One of the most significant patient safety processes impacted by the COVID-19 response has been how family and friends support ill loved ones and interact with the healthcare team.
No healthcare organization has been spared from enforcing new visitor guidelines and policies. The initial visitor limitations across the Metro Atlanta market uniformly allowed no visitors in healthcare facilities.
These stringent measures were selected for the urgent protection of healthcare staff, patients and visitors because little was known about the virus. This decision was driven by required adherence to physical distancing guidelines and conservation of personal protective equipment (PPE).
Unfortunately, the populations most significantly impacted by the COVID-19 visitor restrictions are the elderly and those with advanced illness or care needs requiring stays in facilities such as hospitals, skilled nursing facilities and nursing homes. Most of Georgia’s nursing home facilities have been locked down to visitors since March, and while it was an important measure needed to keep this vulnerable population safe, there are many unintended consequences for patients, families and healthcare providers.
Our medical group, The Southeast Permanente Medical Group (TSPMG), is affiliated with Kaiser Permanente Georgia across the Metro Atlanta area. Our providers and staff work in a variety of settings, including our 25+ outpatient clinics, plus our contracted ‘core’ hospitals and nursing home facilities, and have been experiencing the full range of the effects from these visitor restrictions.
The Kaiser Permanente Georgia COVID-19-related visitor policy began in early March 2020 in all open clinic facilities. Strict measures banning any visitors were enforced in all cases except that minors were allowed one parent/guardian and patients with significant cognitive impairment could bring a caretaker. This strict limitation was met with significant dissatisfaction by many patients and families, especially for pregnant patients as milestones and partnership during the entire journey were missed by expectant partners and/or supportive loved ones.
In our three Advanced Care Centers, which provide 24/7 urgent care for acute illness, the impact mirrored that of surrounding facilities to include significant communication challenges for the elderly, the seriously ill and those needing hospital transfer. Since the patient’s support system of family and caregivers play such a significant role in helping with patient emotional support during and after the visit, their absence has led to gaps in effective discharge instruction communication and follow-up care execution.
Our facility-based visitor limitation experience has additional challenges. When an ambulatory evaluation results in the need for a hospital admission, the family often experiences increased stress when they are not in the room to fully understand the diagnosis and reason for transfer. Once a patient is in the hospital, the ongoing separation due to hospital-based visitor limitations, communication breakdowns and increased family and patient stress impacts the emotional health of the patient. Certainly prior to this global pandemic, hospitalization was already challenging for older, frail adults and for individuals with advanced illness or caretaking needs.
All healthcare providers aim to do their best to communicate frequently with the family and caregivers of their patients. Our physicians had to quickly adapt to the new constraints of caring for patients during this pandemic. To ensure effective family communication, they quickly pivoted from in-person conversations to leveraging video communication applications, conference calls and phones on speaker while in the room with the patient or scheduled at convenient times for the family.
Use of technology in this way helped to decrease the emotional and physical distance that the patient feels from their family and vice versa. This abrupt shift has also been distressing for the facility-based team who are also committed to providing direct comfort for their patients, particularly when the patient is facing end-of-life.
Healthcare teams worked together to provide the much-needed clinical connection between patients and their families. New processes in response to the pandemic, cohorted units, staffing changes, time-consuming PPE requirements/procedures and a sharp increase in the volume of extremely ill patients have made providing this connection overwhelming.
Providers took on the mantle of responsibility and did their best to turn this disconnection and communication challenge into meaningful moments for their patients and their families. They assumed the role of visiting family and went above and beyond to address the emotional and physical well-being of those in their care. They comforted and held the hands of dying patients in their final moments. They reassured and consoled distraught family. They advocated to get the assistance their patients needed when restrictions seemed too inflexible. They were patients themselves, missing the support of their loved ones by their sides. They were worried caregivers unable to hold their own loved one’s hands.
Physical presence of loved ones as well as communication is so valuable in the healing process for our patients. Many of us have heard stories about critically ill patients making a rapid recovery once family visitation was permitted. With the passing of time, as we moved from the acute phase into a more chronic phase of pandemic management, healthcare organizations developed a better understanding of safety processes as well as experience with the deleterious effects of strict limitations on visitors. Thus, many visitor restrictions have been slightly relaxed.
In our Kaiser Permanente Georgia facilities, we have expanded some visitor access to include key milestones or difficult conversations for our obstetrics patients and their families, or expanded caregiver support for disabled, peri-procedure or other patients with extended needs. The hospitals have also adjusted with allowances to include a single visitor the day of discharge for discharge planning, end-of-life care and during obstetrics, and neonatal intensive care services or when patients need one-on-one care. Minors, those with disruptive behavior or those who do not otherwise have the mental capacity to safely be alone while hospitalized are additional examples. Unfortunately, due to unpredictable circumstances, many hospital emergency department policies have had to maintain strict visitor limitations.
These visitor restrictions were put into place with the best of intentions during a scary and chaotic time in our community. The well-intended purpose of these strict visitor limitations was to support provider, staff, patient and family safety from COVID-19 exposures; to support physical distancing guidance; to limit indoor occupancy; and to conserve limited PPE.
Now we have seen some of the unintended, although not entirely unpredictable, negative consequences of these restrictions, including healthcare team and patient and family distress, decreased clinical care plan communication, more difficulty facilitating complex conversations and perhaps even negative health outcomes.
As we collectively enter this “new norm” phase of COVID-19, which will be with us for at least the near-term future, we must reckon with our approach to visitor restrictions in both the ambulatory and facility-based settings. We will need to thoughtfully balance the arguments for limitation with those arguments for a more lenient approach and likely settle into an in-between space where we identify patient-specific or clinical scenarios that benefit from having family present, versus less acute/significant moments where an individual patient can navigate their care on their own. Let us be open to continuing to learn in this space, and to amending our approach as needed to best support safety, clinical care and the patient/family experience.
