Visitor Restrictions During the COVID-19 Pandemic and Increased Falls With Harm at a Canadian Hospital: An Exploratory Study.

BACKGROUND: Falls with harms (FWH) in hospitalized patients increase costs and lengths of stay. The COVID-19 pandemic has resulted in more FWH. Additionally, the COVID-19 pandemic has resulted in increased patients in isolation with fewer visitors. Their relationship with falls has not been previously studied. METHODS: This is a retrospective, single-site, 12-month before pandemic-12-month after pandemic, observational study. Multiple logistic regression analysis was used to model FWH outcome and associations with isolation and visitor restrictions. RESULTS: There were 4369 isolation events and 385 FWH among 22,505 admissions during the study period. Unadjusted analysis demonstrated a FWH risk of 1.33% (95% CI 0.99, 1.67) in those who were placed in isolation compared to 1.80% (95% CI 1.60, 2.00) in those without an isolation event (χ2 = 4.73,P = 0.03). The FWH risk during the different visitor restriction periods was significantly higher compared to the prepandemic period (χ2 = 20.81, P < 0.001), ranging from 1.28% (95% CI 1.06, 2.50) in the prepandemic period to 2.03% (95% 1.66, 2.40) with no visitors permitted (phase A) in the pandemic period. After adjusting for potential confounders and selection bias, only phase A visitor restrictions were associated with an increased FWH risk of 0.75% (95% CI 0.32, 1.18) compared to no visitor restrictions. INTERPRETATION: Our results suggest a moderately strong association between hospitalized patient FWH risk and severe visitor restrictions. This association was muted in phases with even minor allowances for visitation. This represents the first report of the adverse effects of visitor restriction policies on patients' FWH risks.

What is already known on this topic ­ Patient accidents in hospitals account for 4% of all hospital-related harmful events. There are many risk factors that contribute to these accidents, but few interventions that reduce their risk. During the COVID-19 pandemic period, the number of patient accidents has increased. While the reasons for this association are unclear, they may be related to COVID-19-related interventions such as patient isolation and visitor restrictions. What this study adds ­ This exploratory study is the first to demonstrate that visitor restrictions may be associated with an increased risk of patient accidents. How this study might affect research, practice or policy ­ The potential harmful effects of visitor restrictions should be taken into consideration whenever these interventions are being implemented as part of a bundled strategy for prevention of infectious diseases transmission and protection. Patient accidents in hospitals resulting in harm requiring either treatment or prolonged hospital stay are of great interest to health care, policy makers and the general public.1 They account for 4% of all hospital-related harmful events and are included as an indicator in the new Hospital Harm Measure instituted across Canada as a patient safety quality measure of acute hospital care.2 Since the declaration of the COVID-19 pandemic in Canada on March 13, 2020, there were 0.26 patient trauma events per 100 hospitalizations reported in both 2020­2021 and 2021­2022, a 13% increase from 2019 to 2020.3 In a population-based observational study conducted among Ontario patients hospitalized in 2015­2016, patient accidents were estimated to increase the index hospitalization length of stay by 17.3 days (95% CI 17.0, 17.6) and costs by $47824 (95% CI 47,383, 48,266) (CDN).4 There have been over 400 clinical factors identified as being associated with an increased risk of falls in hospitalized patients.5 Risk mitigation strategies have been implemented in many hospitals to prevent anticipatory falls defined as potentially preventable through early identification of patients that exhibit clinical signs associated with increased risk of falls. These anticipatory falls make up approximately 30% of all falls, with the remainder being nonpreventable and due to unanticipated or accidental falls.5 In a recent systematic review and meta-analysis of the effects of falls prevention interventions on fall outcomes for adults in hospital settings, patient and staff education was the only intervention that reduced the fall rate risk ratio (RR) 0.70 (95% CI 0.51, 0.96) and the fall odds ratio 0.62 (95% 0.47, 0.83) with a high level of certainty, while early stratification using fall risk screening tools, rehabilitation and exercise therapies, assistive and alarm devices, system changes such as hourly rounding, and environmental modifications demonstrated no benefit.6 One particular program, the Fall TIPS program,7,8 which leverages visitor engagement to ensure that patients are compliant with fall prevention recommendations printed on a laminated poster or visual aid, demonstrated a 34% reduction in falls with harm, suggesting a potential mechanism through which patient visitation might reduce patient harm. On March 11, 2020, the World Health Organization (WHO) declared a COVID-19 pandemic.9 In an attempt to prevent the introduction and spread of COVID-19 in Canadian hospitals and prevent transmission from patients and healthcare providers to visitors, regional and local public health authorities advised acute care hospitals to cancel elective clinic visits, treatments, and surgical procedures and implement visitor restrictions and enhanced COVID-19 screening and isolation protocols. These recommendations resulted in increased numbers of patients in contact/droplet isolation precautions and more severe patient visitor restrictions. Many of these recommendations were revised during the subsequent pandemic waves, as some were considered by many to be ineffective and potentially harmful.10­12 For example, some have argued that patient visitors are unlikely to be an important source of hospital-acquired COVID-19 infection.12 The authors concluded that severe patient visitor restrictions may have prevented few COVID-19 infections, while contributing to low staff morale and worse patient outcomes. In a retrospective before-after ecological study conducted at 32 hospitals within the Beryl Institute community in the United States from 2019 to 2020, the unadjusted in-hospital fall with hip fracture rates increased from 0.03 events (per 1000 hospital discharges) in 2019 in hospitals with no visitor restrictions, to 0.07 in hospitals with partial limited visitation in 2020, and to 0.14 in hospitals with absolute visitor restriction policies in 2020,13 possibly suggesting a signal for patient harm associated with different levels of visitor restrictions. As for increased numbers of hospitalized patients in isolation, a systematic review noted that isolation practices are associated with less patient-healthcare worker interaction, delays in care, and increased symptoms of depression and anxiety.14 The impact of either visitor restrictions or patient isolation on FWH risks has not been reported.10,11,14 This is an exploratory study to determine if there is an association between either isolation precautions or visitor restrictions and increased falls with harm risk in adult patients hospitalized in an acute care community hospital.

Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study.

BACKGROUND: The current approach to measuring hand hygiene (HH) relies on human auditors who capture <1% of HH opportunities and rapidly become recognized by staff, resulting in inflation in performance. Group electronic monitoring is a validated method of measuring HH adherence, but data demonstrating the clinical impact of this technology are lacking. METHODS: A stepped-wedge cluster randomized quality improvement study was performed on 26 inpatient medical and surgical units across 5 acute care hospitals in Ontario, Canada. The intervention involved daily HH reporting as measured by group electronic monitoring to guide unit-led improvement strategies. The primary outcome was monthly HH adherence (percentage) between baseline and intervention. Secondary outcomes included transmission of antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and other healthcare-associated infections. RESULTS: After adjusting for the correlation within inpatient units and hospitals, there was a significant overall improvement in HH adherence associated with the intervention (incidence rate ratio [IRR], 1.73 [95% confidence interval {CI}, 1.47-1.99]; P < .0001). Monthly HH adherence relative to the intervention increased from 29% (1 395 450/4 544 144) to 37% (598 035/1 536 643) within 1 month, followed by consecutive incremental increases up to 53% (804 108/1 515 537) by 10 months (P < .0001). There was a trend toward reduced healthcare-associated transmission of MRSA (IRR, 0.74 [95% CI, .53-1.04]; P = .08). CONCLUSIONS: The introduction of a system for group electronic monitoring led to rapid, significant improvements in HH performance within a 2-year period. This method offers significant advantages over direct observation for measurement and improvement of HH.

The use of a self-check-in kiosk for early patient identification and queuing in the emergency department.

OBJECTIVE: Delays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification. METHODS: We performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system. RESULTS: Median (interquartile range) time-to-first-identification was 1.4 minutes (1.0-2.08) for intervention patients and 9 minutes (5-18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8-14.5) faster for the intervention group. CONCLUSION: A self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.

OBJECTIF: Les délais d'attente inhérents au processus de triage des malades au service des urgences (SU) peuvent mettre en péril leur sécurité. L'étude visait donc à valider le principe selon lequel l'utilisation d'un guichet d'auto-inscription diminuerait le temps nécessaire pour signaler l'arrivée des malades ambulatoires au SU. A été comparé le processus d'utilisation d'un guichet d'auto-inscription d'un nouveau type pour signaler l'arrivée des malades au SU avec le processus habituel d'inscription des malades par le personnel infirmier. MÉTHODE: L'étude consistait en un essai prospectif, à répartition aléatoire et hebdomadaire, d'inscription, réalisé selon le processus expérimental ou le processus témoin, sur une période de 10 semaines. Durant les semaines d'expérimentation, les malades se dirigeaient vers le guichet d'auto-inscription à leur arrivée; un signal électronique informait le personnel infirmier affecté au triage de l'heure d'arrivée des malades et des motifs de consultation avant le triage lui-même. Durant les semaines témoins, les guichets étaient fermés et les malades étaient inscrits selon le processus habituel de triage effectué par le personnel infirmier. Le principal critère d'évaluation était le temps écoulé avant le signal d'arrivée, défini comme l'intervalle entre l'arrivée des malades au SU et leur inscription dans le système de l'hôpital. RÉSULTATS: Le temps médian (écart interquartile) écoulé avant le signal d'arrivée était de 1,4 minute (1,0­2,08) durant les semaines d'expérimentation contre 9 minutes (5 ­18) durant les semaines témoins. D'après les résultats de l'analyse de régression, le temps rajusté écoulé avant le signal d'arrivée était de 13,6 minutes (IC à 95% : 12,8­14,5) plus court dans le groupe d'expérimentation que dans le groupe témoin. CONCLUSION: L'utilisation d'un guichet d'auto-inscription a permis de réduire considérablement le temps écoulé avant le signal d'arrivée des malades ambulatoires au SU.

Characteristics of physicians and patients who join team-based primary care practices: evidence from Quebec's Family Medicine Groups.

PURPOSE: New models of delivering primary care are being implemented in various countries. In Quebec, Family Medicine Groups (FMGs) are a team-based approach to enhance access to, and coordination of, care. We examined whether physicians' and patients' characteristics predicted their participation in this new model of primary care. METHODS: Using provincial administrative data, we created a population cohort of Quebec's vulnerable patients. We collected data before the advent of FMGs on patients' demographic characteristics, chronic illnesses and health service use, and their physicians' demographics, and practice characteristics. Multivariate regression was used to identify key predictors of joining a FMG among both patients and physicians. RESULTS: Patients who eventually enrolled in a FMG were more likely to be female, reside outside of an urban region, have a lower SES status, have diabetes and congestive heart failure, visit the emergency department for ambulatory sensitive conditions and be hospitalized for any cause. They were also less likely to have hypertension, visit an ambulatory clinic and have a usual provider of care. Physicians who joined a FMG were less likely to be located in urban locations, had fewer years in medical practice, saw more patients in hospital, and had patients with lower morbidity. CONCLUSIONS: Physicians' practice characteristics and patients' health status and health care service use were important predictors of joining a FMG. To avoid basing policy decisions on tenuous evidence, policymakers and researchers should account for differential selection into team-based primary health care models.

Marginal structural models for skewed outcomes: identifying causal relationships in health care utilization.

Evaluating the impacts of clinical or policy interventions on health care utilization requires addressing methodological challenges for causal inference while also analyzing highly skewed data. We examine the impact of registering with a Family Medicine Group, an integrated primary care model in Quebec, on hospitalization and emergency department visits using propensity scores to adjust for baseline characteristics and marginal structural models to account for time-varying exposures. We also evaluate the performance of different marginal structural generalized linear models in the presence of highly skewed data and conduct a simulation study to determine the robustness of alternative generalized linear models to distributional model mis-specification. Although the simulations found that the zero-inflated Poisson likelihood performed the best overall, the negative binomial likelihood gave the best fit for both outcomes in the real dataset. Our results suggest that registration to a Family Medicine Group for all 3 years caused a small reduction in the number of emergency room visits and no significant change in the number of hospitalizations in the final year.

Innovative and diverse strategies toward primary health care reform: lessons learned from the Canadian experience.

INTRODUCTION: In the last decade, Canadian provincial and territorial health systems have taken diverse approaches to strengthening primary care delivery. Although the Canadian and US systems differ in significant ways, important commonalities include the organization of care delivery, core principles guiding primary care reform, and some degree of provincial/state autonomy. This suggests that Canadian experiences, which employed a variety of tools, strategies, and policies, may be informative for US efforts to improve primary care. INNOVATIONS: The range of primary care reform initiatives implemented across Canada target organizational infrastructure, provider payment, health care workforce, and quality and safety. Primary care teams and networks in which multiple physicians work in concert with other providers have become widespread in some provinces; they vary on a number of dimensions, including physician payment, incorporation of other providers, and formal enrolment of patients. Family medicine is attracting more recent medical school graduates, a trend likely affected by new physician payment models, increases in the number of primary care providers, and efforts to better integrate nonphysician providers into clinical practice. Efforts to integrate electronic medical records into practice and pursue quality improvement strategies are gaining ground in some provinces. CONCLUSIONS: Canadian primary care reform initiatives rely on voluntary participation, incremental change, and diverse models, encouraging engagement and collaboration from a range of stakeholders including patients, providers, and policymakers. Cross-country collaboration in evaluating and translating Canada's primary care reform efforts are likely to yield important lessons for the US experience.

Primary health care in Canada: systems in motion.

CONTEXT: During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged. METHODS: This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada. FINDINGS: Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support. CONCLUSIONS: Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert.