Review Article - (2016) Volume 3, Issue 1
Department of Obstetrics and Gynaecology, Mater Dei Hospital, Malta, UK
Received date: January 26, 2016; Accepted date: February 27, 2016; Published date: March 03, 2016
Citation: Baron YM. The Case for Extending Visiting Hours at Mater Dei Hospital. Health Syst Policy Res. 2016, 3:1.
Background: The current visiting hours at the main General Hospital in the Maltese Islands, Mater Dei Hospital are 2¾ hours. In most European and North American hospitals visiting hours are significantly higher, ranging from 5 hours to unlimited visiting times. Methods: Extended visiting hours encourage greater participation of the family members and friends in the care of patients. Scientific evidence indicates that unlimited visitation policies lead to improve patient morale, safety and outcomes (lower heart rates and lower blood pressure). Findings: Family members may assist in mobilization and nutrition of patients. While in hospital the informal careers may acquire obtain “in-house” training as how to continue care at home. This assistance may result in reduction in length of stay and attenuate the risk of long-term institutional care both factors diminishing the pressure on the beset hospital bed-state. Conclusion: Extended hospital visiting hours allow greater freedom of family and friends to visit inpatients elevating morale, encouraging in greater family/friend engagement in the patients’ care ultimately improving patient outcome.
Keywords
Visiting hours; Family engagement; Patient safety
Introduction
Family and close friends of patients are increasingly being viewed in modern Healthcare systems as partners in care rather than passive bystanders. A vital aspect in encouraging family and friends to contribute as partners in care is the modification of restrictive hospital visiting hours.
Literature Review
Scientific evidence is unequivocal in demonstrating that the informal career is crucial in the post hospitalization stage in the continuity of care. This translates into reduced readmission and less relapse in chronic condition [1].
It is now becoming apparent that engagement of family members and close friends during hospitalization has significant positive effects on inpatient care [2]. Moreover restrictive visiting hours may have an adverse effect on this partnership in care [3]. An important recent modification in U.S healthcare provision which catalysed the concept of family/friend partnership in patient care is the removal of restricted hospital visiting hours [4].
The international literature indicates that in the main most hospitals allow visiting hours from 8.00am till 8.00pm. The range in visiting hours varies from unlimited “open” visiting hours to a low average of 6 hours. Unique of European hospitals in the range of hospital visiting hours is found in some Italian hospitals allowing visiting hours of only 1-3 hours [5].
In the U.K. hospital general visiting times are between 11.00 am till 9.00 pm (U.K. HealthCare). Moreover recently British nurses are suggesting that visiting times be actually lengthened [6]. In French Hospitals, visiting hours are unrestricted however emphasis is made that the interval from 2.00 pm till 4.00 pm is designated as “quiet time” and beyond 8.00 pm visitors are encouraged to leave. In Germany the local ethos of work demands that visiting times are only allowed between 2.00 pm till 8.00 pm (Table 1).
| Hospital Name | Visiting Hours | Total Number of visiting hours/day |
|---|---|---|
| Mater Dei Hospital | 12:00-12.30pm;3.45-5.30pm;7.30-8.00pm | 2¾ hrs |
| New York-Presbyterian Hospital USA | Open visiting hours | 24hr |
| Rome Memorial Hospital USA | 11am-8pm | 9hrs |
| Dignity Hospital France | 10:00pm to 2:00pm 4:00pm to 8:30pm | 8hrs |
| UCSF Benioff Children'sHospital USA | Generally 11 am to 8 pm | 9hrs |
| Cedars Sinai Hospital USA | General Visiting Hours - 10 am to 9 pm | 10hrs |
| Greenwich Hospital UK | Visiting Hours. 12noon – 9pm | 9hrs |
| American Family and Children’s Hospital | 24 hours a day, 7 days a week). | 24hrs |
| Birmingham General Hospital UK | Visiting Hours. 12:00pm to 2:00pm 5:00pm to 8:30pm. | 5½ hrs |
| Southampton Hospital U.K. | Visiting Hours. 10:00 am – 9:00 pm | 10hrs |
| Gleneagles Hospital UK | Visiting hours: 8am to 8pm | 12hrs |
| Sibley Memorial Hospital | Visiting Hours 11:00 am – 8:30 pm | 9½ hrs |
| BARNES JEWISH HOSPITAL USA | Generalvisitinghours 11 a.m.-9 p.m. | 10hrs |
| WOMEN’S HOSPITAL HELSINKI FINLAND | 2.00PM -7.00PM | 5hrs |
| LIVERPOOL HOSPITAL UK | 10.00-1.00pm 3.00-8.00pm | 7hrs |
| AUCKLAND HOSPITAL NZ | 11.00- 1.00pm 3.00-8.00pm | 7hrs |
| WINCHESTER HOSPITAL USA | Flexible Times to Visit | 24hrs |
Table 1 Visiting hours in some European and US Hospitals.
Increasingly in the U.S. an open policy is being adopted towards unlimited visiting hours. Studies in the U.S. have shown beneficial effects on patient care with tangible positive effects on patients’ health. Anxiety levels of both patients and relative were much lower in units which had an open visiting hour policy leading to elevated levels of patient and family satisfaction [4].
There is also a cost factor which became apparent with the abolition of restrictive visiting hours in the U.S. Reduction in costs came about with lower length of stay, improved patient care and reduced risk for hospital readmission. Moreover satisfaction scores of patients, family members and healthcare personnel increased significantly [4].
Strengths and opportunities of extending visiting hours at Mater Dei hospital
In a study done in coronary and intensive care units, open visiting times were associated with a significant improvement in the basic vital signs of patients who were admitted to units with unrestricted visiting hours. Patients with unrestricted visiting hours had significantly lower heart rates after family visits than patients with restricted visits [7]. The lowest systolic and diastolic blood pressure values were recorded during visiting, suggesting that the visit had a calming effect on patients [8].
Similar to the importance of encouraging a more active role of patients in the doctor/patient relationship, there appear in the medical literature, calls for patients’ family relatives to take on a more active role so as to fill in this vacuum [9]. Family members are frequently the unsung heroes, referred to in the medical literature as informal caregivers. Of critical importance it must be emphasized that formal care is episodic, whereas “informal caregivers” provide the bulk of care between exacerbations of chronic disease [10].
There is no reason to doubt that Maltese families may also assist in the convalescence of their loved ones at Mater Dei Hospital. It must however be admitted that visiting hours of 2 ¾ hours are too short a time to allow significant family/patient engagement. Moreover the two ½ hour sessions are too short, discouraging family and friends to attend to their loved ones. This leaves only 2¼ hours of effective visiting hours an period which pales compared to other foreign visiting hours.
Due to our “smallness” we have the advantage that logistical barriers are not huge like other larger countries. There are several examples at Mater Dei Hospital which amply illustrate the impact patients’ relatives can have on convalescence. It is not only the physical change of environment that adversely influences the patient who is hospitalized, but more importantly the altered human ambience, in particular the family unit.
There are calls from various sectors of the medical and nursing literature so that patients’ family members are given a more active role in the convalescence of their close ones [11]. Tasks such as administering oral medication, delivering food and assisting in greater mobilization are simple to achieve, but may have dramatic effects to the extent that they may be crucial in the recovery of the patient. Such simple tasks will further aid the nursing and health care personnel at Mater Dei Hospital.
The presence of family members has also been considered as a safety issue. During history-taking family members frequently fill in vital information which the patient has omitted [12]. In 1999 the Institute of Medicine reported alarming data on the impact of medical errors in the US and called for national efforts to address this problem. One of the five key concepts to increase patient safety and reduce medical error was patient/consumer engagement [13].
Recovery may thus be further expedited aiding in achieving more rapid discharge, consequently reducing hospital length of stay. Moreover the family members in close contact with the medical/nursing staff, while in hospital may be acquainted with the medical needs of the patient reinforcing more adequate longterm care at home.
The family and medical/nursing partnership may play a critical role in preparing patients and families for the transition from hospital to home. Together this tandem may identify challenges and opportunities in discharge planning. Effective and efficient patient/family-centered discharge planning processes can facilitate the transition from hospital to home. Moreover this partnership may pre-empt adverse events that may be experienced by some patients in the immediate post-discharge period that may lead to hospital readmission [14].
To achieve a more active role of relatives, it is crucial that the physical separation from their loved ones should be reduced to a minimum. From the first few hours of hospitalization the family members should be allowed to have access to the patient. There are some hospitals that have increasingly encouraging flexibility with visiting hours. Flexible visiting policies provide the ability to amalgamate the concepts of patient/family-centred care into practice [15]. Provided ground rules and guidelines are set up, allowing for proper ward functioning, greater access to patients by their relatives is feasible.
Close communication with family members should be maintained by both the medical and nursing personnel. From the initial stages the patients’ relatives should be engaged and encouraged to partake in the treatment of their ill family member while in hospital. This may assist both the short and long-term care of the patient, promoting appropriately timed discharge. An added bonus is that it is more likely that after-care may be undertaken to such an efficient degree that long-term care in a rehabilitation unit may be avoided altogether, encouraging direct discharge home.
The absence of familiar surroundings and family members appears to accelerate dementia [16]. Among a cohort of elderly patients without dementia at baseline, those who experienced acute care hospitalization and critical illness hospitalization had a greater possibility of cognitive decline compared with those who had no hospitalization. Non critical illness hospitalization significantly correlated with the development of dementia [16].
Threats and weaknesses of extending visiting hours at Mater Dei hospital
There is the possibility that this change in visiting hours at Mater Dei Hospital will encounter some resistance. The waters have already been tested when at a lecture given to “Discharge Liaison Nurses”, the author initially received a lukewarm response to increasing familial engagement [17]. However after demonstrating the huge advantages of patient/ family centred care the attitude changed substantially. This suggests that a hospital-wide educational campaign at Mater Dei Hospital needs to be undertaken.
On the international scene in the decade between 1980-90, nursing staff initiated the curbing of visiting hours as they alluded to significant disruption of their work by visitors. It has been mentioned that the workload on nursing and medical personnel is so heavy that hospital personnel cannot afford any form of interruption [18]. This has been rebutted by emphasizing that should visitors adhere to strict guidelines of behavior then disruption of medical and nursing work should be at a minimum and the benefits outweigh the disadvantages [19]. Moreover in most hospitals the maximum number of visitors is restricted to two except in special circumstances (terminal patients.
The risk of infection has also been referred with the removal of restricted visiting hours. It has been suggested that “mobbing” of patients may increase cross-infection through aerosol or direct contact transmission. This was the case in the 1800’s when smallpox and measles were widespread and wards were closed to relatives to avoid spread of these infections. Although the risk of these infections has diminished the risk of influenza spread does exist, however modern hospital visiting protocols warn relatives that if they have symptoms of coryza or fever they should not come to hospital. There is also the possibility that when there is a great risk of serious influenza infection such as in the H1N1 scenario, visiting hours are further curbed. Despite having open hours a number scientific assessment has not shown an increase in infection with unrestricted visiting hours [20]. It is to be reiterated that if in cases of infectious disease outbreak in the community or in the hospital such as acute respiratory syndrome [21], then measures to restrict access including reducing visiting hours is to be instituted [22].
Visiting hours has held a place of controversy for several decades. An overview of the current literature rebuts most of the rationales that have been used to restrict family visiting not only in the general wards but also in critical care unit s such as the coronary care units and intensive therapy units [21,23,24].
The way forward
Currently the number of hours officially allowed in Mater Dei Hospital totals in 2¾ hours per day. This increases on Sundays and exceptions are allowed for a number of wards at Mater Dei Hospital (Table 2).
>
| 12.00-12.30pm | 3.45- 5.30pm | 7.30-8.00pm | Total 2¾hrs |
Table 2 Current visiting hours at Mater Dei Hospital.
At this point in time it may not be opportune to totally dismantle the current visiting hours at Mater Dei Hospital allowing unrestricted open access to family and friends.
A possible compromise is to allow ward work to proceed unimpeded between 7.00 am till 10.00 am. Following this interval, visiting hours may be opened from 10.00 am till 2.00 pm. Adopting the French system of “quiet time”, visiting hours may be restricted between 2.00 pm and 4.00 pm. Visiting hours can then be restarted from 4.00 pm till 9.00 pm. These modifications would result in a total increase in the number of visiting hours from 2¾ to 9 hours per day (Table 3).
| 7.00am – 10.00am | 10.00 am- 2.00pm | 2.00pm – 4.00pm | 4.00 pm – 9.00pm | Total |
| Ward Work | Visiting hours | “quiet time” | Visiting hours | 9hrs |
Table 3 Proposed visiting hours at Mater Dei Hospital.
Between 7.00 - 10.00 am the bulk of ward work may be enacted including the initiation of treatments. During the 10.00-2.00 pm relatives may be allowed to mobilize and if need be assist in feeding the patient. The 2.00-4.00pm coincides with the “siesta” which is popular locally and also allows a window whereby treatments may be delivered. From 4.00 pm till 9.00 pm visiting hours restart again coinciding with supper. This latter period will also be “visitor friendly” as individuals finishing work (shopping outlets) at 7.00 pm will have ample time to travel and visit patients.
An educational campaign of both staff and the population should be undertaken. During the educational campaign the restriction of two visitors at any one time and the adherence to visitor guidelines should be emphasized. The medical and nursing union should be approached and informed of the healthcare benefits of extending visiting hours.
Conclusion
By European and North American standards the statutory hospital visiting hours in Malta’s main General Hospital, Mater Dei Hospital are significantly low. This may significantly affect patient care, reducing family/friend engagement in the patients’ care and lead to inefficiencies in the delivery of care at Mater Dei Hospital. With education of the hospital personnel and a gradual introduction in the extension of visiting hours the current restriction on visiting times may be addressed.
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