Visiting Hours in the ICU: Too Restrictive? Too Liberal?

Abstract & Commentary

Synopsis: In this article, a leading expert in the area of improving health care quality argues that restricting visiting hours in ICUs is neither caring, compassionate, nor necessary.

Source: Berwick DM, Kotagal M. JAMA. 2004;292:736-737.

In this commentary, Berwick and Kotagal list 3 common reasons for restricting ICU visiting hours. They are: frequent visits by family members and others induce physiologic stress for the patient; such visits create barriers to the effective provision of care; and they lead to exhaustion on the part of those who visit. Berwick and Kotagal examine the rationale and implications of each, and argue that none of them justifies restricting the access of family and friends to their critically ill loved ones. They conclude that "hospitals should open their ICUs, ask their patients and families, their nurses, and their physicians what works, assess the effect of these changes openly and objectively, and move toward a defined but unrestricted ICU visitation policy."

Among their suggestions for improving communication between caregivers and family members, and thus reducing the friction that frequently develops around ICU visitation, are beepers so that the family can be contacted if there is a change in the patient’s condition; automated, secure phone messages updated with changes in the patient’s condition; and regularly scheduled updates from the managing physician.

Comment by James E. McFeely, MD

We are all aware that there is frequently tension between hospital staff and patients’ families around the issue of limited visiting hours in the intensive care unit. Frequently, this tension is directly proportional to the severity of illness of the patient. In this article, Berwick, chief executive of the Institute for Healthcare Improvement, a well-known nonprofit organization with a focus on improving quality in healthcare, suggests that restrictions on visits in the ICU are unnecessary. He cites 3 areas of concern, and argues that they are either overestimated or on balance negated by the benefits to the patient.

I certainly agree with Berwick that, where possible, patients should be allowed to participate in decision-making with regard to deciding who is able to visit them and for how long. It is with the patients who are too ill to be able to participate in this decision-making that the tension most frequently arises. In our institution, we have experimented with both a closed, fixed schedule of hourly visiting times for short periods of time, as well as with a more open visitation schedule, and have frankly found problems with both. Some patients’ family members have complained of a circus-like atmosphere during the open visitation schedule, with large numbers of people coming and going and, in the family member’s opinion, interfering with the care of the patient. Other patients’ families complain that the fixed visiting schedule they were given does not provide enough access to their loved ones.

Most of the time, having a patient’s family in the room probably benefits the patient in terms of reduction in physiologic stress, though we have all seen examples to the contrary. However, and I think in those particular instances, restricting visiting, at least for the individual causing the additional stress, is probably in the patient’s best interest. Systems can be set up to minimize family intrusion in terms of the provision of care, and we have found most individuals are quite accommodating when this is explained to them. It is also true that family and friends are at risk of fatigue and exhaustion, particularly early in the course of a very critically ill patient. I frequently tell patients’ families that what they are experiencing is more akin to a marathon than to a sprint, and I try to assist them in developing a routine that will allow them to spend time away from the hospital and give themselves respite. Things that can help in this regard include having 24-hour phone access to the patient’s nurse, giving beepers to patients’ families so they may be contacted about changes in the patient’s condition, having a secure, updated phone message that patients’ families can access to retrieve information at their convenience, and having a relatively fixed schedule of updates from the patients’ care providers, and in particular from the physician manager.

Minimizing areas of tension between the patient’s family and the health care team is an important goal in the provision of care. One of the frequent areas of conflict is over visiting hours. In general, the goal of minimizing restrictions to visitors is a good one; but it can be a two-edged sword. I encourage all of us to evaluate our current visiting policies in an attempt to make them as family friendly as possible, taking into consideration those factors most relevant to the individual ICU, including the physical constraints of the unit, the types and the number of patients cared for, and the ancillary resources available to both hospital staff and families.

James E. McFeely, MD, Medical Director, Critical Care Units, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor of Critical Care Alert.