End the draconian hospital visitation policies during COVID-19 [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“At the start of the pandemic when hospitals were overrun, testing and PPE were scarce, and unknowns about COVID-19 transmission abound, such restrictions were reasonable, perhaps even essential. But we have made progress since then; most hospitals test most if not all admitted patients for COVID-19; most Americans own a mask, and hospitals are able to provide to those without one. We must still take reasonable precautions. Allowing only one visitor at bedside, placing restrictions on movement of visitors throughout the hospital, and ensuring they practice social distancing from other hospital staff. With this, we can maintain patient and staff safety but also prioritize a part of care that is currently being undervalued.

And as hospitals and cities across the country continue to try and get a handle on the pandemic, we must also continually re-examine what aspects of care we determine to be essential and must preserve in some way. And we must realize that family at the bedside is part of that essential care our patients need to heal.”

Taimur Safder is a cardiology fellow.

He shares his story and discusses his KevinMD article, “It’s time to end draconian hospital visitation policies during COVID-19.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Taimur Safder. He is a cardiology fellow, and he wrote the KevinMD article “It’s time to end draconian hospital visitation policies during COVID-19.” Taimur, welcome to the show.

Taimur Safder: Thank you, Dr. Pho, for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and your journey to where you are today?

Taimur Safder: Yeah, absolutely. I feel like it’s a very long one. I was actually born in Pakistan but came to the States at a very early age. We came straight to Kansas, actually, so I grew up in Kansas for most of my life. I ended up staying there for my early training, med school and residency, at the University of Kansas. After residency, I was interested in public health policy, so I went to Boston to do a year to explore my interests there. Then I came to Dallas, which is where I’m at right now, to do my cardiology fellowship. I’m almost done, with a few months left; I’m a third year. I’m heading to Chicago next, actually, to do my advanced imaging and cardiology training for a couple of years. So it’s 11 years, summarized in a few seconds.

Kevin Pho: All right. Well, best wishes on the remainder of your medical education journey.

Taimur Safder: Thank you.

Kevin Pho: So we are speaking in the middle of February. From a COVID-19 standpoint, tell me what you’re seeing through your lens as a cardiology fellow.

Taimur Safder: Yeah. I like to divide it up into inpatient and outpatient settings, because we often do both. In the inpatient setting, the hospitals are doing their best. I feel like as a trainee, you get a different taste of what’s going on. They’re trying to protect us as much as they can from exposure. Mostly I see them on the consult service, and we’re seeing a lot of troponin elevations, which a lot of times we don’t know what to do with. There are a lot of unsolved answers. What does it all mean? Is it inflammation? Is it myocarditis? Is it some sort of MI, whether that’s type 1 or type 2? So often we don’t have a lot of answers for all these consults, but I would say that’s most of what I’m seeing in patients, just troponin elevations.

Then there were some questions early on, I don’t know if you remember, about ACE inhibitors and some of these medications, questions about “Should we keep them on? Should we keep them off?” So we’re trying to help with that decision as well. And often, the severe end of the inpatient side is cardiogenic shock. We’re seeing that, but the treatment from that standpoint is not necessarily any different. So we’re trying to manage the best we can. We don’t have a lot of data or a lot of evidence to guide what we’re doing, but we’re trying to do it as best as we can on the inpatient side.

On the outpatient side, a lot of it has turned into telemedicine, which I’m sure is similar to a lot of other fields. We’re seeing a lot of patients through telephone and through video encounters. For cardiology, in some aspects, it’s not that bad, because a lot of it depends on history when talking about arrhythmias. But if you’re seeing patients with heart failure, it becomes a bit more difficult, because we do rely on a good exam. So that aspect is a bit more difficult from that standpoint. There’s also this other idea that a lot of patients aren’t seeking care, so we’re seeing some complications from delayed seeking of care from a patient perspective. So we’re seeing a lot of different things, and honestly, I think we probably won’t see a large aspect of this until later on, maybe months or a year down the road.

Kevin Pho: So from a cardiology standpoint, what are some dangers of delaying your cardiology appointment?

Taimur Safder: Yeah. Early on, what a lot of the hospitals were reporting, and I think this was fairly universal across the country, was that STEMI cases were going down. The most logical explanation of that was thought to be that patients just aren’t seeking care, especially early on in the pandemic, when there was a lot more uncertainty. So the idea was that we’re going to start seeing the late complications of MI, whether that’s valvular or whether that’s cardiomyopathy. So the thought was that we’re going to start seeing these complications of MIs down the road. That’s how it was also: that we’re likely going to see more cardiac arrest, as patients with cardiomyopathies or heart failure aren’t seeking regular care. I personally haven’t seen as much of that, but I think there are still some observational studies going on to see if that’s the case. But that’s some of the stuff that we are assuming we’re going to end up seeing: a lot of consequences of delayed care from a cardiology standpoint.

Kevin Pho: All right, so let’s transition to your KevinMD article that you wrote, “It’s time to end draconian hospital visitation policies during COVID-19.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Taimur Safder: Yeah, absolutely. The concept of this article started really during my inpatient rotations early on, when I started noticing small things, some things we get so used to when we see patients and their families by the bedside, whether that’s just when the patients are trying to minimize their symptoms and the family member will speak up. So I started to see how we’re missing that when the hospitals initially just went completely strict, with no visitation for any sort of thing allowed. Even when patients were dying, they weren’t allowing anything. Then, as the months went on, I started to see how this was really affecting not just the emotional stability of the patients, and how they didn’t have the support which they often relied on, but also a lot of times the care that we were providing.

A couple of examples I mentioned in my article: a patient with delirium. Often we rely on family members to keep them attentive and oriented, and we started to see some of that. Then, in terms of cardiology, we often see a lot of patients who are on a lot of medications. Polypharmacy is something we see all the time. Someone comes in with a heart attack or heart failure, a new diagnosis, and suddenly we’re sending them home with five or seven new medications. Family members are a big part of keeping them sane in terms of going through all this and keeping them on track, and then we started seeing that we couldn’t do that as well just on the phone. So I started to see how this was actually affecting the care that we were providing.

Then, just talking to colleagues, it was not just on the side of the physician, but also on the other side, where some of my friends were having their family members, whether they were grandparents or parents, in the hospital, and just how odd that felt and how powerless they felt, even though they’re doctors and so well aware of the system. And then, as I explained, I had a family member who went into the hospital, and I had a similar feeling. And then I finally decided to write something about it.

I’ve had great positive feedback. I’ve heard from multiple people, “Wow.” They’re glad that someone finally wrote something about that, that they read something about that, because it almost feels like a little bit of a taboo. Nobody wants to contribute to worsening the pandemic, especially as health care workers. But at the same time, I feel like the discussion needs to be had: What are the benefits and risks of allowing at least one family member, especially with the context we’re in now?

Kevin Pho: So as far as the hospitals in your area, are there strict no-visitor policies in place right now?

Taimur Safder: Yeah. As trainees at academic centers, we often work at multiple hospitals. For example, I work at the VA, and I work at our major hospital, and it’s very different. That’s one of the things I also note: The CDC is not really giving any clear guidelines on what it should be, so every hospital is left on its own, which is probably good, because regional infection rates are probably different, so it’s best if you base it on that. The VA is really very strict in any sort of visitation policy; they’re not really allowing anyone. Versus our major hospital, Baylor University, it started off very strict, but now it’s starting to allow one visitor for a certain number of hours, and even that small allowance has made a big difference, I think, in our patient care. So one of the things I employ in the article is that we can’t just do one-size-fits-all. We just need to evaluate every scenario, every hospital, every region. There should be more flexibility in what we’re allowing.

Kevin Pho: So as far as you know, have any studies been done looking at the potential correlation between community spread and hospital visitation policies?

Taimur Safder: That’s a good question, and no, to my understanding. I know the data in terms of how much of the infection spread is hospital-based or intra-hospital-based. There were a few studies that came out of Wuhan initially that showed that most of the transmission, most of the health care workers who tested positive, actually got it from the community, not in the hospital. And a couple of studies since have shown the same thing, where a lot of the infection that hospital personnel get is actually community-based and not from the hospital. That makes sense logically, too, because one of the places where we’re really, really good at protecting ourselves is in the hospital. We have the best resources. PPE is now very, very much available, and we’re on really high guard in terms of looking out for it in the hospital, versus we let our guard down in the community. So it makes sense logically, and a couple of studies have now shown that that’s probably the case. So I haven’t seen any specific data clearly stating hospital spread by letting visitors in, but I know there have been some studies showing that most health care workers who get infected are often getting it from the community setting.

Kevin Pho: So in your opinion, what should be the trigger for hospitals to relax their visitation policies?

Taimur Safder: I think there should be clear criteria. One would be that every patient scenario is different, so obviously, the more urgent or critical the condition a patient is in, I think that should be looked at differently than someone who’s just coming in, maybe for something that’s elective, or something where they may go home the same day. I also think the patient characteristics should be looked at. Is there a patient who needs it, maybe younger patients or older patients who are more in need of someone, in supportive care? Maybe patients with psych illness. It doesn’t necessarily have to be something severe, schizophrenia; maybe just anxiety. Maybe patients who just have some sort of issues with dealing with all the stuff that we do in the hospital. Such a high level of mental acuity, I feel, is needed in these scenarios. And in certain situations, a new diagnosis of heart failure or an MI, something that’s more critical.

So I feel like patient characteristics, their health characteristics, all these things need to be taken into account. But I also think regional characteristics would be important to take into account. If you’re in LA, where the rates are much, much higher, maybe you’re a lot more strict in what you’re allowing. But maybe if you’re in a different area where the rates aren’t as high in the community, maybe you’re a bit more flexible with what you’re allowing. So I think it’s a combination of everything. I don’t think there should be any sort of blanket policy one way or the other. But I just think that the mindset of most friends I’ve talked to in the hospitals across the country is that they just seem to be very, very inflexible.

Kevin Pho: We’re talking to Taimur Safder. He is a cardiology fellow, and he wrote the KevinMD article “It’s time to end draconian hospital visitation policies during COVID-19.” Taimur, you mentioned that you had a lot of positive support when you wrote this article, and I’m hearing the same thing as well. Now, are you hearing anything from the flip side? Are you hearing about anyone who wants to continue these strict visitation policies?

Taimur Safder: That’s a great question. I was actually kind of concerned about that when I first wrote it, and so far, no. I have heard only positive messages, but that could be a result of being kind of in an echo chamber, maybe, because mostly I’m hearing from friends and colleagues, and I’m sure they’re less likely to give any sort of significant criticism. There have been a few comments on the piece online, and those were all supportive as well. So I haven’t gotten any significant pushback, which I actually was expecting, but so far I have not.

Kevin Pho: And what about from hospitals or medical institutions themselves? Do you know what their reasons are to continue these policies?

Taimur Safder: I’ve talked kind of off the record with some of the admin people, but I haven’t gotten any sort of clear answer. But I think a lot of it just has to do with everyone being overwhelmed with what’s going on. It’s really difficult to just deal with the normal challenges that this pandemic presents to a lot of hospitals, and on top of that, to layer on all these other complexities, like what do we do with visitation policies? It’s such a complex issue, and to layer on, “Oh, well, we can do this in this scenario,” when they’re just struggling to meet the normal demands, I think it’s just a level of complexity that maybe we’re not ready to handle.

But I feel like now that we’re kind of on the back, I don’t want to say back end of that, but at least somewhere where we feel like we’ve somehow got a little bit of a handle on the situation. A lot of hospitals have universal testing policies, so we’re testing everybody who comes in. So now I feel like we have measures in place where we can start talking about this, where hospitals should feel comfortable talking about what some of our policies are that may not be, because I think it was much easier just to have a blanket policy initially. But I feel like now is the time to start this discussion, and I’m hopefully going to go back to some of our administration and talk more about these issues.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Taimur Safder: Yeah, I would go back to my experience with the family member in the hospital. The feeling I had was a very powerless feeling, sitting at home with a member sick in the hospital and trying desperately to get a hold of someone. What I didn’t include about the hospital was how many times we called the ED and barely got a response, how many times we called the nursing floor when our member moved to the floor, and how difficult it was. And I’m on both sides of that. I know how busy it is on our side, and it’s really hard. Our systems ask a lot of us, and I get that. But I would just like to leave with that message: In those moments, just try your best to take that extra moment to reach out to a family member, especially in these times, because we’re so far removed from that situation now that the family members need better and clearer communication more than ever. So I would just implore our side, the health care workers, to take that extra step, even though we are very, very overworked.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Taimur Safder: Yeah, absolutely. Thank you for having me.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes