NEW YORK (Reuters Health) – Hospital visitation policies have varied widely throughout the pandemic, which could create inequity in access for patients and their families, according to a group of doctors and bioethicists.
Hospital visitation policies should protect, respect and support patients, their visitors, healthcare providers and the surrounding community, the team writes in the American Journal of Infection Control.
“A well-written policy needs explicit, easily interpreted rules that recognize the complexity of the modern healthcare environment. For example, it is a tragedy for a loved one to die alone unnecessarily, but we also cannot allow families to risk exposure to infection without having necessary safety measures in place for the community,” said senior author Dr. Andrew Shuman of the University of Michigan Medical School in Ann Arbor.
“Our findings show that it is very difficult to rapidly change how hospitals operate in the middle of a crisis, and this is reflected in how these policies were written and enacted,” he told Reuters Health by email.
Dr. Shuman and colleagues analyzed 13 pandemic-related visitor policies in Michigan hospitals. They obtained the policies between April 15-19 to understand how initial policies were phrased and created. They picked a diverse assortment of hospitals based on the number of beds, geographic location, profit status and pandemic hotspots.
Overall, all 13 policies included some ethical rationale for protecting both public health and individual liberty. Two policies referred to guidelines from the Centers for Disease Control and Prevention, and four referred to state executive orders. Three policies pointed to key decision-makers, such as hospital staff or leadership, who could grant case-by-case exceptions for visitations.
However, none of the policies gave specific contact information for visitors to submit exception requests or described an ongoing process for visitation policy revisions.
In particular, some policies granted visitor exceptions for patients in labor. Six allowed for one support person to be present, and one permitted both a doula and an additional support person to be present. Four hospitals didn’t have labor and delivery units, and two hospitals didn’t grant exceptions for laboring patients.
Policies related to end-of-life care and critical care varied as well. Four policies allowed case-by-case visitor exceptions but didn’t explain the requirements, and three allowed a limited but unspecified number of visitors. One policy allowed a single visitor, and five provided no end-of-life exceptions. However, no policies defined what “end-of-life” was and if the definition was based on a doctor’s discretion.
With pediatric patients, three policies allowed two parents or guardians to be present, and seven allowed one parent or guardian. Among adult patients, five allowed visitors for vulnerable adults, and four allowed visitors who acted as a power of attorney. Six policies didn’t provide exceptions for adult patients.
Overall, the hospital visitation policies lacked consistency, detailed ethical rationales, definitions of terminology and a process for requesting an exception, the authors note.
These variations could create inequity for access and appeals, which could further disadvantage some groups, they add. Moving forward, hospitals need to update their policies with explicit, easy-to-interpret rules that consider the complexity of family dynamics and a clear exception process, according to the authors.
“As we move into the fall and the concern for increasing numbers of infections, it is critical that hospital visitor policies are clear, fair and reflect community input,” Dr. Shuman said.
Policies could include specifics for different hospital departments as well, the authors write. End-of-life situations and labor and delivery units may need particular visitor exemptions to provide the best care for patients and their families.
“Ethically, clinically and emotionally, exemptions should be made for visitors for labor and delivery. Clear data exists that support in labor improves obstetric outcomes,” said Dr. Kavita Shah Arora of MetroHealth Medical Center in Cleveland, Ohio. Dr. Arora, who wasn’t involved with this study, has written about labor and delivery visitor policies during the pandemic.
“This support may be especially important for women of color, which is crucial to consider when formulating hospital policies given the troubling and ongoing racial disparities in maternal health outcomes,” she told Reuters Health by email.