Podcast: Relaxing hospital no-visitor policies
Transcript
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Andreas Laupacis: Today we're going to talk about hospital policies about visitors during the covid 19 pandemic. At the start of the pandemic, most hospitals in Canada adopted a kind of, quote "no visitors policy", because of concern that visitors would spread the virus both within the hospital and in the community. It was also a way of preserving personal protective equipment, which at the time was in short supply. But now with almost a year's experience under our belt, the authors of a commentary published in CMAJ argue that it's time to reconsider such a strict policy. I'm Andreas Laupacis, editor in chief for the Canadian Medical Association Journal, and today I'm talking to one of the authors of the commentary, Dr. Fahad Razak, a general internist at St. Michael's Hospital in Toronto, Lee Fairclough, president of St. Mary's General Hospital in Kitchener and Corinna Riquelme, who is a caregiver and a member of the Patient and Family Advisory Council at St. Mary's. I reached Fahad in Toronto, and Lee and Corinna in Kitchener. Welcome.
Corinna Riquelme: Thank you.
Fahad Razak: Good to be with you.
Andreas Laupacis: So maybe I'll just start by asking maybe Lee first, how things have been regarding COVID-19 in your hospital recently, now that we're well into the second wave?
Lee Fairclough: Our hospital certainly has seen an increase in the individuals that we're caring for that have COVID and as well, those that we suspect may have COVID-19, and those that have been exposed. And I think what's really different in this wave is the degree of community spread that we're seeing. Our region is in red level at the moment, which means that we do have quite extensive community spread. So right now at our hospital, about 27% of those that are staying with us are there related to COVID-19. In addition, we also have two outbreaks in our units, which means that there's been some evidence of spread within each of those units. And have you had to cancel elective surgery? Yes, we have started to ramp down surgery that requires an inpatient stay. And then we are making decisions, day to day, about some of the procedures that we're able to proceed with. We are a Cardiac Center, and so we are of course maintaining all urgent and emergent. And we're doing what we can to maintain some of the day surgery that of course was cancelled in wave one. But where we stand today, we are now starting to plan for some additional reduction.
Andreas Laupacis: Wow, sounds super stressful. Fahad?
Fahad Razak: Yeah, I think we've been much more fortunate than many of the other hospitals in the province in the second wave. So we're still seeing pretty low numbers on the general medical wards, less than five patients now with COVID, and the ICU's also don't have a significant number. I think a lot of that reflects the pattern of where the outbreaks are happening now. They're largely in suburban regions, regions that have essential workers, and really haven't been concentrated yet in the downtown areas. And the other major difference is that we had outbreaks in homeless shelters and places like that which had high density and spread during the first wave, which led to a lot of admissions, and we haven't seen that this wave. The other major difference I would say from the first wave is that there really was a reluctance, probably on the part of the general public, to come to hospital during the first wave because of fear of exposure perhaps, or other factors, and so our total hospital admission volume was extremely low during the first wave. That has not happened in the second wave. So we're running at 80 to 90% capacity, and that's driving a lot of the concern about even a small uptick in COVID cases could push us over census and lead to cancellation of surgeries.
Andreas Laupacis: And Corinna, what's it been like from your perspective?
Corinna Riquelme: Yeah, from my perspective, it's been a really interesting journey this past year. I had both my parents in medical situations for much of the year and they both ended up passing away this past year. Interestingly I thought from the perspective of pre-COVID, my mom had passed away this past November and then my father ended up getting ill and was in hospital in a long term care facility right at the start of the COVID pandemic. And so from my perspective, having gone from the ability to be with my mother on a regular basis and be in the hospital to support and play a major role in her care, and working very closely with hospital staff, to being in a position where we were restricted right down to the point of no visit patient, and at the time really care partners was very limited. The concept of care partners was very limited. And we ended up being allowed, I was allowed, to be in with my dad pre-surgery up to the point that they took him away. And that was actually the last time that I saw him again, you know, before he went into surgery. He went back to the home and with the COVID, we just were not able to be there for him in the way that we wanted to. And we saw the suffering it caused him, you know, it was difficult for him, it was difficult for the staff working with him at the hospital and at the home, it was really stressful. So, knowing the importance of having people with their families and loved ones in this situation is extraordinary, but understanding that it's such a privilege to be given that opportunity to be close to them right now based off of what we've learned in this past year, and where we're going with COVID and trying to attempt to still allow the folks to be together when we could, but still maintain the safety and security that we need to do for the community and to avoid the spread of infection. So it's been a really interesting journey from my perspective as a caregiver and as a family member.
Andreas Laupacis: So condolences about the passing of both of your parents and makes me even more grateful that you're willing to share your experience on the podcast. So thanks very much.
Corinna Riquelme: Thank you.
Andreas Laupacis: Fahad you're a general internist. Why did you write this commentary and your colleagues?
Fahad Razak: Yeah, my condolences as well, Corinna. So I think your story is something that was an important factor in the kinds of experiences that we were seeing during the first wave when visitor restrictions became quite significant. Myself and the colleagues who wrote this are an intensive care physician and an infectious disease doctor. And all of us were talking about the experience of having to care for patients with no family or caregivers present and how different that was than anything we'd seen at any point in our career. And at first, we noticed small things. We would get very frequent phone calls for updates but it progressed well beyond that. We would sometimes spend hours over days on the phone, speaking to family members and trying to give updates, but you could hear the concern, and there's only so much you can do by phone calls. Sometimes when someone is really sick, you're trying to describe what you're seeing but the family member, that caregiver, is not able to actually see the patient. And we noticed a lot of dysfunction arising in decision making that otherwise, we were able to support families through difficult decisions around end of life care, when there was different therapeutic options available, and families had to help a patient decide who is potentially no longer capable. Those became very difficult to do and often the decisions would linger for days and days and days. And the experience of that led us to bring up this topic to the provincial Science Advisory Table which myself and the co-author sit on. So the province struck up a Table in September and we were able to advocate for this being a topic to do a formalized literature review on. So, the question was, how effective are these visitor restrictions? Is there strong evidence to suggest that they are necessary? And what is the harm that's being caused? So the flip side is, maybe you are preventing some COVID transmission, but what is the harm that is caused by preventing family and caregivers from being at the bedside? So that was that was the motivation for writing this commentary.
Andreas Laupacis: Maybe I'll ask you to answer your two questions and then I'll ask Lee for her thoughts about this.
Fahad Razak: Yeah. So you know, in brief, I would say the most important thing to realize is that our understanding of this illness is extremely limited. And so I think as a scientist, and as a physician, I want to be humble in saying that we were able to summarize the evidence that's out there, but that is not the only way to make these kinds of decisions. And I respect and understand the reasons why hospitals implemented these policies. We were really afraid during that first wave, we're afraid now during the second wave, and there was really a desire to protect staff, protect vulnerable patients. And so I understand why these restrictions were made. That said, COVID has been one of the most intensely studied areas in human history. So it hasn't even been a year since we've had COVID-19 and there's more than 75,000 research articles that have now been published on it. And we completed a systematic review of the articles that are published and the evidence to show that visitors were an important mechanism of disease transmission, either to other visitors or to healthcare staff, or that visitors themselves would get exposed, was very limited. And you know, I'll give one example: So there was a study of more than 9000 people conducted in the United States, hospitalized patients. About 700 of them had COVID and they looked at how many of those 700 could be plausibly explained by a hospital related exposure, either by a visitor or from a patient to a visitor, and they only found one example in that entire study. So it suggested that the rates were very, very low. There's other evidence like that as well. Now, again, it's not that it's been extensively studied, but what evidence was available suggested that visitors were not a major mechanism of disease transmission. And just on the other side, I can say briefly, Andreas, the evidence for visitor restrictions causing harm for patient care is extensive and has been accumulated over decades of research. And it covers broad areas and includes things like family members and caregivers being important advocates for patients, especially for patients with reduced ability to make decisions because of cognitive impairment, or disease, or for patients with language barriers. There's a lot of evidence to support families being crucial for things like personal care, feeding, mobility for patients. One of the most feared complications in hospital is delirium, hospital acquired delirium. This is a acute confusional state where there's increased mortality, and many patients don't return to baseline. And there's good evidence to suggest that having caregivers and family at the bedside reduces rates of delirium. So those are some concrete examples. But it does highlight that there is very concrete harm from these visitor restrictions.
Andreas Laupacis: Lee, what are your thoughts as a hospital president who, you know, you need to think about your staff, you just got a lot of things to think about.
Lee Fairclough: I mean, I think Fahad has summarized all of the issues that we would be weighing when we were trying to make these choices and decisions. When I think back to the day, which is a very vivid day in my memory, actually, where we had to make the choice to reduce visitors coming into the hospital, it was a very tough decision. And part of that was because of the experience at Princess Margaret Hospital during SARS. I remember when we made that choice and I remember the impact that it was having, and so it felt very difficult to go back to that place. But as he said, you know, there was a lot of fear of what we were dealing with, we were the regional respiratory center so we saw all the cases come very quickly to hospital and to our hospital. And so we did reduce visitors to the building, we always allowed entry, though, for compassionate reasons and also at the discretion of the care team, if it felt it was going to change the course and the outcome for a patient to be able to allow somebody to come in. So that was that was the approach that we took. Through it, I would say though, we all learned that, you know, that was probably scaling back too far. Certainly, I also worked on the ground in some long term care homes, through some of the management orders and saw the effect and spoke directly with families about the effect of that. So as we approach wave two, I think we've had a very different mindset. One of the distinctions I think all of the hospitals in our regions here in Waterloo Wellington made, was this distinction between a care partner versus a visitor and we liked this. This was some work that has certainly been developed through the years with The Change Foundation, we like this approach, because it really put the choice of who was coming to visit with you, with the patient themselves. So our care partner approach was for patients to define sort of who would they like to have visit and be part of their care, and that you would see those individuals actively supporting and actively being part of their care. And so, since really through wave two up until just this last week, we had an approach in place that allowed people to define at least two of those individuals, that they had flexibility and how long they stayed. We increase the hours that people could visit so we can spread people out and not have as many people in the building at the same time. And we've had care partners coming in for people coming for day procedures as well, and we've maintained that as long as we could. I would just say though, the degree of community spread now has made this very complicated. And so in the last, just this last week, since we've had the two outbreaks, certainly for the outbreak floors, we have limited that now for care partner visits for compassionate reasons only, and of course, we've supplemented as much as we could with virtual visits. And then the rest of the hospital we've now moved to one defined care partner per patient, defined by the patient for an hour each day and part of the reason for the hour is just the risks of the eating and drinking throughout the building. There's two parts to it: One is that people are, you know, going up and down, and then eating and drinking and in different spaces but also, we need break spaces for our staff, where they can safely space out as well to be able to eat and drink, etc., unmasked. So we know, you know, these are hard choices for us. We certainly did share that with our Patient Family Advisory Committee. Again, I think it's been - there's an understanding of the complexity that we're dealing with through this wave, and even when we're trying to do our tracing and understand all the different ways that COVID could be coming in the building, we have to consider, as well, care partners as part of that. So that's where we are today. We've scaled that back quite substantially in most areas.
Andreas Laupacis: Corinna, do you want to - I'm sure you've been involved in this in your role in the Patient and Family Council? And then you said that you, yourself, was care partner for your dad during COVID?
Corinna Riquelme: Yeah, I mean, you know, everything that's been said is, you know, is 100% bang on. I mean, we certainly advocate to have the care partners there, but within the reason and the scope of what makes sense for the community, for hospital, and for the safety of everybody involved. So I think, you know, it's coming at it from the perspective of working together and making sure that the voices of the patient are still heard, but overlaying that with the situation of where we're at knowing that it's always fluid. And, you know, we really have to adapt quickly to the changes of the virus and what's happening in the community and working with our partners at the hospital, to make sure that we're doing the right thing for the right reasons, and making sure that that's communicated forward. So I think we've done a really good job of partnering that way, and then pushing that communication, both through internal communication methods, and also getting out to the general public and through all of the doctors and other offices that work alongside the hospital and trying to get this moving along. So I think it's just remaining fluid and aware of the situation and adapting to it accordingly and I think so far, it's worked really well. And I think that, especially being on this side of the fence now and saying, you know, what a tough decision it is to draw back on what we've done up to this point, you know, it has to be for the right reasons, and it is for the right reasons. And I think I as a care partner and I as a family member, do you understand that, and I need to pass that message along, you know, to other members of our PFAC committee and as well, to just people in the community in general.
Andreas Laupacis: Corinna, when you were being trained how to put on PPE as a care partner, how did that go? And was there inconsistency or consistency among the staff in terms of training you and making sure, you know - when I'm sometimes out on the street, and I see people wearing a mask that sort of hanging down below their nose. Tell us a bit a bit about that, and how that went?
Corinna Riquelme: I think the training in and of itself has been relatively consistent. I think, where you start seeing the slip is people getting lax about what they're doing or how they're doing it. But I think when the training comes from a professional environment, and from the folks who are trying to manage what's coming in the door, you know, it's been very good, been consistently good and clear, and again, it's been through different hospitals that I've been at, through long term care facilities. And then again, it's our job as the care partner, the person at the bedside, to make sure that we adhere to those procedures, and that we apply it accordingly. And quite frankly, help others who are in that boat who may not have that same level of understanding and guide them through that process as well.
Andreas Laupacis: Lee, are there problems - I mean, there are, I imagine there are people that might have trouble sticking to the rules or might even sort of be COVID deniers. Has it been a big issue for you to, sort of, enforce?
Lee Fairclough: Yeah, I mean I think that what we have seen, I would say, you know, as we've worked through this, through wave one and the start of wave two, I think that people were very understanding. What we have seen, you know, I would say, at different time points in this wave, we have been dealing at times with people that want to refuse to wear a mask, certainly we're sensitive to those that for medical reasons cannot, but we have had situations at the door where people were sort of insisting that they that they wouldn't want to do that. I would also just say, you know, I think to Corinna's point like that, the compliance when people are up on the floors and elsewhere, has not always been perfect. And I think, you know, as I talked to staff even the other day about this issue, they are feeling very torn, because everybody knows the value, they see the value of having care partners coming to be with their loved ones, but at the same token, especially with the level of community spread, and now seeing outbreaks - I mean, we've got outbreaks at four of our five hospitals in this region - you know, people are increasingly concerned. And so when they're seeing some level of non compliance, it's making them nervous. And so, you know, I think these are all of the things that we've been trying to balance, and then weighing that, again, with the degree of community spread, and once you get to a certain tipping point, that's why we've had to make some adjustments to balance those different stresses.
Andreas Laupacis: How do you, maybe a question to all of you, but I'll start with you Lee. I mean, this has got to be a super emotionally tough thing, making the big policy decisions, and then people on the frontlines, the security guards and others, sort of, trying to enforce them. What's it been like, emotionally? And how have you supported each other and tried to deal with that?
Lee Fairclough: Yeah, I mean, I think that, you know, for those that are at the doors and security, etc, as I say, a lot of people, I would say, have been good about it and you can speak to them. There have been moments when things have been confrontational, and we work to try and support them. And again, at a certain point, you know, that's when you start to hear a little bit more about, "are we doing the right thing here?" You know, I would say as well, throughout this pandemic, we're all being faced with options that are both poor decisions, right? They feel like poor decisions from what we would normally do. And, you know, there's really no best answer because neither of them are ideal. And so one of the ways, we just talked about it openly that way, you know, I think it's important, I mean, to me to move to the level that we did this week. You know, that was a very tough decision for us all. We all understand the implication of it. I think we like to see them as temporary and know that we will work to find our way out of them when we can. So that's sort of our commitment. And I think the way we stay grounded is making sure that we're retesting that all the assumptions that lead to a choice still hold, and is it time to shift back again?
Andreas Laupacis: Fahad, being a general internist is a tough job at the best of times, it's super busy, you're looking after many, many sick patients. Has COVID, and particularly the visitors policies, made it different for you when you wake up and go into work.
Fahad Razak: Yeah, absolutely. So the kind of medicine that general internist do is the typical admission for a COVID patient, about 80% of hospitalized patients will end up on a general medical type ward. And so, we are doing the majority of care for hospitalized patients. And it was it was a scary time, the degree of personal protective protective equipment you'd have to wear to ensure protection during the first wave wasn't completely clear and there was conflicting advice. I was on a team where one of our health care staff had become positive while we were working together and we were in conference rooms and things where, while having coffee, while reviewing patient cases in the morning, we'd taken our masks off, and so everyone was worried. So there was an exposure worry that we all had, on the patient side, the personal experience of trying to be a substitute for family members. We had a few patients die with COVID, during the first wave when I was on and caring for patients, and that was really difficult. And I remember one case that really stuck with me, and really made it much more real for me, which was someone who died very early in the first wave of the pandemic, whose modest belongings that had come with him to the hospital. No one was sure whether it was safe for the families to get them afterwards, because we didn't know enough even about surface transmission about the disease at that point, and the decision was made at that point, and the family agreed but it was just heartbreaking on all ends, that the personal possessions wouldn't go to the family afterwards. That was a an example that I don't think I'll ever forget. And I'll just start from a research perspective, there has been a little bit of research to look at the impact of health care staff of visitor restrictions. And there was a study done in France during the first wave, where they looked at the experience of healthcare staff as the heavy visitor restrictions came on in the hospitals. And a significant driver of lingering depression and anxiety among the healthcare staff was regret about the visitor policies about the strictness of the visitor policies. And probably a lot of that was driven by the experiences that I'm describing, trying to act as a placeholder, seeing these really tragic situations when there was no family when someone died.
Andreas Laupacis: Corinna, I mean, you've got kind of two roles: You're representing and speaking out for patients and families, yet at the same time, you're a member of a committee, that's part of the hospital that's got that responsibility. How's that been for you?
Corinna Riquelme: Um, I mean, I'm very passionate about the entire process on both sides of the spectrum. And it's been, you know, again, just sitting and hearing everything from the hospital perspective, and getting that full picture and looking at it from all angles has been a real eye opener in a lot of ways. There's always the assumptions that go through your head on why decisions are being made and how things happen and I think what it's really led to me is just how intensive these decisions are, you know, there's a lot of thought put forward into it, there's a lot of pros and cons discussed, there's a lot of issues brought up and a lot of differing opinions that are looked at and assessed. And I think it's just made me appreciate even more the policies and the decisions that are pushed down through the hospital out to the community, and it allows me to see really how much work and effort, and sometimes it's gut wrenching to see, you know, what these decisions are. But being on the other end of it, then, you know, I feel like, it's my responsibility to make sure that people in the community are aware that there is a lot of thought, it's not just, you know, people making decisions willy nilly. And, you know, somehow it's to the benefit of the hospital or the medical team. It really is advocating on both sides of the fence, you know, from the family perspective and making the decisions and putting it forward, and making sure that voices are heard across both sides of the stream. So it bridges any gaps and hopefully, will bring to light, you know, just how important communication is across these factors in these committees, in these working groups, right down through to our community discussions and what, you know, people who are coming into the hospital here and now. So it's just been a real eye opener for me, and it's been, you know, I feel like it's something that I wish more people could have the experience of going through, because I think it's just really almost life altering, and knowing and experiencing, and seeing what, you know, what happens, you know, at the end of the decision making process and right through to how this even got to a point where it's a decision to be made.
Andreas Laupacis: And maybe you have experience with new ways, or innovative ways, of communicating with the community about what you've said?
Corinna Riquelme: We tend to focus very much on social media. There's flyers and postings around the hospital. You know, I know for myself, because of the fact that I work closely with the public and I have, you know, a job that I go to, I bring it up whenever I can, and I bring it up through forums that way as well. I mean, COVID has hit us in so many levels, not just in the medical community, but just in our personal lives. So for me, you know, I kind of get on my soapbox whenever I can, and speak about, you know, what's been going on how it's happening. I stay close to what I hear on the radio and through the service resumption meetings and our PFAC meetings, and from there, you know, I just try to advocate and speak through it through whatever means I have, whatever actions I can take outside of the normal streams of communication that come through, through website changes, and through any other brochures or documentation that gets put up for the hospital.
Andreas Laupacis: Are there any - it's always sort of dangerous to think that technology is going to solve a complex problem - but is there anything on the horizon that might make this a little easier, like rapid testing, for example, or the vaccine coming out?
Lee Fairclough: Yeah, I mean, I think that we've talked about rapid testing, and seeing about the potential for that, particularly if we wanted to get to a place where we could more easily test more care partners that wanted to come in, let's say, if you wanted to set similar expectations, even that we have in long term care homes today. You know, in terms of vaccines, I think we're all hopeful aren't we about vaccines? And, you know, thinking through what that might mean, once we get to a certain level of vaccination in population, and certainly that offers some hope, I think, for not just care partners, but all of us in the community and for sure, health care workers as well.
Andreas Laupacis: That's not on the immediate horizon. That's not going to affect your policy in the short term.
Lee Fairclough: Not in the very immediate until we can get to a place where, you know, and I think that there's been some criteria that have been set, you know, for where the initial vaccines will come. Sounds like they'll be coming in relatively small batches. And so, you know, I do think that with time, you know, we should really think about how they should fit in with our policies, both for our staff and and for their partners.
Andreas Laupacis: Maybe I'll just ask whether there's any last comments as to three of you?
Corinna Riquelme: Yeah, I mean, I think I just would end it by saying that being given the opportunity to be a care partner is really giving voice to our patients, especially when it comes to decision making in, you know, the short and long term goals, through the recovery process. You know, just allowing the patient medical staff to recognize and support each other through the experiences and capabilities that we can bring forward, encourage the sharing of information, and empowering those decision making processes that we all need to go through. So I think it's just really added to that patient engagement that is so vital and so necessary to bring somebody, hopefully to keep them aligned, and bring them through rapid health, or at least to provide them with the comfort and to know that they're being looked after and that they have a loved one nearby to support them.
Fahad Razak: Yeah, maybe I'll just close by, you know, one of the ideas that we put forward towards the end of the article, which is that there is a risk that we may have over learned part of the lesson from SARS. You know, the post mortem report that was written by Justice Campbell, suggested that the default for Canadian healthcare after SARS be to adopt the precautionary principle, which means that you don't have to wait for science to make a decision when there's plausible risk. And that was one of the criticisms of how SARS was managed, that there was a delay that shouldn't have occurred. I think the situation with the COVID-19 suggests that we cannot be certain on the science to say that visitors don't have a role. I think what little signs that we see suggests that it's not a major part of transmission, but we have to be humble about the disease. But there is a lot of evidence for harm when you keep visitors and when you keep family and caregivers away from patients, especially critically ill patients. And so, I hope there's consideration of a slow relaxing of some of the tighter visitation policies, but that has to be accompanied by very careful measuring and monitoring to detect an outbreak if it does occur, to adjust policies if there is new evidence that emerges. I hope that's something that the article, at least a discussion, that the article may trigger.
Andreas Laupacis: That's something it sounds like I heard Lee saying that her hospital is doing exactly. Lee you want to final comment to you?
Lee Fairclough: Yeah, I mean, first of all, I also want to just say thank you to Fahad and the team of researchers that pulled that evidence together in the way they did, I think it's going to be very valuable to have that. I completely agree. I mean, I think this is something we have learned throughout this pandemic, and we've also learned it needs to be a very dynamic process of decisions and reevaluating as we go. I really would underscore that comment that you made Fahad and, you know, I think at the end of the day, all of us that are working in hospitals certainly do know the incredible value of having care partners as part of care teams, ultimately. And so you know, we need to really keep these things in balances as we go.
Andreas Laupacis: So listen, I'd like to thank all three of you, Corinna especially given the personal circumstances that you've gone through in the last year, for joining me today. Thank you very, very much.
Corinna Riquelme: Thank you so much for having me.
Lee Fairclough: Thank you very much.
Andreas Laupacis: I've been speaking with Corinna Riquelme, Lee Fairclogh and Fahad Razac. To read the commentary that Fahad was a co-author on published in the CMAJ, please visit cmaj.ca. Also, don't forget to subscribe to CMAJ podcasts on Soundcloud or a podcast app. Let us know how we're doing by leaving a rating. I'm Dr. Andreas Laupacis, editor-in-chief for CMAJ. Thank you for listening.