission. Critically ill patients received treatment with invasive mechanical ventilation (88.8%), renal replacement therapy (14.9%) and extracorporeal membrane oxygenation (4.0%); 26.2% died. Among those receiving mechanical ventilation, 31.2% died. Age was an influential predictor of mortality (odds ratio per additional year of life 1.06, 95% confidence interval 1.03-1.09). INTERPRETATION: Patients admitted to hospital with COVID-19 commonly had fever, respiratory symptoms and comorbid conditions. Increasing age was associated with the development of critical illness and death; however, most critically ill patients in Canada, including those requiring mechanical ventilation, survived and were discharged from hospital.

Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review.

BACKGROUND: Prior to the COVID-19 pandemic, physicians experienced unprecedented levels of burnout. The uncertainty of the ongoing COVID-19 pandemic along with increased workload and difficult medical triage decisions may lead to a further decline in physician psychological health. METHODS: We searched Medline, EMBASE, and PsycINFO for primary research from database inception (Medline [1946], EMBASE [1974], PsycINFO [1806]) to November 17, 2020. Titles and abstracts were screened by one of three reviewers and full-text article screening and data abstraction were conducted independently, and in duplicate, by three reviewers. RESULTS: From 6223 unique citations, 480 articles were reviewed in full-text, with 193 studies (of 90,499 physicians) included in the final review. Studies reported on physician psychological symptoms and management during seven infectious disease outbreaks (severe acute respiratory syndrome [SARS], three strains of Influenza A virus [H1N1, H5N1, H7N9], Ebola, Middle East respiratory syndrome [MERS], and COVID-19) in 57 countries. Psychological symptoms of anxiety (14.3-92.3%), stress (11.9-93.7%), depression (17-80.5%), post-traumatic stress disorder (13.2-75.2%) and burnout (14.7-76%) were commonly reported among physicians, regardless of infectious disease outbreak or country. Younger, female (vs. male), single (vs. married), early career physicians, and those providing direct care to infected patients were associated with worse psychological symptoms. INTERPRETATION: Physicians should be aware that psychological symptoms of anxiety, depression, fear and distress are common, manifest differently and self-management strategies to improve psychological well-being exist. Health systems should implement short and long-term psychological supports for physicians caring for patients with COVID-19.