Ms. M, an elderly woman with limited English proficiency, arrives in our emergency department after she was found confused on her kitchen floor by EMS. She is alone, frightened, and unable to meaningfully communicate with her medical providers. Her daughter is anxiously waiting outside the double doors of the emergency department; she pleads to see her mom. We’ve changed the details of this encounter slightly to protect patient privacy, but it’s one of so many similar interactions both of us have had over the course of the pandemic. All we can do in these instances is repeat the same phrase we’ve said too many times over the past 12 months: “I’m so sorry. Our policy during COVID is that we can’t have visitors right now.”
In the early months of the pandemic, cities around the country passed ordinances restricting visitors in hospitals to protect patients and health care providers from the spread of COVID-19, as well as conserve the dwindling supply of masks. These restrictions set the stage for some of the most heartbreaking stories of the pandemic: older patients who became disoriented without their children, young women birthing babies without their families present, and patients saying goodbye to loved ones in their last hour via an iPad. Many hospitals continue to restrict the number of visitors and maintain limited visiting hours, even for patients who are imminently approaching the end of their life. As the number of COVID-19 hospitalizations and deaths decline nationally, and with more than half of all adults in the U.S. having received at least one dose of the COVID-19 vaccine, it is time to phase out visitor restrictions in our hospitals.
Evidence shows that the risk of contracting COVID-19 in a hospital is low. In a contact-tracing study of patients exposed to health care workers with confirmed COVID-19 in Boston during a time of high community prevalence, only one case of possible transmission was found. The study defined exposure as an extended encounter in which either the patient or the health care worker was unmasked—suggesting even lower rates of hospital transmission in the setting of universal masking. Another study of 9,000 patients found only one case of hospital-acquired COVID-19, even before visitor restrictions were implemented. Although COVID outbreaks have occurred in hospitals, they have been rare and usually involve situations with inadequate personal protective equipment. Hospitals have largely been relatively safe thanks to precautions such as mandatory masking, social distancing, and rigorous testing and screening protocols. It’s true that visitor restrictions have likely helped keep hospital-acquired cases low, especially before we had vaccines. But they’re a precaution that came with a large cost and now, arguably, diminishing returns.
We’ve seen firsthand how damaging it is to continue disallowing visitors. Front-line health care providers like us have witnessed the physical and emotional isolation of patients in the hospital, especially those in the intensive care unit. The absence of family members has underscored the vital role they play in care delivery and healing. Loved ones participate in shared clinical decision-making and patient advocacy. Family members write things down, ask questions, and may even catch discrepancies among recommendations from different providers. They are particularly important for patients with limited English proficiency and those who may suffer from dementia, hospital-acquired delirium, or other medical and psychosocial conditions that limit their ability to interact with medical staff. No matter the patient, the presence of a loved one makes us slow down and be better clinicians; their questions may trigger additional thoughts and ideas, or even uncover impending medical errors. In fact, physicians are even more likely to follow proper hand hygiene protocols when others are in the room. Medical research has consistently shown that including loved ones in care planning for patients reduces hospital readmissions. A 2017 survey suggested that 2 in 5 caregivers feel that they have insufficient information to best care for patients at home. This failure could only have been worsened by pandemic visitation restrictions.
Hospitals have tried hard to bridge the gap created by visitor restrictions. Many institutions built inpatient telehealth infrastructure to keep hospitalized patients connected with loved ones. By engaging loved ones over video, providers have tried to keep them included in shared decision-making, goals of care conversations, and even end-of-life care. Although a helpful stopgap in a time of crisis, two-dimensional screens just aren’t enough. Episodic video calls cannot replace the family member who is present at the bedside day and night. Telemedicine cannot replace the son or daughter who knows which milkshake to order from the cafeteria, knows the names of all the floor nurses, and can pick up on minor clinical status changes—sometimes before we can. Furthermore, some individuals from lower socioeconomic backgrounds may lack access to the computers, tablets, or smartphones needed to engage in video visits, while others, including the elderly, may lack digital literacy.
This isn’t an all-or-nothing proposition. In regions with surging community transmission, such as Michigan, it’s prudent to maintain visitor restrictions to ensure patient and staff safety. But in areas where vaccines are widespread, and cases are lower, more visitors could be allowed safely. By using the number of active COVID-19 cases, community prevalence, availability of PPE, and access to testing, health systems can relax visitor restrictions in a stepwise manner. The hospital system where we work, UCSF Health, developed a four-tiered approach, where more or fewer visitors are allowed based on how the numbers look. This tiered approach not only reduces risk even further in the event that cases rise, it also has helped mitigate the burden on front-line workers to enforce general PPE guidelines. The institution has also built a contact tracing and infection prevention program that has enabled the hospitals to both study and maintain rigorous control over SARS-CoV-2 incidence and transmission in clinical settings. Notably, the emergency department remains one of the most challenging settings to safely reintroduce visitors and maintains the most stringent restrictions, given that many patients present with symptoms that mimic COVID-19, such as cough and shortness of breath, and must be presumed positive until they can be tested. Equipping visitors with appropriate personal protective equipment and expanding widespread rapid testing can enable loved ones to safely enter our emergency departments again, where important collateral information can shape the course of a patient’s clinical trajectory.
For front-line health care workers, uncertainty and fear characterized the first several months of the pandemic. PPE policies changed daily, caseloads rose each week, and unintentional exposures sidelined colleagues. While we were heartbroken watching our patients suffer alone, visitor restrictions seemed necessary to protect both our patients and ourselves from the spread of COVID-19. With more than 100 million Americans vaccinated and broad access to reliable, rapid testing, we now have the tools to reopen our hospitals safely. History may judge us harshly if we do not.
