They're Not Visitors: COVID-19 Visitor Restrictions Highlight Need for Change

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Health care providers braced for the worst as COVID-19 began to sweep the nation in early March 2020. Visitor restrictions were just one of many protocol changes that affected the care experience. Many hospital leaders and clinicians have thought creatively about how to fill the gaps in care and support previously given by family and friends before restrictions were implemented. For older patients with dementia or cognitive impairment, the absence of a care partner is particularly challenging. These most vulnerable patients are more likely to experience agitation and delirium in the hospital. When a family caregiver is blocked from serving as the patient’s support system, already-stretched clinicians are left to fill that role.

Experts warn that most hospitals should expect a continued inpatient flow of COVID-19 patients for many months to come. “COVID-19 is not a surge, it’s a siege,” explained Dr. Kevin Biese, co-director of the Division of Geriatric Emergency Medicine at the University of North Carolina (UNC) at Chapel Hill School of Medicine.

Now is the time for system leaders to reflect on crisis protocol and design long-term operational processes for delivering quality care under new circumstances. Dr. Biese continued, “Hospital leaders want to do the right thing to protect their employees and the community from COVID-19. We must think about whether the infection control measures in place are sustainable. Are we balancing infection risk with the preservation of person-centered care?”

Adapting with New Solutions
Advocate Aurora Health is among the 10 largest integrated health systems in the U.S., operating 29 hospitals and 500 care sites across Illinois and Wisconsin. It also was one of the earliest hospitals systems to embrace technology to comfort isolated patients and provide updated information as the pandemic emerged. Mary Beth Kingston, chief nurse officer for the system explained, “We realized early on that clear and routine communication to clinicians and staff was going to be critical to our ability to adapt to the rapidly changing circumstances around COVID-19—especially two-way communication so hospital leaders could hear feedback from clinicians, staff, patients, and families on their trending needs.”

Advocate Aurora Health is a powerful example of how big system change can happen quickly when leadership is deeply attuned to the needs of its community. In a matter of days, Advocate Aurora Health built a technology platform to ensure isolated patients could have access to virtual visits with loved ones; it deployed 1,300 tablets reserved for communication between separated loved ones and care partners.

Advocate Aurora Health went further, also offering families a Virtual Vigil Program to connect loved ones with patients who were nearing the end-of life. The Virtual Vigil team swiftly developed a process to connect nurses and other team members from across the system to Vigil Coordinators who immediately arranged an online connection for family members and loved ones to remotely sit vigil with the patient. The Virtual Vigil team also trained 100 volunteers who already had experience with virtual work to be on- call 24 hours a day for patients near the end-of-life who did not have loved ones to be with them. Advocate Aurora Health used a global meeting platform to create Virtual Vigil “rooms” and offered unlimited, uninterrupted visitation allowing loved ones and pastoral care team members to be present with patients at this most vulnerable and sacred time.

“The key to quickly launching the virtual program,” said Bradley Kruger, vice president of patient experience, “was tapping into our experienced pool of virtual volunteers, coupled with a clear call-to-action from our nursing teams, who welcomed the extra support from volunteers in tending to the patients, families, and care partners’ emotional needs from afar.”
  
Some health care leaders suggest that systems with geriatric emergency departments or those designated by the Institute for Healthcare Improvement as “age friendly” are more aware of the need to invest in creative solutions for mitigating the emotional impact of isolation on older patients. Dr. Maura Kennedy, division chief of geriatric emergency medicine, and a team of physician collaborators from Massachusetts General Hospital and Harvard Medical School’s Department of Emergency Medicine underscore the need to renew focus on compassion during COVID-19 in an expert commentary.

In that commentary, the authors describe a myriad of ways to feature humanism in this time of extreme isolation for patients. Helping them feel comfortable from the moment of admission is critical, they say. Scripted, compassionate language for front-office and triage staff, such as, “We are here to keep you safe,” can go a long way in calming a patient upon admission, as can softening the harsh signage and anxiety-provoking barriers intended to control infection spread. Large-print signage and access to medical interpreters is essential. Care team members can introduce themselves while sitting on a stool instead of standing over the patient. And at discharge, Dr. Kennedy and team suggest using uniform discharge instructions specifically for COVID-19 patients to ensure patients and care partners feel adequately prepared for recovery at home.

Beyond Virtual
Of course, virtual communication is not a panacea. All hospital leaders need to think hard about meaningful practice changes they can champion beyond virtual alternatives for older patients. This starts with deep collaboration and two-way communication with providers and staff to listen for patient and care partner needs that can be addressed. Dr. Biese provided insight on how providers can build leadership support, suggesting the need to emphasize what family caregivers bring to the table. “It’s wise not to fight the wisdom of the visitor restriction policy with hospital leadership but rather show how care partners are essential to the clinical team and care experience,” he said.

As some hospitals begin to ease visitor restrictions and others are reinstated due to increased COVID-19 spread; all hospitals must reassess their approaches. They must reflect on whether restricting access for care partners of those with dementia, delirium, or cognitive impairment, or those at end-of life, is more helpful or harmful to their hospital community at large. If providers can effectively communicate how much care partners can help in the hospital setting, the case for allowing these care partners becomes very strong. Moreover, suggesting everyday practical tactics, or a “third way,” also can support the argument. Some geriatric emergency medicine providers, for example, suggest that providing these family caregivers with clear training on how to wear and remove personal protective equipment is the better long-term alternative to strict restrictions.

Time to Pause and Reflect
As we settle into our new normal and wait for COVID-19 vaccine trials to advance, now is the time to reflect on the protocols that were urgently deployed under the rise of COVID-19 infections nationwide. The solution is not continued ad-hoc exceptions to the restriction policies on a case-by-case basis.

“While COVID-19 catalyzed the urgent mobilization of our virtual program, I have asked myself and my colleagues, ‘Why haven’t we done this sooner?’” said Advocate Aurora Health’s Kruger, reflecting on his system’s mobilization of new protocols during crisis times. “Giving unlimited virtual access to the bedside of a critically-ill patient for loved ones who can’t be there can be meaningful under any circumstances that go beyond COVID-19.”

As Kruger has done, hospital leaders must take time to reflect deeply and collaborate with clinicians, staff, and patients. The outcome will lead to long-term systems change for the better.

This is the second post in a three-part blog series for health care leaders focused on the impact of hospital visitation policies on families and older patients during COVID-19.

The first post outlined the effects of hospital visitor restrictions on patients and their care team. The third and final post will address the implementation process, bringing hospital visitation policy change to scale, and implications at the state and system level.

AARP is soon to launch a larger initiative exploring trends across health care systems all focused on how to support family caregivers in getting more guidance and help from the hospital before the patient is discharged. The “Supporting Family Caregivers Providing Complex Care” series aims to share insights and promising practices from health care systems that are implementing the Caregiver Advise, Record, Enable (CARE) Act in support of family caregivers.

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