Hospitals put out the welcome sign

Campaign aims to change the concept of families as ‘visitors'.

As the president and CEO of the Institute for Patient- and Family-Centered Care (IPFCC), Beverley Johnson knows how complicated a hospital stay can be. So when her 101-year-old mother was in intensive care, she wanted to be in her room as much as possible. Yet the nurses never acknowledged her role as a partner in her mother's care and continually asked her to leave the room during shift changes.

“The written policy posted in this single ICU room said that I could not be in the room when nurse change of shift occurred because of HIPAA [the Health Insurance Portability and Accountability Act], which is just inaccurate. My mother wanted me to be present, and yet I could not get them to do report while I was in her room throughout her entire hospital stay,” said Ms. Johnson.

Photo by Thinkstock
Photo by Thinkstock.

The IPFCC recently launched an effort to encourage hospitals to change such policies and practices and support family presence and participation. The “Better Together: Partnering with Families” campaign, begun in June, has a goal of getting at least 1,000 hospitals to change the concept of families as visitors and create welcoming policies by 2017. Hospitals that join the campaign pledge to review their policies with input from staff and patients and, in return, are given access to an online learning community.

The campaign and other advocates of changing visiting policies aren't asking hospitals to remove all restrictions on visitors, but to reconsider the role of family members or other care partners on both general wards and in the ICU. “The campaign is seeking to ensure that families and other care partners are welcomed, encouraged, and supported in being present and participating in care and decision making according to the patient's preference,” Ms. Johnson said.

Many hospitals' existing policies have not been so carefully considered. “It seems mostly historical. Hospitals came up with these policies and have continued to follow them,” said Vincent Liu, MD, MS, a research scientist and critical care physician with Kaiser Permanente Northern California. “There may not have been a thoughtful approach: What can really maximize the benefit that family and visitors have on our hospitalized patients, and what can minimize harms?”

Hospitalists can lead their facilities in thinking about this question and successfully implementing policy and practice changes in response, experts said.

Restrictions widespread

Currently, most hospitals in the U.S. restrict visits in some way, especially in ICUs, according to a study Dr. Liu led. In a phone survey of 606 hospitals, 76.9% reported at least 1 restriction on visits, as did 89.6% of ICUs. More than half of the ICUs had 3 or more restrictions, with the most common being when visitors could be present, followed by the number and age of visitors allowed.

“Having practiced in a lot of different hospitals, I have found that most hospitals have a high number of restrictions, but I've also seen a lot of variability in existing policies on visitation,” Dr. Liu said.

The study also looked at hospital factors that might affect the policies, and the only significant difference observed was that open-visitation ICUs were more common in hospitals with fewer than 150 beds. “We really didn't find a good association with hospital size, type of hospital, number of beds, percentage of beds, or the presence of leadership, which I think suggests that these policies remain somewhat arbitrary,” he said.

Hospitals have historically had a number of justifications for visitation limits. “Is it going to interfere with the process of medical care? Is it going to be overwhelming and distracting? Is it actually going to lead to more safety issues?” listed Dr. Liu.

“People said, ‘Oh, there's more infections' and this and that,” added Mitchell M. Levy, MD, a critical care specialist and professor of medicine at Brown University in Providence, R.I. “The few studies that have actually looked at that in a rigorous way are all negative...There's no evidence in the literature of any deleterious effects of unrestricted visiting hours, except on nursing convenience and physician convenience.”

The effects of relaxing visiting hours on clinicians' workload and practice patterns were initial concerns for hospitals that have made the change. “We went to the nurses and said, ‘What are you worried about?’” said Terrell Smith, RN, director of patient and family engagement at Vanderbilt University Medical Center in Nashville, Tenn.

Common responses were that the presence of visitors might distract from clinical tasks, that HIPAA-mandated privacy might be difficult to maintain, and that visitors might get unruly. Solutions have been found to all these challenges, experts said.

For example, for critical care nurses worried about visitors talking to them as they calibrate intravenous drips, Vanderbilt leaders developed a script. “Before you start, turn to the family member and say, ‘I am about to do some important safety work on behalf of your patient and it requires that I have about 10 minutes of dedicated concentration to this task. If you've got any questions or need to tell me something, if you'll hold that for 10 minutes while I do this, it's really important,’” said Ms. Smith.

Compliance with HIPAA in a family member's or visitor's presence requires just a quick conversation with the patient. “It isn't difficult to turn to the patient and say, ‘We're going to be talking about your care now. Would you like whomever—your loved one, your friend, your guest—to be in the room with you today, or he could step out briefly and then return?’” said Ms. Johnson.

As for maintaining order among visitors, that's a challenge that staff at most hospitals have already had to deal with. “What do you do now on the day shift when we don't have restrictions for the family members? We helped them problem-solve their own questions and concerns,” said Jaspreet Benepal, RN, chief nursing officer for Contra Costa Regional Medical Center in Martinez, Calif.

Some rules remain

It's also important to note that relaxing visiting policies doesn't mean abandoning rules for visitors altogether, the hospital leaders said. For instance, patients at Vanderbilt can pick selected visitors to be at their bedside 24/7, but there are visiting hours for the general public. “Your bridge club...or your soccer team can come between 9 a.m. and 9 p.m.,” said Ms. Smith.

Nighttime protocols in the hospital also apply to the visitors. “We dim the lights. We have quiet. You cannot be on your cell phone,” said Cheryl Sheridan, RN, chief nursing officer for Rochester Regional Health System in Rochester, N.Y.

Clinicians may also sometimes encourage visitors not to make constant use of the open hours. “Look at situations where it may not be in the best interest of the patient and the family member. It's a good time to reassure the family member we're going to keep a close eye on your loved one. We will call you if there's any problem, but you need to go home and get your rest, so you can feel well and be there to support your loved one,” said Ms. Sheridan.

A more open visitation policy in the ICU may put some enforcement duties on clinicians, said Dr. Levy. “If you have a sign that says you can only be here for a half-hour, then I don't have to take responsibility to ask families to leave,” he said. When Dr. Levy tells families that he's sorry, but they will have to eat outside in the waiting room, he often encounters resistance.

He also noted that staff may sometimes have to deal with potential complications that may come along with having more people on the wards. “My intensive care unit is like a big house, with lots of family wandering around all the time. Just as with our own family, sometimes that's great and sometimes it's a bit of a pain in the neck,” said Dr. Levy.

Ms. Johnson, in turn, believes that creating a welcoming ICU environment, instead of environments with rigid rules, removes nurses and physicians from the enforcing role. But that doesn't mean there are no boundaries for family members or other visitors in areas like respecting patient privacy, avoiding excessive noise, and preventing any disruptions that might interfere with care, she stressed.

“Nurses and physicians do need to step in and deal with these situations when they occur, but these are the outliers,” Ms. Johnson said. “These situations can be minimized by setting a respectful, welcoming tone from the beginning of a hospital stay, having clear guidelines for behavior, and communicating expectations for mutual respect for everyone on the unit.”

Dr. Levy said that nurses will end up dealing with most problematic situations, but physicians need to be ready to back them up. “The most important thing is making it clear to the nursing staff that you will be supportive, that you will not abandon them to enforce the rules,” he said. Partnering with hospital security teams can also be helpful, Ms. Johnson noted.

Hospitals that have opened visits up have also had to deal with logistical challenges of welcoming visitors at night. “The door is not working. The elevators don't stop at the floor where we want them to stop. Having facilities and security involved was extremely helpful,” said Ms. Benepal.

Shared rooms also can pose issues. “We will ask the roommate if they have a problem with the family member staying. Or we will make arrangements for another area in the hospital, maybe a lounge area for that family member, so they can be close but not in the room,” said Ms. Sheridan.

These downsides are smaller than the upsides of supporting family presence and participation, however, according to advocates. “That inconvenience is so outweighed by the trust that's engendered by open visiting hours and, more than that, the kind of contact that open visiting hours facilitates between families and all members of the health care team,” said Dr. Levy.

Relaxed visiting policies do yield lots of happy anecdotes from patients and families. “One of the loveliest ones I got right after we really opened visiting hours up was a story about a couple who had been married for over 60 years and they had never been apart, and she had to go for a valve replacement. They were just so thankful that they could be in the room together when she woke up,” said Ms. Smith.

There can be clinical benefits, too. “When you're in the hospital, you're usually in a lot of pain, you're unconscious, or you're on drugs, so it's really hard to follow anything that physicians or staff members are saying,” said Ms. Smith. “A lot of times [patients are] just not awake enough or don't feel good enough to participate in their care. This is where family or a support person comes in.”

Dr. Liu agreed. “They provide perspective on the patient's condition before they were hospitalized, and they can provide information about how they've been over the day. In general, you can give news to the patient and the family members together, which is often beneficial,” he said.

He believes that more involvement of families and caregivers could help clinicians achieve some other goals of care, too. “Increasingly we're trying to get patients to maintain good health habits while in the hospital—sleep/wake cycles, frequent mobilization, and good nutrition—so to the extent that bringing elements of home like family and caregivers into the hospital can improve those issues, that's something that deserves a lot of consideration,” said Dr. Liu. “Reorienting a person who becomes disoriented during critical illness is much more likely to be successful when done by a person that's familiar to them.”

Data collection

More research is still needed in this area, Dr. Liu said. The results may help convince hospitals to reduce their restrictions. “I don't think it's purely making concessions from a hospital's perspective to just improve satisfaction. It has also the potential to improve outcomes that we care about, such as quicker restoration to their baseline health,” he said.

Collection of data, along with anecdotes, can also be used to convince clinicians of the value of open visitation, other experts said. After the change at Contra Costa, “we looked at our data not only per unit, but also per day and per shift. If we had 200 family members come visit on a medical/surgical unit in the month of November, we shared that with [staff],” said Ms. Benepal. “Day after day, we saw that there were such positive experiences reported back to us...They thought that this would not work, and they were surprised how helpful it was.”

Another reason to track the effects of changing visitor policies is that they may need to be revised again. Several of the hospitals that began loosening restrictions by expanding when patients could be visited followed that change by expanding who could visit during off hours, especially after President Obama issued a memorandum on patient visitation, focusing on gay and lesbian partners, in 2010.

“When we talked about families in our policy, we meant family as defined by the patient,” said Ms. Sheridan. “We updated the wording to include other care partners.”