PHILADELPHIA — On an early summer morning in North Philadelphia, Marsha El sits on a bench outside Temple University Hospital, scrolling on her phone. Inside, doctors perform a heart procedure on her husband, Timothy. Barred from being by his side due to Covid-19 visitor restrictions, Marsha, a retired insurance company branch manager, anxiously waits for a phone call with any update on his condition.
“I’m just praying that when they take him upstairs, I’m able to go up here and visit him for a while,” she says.
Even as most businesses in the U.S. have been removing Covid mask mandates and social distancing policies, one major exception continues to be hospitals, which have been more cautious in lifting restrictions. At the start of the pandemic, in the face of a new virus and the many unknowns that came with it, hospitals rushed to implement rules to keep patients as well as hospital staff safe, including barring visitors from entering altogether. Now, with the nature of the pandemic changing in the U.S. and increasing vaccination rates among the general population, patients and many physicians say the more restrictive ongoing limits, like only allowing one visitor, are no longer justified and may actually be harming patients’ mental health and leading to worse outcomes.
“It’s understandable that when fear strikes, like when a new contagious disease comes along, we’re going to be very guarded about who can be in the hospital,” said Kevin Biese, an emergency medicine physician and geriatrician at the University of North Carolina at Chapel Hill. But with the current state of the pandemic, he believes that “if [visitors] have no identified risk, they should be allowed to go on in and see their loved ones.”
Timothy and Marsha El have acutely felt the drawbacks of the restrictions since their first visit to Temple University Hospital more than a month ago. In the beginning of June, Timothy had an eight-hour heart procedure, after which hospital policies at the time kept Marsha from seeing him at all during his four-day stay. Once Timothy was stabilized and taken back to his room, neither Marsha nor her husband could sleep. Worried about how each other was doing, they talked on the phone until 11 p.m., and Marsha’s apprehension only worsened when he was moved to the ICU with complications.
“If I could have been there, it could have been a comfort to him and to myself,” she said. “When you don’t see [the procedure] firsthand, you start wondering, ‘Is he breathing? Is he on a lot of machines?’ I asked myself a thousand questions.”
Temple University Hospital did not respond to multiple email requests and calls for comment.
During the height of the pandemic in the U.S. last year, 93% of hospitals had implemented Covid-related visitor policies, according to an analysis of about 350 hospital websites conducted between June and September 2020. Many prohibited all visitors except those coming to see children, patients with disabilities, or patients at the end of life.
Hospitals now generally allow one or two visitors per patient, as long as they go through a screening process that asks about symptoms or exposure to Covid-19. But they remain cautious about returning to their pre-pandemic policies. “It was a very fine line to try to meet the priorities of [a patient’s well-being], but at the same time we needed to make sure that the safety of the family was maintained,” said Sam Torbati, emergency physician and medical director of the emergency department at Cedars-Sinai Medical Center in Los Angeles who was involved in the hospital’s Covid policy decisions. Currently, Cedars Sinai allows two healthy visitors in most inpatient areas and one visitor in the emergency room, which was the policy before the pandemic.
Even with widespread vaccination, visitor limits are still in place. Hospital officials said that their mission is to protect patients who are ill, meaning they need to be more careful than other businesses, such as restaurants. “It’s important to remember that we are a health care organization and our obligation is to keep patients at the center of all of the decisions that we make,” said Aliza Narva, director of ethics at the Hospital of the University of Pennsylvania. “We’re not looking to fill tables, so the values that drive our mission are very different.”
Lori Handy, medical director of infection prevention and control at Children’s Hospital of Philadelphia, also pointed out that there is still ongoing community transmission of SARS-CoV-2 and especially of the more infectious Delta variant. This puts patients, particularly unvaccinated children, at risk. And with cases increasing in many parts of the country, the pandemic continues to be unpredictable, she added. As long as there are unvaccinated visitors, they present a risk to patients.
One way to get around this would be to ask visitors for proof of vaccination. An increasing number of hospitals are requiring proof of vaccination from health care workers, and hospitals may soon start asking proof from visitors as well. But that can get into tricky legal territory, said Torbati. In April, for example, Houston Methodist Hospital became the first hospital system to require all their employees to be vaccinated, which eventually led to the firing or suspension of around 150 employees who refused to get the vaccine. Nearly 120 of those employees sued the hospital system over its vaccine requirements, citing concerns that the vaccine was not yet fully approved by the Food and Drug Administration, but the lawsuit was eventually dismissed.
Torbati said that Cedars-Sinai currently does not require proof of vaccination from its visitors. Other facilities like Temple University Hospital say on their website that visitors should be vaccinated and that they may require proof.
Even with concerns over ongoing viral spread, some doctors who witnessed the negative impact of policies barring or limiting visitors altogether said hospitals need to consider the trade-offs and emphasize that family caregivers are more than simply visitors. It’s a point also highlighted in the Centers for Disease Control and Prevention’s guidelines, which state that “visitation should continue to be prioritized for those visitors important for the patient’s physical or emotional well-being and care.”
Limiting caregivers’ access to patients may mean doctors miss out on critical information about a patient’s medical history, especially when a patient is confused or cognitively impaired, said Maura Kennedy, an emergency physician at Massachusetts General Hospital in Boston.
Beyond helping doctors make treatment decisions in the short term, family caregivers can also affect patients’ health and their hospital experience in the long term. One review that examined 15 studies on caregiving outcomes published between 1990 and 2016 found that including caregivers in the hospital discharge planning process was associated with 25% fewer readmissions 90 days after patients went home. A separate study of patients who had surgery found that, compared to patients who were allowed visitors, those who were isolated reported feeling less satisfied with the care they received.
And because caregivers can advocate for patients’ treatment choices or even food preferences, it was not surprising that patients in that study were also less likely to report timely access to medications and less likely to agree that their preferences were adequately considered during discharge.
Marsha El — who has been married to her husband for almost 40 years and, as a kidney transplant recipient, knows what it’s like being a patient — is one such advocate. During Timothy’s stay in the hospital, he relied on her to organize his discharge papers and interact with doctors. “Sometimes when you’re sick, you don’t feel like asking questions,” she said.
The absence of caregivers at a patient’s bedside can also negatively impact their mental health. Research shows that social isolation can cause psychological distress and worsen delirium, especially in older patients. Covid-19 highlighted this, leading to higher levels of stress and incidence of anxiety and depression in older adults who were alone.
Kennedy saw this firsthand during one shift in the emergency department. A cognitively impaired patient experiencing an asthma exacerbation became increasingly anxious and fearful, and her blood pressure soared. Eventually, the staff got a family member to calm her down over the phone. “Had a caregiver been sitting by her side, how would that entire episode have changed?” Kennedy wondered.
Visitor restrictions could unfairly impact the most vulnerable populations, particularly people of color whom Kennedy said may have a harder time asking for exceptions to visitor policies. They might have language barriers or less experience with the health care system — and not feel comfortable advocating for themselves. And for patients who don’t speak English, family members often serve as interpreters in medical settings.
Experts said that, looking back, there is a lot to be learned about the impact of visitors and how they help patients to inform future practices during emergencies. Even at the height of the pandemic, some physicians such as UNC’s Biese said a complete ban of visitors went too far and remained in place “even as they stopped making sense.” In some cases, he added, “the downsides of having [restrictions] in place were much greater than the upsides of having them.”
Biese said that hospitals need to distinguish caregivers from visitors and be proactive about deciding on visitor policies rather than having to make decisions on the fly. “[Frontline workers] were not the right people to be trying to make the 30,000-foot decisions” when Covid-19 cases were skyrocketing and their main priority was attending to sick patients, he said.
These decisions should involve physician experts at the center but they should be counterbalanced with voices from patients, their families, and advocacy groups to develop patient-centered strategies and consider the humane side of patient care, experts said.
Finally, hospitals need to be clear in their communication about visitor policies. In their review of 350 hospital websites, Kennedy and colleagues found that only 12% had the visitor policy information in a language other than English. Another review found that Michigan hospital websites did not provide contact information to request an exception to the visitor policies, making it hard for patients and their families to get necessary information.
Marsha El experienced this uncertainty around policies herself. As she waited outside the hospital for her husband, she hadn’t been told whether she would be able to stay with him or even if she would be able to see him when he was moved to a room. She worried another long night of phone calls with her husband and his doctors awaited.
“It’s very, very hard,” she said. “I understand what the hospital has to do to protect patients, but I will just be so happy when all of this is over.”
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