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Flexible Versus Restrictive Visiting Policies in ICUs

A Systematic Review and Meta-Analysis*

Nassar Junior, Antonio Paulo, PhD1; Besen, Bruno Adler Maccagnan Pinheiro, MD2,3; Robinson, Caroline Cabral, PhD4; Falavigna, Maicon, PhD5; Teixeira, Cassiano, PhD6; Rosa, Regis Goulart, PhD6

doi: 10.1097/CCM.0000000000003155
Review Articles

Objectives: To synthesize data on outcomes related to patients, family members, and ICU professionals by comparing flexible versus restrictive visiting policies in ICUs.

Data Sources: Medline, Scopus, and Web of Science.

Study Selection: Observational and randomized studies comparing flexible versus restrictive visiting policies in the ICU and evaluating at least one patient-, family member–, or ICU staff–related outcome.

Data Extraction: Duplicate independent review and data abstraction.

Data Synthesis: Of 16 studies identified for inclusion, seven were meta-analyzed. Most studies were rated as having a moderate risk of bias. Among patients, flexible visiting policies were associated with reduced frequency of delirium (odds ratio, 0.39; 95% CI, 0.22–0.69; I2 = 0%) and lower severity of anxiety symptoms (mean difference, –2.20; 95% CI, –3.80 to –0.61; I2 = 71%). Flexible visiting policies were not associated with increased risk of ICU mortality (odds ratio, 0.71; 95% CI, 0.38–1.36; I2 = 86%), ICU-acquired infections (odds ratio, 0.98; 95% CI, 0.68–1.42; I2 = 11%), or longer ICU stay (mean difference, –0.26 d; 95% CI, –0.57 to 0.05; I2 = 54%). Among family members, flexible visiting policies were associated with greater satisfaction. Among ICU professionals, flexible visiting policies were associated with higher burnout levels.

Conclusions: Flexible ICU visiting hours have the potential to reduce delirium and anxiety symptoms among patients and to improve family members’ satisfaction. However, they may be associated with an increased risk of burnout among ICU professionals. These conclusions are based on few studies, with small samples and moderate risk of bias.

1Department of Critical Care, A.C. Camargo Cancer Center, São Paulo, Brazil.

2Division of Emergency Medicine, School of Medicine, Universidade de São Paulo (USP), São Paulo, Brazil.

3Intensive Care Unit, Hospital da Luz, São Paulo, Brazil.

4Institute for Education and Research, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil.

5Institute for Education and Research, HMV, Porto Alegre, Brazil.

6Intensive Care Unit, HMV, Porto Alegre, Brazil.

*See also p. 1203.

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Supported, in part, by the Brazilian Ministry of Health through the Program of Institutional Development of the Brazilian Unified Health System (PROADI-SUS).

Drs. Robinson’s and Falavigna’s institutions received funding from the Brazilian Ministry of Health. Dr. Falavigna disclosed that he is an associate of a consulting and training company in Health Economics field called “HTAnalyze (,” which provides services for both the public and private sectors. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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