Counting the minutes at bedside

At Harlem Hospital, visitors in the emergency department can only see patients for 10 minutes every hour. Photo: Curtis Skinner

On a recent Friday night, Sonia Agate, 46, vacantly flipped through the pages of her book in Harlem Hospital’s emergency room. She was waiting to see her partner, Suthell, who was suffering from a severe case of allergies. Agate was one of a dozen and a half others passing the time — some staring blankly at the tiled floor, others chatting idly or snoozing — until they’d be allowed to see their sick or injured loved ones.

Despite a mountain of research showing that family presence in the hospital leads to better health outcomes, New York City’s public hospitals lag in adopting more flexible visiting policies. At Harlem Hospital, visitors in the emergency department can sit with patients for just 10 minutes in an hour. Agate anticipated she would stay at the hospital for another five hours, only being able to see her partner for less than one-fifth of that time.

“There’s no leeway. They come back there and get you,” said Agate, speaking from experience. She said she has sat in that same room waiting to see loved ones six times this year, wasting countless hours in a mix of anxiety and boredom. And while some city hospitals give nurses discretion over the length of visits to patients, Agate said that Harlem Hospital doesn’t bend.

“They say 10 minutes and they mean 10 minutes,” she said. “They don’t play.”

An August report by an advocacy group, New Yorkers for Patient and Family Empowerment, found that New York state and city hospitals have largely resisted expanding visiting hours despite increasing pressure from health care quality groups and government agencies. New research on the subject of visitation in hospitals suggests that the traditional medical wisdom — that unbounded family presence can be harmful to patient care — is wrong.

The city’s Health and Hospitals Corporation, which runs 11 of the city’s hospitals, has particularly strict visiting rules. The report found that only one in the network offers at least 10 hours daily of visitation on average across departments. And Harlem Hospital is one of seven to limit emergency department or intensive care unit visits to between 10 and 15 minutes an hour.

The city hospital agency has been assessing its visiting hours and making some improvements. “HHC has been actively expanding it visitation policies as part of a comprehensive ongoing review effort, and in 2012 alone visiting hours were increased at seven separate HHC hospitals and several nursing and long-term care centers,” said a spokesperson for the agency. Those facilities, the spokesman said, were Coney Island, Harlem, Kings County, Metropolitan, North Central Bronx, Lincoln and Woodhull hospitals.

“However, the process of setting visitation policy is a complicated one and requires balancing several factors, including evidence of how visitor policies affect patient care, the constraints brought on by staffing and security requirements, operational capabilities, and the need for patients to be able to rest and have quiet within their rooms.”

Yet research on the topic has found that family presence in the emergency room and hospital wide actually leads to better patient outcomes and higher patient satisfaction — both key metrics in new federal reforms to financially reward or penalize hospitals based on care. The Joint Commission, the agency charged with accrediting hospitals across the state including HHC facilities, updated its rules last June, adding a provision requiring hospitals to allow friends, families and other supporters to visit patients “during the course of stay.”

Meanwhile, a growing number of advocates, academics and health-care worker associations maintain that better access to loved ones actually leads to healthier patients.

“Patients need their family, and whenever possible we advocate keeping loved ones with the patient,” said Gail Lenehan, President of the Emergency Nurses Association — a 40,000-strong group of nurses who work in emergency rooms across the country. In 2009, the association published a report supporting open visitation for families, friends and other support persons even during the most intensive procedures. Three years later, Lenehan said the group is still a “strong advocate.”

“After 30 years of experience in the emergency room, what you learn is what bothers people the most, what’s the most unbearable, is not knowing,” she said.

A few hospitals around New York State and City offer around-the-clock visiting hours, and administrators there say they have been pleased with the results. The North Shore­–Long Island Jewish health system, which runs 16 hospitals in the state — including Lenox Hill Hospital, Long Island Jewish Medical Center and Staten Island University Hospital in the city — recently rolled out a 24-hour visiting policy across all of its hospitals and departments.

Elaine Smith, vice-president of nursing education for the system and one of the lead administrators behind its visitation reform task force, said administrators faced some resistance among doctors and nurses after the change was announced, but that hospitals and their staffs are now on board.

“It is a matter of making adjustments to how we as care providers think and perhaps have been trained,” said Smith. She added that when caregivers stopped to really think about how extending visiting hours could actually interfere with care, they could often come up with no evidence-based rationale.

“It’s about placing the control back in the hands of the patients and family,” she said. “It’s about them and it’s about their care. We, as caregivers, are the visitors in their lives, it’s not the other way around.”

While 24-hour visitation is becoming more common nationally, doctors and other health care providers often have reservations. A study out of the University of Texas surveyed the feelings of more than 1,000 health care professionals on family presence during the resuscitation of children. The majority were in favor, but some indicated strong opposition, citing concerns over potential lawsuits as well as nervousness impairing their ability to perform.

The study quotes professionals who suggest family presence is “highly, highly disruptive,” and one instance where it caused “mistakes made.” Health workers in urban settings often cite space and safety concerns as reasons to moderate visiting hours, arguing that packed emergency rooms can interfere with care or, worse, present a danger if visitors aren’t properly supervised.

But Barbara L Jones, associate professor and co-director of the University of Texas at Austin’s Institute for Grief, Loss and Family Survival, and author of the study, contends that it’s not a question of if hospitals adopt more flexible policies, but when.

“I think it’s just systems waiting to catch up,” she said.

In 2009, a New York Times story highlighted the barriers to visits of loved ones to patients of patient visitation and pushed the Obama administration to initiate rule changes at the federal Centers for Medicare and Medicaid Services, including a requirement that hospitals show clinical necessity in limiting visits — not just who visits, but also the hours they can stay.

Health care quality experts in New York argue that the federal Centers for Medicare and Medicaid Services were right in making the change.

“It’s a no-brainer for hospitals to be listening to their patients. And that’s all the regulations say: ‘Do what your patients want,’” said Bruce Boissonnault, president of the Niagara Health Quality Coalition, which produces report cards on New York State hospitals.

“Many of the problems with health care over past couple of decades have stemmed from the fact that we didn’t put the patient at the center of decisions about care. What was done was what was convenient by staff and sometimes that differed by which staff member answered the phone.”

Of the 10-minute emergency department visiting windows at some HHC hospitals, Boissonnault said, “That is unnecessary.”

But that hasn’t changed the policy at Harlem Hospital or the 50-minute waits for Agate. As the minutes passed she reminisced about visiting her son at New York Presbyterian, which has a more flexible emergency department visitation policy, years earlier.

“I could actually communicate with the doctor,” she said. “Basically, I knew what was going on, and that meant a lot to me.”

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