应对 COVID-19 大流行期间的无访客政策：住院患者的虚拟护理计划

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At the time of writing, the COVID-19 pandemic has provided challenges to health services globally for close to 2 years. These challenges have included the need for enhanced infection control procedures, markedly increased demand for services, rapid upskilling and redeployment of the workforce, support for staff physical and psychological welfare as they deliver services and deal with considerable loss of life, and in many settings, responsibility for vaccine rollout. Many services have faced significant changes to daily operations, and previously unproblematized and uncomplicated aspects of service delivery, such as the presence of visitors in hospitals has been affected. Many hospitals and other health services have had strict restrictions in place about visiting, as one strategy for keeping COVID-19 out of hospitals.

While the implementation of no-visitor policies has been necessary to protect the health of patients and the workforce in hospitals, such restrictions have also caused hardship to patients, families and staff. Many approaches to healthcare assume that family support (however defined) is available to patients, and that family members will be involved in care and decision-making. These approaches depend on authentic and reliable communication involving the patient, family members and health care personnel. Furthermore, visiting of friends and family can be a significant variable to the emotional well-being of patients and their loved ones and a great source of comfort to families experiencing the illness or incapacity of a family member. Thus, visitation restrictions in hospitals implemented during the COVID-19 pandemic has resulted in significant barriers to communication among clinicians, patients and families. No-visitor-policies not only have emotional impact on patients and their loved ones, but also have negative impact on patient and family-centred care initiatives due to suboptimal communication. The effects of no-visitor policies can be particularly difficult for patients and their loved ones where the patient may lack capacity, have language barriers, are critically ill or otherwise dependent on their carers. Family members can become very anxious, distressed and even distraught when unable to visit with loved ones while in hospital. Meanwhile staff who are already pressured and may also experience communication impairment due to the effects of personal protective equipment (PPE), are called on to provide additional emotional support to distressed patients and their loved ones.

The importance of visiting means that health services personnel have been challenged to provide alternative means of ensuring patients can have meaningful contact with loved ones, while maintaining the restrictions necessary to reduce the spread of infection. Virtual care initiatives have been implemented in many settings. These initiatives have the advantage of providing ways that friends and family can visually and verbally engage with their family member, and connect with the health care team. It can allow for patients to have their family members (virtually) present for the purposes of visiting, as well as family-centred care initiatives. It is especially helpful given that many people have been (and many still are) affected by travel restrictions, which has imposed additional difficulties for families dealing with the illness or incapacity of a loved one.

Virtual care is not a novel technology. Various forms of virtual care have been used in healthcare for several years (Webb et al., 2020). However, the pandemic has seen much more rapid and widespread implementation of virtual care and virtual visiting in hospitals to replace or supplement in-person visitation.

Available literature supports the implementation of virtual care. Licurse (2016) describes the use of virtual visits for outpatients with chronic diseases where 97% of patients reported satisfaction with the experience and 74% felt the virtual interaction in fact improved their relationship with the care provider. During the current pandemic, virtual care has been particularly useful in intensive care units, with National Health Services (NHS) hospitals in the United Kingdom (n = 117) reporting changes in ICU family visiting policy during the COVID-19 surge (Rose et al., 2021). The vast majority of these hospitals (97%) had adopted virtual family visiting, and the most common indications identified were to alert and orient patients, and to facilitate family interaction for patients at the end of life (Rose et al., 2021).

There are many benefits of virtual visiting, including reduced patient psychological distress, improved staff morale, reorientation of delirious patients with help of family, overcoming language barrier and enhancing patient-centred care (Rose et al., 2021). Use of virtual care can not only enhance the quality of life for patients and their loved ones, but also lead to additional benefits such as reducing anxiety and allowing non-vocal patients to communicate via computer keyboards (Nusdorfer, 2013). Furthermore, Angus and Connolly (2020) describes multiple uses of virtual care in healthcare system in the context of COVID-19 pandemic, such as monitoring patients with milder COVID-19 symptoms in their homes, being able to ensure effective contact and involvement of quarantined health workers and providing continuity of care for people with chronic illnesses remotely.

Virtual care is not only relevant in the emergent COVID-19 pandemic. Looking beyond the pandemic, virtual care initiatives have long-term potential to enhance and broaden delivery of future healthcare. Virtual visiting will continue to be beneficial for families who are unable to attend hospitals regularly (Cheney, 2020; Webb et al., 2020). Use of virtual clinics could allow patients who are at a distance or have other difficulties physically attending appointments to continue to receive optimal healthcare, have increased compliance and have reduced cost of travelling.

There are however some barriers to widespread adaptation of virtual care. This includes staff availability to facilitate video calls, provision of training for staff and concern for security and privacy (Rose et al., 2021). Furthermore, some healthcare providers may have difficulty implementing virtual care in their practice due to financial constraints, technological incompetence and difficulty with remote assessment with visual cues (Angus and Connolly, 2020). Some patients and family members may have difficulty with videoconferencing capability or may not have access to virtual devices (Rose et al., 2021). These barriers should be considered for effective implementation of virtual care in the future.

While further research is needed to ascertain the qualitative experiences of patients, their families and friends and health care staff, and to provide thorough and accurate cost-benefit analyses, we argue that virtual care initiatives can provide important and tangible benefits to patients and families as well as to health care providers, especially in the current context of no-visiting policies and other visiting restrictions. The effective utilization of virtual care during the COVID-19 pandemic provides an opportunity for change in the future of healthcare delivery.

全文翻译（仅供参考）

在撰写本文时，COVID-19 大流行已为全球卫生服务带来了近 2 年的挑战。这些挑战包括需要加强感染控制程序，对服务的需求显着增加，快速提升和重新部署劳动力，支持工作人员在提供服务和处理大量生命损失时的身心福利，以及在许多情况下，疫苗推广的责任。许多服务的日常运营都面临着重大变化，以前没有问题和简单的服务交付方面（例如医院的访客数量）受到了影响。许多医院和其他卫生服务机构对探视有严格的限制，这是将 COVID-19 排除在医院之外的一种策略。

虽然实施无访客政策对于保护患者和医院工作人员的健康是必要的，但这种限制也给患者、家属和工作人员带来了困难。许多医疗保健方法都假设患者可以获得家庭支持（无论如何定义），并且家庭成员将参与护理和决策。这些方法取决于涉及患者、家庭成员和卫生保健人员的真实可靠的沟通。此外，探望朋友和家人可能是影响患者及其亲人情绪健康的一个重要变量，并且是家庭成员患病或丧失工作能力的家庭的重要安慰来源。因此，在 COVID-19 大流行期间实施的医院探视限制导致临床医生、患者和家属之间的沟通出现重大障碍。无访客政策不仅对患者及其亲人产生情感影响，而且由于沟通不畅，还会对以患者和以家庭为中心的护理计划产生负面影响。对于患者及其亲人来说，无访客政策的影响可能特别困难，因为患者可能缺乏能力、有语言障碍、病危或以其他方式依赖他们的照顾者。当住院期间无法探望亲人时，家人会变得非常焦虑、痛苦甚至心烦意乱。

探访的重要性意味着卫生服务人员面临着提供替代方法的挑战，以确保患者能够与亲人进行有意义的接触，同时保持减少感染传播所需的限制。虚拟护理计划已在许多环境中实施。这些举措的优势在于提供了一种方式，让朋友和家人可以与家人进行视觉和口头交流，并与医疗保健团队建立联系。它可以允许患者让他们的家庭成员（虚拟地）在场，以进行探访以及以家庭为中心的护理计划。鉴于许多人已经（而且许多人仍然）受到旅行限制的影响，这尤其有用，

虚拟护理并不是一项新技术。多年来，各种形式的虚拟护理已在医疗保健中使用（Webb 等人，2020 年）。然而，在大流行中，虚拟护理和虚拟访问在医院中的实施更加迅速和广泛，以取代或补充亲自访问。

现有文献支持虚拟护理的实施。Licurse ( 2016 ) 描述了慢性病门诊患者使用虚拟就诊的情况，其中 97% 的患者表示对体验感到满意，74% 的患者认为虚拟互动实际上改善了他们与护理提供者的关系。在当前的大流行期间，虚拟护理在重症监护病房中特别有用，英国的国家卫生服务 (NHS) 医院（n  = 117）报告了 COVID-19 激增期间 ICU 家庭探视政策的变化（Rose 等人., 2021）。这些医院中的绝大多数 (97%) 都采用了虚拟家庭探访，确定的最常见的适应症是提醒和引导患者，并促进临终患者的家庭互动（Rose 等，2021）。

虚拟探视有很多好处，包括减少患者的心理压力、提高员工士气、在家人的帮助下重新定位精神错乱的患者、克服语言障碍和加强以患者为中心的护理（Rose 等，2021）。使用虚拟护理不仅可以提高患者及其亲人的生活质量，还可以带来额外的好处，例如减少焦虑和允许非语音患者通过计算机键盘进行交流（Nusdorfer，2013 年）。此外，安格斯和康诺利 ( 2020) 描述了在 COVID-19 大流行的背景下，虚拟护理在医疗保健系统中的多种用途，例如在家中监测 COVID-19 症状较轻的患者，能够确保被隔离的卫生工作者的有效接触和参与，并提供连续护理对于远程慢性病患者。

虚拟护理不仅与紧急的 COVID-19 大流行有关。超越大流行，虚拟护理计划具有增强和扩大未来医疗保健服务的长期潜力。虚拟访问将继续对无法定期去医院的家庭有益（切尼，2020 年；韦伯等人，2020 年）。使用虚拟诊所可以让距离较远或有其他身体障碍的患者继续接受最佳医疗保健，提高依从性并降低旅行成本。

然而，虚拟护理的广泛适应存在一些障碍。这包括员工的可用性以促进视频通话、为员工提供培训以及对安全和隐私的关注（Rose 等人，2021 年）。此外，由于财务限制、技术无能和视觉提示远程评估的困难，一些医疗保健提供者可能难以在他们的实践中实施虚拟护理（Angus 和 Connolly，2020 年）。一些患者和家庭成员可能无法使用视频会议功能，或者可能无法使用虚拟设备（Rose 等人，2021 年）。在未来有效实施虚拟护理时，应考虑这些障碍。

虽然需要进一步的研究来确定患者、他们的家人和朋友以及医疗保健人员的定性体验，并提供彻底和准确的成本效益分析，但我们认为虚拟护理计划可以为患者和家庭提供重要和切实的好处，因为以及医疗保健提供者，尤其是在当前禁止探视政策和其他探视限制的背景下。