Visitor Restrictions During the COVID-19 Pandemic and Increased Falls With Harm at a Canadian Hospital: An Exploratory Study
Authors: Shennan Stephanie , Coyle Natalie , Lockwood Brittany , DiDiodato Giulio 
Published: June 2024

Key messages
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 2020–2021 and 2021–2022, a 13% increase from 2019 to 2020.
3
In a population-based observational study conducted among Ontario patients hospitalized in 2015–2016, 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.
10–12
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.

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 (χ
2 = 4.73,P = 0.03). The FWH risk during the different visitor restriction periods was significantly higher compared to the prepandemic period (χ
2 = 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.