Review: In the ICU, flexible visiting policies reduce the frequency of delirium and the severity of anxiety symptoms compared with restrictive policies.
Nassar Junior AP, Besen BAMP, Robinson CC, et al. Flexible Versus Restrictive Visiting Policies in ICUs: A Systematic Review and Meta-Analysis. Crit Care Med. 2018 Jul;46(7):1175-1180. doi: 10.1097/CCM.0000000000003155.

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; I = 0%) and lower severity of anxiety symptoms (mean difference, -2.20; 95% CI, -3.80 to -0.61; I = 71%). Flexible visiting policies were not associated with increased risk of ICU -mortality (odds ratio, 0.71; 95% CI, 0.38-1.36; I = 86%), ICU-acquired infections (odds ratio, 0.98; 95% CI, 0.68-1.42; I = 11%), or longer ICU stay (mean difference, -0.26 d; 95% CI, -0.57 to 0.05; I = 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.

Specialty Area Score
Hospital Doctor/Hospitalists
Internal Medicine
Intensivist/Critical Care
Comments from MORE raters


Flexible versus restrictive visiting policies may affect risk for delirium and mortality in ICU patients, and may affect risk for ICU staff burnout, as well. This meta-analysis found 1 big study showing reduced mortality with flexible visiting policies, 2 very small studies showing lower delirium risk with flexible visiting policies, and several small studies suggesting increased ICU nursing (not physician) burnout with flexible visiting policies. It is a stretch to call this group of trials with wildly differing methodologies a meta-analysis.

A refreshing evidence-based approach to the very common custom of isolating ICU patients from families. The reduction in delirium is clinically significant. Also, the observation that there was more "burnout" in staff in ICUs with liberal family visitation speaks volumes as to how we train and support (or not) health care personnel. Important publication in my opinion.

Hospital Doctor/Hospitalists

I like this article because it highlights how changes to the processes of care can potentially impact clinical outcomes. Patient-centered care is always the goal, but the side effects of this can sometimes mean physician burnout, as this article found. Physician burnout and wellness is a huge focus right now in the US, and it's great to see it discussed as an important counter measure to clinical outcome benefits. Study not methodologically perfect, of course, but it brings up very topical issues.

This meta-analysis included 7 studies with moderate risk of bias. Flexible visiting hours decreased the frequency of delirium and did not increase mortality or rate of infection. Based on this, I would be comfortable using the flexible visiting hours policy.

Intensivist/Critical Care

The literature base is modest as this topic has only recently become topical. Its a fair summary but a lot is not yet known.

Comments from JournalWise subscribers

No subscriber has commented on this article yet.