Hospital Visitation Policies During the SARS-CoV-2 Pandemic

Abstract

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.

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 , 2} One major change was visitor restriction within clinical environments.^{3 , 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 analysis⁶ 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

RESULTS

All thirteen hospitals had SARS-CoV-2 visitor restriction policies (Table 1 ); described below.

Table 1.

Characteristics 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.⁵

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.⁹ 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.