A significant change for patients and families during SARs-CoV-2 has been the restriction of visitors for hospitalized patients. We analyzed SARs-CoV-2 hospital visitation policies and found widespread variation in both development and content. This variation has the potential to engender inequity in access. We propose guidance for hospital visitation policies for this pandemic to protect, respect, and support patients, visitors, clinicians, and communities.
Keywords
INTRODUCTION
During the SARS-CoV-2 pandemic, policies and patient care rapidly transformed as U.S. hospitals endeavored to treat patients, protect public health, and steward resources.
1
,Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. Cases in the U.S.[cited 2020 Apr 20] Available at: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed October 19, 2020.
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One major change was visitor restriction within clinical environments.World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report 94. [cited 2020 Apr 23] Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200423-sitrep-94-covid-19.pdf?sfvrsn=b8304bf0_4. Accessed October 19, 2020.
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,4
The impact, content, underlying ethical principles, stakeholder involvement, and accessibility and transparency of SARS-CoV-2 visitor policies remains underexplored.5
Comparison of SARS-CoV-2 visitor policies could reduce inconsistencies in policy application and promote more equitable care. Here, we analyze, compare, and describe visitor policy content with the goal of providing guidance for future visitation policies.
METHODS
We conducted a content analysis of thirteen SARS-CoV-2 visitor policies within Michigan. Policies were obtained between April 15-19, 2020. This study was exempt from review by the University of Michigan IRBMED.
Sample
Hospitals in Michigan (n=13) were purposively identified through the Michigan Health and Hospital Association and Michigan Clinical Ethics Resource Network (MiCERN, a statewide ethics consortium). Hospital diversity was sought based upon number of beds, type, geographic location, and profit status, and selected based on proximity to pandemic hot spots and to represent major healthcare systems in Michigan. Hospital characteristics were gathered from publicly available websites.
Data Collection
First, we searched hospital websites for relevant policies. For policies not readily accessible, we contacted hospitals via phone. For institutions without explicit, written policies, we inquired about policy creation and visitation exceptions.
Data Analysis
We used conceptual content analysis
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to assess public-facing visitor policy content. For confidentiality, each policy was assigned an identifier (letters A-M). The initial codebook was generated from professional recommendations (CDC guidelines, state executive order), relevant ethical principles, stakeholders, policy development, dispute processes, screening procedures, and exception type.6
Visitor policies were single-coded into content categories (HSW), with discrepancies reconciled by JIF and AGS, who engaged in critical reflection, systematically attending to the context of knowledge construction to limit bias.
7
We used the Standards for Reporting Qualitative Research (SRQR) to present the study design, analysis, and results.8
- O'Brien BC
- Harris IB
- Beckman TJ
- Reed DA
- Cook DA
Standards for reporting qualitative research: a synthesis of recommendations.
Acad Med. 2014; 89 ([26]“Michigan Legislature Mental Health Code Excerpt.” Michigan Legislature - Section 330.1100a, Michigan Legislature, 2020. Available at:) (Accessed October 19, 2020): 1245-1251
RESULTS
All thirteen hospitals had SARS-CoV-2 visitor restriction policies (Table 1); described below.
Table 1Characteristics of Public Visitor Policies from a Michigan Statewide Sample (n=13)
| Hospital Identifier | Hospital Characteristics (funding, network, bed-size) | Policy Accessibility | Framework Ethical Principles Informing Policy | Stakeholders Involved in Policy Creation | Decision Maker Granting Exceptions | Definitions of Policy Terms | Exceptions for SARS-CoV-2 Positive Patients | Exceptions for Labor & Delivery | Exceptions for End of Life | Exceptions for Pediatric Patients | Exceptions for Other Vulnerable Populations | Exceptions for Out-patient Procedures and Visits | Explicit Public Process for Dispute Resolution (Public Facing) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| A | Voluntary nonprofit, In-state health system, Bed-size > 500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Clinical Leadership or administrator, No Contact Information | No Stated Definitions | Visitors permitted in end-of life situations with approval | Doula and Significant other/support person | No Stated Exceptions | Children who are 21 years of age or under: two parents | Patients with cognitive, physical, or mental disabilities may have one visitor; People who must exercise power of attorney or court-appointed guardianship for a patient | Patients undergoing surgery or an outpatient test or procedure may have one support person | None Stated |
| B | Voluntary nonprofit, Church, Community, Critical access, bed-size < 100 | Not found Online, Phone Call, Verbal | Protection of the Public from Harm, Individual Liberty | Unknown | Hospital Administration, No Contact Information | No Stated Definitions | No Stated Exceptions | No Labor and Delivery department | No Stated Exceptions | Children who are 21 years of age or under: one parent or guardian | Patients with cognitive or mental disabilities may have one visitor; Patients without decision-making capacity may have one visitor | No Stated Exception | None Stated |
| C | Proprietary, corporation, Teaching, Community hospital, in-state health system, bed-size 100-500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty, Stewardship | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | No Stated Exceptions | Non-specific/ Unclear Exception | No Stated Exception | Non-Specific/Unclear Exception | No Stated Exception | None Stated |
| Hospital Identifier | Hospital Characteristics (funding, network, bed-size) | Policy Accessibility | Framework Ethical Principles Informing Policy | Stakeholders Involved in Policy Creation | Decision Maker Granting Exceptions | Definitions of Policy Terms | Exceptions for SARS-CoV-2 Positive Patients | Exceptions for Labor & Delivery | Exceptions for End of Life | Exceptions for Pediatric Patients | Exceptions for Other Vulnerable Populations | Exceptions for Out-patient Procedures and Visits | Explicit Public Process for Dispute Resolution (Public Facing) |
| D | Voluntary Nonprofit, Teaching hospital, Community hospital, in-state health system, bed-size 100-500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | Case-by-case decisions by the healthcare team | One significant other/support person | Limited number of visitors; Family members under the age of 16 with permission of the healthcare team | Children who are 21 years of age or under: one parent or guardian | People who must exercise power of attorney or court-appointed guardianship for a patient | Patients undergoing surgery or an outpatient test or procedure may have one support person | None Stated |
| E | Voluntary Nonprofit, other, Community, bed-size 100-500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | One significant other/support person | No Stated Exceptions | Children under the age of 18: one parent or guardian | No Stated Exceptions | Patients undergoing surgery or an outpatient test or procedure may have one support person | None Stated |
| F | Governmental, city, Teaching hospital, public health, community, bed-size 100-500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | One significant other/support person | No Stated Exceptions | Two adult primary caregivers | No Stated Exceptions | No Stated Exceptions | None Stated |
| G | Community, Critical access hospital, in-state health system, bed-size < 100 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Visitors with No Exceptions | No Labor and Delivery Department | Limited number of visitors | One adult parent and one support person | Patients with disruptive behavior may have one visitor; Patients requiring a trained home caregiver may have one visitor | Patients undergoing surgery or an outpatient test or procedure may have one support person | None Stated |
| Hospital Identifier | Hospital Characteristics (funding, network, bed-size) | Policy Accessibility | Framework Ethical Principles Informing Policy | Stakeholders Involved in Policy Creation | Decision Maker Granting Exceptions | Definitions of Policy Terms | Exceptions for SARS-CoV-2 Positive Patients | Exceptions for Labor & Delivery | Exceptions for End of Life | Exceptions for Pediatric Patients | Exceptions for Other Vulnerable Populations | Exceptions for Out-patient Procedures and Visits | Explicit Public Process for Dispute Resolution (Public Facing) |
| H | Community, Critical access hospital, bed-size < 100 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | No Labor and Delivery Department | No Stated Exceptions | No In-Patient Pediatrics | No Stated Exceptions | No Stated Exception | None Stated |
| I | Voluntary nonprofit, Community, Critical access hospital, bed-size < 100 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | One significant other/support person | One visitor | Pediatric patient 21 years of age or under: One adult primary caregiver | No Stated Exceptions | Patients undergoing surgery may have one support person | None Stated |
| J | Proprietary, Corporation, bed-size < 100 | Not found online, Phone call, Verbal | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | No Labor and delivery Department | No Stated Exceptions | No Stated Exceptions | No Stated Exceptions | No Stated Exceptions | None Stated |
| K | Government, Teaching, Community, bed-size > 500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | One significant other/support person | Up to two visitors | One adult primary caregiver | Patients with developmental delays | Patients undergoing surgery may have one support person Outpatient clinics: One visitor may accompany each patient to an appointment | None Stated |
| Hospital Identifier | Hospital Characteristics (funding, network, bed-size) | Policy Accessibility | Framework Ethical Principles Informing Policy | Stakeholders Involved in Policy Creation | Decision Maker Granting Exceptions | Definitions of Policy Terms | Exceptions for SARS-CoV-2 Positive Patients | Exceptions for Labor & Delivery | Exceptions for End of Life | Exceptions for Pediatric Patients | Exceptions for Other Vulnerable Populations | Exceptions for Out-patient Procedures and Visits | Explicit Public Process for Dispute Resolution (Public Facing) |
| L | Voluntary Nonprofit, Church, Teaching, Community, In-state health system, bed-size 100-500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty | Unknown | Hospital Leadership, No Contact Information | No Stated Definitions | No Stated Exceptions | No Stated Exceptions | Non-specific/ Unclear Exception | Patients 21 or under: one adult primary caregiver | Visitors are permitted if they are necessary to activities of daily living Visitor with power of attorney or court-appointed | No Stated Exception | None Stated |
| M | Voluntary nonprofit, Teaching, Community, in-state health system, bed-size > 500 | Online, Explicit, Publicly Accessible | Protection of the Public from Harm, Individual Liberty, | Unknown | Unknown | No Stated Definitions | No Stated Exceptions | One significant other/support person | Non-specific/ Unclear Exception | One approved visitor | No Stated Exceptions | Patients undergoing surgery may have one support person | None Stated |
Policy Overview
All policies incorporated some ethical rationale regarding protecting both public health and individual liberty,A-M one specifically considered stewardship of protective equipment.C Two referenced CDC guidelines,A,G and four referenced state executive orders.C,D,G,L Three specified decision-makers, including hospital staff or leadership, involved in granting case-by-case exceptions.A,B,L
No policies provided specific points-of-contact for exception requests or reported stakeholder involvement. All policies utilized specific language without providing definitions; none described processes for iterative policy revision.
Inpatient Exceptions
Policies varied in visitor exceptions for laboring patients. Four had no labor and delivery units. B,G,H,J One permitted both a doula and additional support person,A six allowed one support person. D,E,F,I,K,M. Two did not grant exceptions for laboring patients.C,L
In end-of-life or critical care situations, policies differed: four had case-by-case visitor exceptions but did not provide numeric requirements,C,J,L,M three allowed a limited but unqualified number of visitors,D,G,K one allowed a single visitor,I and five had no end-of-life exceptions.A,B,E,F,H For patients SARS-CoV-2 positive or under investigation, one policy permitted an unspecified number of visitors for end-of-life.A No policy defined “end-of-life” and/or if this was at clinician discretion.
For pediatric inpatients, three policies permitted two parents/guardians to be present,A,F,G seven allowed one parent/guardian,B,D,E,I,K,L,M and two did not state exceptions.C,J (one provided no pediatric inpatient care).H
For adult inpatients: five policies had guidelines for vulnerable adults,A,B,G,K,L four permitted visitors acting as power of attorney,A,B,D,L one permitted visitors necessary for patient care,C and six had no stated exceptions. Policies did not define “vulnerable adult.”
DISCUSSION
In a purposive sample of SARS-CoV-2-related hospital visitation policies, we identified differences in approach and content. Most policies lacked elements, including stated ethical rationales for their stipulations and stakeholder participation, and failed to define terminology or exception request processes.
Numerous local and institutional factors might justifiably motivate institution-specific policy content and enforcement variation. These differences could engender inequity in visitation access and fair appeals processes; further disadvantaging specific populations.
The policies did not specify stakeholder involvement and we could not assess whether and how stakeholders’ perspectives informed policies. While assembling institutional and community stakeholders to inform policies is time-consuming and labor-intensive, moving forward it is critical to ensure these voices are heard.
The absence of transparent exception processes could also contribute to disparities, as patients and families enabled to advocate for themselves in such settings differ in kind from those who are not. A centralized exception request process is preferable to unit-based processes, to support equitable application across multiple hospital units or clinics. Accessibility of the exception process supports frontline staff and/or family members struggling to understand visitor restrictions, and facilitates resolution with appropriate triage of exception requests.
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A major challenge of these policies involves the need for explicit, easily interpreted rules, sensitive to the complexity of familial dynamics and contemporary care delivery across a variety of settings within a given institution.
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Specification for which visitors are permitted, such as parents or immediate family, could overgeneralize familial structure, excluding individuals important to the patient arbitrarily and unnecessarily; inadvertently creating disparities and inequality for a multi-cultural society with complex family dynamics.10
While this analysis benefits from a purposive sample representative of Michigan's inpatient hospitals, we recognize limitations including a modest sample size from a single state, and that a snapshot in time of policies does not reflect their likely evolution at each institution. Assessment of effectiveness or response from patients’ or clinicians’ perspectives and analyses of implementation experiences are critical next steps.
CONCLUSION
Individual hospital visitor policies during the spring of SARs-CoV-2 pandemic varied widely. Given the importance of public health and hospital measures to prevent viral transmission, preserve PPE, and maintain a healthy medical workforce, we argue that hospitals should develop:
- 1.visitor restrictions informed by the best epidemiological data possible, consideration of available resources, and stakeholder input;
- 2.policy definitions delineating who may visit in which exceptional circumstances;
- 3.transparent, public exception request processes; and
- 4.plans for clear and consistent communication.
Further exploration of hospital visitation practices in a public health crisis are essential to support future policies that protect and support patients and communities.
Acknowledgments
1. Contributors: None
2. Funders: None
3. Prior presentations: None
References
Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. Cases in the U.S.[cited 2020 Apr 20] Available at: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html. Accessed October 19, 2020.
World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report 94. [cited 2020 Apr 23] Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200423-sitrep-94-covid-19.pdf?sfvrsn=b8304bf0_4. Accessed October 19, 2020.
- “Not Dying Alone — Modern Compassionate Care in the Covid-19 Pandemic.”.N Engl J Med. 2020; 382: e88
- A Heart-Wrenching Thing: Hospital Bans on Visits Devastate Families.The New York Times. 2020 Mar 29;
- Attitudes of Patients, Visitors and Healthcare Workers at a Tertiary Hospital towards Influenza A (H1N1) Response Measures.Ann Acad Med Singapore. 2010; 39: 303-304
- How to plan and perform a qualitative study using content analysis.Nursing Plus Open. 2016; 2: 8-14
- Encyclopedia of case study research. 1-0. SAGE Publications, Inc., Thousand Oaks, CA2010
- Standards for reporting qualitative research: a synthesis of recommendations.Acad Med. 2014; 89 ([26]“Michigan Legislature Mental Health Code Excerpt.” Michigan Legislature - Section 330.1100a, Michigan Legislature, 2020. Available at:) (Accessed October 19, 2020): 1245-1251
- Labor and Delivery Visitor Policies During the COVID-19 Pandemic: Balancing Risks and Benefits.JAMA. 2020; 323: 2468-2469
- Patient- and Family-Centered Care Interventions for Improving the Quality of Health Care: A Review of Systematic Reviews.Int J Nurs Stud. 2018; 87: 69-83
Article info
Publication history
Published online: September 26, 2020
Footnotes
Conflicts of interest: The authors declare no funding sources nor conflicts of interest. The contents of this original manuscript have not been presented or submitted elsewhere. All authors had access to all study data, take responsibility for the accuracy of the analysis, and had authority over manuscript preparation and the decision to submit the manuscript for publication. All authors approve the manuscript and adhere to all terms outlined in the American Journal of Infection Control information for authors including terms for copyright.
Identification
Copyright
© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- The impact of visitor restrictions on health care-associated respiratory viral infections during the COVID-19 pandemic: Experience of a tertiary hospital in SingaporeAmerican Journal of Infection ControlVol. 49Issue 1
- PreviewWe read with interest the recent article by Weiner et al that described hospital visitation policies during the coronavirus disease 2019 (COVID-19) pandemic, and called for epidemiological evidence to support and inform the imposition of visitor restrictions.1 Indeed, the imposition of visitor restrictions has been introduced in various healthcare settings to mitigate transmission of SARS-CoV-2;2,3 however, as such measures were typically imposed as part of a bundle of other infection-prevention measures, the actual contribution of visitor restrictions in minimizing health care-associated transmission of respiratory-viral-infections (RVIs) is unclear.
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