Visitor restrictions in hospitals during infectious disease outbreaks: An ethical approach to policy development and requests for exemptions.

In this paper, we explore the ethics of restricting visitation to hospitals during an infectious disease outbreak. We aim to answer three questions: What are the features of an ethically justified hospital visitor restriction policy? Should policies include scope for case-by-case exemptions? How should decisions about exemptions be made? Based on a critical interpretive review of the existing ethical literature on visitor restrictions, we argue that an ethically justified hospital visitor restriction policy has the following features: proportionality, comprehensiveness, harm mitigation, exemptions for specific patient populations, visitation decisions made separately from a patient's treating clinicians, transparency, and consistency in application. We also argue that an ethical policy ought to include scope for case-by-case exemptions for individual patients. We propose a process for ethical decision-making that provides a shared language and structure to decrease the risks and burdens of decision-making when clinicians or managers are considering requests for exemptions.

After COVID-19 vaccinations: what does living and working in nursing homes look like?

BACKGROUND: Nursing homes were disproportionally affected by the COVID-19 pandemic. Vaccination was considered critical for the normalization of daily live of nursing home residents. The present study investigates the impact of the prolonged COVID-19 pandemic and the effect of vaccinations on the daily lives of residents and staff in Dutch nursing homes. SETTING AND PARTICIPANTS: The sample consisted of 78 nursing homes that participated in the Dutch national pilot on nursing home visits after the COVID-19 pandemic. One contact person per nursing home was approached for participation in this mixed-methods cross-sectional study. METHODS: Data was collected twice through questionnaires in April and December 2021. Quantitative questions focused on recent COVID-19 outbreaks, progress of vaccination, effects of vaccination on daily living in the nursing home and burden experienced by staff. Open-ended questions addressed the prolonged effect of the pandemic on residents, family members and staff. RESULTS: The overall vaccination rate of residents across nursing homes appeared to be high among both residents and staff. However, daily living in the nursing home had not returned to normal concerning personal interactions, visits, the use of facilities and work pressure. Nursing homes continued to report a negative impact of the pandemic on residents, family members and staff. CONCLUSIONS: Restrictions to the daily lives of residents in nursing homes were stricter than restrictions imposed on society as a whole. Returning to a normal daily living and working was found to be complex for nursing homes. With the emergence of new variants of the virus, policies strongly focusing on risk aversion were predominantly present in nursing homes.

Evolution of Visiting the Intensive Care Unit.

This article gives a historical perspective of visitation in the intensive care unit (ICU) since the establishment of critical care units. Initially, visitors were not allowed because it was thought to be harmful to the patient. Despite the evidence, ICUs with open visitation have consistently been in the minority and the COVID-19 pandemic halted progress in this area. Virtual visitation was introduced during the pandemic to maintain family presence, but limited evidence suggests that this is not equivalent to in-person visitation. Going forward ICUs and health systems must consider family presence policies that allow for visitation under any circumstance.

Family member perspectives on intensive care unit in-person visiting restrictions during the COVID-19 pandemic: A qualitative study.

BACKGROUND: Family member presence in the intensive care unit is important for patient well-being and recovery. Limitations to visits increase the risk of psychological distress in family members. During the COVID-19 pandemic, in-person visiting restrictions were introduced to prevent the spread of infection. PURPOSE: To explore the experience of in-person visiting restrictions imposed during the pandemic on family members of patients with COVID-19 admitted to an intensive care unit. METHOD: Qualitative method with thematic analysis. Individual semi-structured telephone interviews were conducted. FINDINGS: We interviewed 21 family members. The results are presented in one overall theme with two main themes and five sub-themes. The theme 'Striving for closeness even at a distance describes the experience of being kept at a physical distance when participants needed closeness the most. Even participants who were allowed in-person visits perceived a 'distance' due to personal protective equipment or because they could only view the patient from a window. Participants reported that contact with and information about the patient was of utmost importance. Visits were viewed as essential in providing for the patient's wellbeing. Meaningful contact with the ICU team was vital for getting useful information. Phone calls became a lifeline, with digital aids such as video calls used occasionally to overcome the feeling of distance. CONCLUSION: Visiting restrictions imposed during the COVID-19 pandemic made straightforward and comprehensible communication of information from the ICU team more essential to reduce family members' perceptions of distance and exclusion from the intensive care unit.

Impact of an Inclusive COVID-19 Visitation Policy on Patient Satisfaction and Visitor Safety.

BACKGROUND: The COVID-19 pandemic presented unique and unprecedented challenges due to limited knowledge regarding the virus's transmissibility. With guidance from the Center for Disease Control (CDC), healthcare systems instituted widespread visitor restrictions. Hospitalization is a stressful time for patients. Visitor support can help minimize this during and after discharge. METHODS: A telephone interview was conducted among hospitalized COVID-19 positive patients discharged between March 1st - August 31st, 2021 to explore the patients and visitors' experiences and the impact of the visitor policy during their hospitalization. RESULTS: A total of 238 patients were interviewed. For patients with visitors, 98% felt that the presence of visitors improved their overall wellbeing and satisfaction. Additionally, 86% reported that visitors were involved in helping with their care upon discharge. For patients with no visitors, 59% felt that having a visitor would have improved their hospital stay. Nearly 50% reported that the absence of visitors made it difficult for family members to remain updated and informed of their hospital care. CONCLUSION: This study demonstrates that visitation for COVID-19 patients can be done safely and that there is a positive impact on patient wellbeing with increased visitor access. As we move towards COVID-19 endemicity, implementing evidence-based visitation policies that maximize patient wellbeing will be essential.

Restricted family presence for hospitalized surgical patients during the COVID-19 pandemic: How hospital care providers and families navigated ethical tensions and experiences of institutional betrayal.

Early in the COVID-19 pandemic restricted family presence in hospitals was a widespread public health intervention to preserve critical resources and mitigate the virus's spread. In this study, we explore the experiences of surgical care providers and family members of hospitalized surgical patients during the period of highly restricted visiting (March 2020 to April 2021) in a large Canadian academic hospital. Thirty-four interviews were completed with hospital providers, family members and members of the hospital's visitor task force. To understand hospital providers' experiences, we highlight the ethical tensions produced by the biomedical and public health ethics frameworks that converged during COVID-19 in hospital providers' bedside practice. Providers grappled with mixed feelings in support of and against restricted visiting, while simultaneously experiencing gaps in resources and care and acting as patient gatekeepers. To understand family members' experiences of communication and care, we use the theory of institutional betrayal to interpret the negative impacts of episodic and systemic communication failures during restricted visiting. Family members of the most vulnerable patients (and patients) experienced short- and long-term effects including anxiety, fear, and refusal of further care. Our analysis draws attention to the complex ways that hospital care providers and families of hospitalized surgical patients sought to establish and reconfigure how trust and patient-centeredness could be achieved under these unprecedented conditions. Practical learnings from this study suggest that if family presence in hospitals must be limited in the future, dedicated personnel for communication and emotional support for patients, families and staff must be prioritized.

Birth Doula Care in California During COVID-19: The Impacts of Social Distancing on a High-Touch Helping Profession.

Birth doulas were deemed "non-essential" personnel during the COVID-19 pandemic and were generally excluded from attending hospital births in person. This study documents the impacts of pandemic-related contextual factors on birth doula care in the San Francisco Bay Area, examines how doulas adapted their services, and explores implications for policy and practice. We employed a contextually bound qualitative case study methodology driven by social action theory and conducted interviews with 15 birth doulas. The pandemic disrupted physical settings, the social environment, communication modalities, contractual arrangements, and organizational level factors. The historical context also amplified awareness of institutionalized racism in birth settings and highlighted birth doulas' advocacy role. Striking deficits exist in birth doulas' integration into US healthcare systems; this made their services uniquely vulnerable to the pandemic circumstances. Birth doulas' value ought to be more formally recognized within health policy, health insurance, and hospital systems as complementary care to that provided by medical providers to improve access to high-quality perinatal care.

#Morethanavisitor: Experiences of COVID-19 visitor restrictions in Canadian long-term care facilities.

Objective: The purpose of this study was to understand the experiences of families, residents, and staff around visitor restriction policies in long-term care during the COVID-19 pandemic in Canada. Background: Beginning in March 2020, public health orders across Canada restricted visitors to long-term care facilities to curb the spread of the infection. This included family caregivers who provide significant support to residents to meet their physical, psychological, social, and safety needs. Method: We collected data from publicly available news and social media. News articles, blogs, and tweets from Canada were collected from March 2020 to April 2021. In total, 40 news articles, eight blogs, and 23 tweets were analyzed using generic qualitative description. Results: Reports from family members indicate that some residents may have died from malnutrition, dehydration, and isolation, rather than from COVID-19, because of the sudden and prolonged absence of family caregivers. There are long-term impacts on family suffering and long-term care worker burnout. Policy and structural issues were identified. Conclusion: Experiences in long-term care reflected not only impacts of pandemic-related visitor restrictions, but also long-standing funding and workforce issues. Implications: Involvement of family, and specifically family caregivers, is crucial in policy decisions, even in unusual circumstances, such as the pandemic.

Relatives' experiences of the hospitalisation of older people with COVID-19: A qualitative interview study.

BACKGROUND: During the COVID-19 pandemic, visitors were restricted from hospitals, separating them from hospitalised friends and family to reduce the infection risk. OBJECTIVES: The objective was to explore how relatives of older people acutely admitted to hospital with COVID-19 experienced being a relative, and how they felt about their contact with health care professionals (HCPs) when visitor restrictions prevented their physical presence in the ward. METHOD: This study employed a qualitative design. We used individual qualitative semi-structured interviews and the participants were relatives of acutely admitted older people from three COVID-19 wards in Denmark. A total of 18 relatives participated, 14 female and 4 male, aged between 45 and 83 years. The analysis was guided by Graneheim and Lundman's qualitative content analysis. RESULTS: The analysis derived the following three themes: (1) the importance of trust in a period of uncertainty; (2) the meaning of contact with HCPs, and (3) active but at a distance-a balancing act. The participants' feelings of uncertainty were prominent. The unknown nature of the disease and the unusual situation challenged relatives' trust in HCPs and the health care system. CONCLUSIONS AND RELEVANCE TO PRACTICE: The findings highlight relatives' stress when the possibilities for visiting are restricted and the importance of trust in, and the relationship with HCPs. This study can strengthen HCPs' understanding of relatives' situation when older people are hospitalised during and after the COVID-19 pandemic.

When 'Being There' Is Disallowed: Disruptions to Knowing and Caring During COVID-19 Visitor Restrictions.

This qualitative study explored the accounts of five health professionals working in hospitals in Hamilton, Ontario, Canada who provided end-of-life care during the COVID-19 pandemic. The study goal was to understand how palliative care providers experienced and responded to the significant change in family presence when visitors were restricted to slow the spread of the virus. Identified was the loss and disruption of important forms of knowing including observational and embodied knowing. Family members' knowledge of how their person was faring was curtailed, as was providers' capacities to know families personally. Family members' less obvious needs did not come forward as readily in the absence of informal encounters with providers. Constraints on knowing and embodied actions often meant phone and video meetings failed to provide meaningful connection. Providers adapted their practice in a range of ways, including by offering verbal and visual images of the person in the setting, paying attention differently, and conveying to family members their knowledge of patients as individuals. The changes and challenges health providers remarked on and the ways they adapted and extended themselves reveal in a new way how the regular presence of family in the care setting shapes the quality of end-of-life care.

Heart transplantation in the era of COVID-19 pandemic: delirium, post-transplant depression, and visitor restrictions; the role of liaison and inpatient psychosomatic treatment-a case report.

BACKGROUND: Heart transplant recipients show a high risk of developing major depression with an increased risk of post-transplant morbidity and mortality. Heart transplant specialists and patients face unprecedented challenges during the COVID-19 pandemic, which have enormous clinical implications such as the increased risk of COVID-19 as well as visitor restrictions with social isolation during the post-transplant inpatient treatment. CASE SUMMARY: We present a case of a 64-year-old woman with end-stage heart failure caused by non-compaction cardiomyopathy who received an orthotopic heart transplant (OHT) without any intra-operative complications. Post-operatively, she showed acute psychotic symptoms in the intensive care unit (ICU) with improvement after switching intravenous tacrolimus treatment to an oral intake. Furthermore, the patient developed severe depressive symptoms with malnutrition and had a prolonged hospitalization. Standard medical care was complemented by intensive psychocardiological treatment to overcome the crisis. CONCLUSION: High complexity of the post-transplant management after OHT underlines the importance of multidisciplinary teamwork, involving heart transplant specialists and allied mental health professionals. This collaboration led to an excellent long-term result. Facing the COVID-19 pandemic, the hospital visitor policies may be scrutinized, carefully looking at the role of social isolation, post-operative experience in the ICU, and medical complications after OHT.

An Introduction to a Novel Intervention, "This is My Story", to Support Interdisciplinary Medical Teams Delivering Care to Non-Communicative Patients.

This set of three case studies portrays a unique intervention undertaken at The Johns Hopkins Hospital in response to the COVID-19 pandemic with a goal to reduce the impact of absentee visitors during patient care on physicians, nurses, and the patient's loved ones. The intervention, known by the acronym TIMS, "This is My Story", involves a chaplain-initiated telephone call to a loved one, someone who has been identified by the patient as part of their care discussions, of hospitalized patients who have difficulty with communicating to the medical team. The call is recorded then edited for conciseness, and attached to the electronic health record for the entire medical care team to hear. The focus of the chaplain lead conversation with a loved one centers around gathering and presenting information about the patient as a person. Medical team members listen to the edited audio file either on rounds or by utilizing a hyperlink in the electronic health record (EHR). The audio file is two minutes or less in length, as this is the optimal size for comprehension without overburdening the care provider. While conducting the interview, there is an opportunity for chaplains to provide spiritual and emotional support to loved ones and medical staff, contributing substantively to patient care, as is illustrated in the case studies.

Developing an Innovative System of Open and Flexible, Patient-Family-Centered, Virtual Visiting in ICU During the COVID-19 Pandemic: A Collaboration of Staff, Patients, Families, and Technology Companies.

Few challenges of the COVID-19 pandemic strike at the very core of our humanity as the inability of family to sit at the bedside of their loved ones when battling for their lives in the ICU. Virtual visiting is one tool to help deal with this challenge. When introducing virtual visiting into our ICU, we identified 5 criteria for a sustainable system that aligned with patient-family-centered care: virtual visiting needed to (1) simulate open and flexible visiting; (2) be able to accommodate differences in family size, dynamics, and cultural practices; (3) utilize a video conferencing platform that is private and secure; (4) be easy to use and not require special teams to facilitate meetings; and (5) not increase the workload of ICU staff. There is a growing body of literature demonstrating a global movement toward virtual visiting in ICU, however there are no publications that describe a system which meet all 5 of our criteria. Importantly, there are no papers describing systems of virtual visiting which mimic open and flexible family presence at the bedside. We were unable to find any off-the-shelf video conferencing platforms that met all our criteria. To come up with a solution, a multidisciplinary team of ICU staff partnered with healthcare technology adoption consultants and two technology companies to develop an innovative system called HowRU. HowRU uses the video conferencing platform Webex with the integration of some newly designed software that automates many of the laborious and complex processes. HowRU is a cloud based, supported, and simplified system that closely simulates open and flexible visiting while ensuring patient and family privacy, dignity, and security. We have demonstrated the transferability of HowRU by implanting it into a second ICU. HowRU is now commercially available internationally. We hope HowRU will improve patient-family-centered care in ICU.