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Before COVID-19 hit New York City, Mount Sinai Morningside Hospital had a flexible, 24-hour visitor policy for patients in the intensive care unit (ICU).

People would visit their loved ones at any hour of the day, coming and going as they pleased. Doctors and nurses said the constant support of family members was beneficial to these gravely ill patients.

Now, per New York State Department of Health guidelines that apply to all areas of the hospital, visitors are limited to one 4-hour session per day, and only one person is allowed at the bedside at a time. At Morningside, that has to be done between the hours of 10 a.m. and 6 p.m. so visitors can undergo temperature and symptom checks before being permitted on the floors.

Morningside ICU physicians and nurses told MedPage Today those visitation policies are too restrictive, especially as staff have become more adept at managing COVID-19 transmission risk.

“It’s particularly challenging for this community because these families have a lot of restrictions,” said Mirna Mohanraj, MD, an ICU physician at Morningside (formerly St. Luke’s Hospital), which predominantly serves minority patients from Harlem and the Bronx. “Not everyone has a flexible job they can leave for 4 hours. They don’t have the financial resources to hire childcare.”

In an emailed statement, the New York State Department of Health said that hospitals “can authorize visits longer than four hours depending on a patient’s status and condition” and noted that labor & delivery patients, pediatric patients, and those with intellectual or developmental disabilities can have a support person at all times.

“This policy remains in place to safeguard and maintain the health and wellbeing of patients, staff and visitors while the need to contain the spread of COVID-19 continues,” the statement read.

The new visitation rules are a vast improvement from the disease peak, when visitors were barred from hospitals altogether and patients died alone. But while the policy may be sufficient for patients elsewhere in the hospital, it poses particular challenges for the ICU, Mohanraj said.

“The ICU is such a dynamic place, things change frequently and unexpectedly,” she said. “It’s traumatic for a family member not to be present when things are changing rapidly.”

Morningside ICU charge nurse Jessica Montanaro, MSN, RN, said while the visitation rules “make sense on regular floors, you have more grave situations [in the ICU]. You’re dealing with death and difficult decisions. In truly grave situations, people need more support. It should be a different situation for the ICU.”

Mohanraj said the literature “shows that having family at the bedside can be beneficial to patients” in the ICU, which is why many ICUs have adopted flexible visitor policies in recent years.

“Family members can provide emotional and psychological support,” she said. “Often, they’re the ones re-orienting patients, moving their legs, alerting the nurses to issues like pain control or a bedpan.”

“They’re also the constant reminder of the full lives that patients had before they got to the ICU,” she added. “And it helps the family develop trust in us as their healthcare team.”

Hospital administrators have allowed exceptions on a case-by-case basis, as called for by the state guidelines. But that means more time spent trying to cut through red tape, and the possibility of request denials.

Eric Gottesman, MD, medical director of the ICU at North Shore University Hospital in Manhasset, New York, which was also hit hard during the COVID-19 peak, said administrators there typically make exceptions to the visitor rule for end-of-life discussions.

“We follow the guidelines but if there’s an emergent issue, we do stray a little,” Gottesman told MedPage Today. “We try to bend, not break.”

Gottesman was similarly accustomed to a liberal visitation policy before COVID-19 hit. The new policy “puts more pressure on us by having to tell patients about the limitations,” he said. “Also, if we’re on rounds and no family member is present to take in the info, we have to come back and do it over.”

So what changes would ICU doctors and nurses like to see?

Family members should be able to stay for longer than 4 hours, Mohanraj said, especially if that person is the patient’s only visitor. That visitor should also be allowed to return to the bedside after they’ve left (right now, once a visitor leaves a hospital floor, they’re not allowed to return).

Finally, Mohanraj said nighttime visits would be especially helpful because ICU patients who experience delirium typically get worse at night, so the additional family support might alleviate related issues.

Safety is the first priority, she said, and thus far preventing transmission among visitors “has been perfectly manageable,” especially as very few patients with COVID-19 remain in the hospital, she said.

ICU providers in New York hospitals say the trauma of seeing families separated during the peak of the crisis has stuck with them, and makes their current push to have family members around more urgent.

In the beginning of the crisis, visitors weren’t allowed unless a patient was imminently dying — but that’s not always easy to call, Montanaro said.

“We had difficult cases where we would allow one family member to come up and stand in the patient’s doorway, say their goodbyes, and then the patient didn’t pass,” Montanaro said.

As policies eased over time, and patients could have two visitors, she recalled a case of a dying mother with three family members who wanted to say goodbye — her husband and two sons.

“That family had to choose which son would say goodbye to their mother,” she said. “So many things about that experience will haunt us for the rest of our lives.”

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