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Original Article
Neurology The effects of restricted visitation on delirium incidence in the intensive care units of a tertiary hospital in South Korea
Acute and Critical Care 2025;40(3):452-461.
DOI: https://doi.org/10.4266/acc.000500
Published online: August 21, 2025

1Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

2Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea

3Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul,Korea

Corresponding author: Hannah Lee Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-3538 Fax: +82-2-747-5639, E-mail: crisp0301@snu.ac.kr
• Received: February 3, 2025   • Revised: May 1, 2025   • Accepted: May 7, 2025

© 2025 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Background
    Delirium is a common but serious complication in critically ill patients. Family visitation has been shown to reduce delirium; however, during the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) restricted regular visitation to prevent the spread of infection. This study aimed to evaluate the association between visitation policies and incidence of delirium in the ICUs.
  • Methods
    This was a retrospective before-and-after study conducted in medical and surgical ICUs at a tertiary hospital. Adult patients admitted to an ICU during one of two periods were included: before the COVID-19 pandemic (June 2017 to May 2019) with regular visitation and during the pandemic (June 2020 to May 2022) with prohibited visitation. Delirium was assessed using the Confusion Assessment Method for the ICU. The primary outcome was association between delirium incidence and visitation policy.
  • Results
    Totals of 1,566 patients from the pre-COVID-19 period and 1,404 patients from the COVID-19 period were analyzed. The incidence of delirium was higher during the COVID-19 period (48.1% vs. 38.4%, P<0.001). After adjusting for relevant variables, the restricted visitation policy during COVID-19 remained a risk factor for delirium (odds ratio, 1.37; 95% CI, 1.13–1.65; P=0.001).
  • Conclusions
    Complete restriction of ICU visitations during the COVID-19 pandemic was associated with a significant increase in delirium incidence. These findings suggest the importance of visitation policies on patient outcomes and suggest the need for alternative strategies, such as video visitation, to mitigate the adverse effects of visitation restrictions during pandemics.
  • Key Words: caregivers; delirium; intensive care unit
Delirium is a type of sudden and reversible brain dysfunction characterized by decreased attention, impaired memory, reduced awareness of the surrounding environment, and changes in consciousness. The incidence of delirium in critically ill patients in Korea varies from 20% to 70%, with higher rates reported in surgical intensive care units (ICUs) [1]. Delirium not only significantly prolongs the ICU and hospital lengths of stay [2-4], but also increases the risk of long-term cognitive impairment, even after recovery [5,6]. Additionally, delirium has a high mortality rate, with hospital mortality rates of those with delirium more than twice as high as those of patients without delirium, with one-year mortality rates reaching 35%–40% [7].
The role of patient families in the ICU extends beyond basic caregiving and is a significant aspect of ICU care. This has been particularly emphasized since the introduction of the ICU Liberation Bundle, which aims to improve care culture and patient outcomes [8]. Family involvement includes physical and emotional support and participation in decision-making processes [8-10]. By reducing anxiety, depression, and feelings of isolation and providing emotional stability, family visitation can significantly contribute to patient treatment and recovery in the ICU setting, including reduced mortality and increased delirium-free days [11,12].
A retrospective Canadian study of almost 25,000 ICU patients found that the association between delirium and family visitation varied depending on the type of family visitation (in-person or telephone), the type of ICU admission, and the patient’s Glasgow Coma Scale (GCS) score [13]. In patients with intact mentality (GCS 15) admitted to the ICU after elective surgery, family visitation showed a significant correlation with decreased delirium [13]. A more recent meta-analysis suggested that an unrestricted visiting policy may significantly reduce the incidence of delirium in ICU patients compared with a restricted visiting policy [14]. However, following the rapid spread of coronavirus disease 2019 (COVID-19) during the pandemic, almost all hospitals implemented policies restricting visitation to prevent the transmission of COVID-19 [15,16]. Restriction or complete prohibition of family visitations in acute care settings during the COVID-19 pandemic impacted the incidence of delirium according to some studies [15,17], whereas others reported that visitation policies had no significant effect on the incidence of delirium in the ICU [18,19].
Therefore, we aimed to investigate the association between delirium and visitation policy in the ICU by comparing the incidence of delirium during the period when regular visitation was prohibited due to COVID-19 with the period before the pandemic.
This study was a retrospective before-and-after study, which was approved by the Institutional Review Board of Seoul National University Hospital, Seoul, South Korea, on March 20, 2023 (No. H-2303-072-1411). The requirement for informed consent was waived by the review board due to the retrospective nature of the study.
Study Population
Electronic medical records of all adult patients (age >18 years) admitted to the medical ICU or surgical ICU of Seoul National University Hospital were reviewed. In our institution, surgical patients are admitted to different types of ICU according to the surgical department, and these ICUs are managed by different intensivist teams. In this study, all surgical patients were included except for those who underwent cardiothoracic surgery or neurosurgery. Patients who underwent cardiothoracic surgery and neurosurgery were excluded due to their higher risk of delirium influenced by surgery-specific factors, such as prolonged operation time, inflammation due to cardiopulmonary bypass, or direct brain injury [20-22]. Data from two study periods were analyzed: before the COVID-19 pandemic and during the COVID-19 pandemic. The period before COVID-19 was the interval from June 2017 to May 2019, while the COVID-19 period spanned June 2020 to May 2022. While regular visitation was allowed twice a day for 30 minutes each before the COVID-19 period, visitation was prohibited during the COVID-19 period.
When patients were admitted to the eligible ICUs multiple times, only the initial admission was included in the analyses. Patients discharged within 24 hours of admission were also excluded because we considered this duration of stay too short to explore the effect of visitation policy. Patients with cognitive dysfunction or delirium at ICU admission were also excluded. Patients with active COVID-19 were not included as our institution had separate ICUs for patients with active COVID-19 infection.
Data Collection
Baseline characteristics including age, sex, and comorbidities at admission were included. Disease severity was assessed at ICU admission using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. GCS score was collected as a measure of baseline neurological status; altered mental status recorded using this score could be due to critical illness, sedation, or metabolic encephalopathy. Use and type of sedative agents including dexmedetomidine, propofol, and midazolam during the ICU stay were collected. Application of mechanical ventilation or continuous renal replacement therapy during the ICU stay, which are well-known risk factors for delirium, were also collected. Duration of ICU and hospital stays as well as mortality were also assessed.
To determine the presence of delirium, we evaluated all records of the Confusion Assessment Method for the ICU (CAM-ICU). In our institution, all patients are assessed for delirium at least once daily during their ICU stay by an assigned nurse who has received formal training in implementation of the CAM-ICU. When patients were “un-assessable” using the CAM-ICU, we additionally evaluated the Richmond Agitation-Sedation Scale (RASS). After evaluation for the presence of delirium, patients who were unconscious or deeply sedated with a RASS of –5 or –4 during their entire ICU stay were excluded from the analyses. Delirium was defined as positive CAM-ICU assessment records or an “un-assessable” CAM-ICU with a RASS of –3 to +4. Not only the presence of delirium during the ICU stay, but also the duration of delirium was evaluated.
Outcome Variables
The primary outcome was the association between delirium incidence and visitation policy before and during the COVID-19 pandemic. Secondary outcomes were risk factors for delirium in the ICU, and the ratio and duration of delirium in patients with delirium before and during the COVID-19 period. Subgroup analyses by age, use of a sedative agent, mechanical ventilation, type of ICU, length of ICU stay, initial GCS score, postoperative admission, and APACHE II score at ICU admission were also included in the analyses to investigate the potential effects of visitation policy on delirium.
Statistical Analysis
Continuous variables are expressed as medians [interquartile ranges], while categorical variables are expressed as numbers (%). Mann-Whitney U-test or chi-square test was used to compare variables as appropriate. To evaluate the association between delirium and visitation policy and to explore risk factors for delirium, univariate and multivariate generalized linear models were used. Variables with P<0.1 in the univariate analysis and those considered clinically relevant were included in multivariate analyses. Subgroup analysis was conducted to assess the effects of visitation policy on delirium incidence across subgroups and to identify those particularly vulnerable to visitation restrictions. A univariate analysis was performed for each subgroup, and results were visualized using a forest plot. Subgroups were defined based on age, use of sedative agents, mechanical ventilation, type of ICU, length of ICU stay, GCS and APACHE II scores at admission, and postoperative admission status. All statistical analyses were performed using R 4.1.1 (The R Foundation for Statistical Computing). A P value less than 0.05 was considered statistically significant.
Totals of 1,566 and 1,404 patients were included in the analysis for the pre-COVID-19 period and COVID-19 period, respectively (Figure 1). Baseline characteristics according to the study periods are shown in Table 1. Patients in the COVID-19 group had a significantly lower initial GCS, higher APACHE II score at admission, received more frequent concomitant treatment, as well as more frequent sedative agents than those patients admitted pre-COVID-19 (Table 1). Delirium occurred in 602 (38.4%) of patients in the pre-COVID-19 group and 675 (48.1%) in the COVID-19 group (P<0.001). CAM-ICU was more frequently assessed during the COVID-19 period. For patients with delirium, the incidence of a positive CAM-ICU finding was twice as high as in the COVID-19 period, whereas there was no significant difference in the duration of delirium between the two groups (Supplementary Material 1).
Multivariate analysis showed that visitation policy, represented by the admission period, was significantly associated with an increased risk of delirium in the ICU, even after adjusting for other relevant factors (adjusted odds ratio [OR], 1.37; 95% CI, 1.13–1.65; P=0.001) (Table 2). Older age, admission to the medical ICU, ICU admission for a reason other than elective postoperative admission, cerebrovascular disease, mechanical ventilation or continuous renal replacement therapy during ICU stay, lower GCS score, and higher APACHE II score at admission were identified as risk factors for delirium in the ICU (Table 2). Benzodiazepines were associated with an increased risk of delirium, while non-benzodiazepine sedatives were inversely associated with delirium.
In subgroup analysis, the effect of visitation policy on delirium varied depending on the subgroup. When regular visitations were allowed, the risk of delirium was significantly lower in cases when patients received mechanical ventilation, were admitted to the medical ICU, had longer ICU stays, presented with a lower GCS score and higher APACHE II score at admission, or were admitted to the ICU through routes other than surgical admission compared to when visitation was prohibited (Figure 2).
In this study, ICU admission during the COVID-19 period was significantly associated with increased risk of delirium in the ICU. The restricted family visitation policy implemented during the COVID-19 period appeared to contribute to the increased risk of delirium during the COVID-19 period. Although several studies conducted before the COVID-19 period on the impact of family visitation on delirium have reported varying findings [13,23,24], research has consistently indicated that liberal ICU visitation policies do not increase infection risk, burden medical staff, or exacerbate patient and family anxiety and depression, supporting the potential benefits of liberal visitation [23,24]. However, the COVID-19 pandemic led to widespread visitation restrictions in healthcare settings, including ICUs and nursing homes, to prevent infection spread [15]. Subsequent studies assessing the impact of these policies on delirium reported varying findings, similar to the studies conducted before the COVID-19 period. One study of about 6,000 acute cerebrovascular disease patients found that limited (1 hr/day) or completely prohibited visitation was significantly associated with increased delirium risk (adjusted OR, 1.36) [25]. In contrast, a study of 200 critically ill patients found no significant association between visitation restriction and delirium [18]. Additionally, randomized controlled trials conducted during the pandemic offered mixed findings; one reported that unrestricted visitation reduced delirium incidence significantly to one-third of the level observed for restricted visitation (17.1% vs. 5.7%) though the actual visitation times were similar (24.7 minutes vs. 23.9 minutes) [26]. Regarding the effect of virtual visitation on the reduction of delirium, prospective studies with small sample sizes have shown mixed results [27,28].
We suggest that the mixed results are primarily due to the varying definitions of restrictive, liberal or extended visitation across studies. The time definition of restrictive visitation varied widely, ranging from complete prohibition to less than 4.5 hours per day [18,23-26]. Furthermore, the time frame classified as restrictive visitation in one study would be considered liberal visitation in other studies, illustrating the inconsistent definitions of visitation time among studies [18,23,24]. The definition of delirium and the reported incidence also varied significantly between studies, with rates ranging from 5% to over 60%. We speculate that the significant associations between visitation policies during the pre- and COVID-19 periods and delirium were attributable to several factors. Sedative agent use during the COVID-19 period was higher than before the pandemic, and use of the CAM-ICU to diagnose delirium in this study appears to be more sensitive at detecting hypoactive delirium than does the Intensive Care Delirium Screening Checklist [29]. The relatively high incidence of delirium and the larger patient sample included in the present study facilitated statistical significance.
Regarding visitation times during the pre-COVID-19 period of this study, visitation was conducted twice daily for 30 minutes each, totaling 1 hour, which is much shorter than that reported in previous studies. However, complete prohibition of visitation during the COVID-19 period was a significant risk factor for delirium compared to the regular visitations conducted during the pre-COVID-19 period. This suggests that even short, regular family visits may reduce the risk of delirium. Notably, as previous studies have shown unclear effect of telephone or video visits on reducing the risk of delirium compared to no visitation, the physical presence of family, even for short durations, appears to have played a crucial role in reducing the risk of delirium during the pandemic [13,27,28]. However, some studies have demonstrated the effectiveness of virtual visitations in reducing patient anxiety and depression while increasing family satisfaction; virtual visitation could be a cost-effective alternative to mitigate patient and family distress while potentially contributing to the prevention of delirium, particularly during the early stages of a pandemic when in-person visitations are generally prohibited [28,30].
By extensively evaluating and adjusting various factors known to increase the risk of delirium, this study aimed to assess the effect of visitation policy on delirium incidence in critically ill patients. To minimize the confounding effects of pre-ICU factors, patients with pre-existing cognitive dysfunction or delirium before ICU admission were excluded. In addition, COVID-19 infection itself has been shown to be related to cognitive dysfunction [31,32]. At our facility, however, patients with active COVID-19 infection were admitted to separate ICUs during the pandemic and were excluded from our analyses. There were, however, differences in ICU care strategies between the two periods that could have affected delirium incidence. Early mobilization was more actively encouraged during the COVID-19 period as part of a quality improvement campaign, although direct comparison of its frequency was limited due to the retrospective design of this study. Sedation protocols targeting light sedation were consistently applied in the two periods, with deep sedation applied for cases such as severe acute respiratory distress syndrome. Additionally, the ICU environment transitioned from a semi-open system before the pandemic to a closed system during the COVID-19 pandemic, potentially reducing exposure to environmental factors such as noise and light [33]. We believe that this explains why complete restriction of visitation was significantly associated with an increased risk of delirium, even after adjusting for variables such as mechanical ventilation, use of benzodiazepine sedatives, and disease severity. Furthermore, because previous studies have suggested that certain patient populations could benefit from the visitation policy, we assessed the effects of visitation policy on the risk of delirium in different patient cohorts by including both medical and surgical patients and patients admitted for either elective or emergency surgery.
During the COVID-19 period, as shown in Table 1, the use of mechanical ventilation and sedative agents increased, and APACHE II scores were higher at admission, reflecting the increased disease severity. We suggest that these changes were related to institutional policies during the period, where only high-risk patient admissions were allowed to prevent the spread of infection. This exacerbated the concentration of high-risk patients at our institution from other facilities lacking ICUs during the period. Additionally, the establishment of separate ICUs for COVID-19 patients necessitated a partial reduction in the operations of the pre-existing ICUs, leading to prioritization of admissions for patients with higher disease severity, constrained by the limited availability of resources. However, even after adjusting for known risk factors reflecting disease severity such as the use of mechanical ventilation, administration of benzodiazepine sedatives, and high disease severity or low GCS scores, restricted visitation during the COVID-19 period was a significant risk factor for delirium.
The significantly lower prevalence of chronic kidney disease and cerebrovascular disease in the COVID-19 group compared to the pre-COVID-19 group could have resulted from referral of patients with chronic but relatively stable comorbidities, such as chronic kidney disease and history of cerebrovascular disease, for management outside the ICU or to other institutions during the pandemic. However, given the retrospective nature of our study, these differences could also represent random variations in patient characteristics between the two time periods rather than systematic changes in admission policies. Although the exact reason for this difference is uncertain, both chronic kidney disease and history of cerebrovascular disease were included as covariates in the multivariable analysis (Table 2) to adjust for their potential impact on delirium. Even after adjusting for these and other indicators of disease severity—such as mechanical ventilation, sedative agent use, GCS, and APACHE II score—the restricted visitation policy during the COVID-19 period remained a significant risk factor for delirium, suggesting that our primary finding is robust despite these baseline differences in comorbidities.
Subgroup analyses revealed that family visitation may be beneficial in preventing delirium among medical ICU patients or those not undergoing surgery compared to surgical ICU or post-surgical admission patients. Moreover, family visitation may also be advantageous for patients with ICU stays exceeding 48 hours, those with higher APACHE II scores or lower GCS scores at admission, as well as those requiring mechanical ventilation. The results of our subgroup analyses differed slightly from those reported in previous studies, which reported family visitation as a modifiable risk factor for delirium in patients with a GCS score of 15 [13], those undergoing elective surgery [13,24], or those not requiring mechanical ventilation [24]. However, in the subgroup analyses in this study, we calculated only crude odds ratios and did not adjust for other variables; thus, caution should be exercised when interpreting these results.
This study had several limitations. First, as a retrospective cohort study, there were significant differences between the two groups in underlying diseases, organ support treatments such as renal replacement therapy or mechanical ventilation, and use of sedative agents during the ICU stay. Although we attempted to adjust for these differences using multivariate analysis, the adjustment may have been insufficient. Second, detection bias may have contributed to the increased incidence of delirium during the COVID-19 period. As shown in Supplementary Material 1, while CAM-ICU was performed an average of 1.1 times per day per patient before the COVID-19 period, this increased to 1.9 times during the COVID-19 period, a significant difference, likely due to increased use of sedative agents. Although the increased use of sedatives could have been a result of more numerous diagnoses of hyperactive delirium, this seems unlikely as sedative agents were only used prior to the onset of the pandemic for patients who developed delirium. Third, there is the potential that hypoactive delirium was under-detected given that CAM-ICU assessments were conducted less frequently than twice daily. However, considering that previous studies reported delirium incidences between 2% and 55% [18,24,26,27,32], the incidences of 38.4% and 48.1% in this study appear reasonable. Moreover, patients who were un-assessable using CAM-ICU during their entire ICU stay were excluded, and all patients in this study with an un-assessable CAM-ICU result had at least one positive CAM-ICU record, reducing the likelihood of under-detection. Last, this study indirectly assessed the association between visitation policies and delirium by comparing the periods before and during the COVID-19 pandemic, suggesting that factors beyond visitation policies, such as changes in admission and discharge protocols, clinical practices, and patient demographics during the COVID-19 period, contributed to the observed increase in delirium.
In conclusion, complete restriction of visitation in the ICUs during the COVID-19 period was a significant risk factor for increased delirium incidence. In this global era, characterized by frequent international travel and interactions, several respiratory infectious disease outbreaks have occurred, including COVID-19, 2003 Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1), and the 2014 Middle East Respiratory Syndrome outbreaks, and it is likely that similar events will occur in the future. Therefore, when developing visitation policies for critically ill patients during pandemics, it is crucial to consider the lessons from the COVID-19 period that the risks of infection transmission need to be balanced with the impacts of visitation restrictions on delirium and the mental health of both patients and their families. Additionally, the introduction of tailored solutions, such as video visitations for patients who may benefit from family presence, should be considered to mitigate the effects of visitation restrictions. However, given the limited evidence and mixed findings on the effectiveness of virtual visitations at preventing delirium, further studies are warranted to evaluate their potential role as an alternative strategy to in-person visitation during pandemic-related restrictions.
▪ Restricted visitation during the coronavirus disease 2019 (COVID-19) period was significantly associated with increased incidence of delirium in critically ill patients.
▪ The findings of this study highlight the need to balance prevention of infection spread with the potential negative impact of visitation restriction on patient outcomes.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: LL, HL. Data curation: LL, CK, MK. Formal analysis: LL, HYL, JL, SYO, HGR, HL. Methodology: LL, SYO, HGR, HL. Writing – original draft: LL, HL. Writing – review & editing: CK, MK, HYL, JL, SYO, HGR. All authors read and agreed to the published version of the manuscript.

Supplementary materials can be found via https://doi.org/10.4266/acc.000500.
Supplementary Table 1.
Incidence and assessment of delirium
acc-000500-Supplementary-Table-1.pdf
Figure 1.
Flowchart of patient selection. COVID-19: coronavirus disease 2019; ICU: intensive care unit; CAM-ICU: Confusion Assessment Method for the ICU; RASS: Richmond Agitation-Sedation Scale.
acc-000500f1.jpg
Figure 2.
Forest plot of results from subgroup analyses to assess the effects of visitation policy on delirium incidence. OR: odds ratio; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.
acc-000500f2.jpg
Table 1.
Baseline characteristics
Variable Pre-COVID-19 period (n=1,566) COVID-19 period (n=1,404) P-value
Age (yr) 66 (55–74) 65 (56–74) 0.201
Sex (female:male) 968 (61.8):598 (38.2) 901 (64.2):503 (35.8) 0.197
ICU type 1.000
 Medical 653 (41.7) 586 (41.7)
 Surgical 913 (58.3) 818 (58.3)
ICU admission type 0.224
 General ward 639 (40.1) 592 (42.2)
 Emergency room 189 (12.1) 175 (12.5)
 Elective surgery 517 (33.0) 475 (33.8)
 Emergency surgery 221 (14.1) 162 (11.5)
Comorbidity
 Hypertension 855 (54.6) 733 (52.2) 0.205
 Diabetes mellitus 602 (38.4) 517 (36.8) 0.384
 Chronic kidney disease 356 (22.7) 170 (12.1) <0.001
 Cerebrovascular disease 239 (15.3) 170 (12.1) 0.015
 Coronary artery disease 214 (13.7) 182 (13.0) 0.611
Initial GCS score 10 (3–14) 7 (3–13) <0.001
APACHE II score at admission 22 (15–29) 25 (18–32) <0.001
Concomitant treatment
 Mechanical ventilation 945 (60.3) 931 (66.3) 0.001
 Continuous renal replacement therapy 284 (18.1) 303 (21.6) 0.021
 Vasopressor 414 (26.4) 359 (25.6) 0.620
Sedative agents 401 (25.6) 470 (33.5) <0.001
 Benzodiazepines 281 (17.9) 132 (9.4) <0.001
 No benzodiazepines 312 (19.9) 414 (29.5) <0.001
Use of sedative agents
 Dexmedetomidine 356 (22.7) 296 (21.1) 0.298
 Propofol 115 (7.3) 264 (18.8) <0.001
 Midazolam 89 (5.7) 56 (4.0) 0.040

Values are presented as median (interquartile range) or number (%).

COVID-19: coronavirus disease 2019; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

Table 2.
Univariate and multivariate logistic regression analyses for risk factors of delirium
Variable Unadjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value
Age (yr) 1.02 (1.01–1.02) <0.001 1.02 (1.01–1.02) <0.001
Route of ICU admission
 Elective operation Reference Reference
 Emergency operation 1.93 (1.50–2.48) <0.001 1.90 (1.39–2.61) <0.001
 General ward 4.11 (3.42–4.94) <0.001 3.01 (2.17–4.18) <0.001
 Emergency room 2.78 (2.16–3.57) <0.001 2.49 (1.66–3.72) <0.001
Type of ICU
 Surgical Reference Reference
 Medical 4.06 (3.48–4.75) <0.001 1.44 (1.08–1.91) 0.013
Visitation policy
 Visitation group Reference Reference
 No-visitation group 1.48 (1.28–1.72) <0.001 1.37 (1.13–1.65) 0.001
Cerebrovascular disease 1.26 (1.02–1.55) 0.031 1.49 (1.13–1.97) 0.005
Concomitant treatment
 Mechanical ventilation 11.2 (9.15–13.7) <0.001 4.37 (3.28–5.83) <0.001
 Continuous renal replacement therapy 4.01 (3.31–4.88) <0.001 1.90 (1.47–2.46) <0.001
 Use of vasopressor 1.85 (1.57–2.18) <0.001 1.13 (0.91–1.40) 0.266
Sedative agents
 No sedation Reference Reference
 Benzodiazepines 11.3 (7.28–18.4) <0.001 2.13 (1.28–3.71) 0.005
 Non-benzodiazepine sedatives 3.50 (2.94–4.18) <0.001 0.70 (0.54–0.90) 0.006
Initial GCS 0.79 (0.77–0.80) <0.001 0.89 (0.56–0.91) <0.001
APACHE II score at admission 1.15 (1.13–1.16) <0.001 1.03 (1.01–1.05) <0.001

OR: odds ratio; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

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        The effects of restricted visitation on delirium incidence in the intensive care units of a tertiary hospital in South Korea
        Acute Crit Care. 2025;40(3):452-461.   Published online August 21, 2025
        DOI: https://doi.org/10.4266/acc.000500
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      The effects of restricted visitation on delirium incidence in the intensive care units of a tertiary hospital in South Korea
      Image Image
      Figure 1. Flowchart of patient selection. COVID-19: coronavirus disease 2019; ICU: intensive care unit; CAM-ICU: Confusion Assessment Method for the ICU; RASS: Richmond Agitation-Sedation Scale.
      Figure 2. Forest plot of results from subgroup analyses to assess the effects of visitation policy on delirium incidence. OR: odds ratio; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

      Figure 1.

      Figure 2.

      The effects of restricted visitation on delirium incidence in the intensive care units of a tertiary hospital in South Korea
      Variable Pre-COVID-19 period (n=1,566) COVID-19 period (n=1,404) P-value
      Age (yr) 66 (55–74) 65 (56–74) 0.201
      Sex (female:male) 968 (61.8):598 (38.2) 901 (64.2):503 (35.8) 0.197
      ICU type 1.000
       Medical 653 (41.7) 586 (41.7)
       Surgical 913 (58.3) 818 (58.3)
      ICU admission type 0.224
       General ward 639 (40.1) 592 (42.2)
       Emergency room 189 (12.1) 175 (12.5)
       Elective surgery 517 (33.0) 475 (33.8)
       Emergency surgery 221 (14.1) 162 (11.5)
      Comorbidity
       Hypertension 855 (54.6) 733 (52.2) 0.205
       Diabetes mellitus 602 (38.4) 517 (36.8) 0.384
       Chronic kidney disease 356 (22.7) 170 (12.1) <0.001
       Cerebrovascular disease 239 (15.3) 170 (12.1) 0.015
       Coronary artery disease 214 (13.7) 182 (13.0) 0.611
      Initial GCS score 10 (3–14) 7 (3–13) <0.001
      APACHE II score at admission 22 (15–29) 25 (18–32) <0.001
      Concomitant treatment
       Mechanical ventilation 945 (60.3) 931 (66.3) 0.001
       Continuous renal replacement therapy 284 (18.1) 303 (21.6) 0.021
       Vasopressor 414 (26.4) 359 (25.6) 0.620
      Sedative agents 401 (25.6) 470 (33.5) <0.001
       Benzodiazepines 281 (17.9) 132 (9.4) <0.001
       No benzodiazepines 312 (19.9) 414 (29.5) <0.001
      Use of sedative agents
       Dexmedetomidine 356 (22.7) 296 (21.1) 0.298
       Propofol 115 (7.3) 264 (18.8) <0.001
       Midazolam 89 (5.7) 56 (4.0) 0.040
      Variable Unadjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value
      Age (yr) 1.02 (1.01–1.02) <0.001 1.02 (1.01–1.02) <0.001
      Route of ICU admission
       Elective operation Reference Reference
       Emergency operation 1.93 (1.50–2.48) <0.001 1.90 (1.39–2.61) <0.001
       General ward 4.11 (3.42–4.94) <0.001 3.01 (2.17–4.18) <0.001
       Emergency room 2.78 (2.16–3.57) <0.001 2.49 (1.66–3.72) <0.001
      Type of ICU
       Surgical Reference Reference
       Medical 4.06 (3.48–4.75) <0.001 1.44 (1.08–1.91) 0.013
      Visitation policy
       Visitation group Reference Reference
       No-visitation group 1.48 (1.28–1.72) <0.001 1.37 (1.13–1.65) 0.001
      Cerebrovascular disease 1.26 (1.02–1.55) 0.031 1.49 (1.13–1.97) 0.005
      Concomitant treatment
       Mechanical ventilation 11.2 (9.15–13.7) <0.001 4.37 (3.28–5.83) <0.001
       Continuous renal replacement therapy 4.01 (3.31–4.88) <0.001 1.90 (1.47–2.46) <0.001
       Use of vasopressor 1.85 (1.57–2.18) <0.001 1.13 (0.91–1.40) 0.266
      Sedative agents
       No sedation Reference Reference
       Benzodiazepines 11.3 (7.28–18.4) <0.001 2.13 (1.28–3.71) 0.005
       Non-benzodiazepine sedatives 3.50 (2.94–4.18) <0.001 0.70 (0.54–0.90) 0.006
      Initial GCS 0.79 (0.77–0.80) <0.001 0.89 (0.56–0.91) <0.001
      APACHE II score at admission 1.15 (1.13–1.16) <0.001 1.03 (1.01–1.05) <0.001
      Table 1. Baseline characteristics

      Values are presented as median (interquartile range) or number (%).

      COVID-19: coronavirus disease 2019; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

      Table 2. Univariate and multivariate logistic regression analyses for risk factors of delirium

      OR: odds ratio; ICU: intensive care unit; GCS: Glasgow Coma Scale; APACHE: Acute Physiology and Chronic Health Evaluation.

      Table 1.

      Table 2.

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