In early March 2020, the WHO declared the emerging COVID-19 infection a global pandemic [1]. From the beginning of the pandemic until March 28, 2022, 11.5 million cases of COVID-19, 653,000 hospitalizations, 55,000 intensive care unit (ICU) admissions and 119,000 deaths were identified in Spain. In the Balearic Islands, approximately 268,000 cases, 10,000 hospitalizations, 1,300 admissions in ICU and 1.600 deaths were recorded. These data were obtained from the report on the COVID-19 situation of the national epidemiological surveillance network [2]. In the hospital of Manacor, data obtained from the hospital’s database shows that during the same period, 705 patients were admitted for COVID-19. 92 were admitted to ICU and 62 deaths were recorded. We have counted the cases until March 28, 2022, since from this moment on, a new COVID-19 Surveillance and Control Strategy was established, which determines the diagnosis of all suspected cases in people aged 60 years or older [2].
The first wave of COVID-19 resulted in increased casualties among the most vulnerable, frail, chronically advanced patients, and dementia patients, causing major outbreaks in nursing homes [3–5].
These figures show the magnitude of the COVID-19 problem, considering the human, social and economic cost it has entailed both locally and globally [6]. In addition, the COVID-19 pandemic has put the health system to the test in areas such as the restructuring of hospitalization units and surgical units throughout the country, increasing the number of beds in intensive care to face the demand for care caused by contagion.
During this crisis, the health authorities recommended strict isolation and home confinement to minimize the risk of contagion and to ensure acceptable epidemiological levels and avoid collapsing health centres.
The restrictive health and safety measures conditioned the way patients were cared for, as well as their social and family lives [7]. There is evidence that the health of the most vulnerable and fragile people from a biopsychosocial approach worsened due to isolation and confinement [8–11]. This situation caused an increase in the consumption of psychotropic drugs, demands related to chronicity, and a delay in urgent surgical interventions among other causes, leading to an increase in morbidity and mortality [12–15].
On the other hand, prolonged use of personal protective equipment (PPE) was one of the reasons for increased difficulties in communicating effectively with patients [16]. Altisent explains his experience as a physician and patient for COVID-19. He explains how he felt both physically and emotionally vulnerable, and how he greatly appreciated the treatment received by professionals and the importance of small details to prevent everything from collapsing, experiencing what compassion means [17].
Given the social and health impact caused by the COVID-19 pandemic, due, among other factors, to the large number of infected people and the need to protect the population from contagion and avoid intrahospital outbreaks, strategies were designed. These policies established visiting guidelines for patients with poor immediate prognosis [18]. Most of these recommendations restricted visits by relatives to patients admitted to hospitals, nursing homes, social and primary health care centres, causing a situation of fear and shock among citizens [19, 20].
In the Balearic Islands, in April 2020, the Sub-directorate of Humanization, User Care and Training of the Health Service of the Balearic Islands, in collaboration with the Son Espases University Hospital and the Sub-directorate of Care Care proposed a visitors’ policy for all hospitals in the Autonomous Community during the pandemic. They aimed to improve visitation and the emotional well-being of admitted patients and their families. To prepare the charter, they based it on the recommendations of the Ministry of Health, Consumers and Social Welfare [21]. They identified as a key point the prevention and control of infection in the management of patients with COVID-19 where it is specified that family visits must be made following the protocols of each hospital. If allowed, they should be restricted to a single person and if possible, always the same person. In the case of minor patients or those who need accompanying, the companion must take the necessary measures to protect themselves by wearing PPE. The document clarifies that visits are subject to the availability of adequate PPE, alternatives to face-to-face visits must be prioritized, such as video calls and others which may facilitate family support. On the other hand, if there are limitations to visits, it is necessary to prioritize those to patients who are in their last days. In the hospital of Manacor, the members of the COVID-19 Commission consisting of different services relevant to the organisation, adapted the recommendations to our context. They aimed to contribute as much as possible to the emotional well-being of admitted patients and their families, and depending on the health situation, proposed the least restrictive measures as possible, while always guaranteeing the safety of all those involved.
During visiting hours, the family member or caregiver could remain in the room with the patient with COVID-19 for a maximum of 15 minutes. The family member or caregiver could stay 24 hours a day with the patient, assuming a risk of contagion and then several days of quarantine at home when the patient was discharged. These measures were reviewed and adapted according to the epidemiological evolution of the disease and the vaccination of the population.
When the patient or family member expressed the need to visit, or a professional detected this need, the Case Manager Nurse (CMN) initiated a series of actions so that the visit could be carried out. The CMN conducted an interview with possible visitors to identify the family member or caregiver with the least risk to their health. Those allowed would later be informed of the risks of contagion, of the compulsory nature as well as the use of PPE and asked to sign an informed consent.
For patients admitted during the pandemic due to other non-COVID-19 conditions, visiting was also restricted. Depending on the epidemiological situation, restrictions varied accordingly. Generally, a family member was allowed to visit for one hour twice a day. Visitors were allowed for the most vulnerable patients with dependence, dementia, end of life and other cases at the discretion of the patient's referral team, family member or caregiver. As of January 2021, and during times of higher incidence, weekly SARS-CoV-2 PCR controls were carried out on all non-COVID patients and their companions. This made the organization of visits easier.
The objective of this study is to explore the experiences and perceptions of patients and their caregivers on visitor guidelines during hospital admission in the COVID-19 Pandemic. To this end, we analyse the perceived impact and improvement strategies proposed by patients and caregivers to be later included in future health crisis guidelines or protocols.
Premises and reflexivity
The team consists of researchers with differing experience and professional backgrounds. Some were clinical researchers and managers who were directly linked to the care of COVID patients or who were members of ethical or clinical committees during the pandemic. Others were researchers outside the hospital, experts in qualitative health research, and specialising in qualitative data analysis. Researchers start from a series of reflective premises that make up the reflective positioning of the research team. On the one hand, we consider that the knowledge and experiences of patients and relatives in relation to hospital visitor guidelines during the pandemic are key points for the review and edition of future protocols or interventions in similar crises, such as the one experienced with COVID-19. On the other hand, we believe that the experiences, opinions and perspectives of patients and relatives are relevant data for the revision of existing visitor guidelines and thus focus on them, making policies more participatory and humanizing.
Objectives
General objective: To explore the experiences and perceptions of patients and caregivers on visitor guidelines for patient care during hospitalization in times of COVID-19 pandemic.
Specific objectives:
- To analyse the personal and family impact perceived by patients and caregivers by visiting policies during hospitalization in the pandemic.
- To identify improved strategies proposed by patients and caregivers in relation to visiting policies.