Hospital visiting during the coronavirus outbreak: guidance

We want to ensure the health and safety of patients/service users and staff:

• our first priority is the prevention and control of infection in healthcare settings
• we need to continue restricting the number of visitors to comply with social distancing measures
• virtual visiting should be encouraged and supported where possible
• face-to-face visiting needs to be agreed in advance and outdoor visits may be offered if appropriate
• visiting should be with a clear purpose
• agreement for visiting based on the best interests of the patient/service user or the well-being of the visitor

We want to ensure that people can visit friends and family in hospital as much as possible.  But, COVID-19 is still spreading in our communities and we need to prevent and control its spread in our healthcare settings. This is to protect the health, safety and wellbeing of patients/service users, staff and visitors.

We need to restrict the number of visitors in healthcare settings to ensure that we adhere to the social distancing guidance.

We appreciate that it is important to support the well-being both of patients/service users and their families and loved ones.

We recognise the innovative ways our health boards and trusts have enabled patients to stay in touch with their families and friends.

Patients/service users can now connect with loved ones virtually via mobile phones and tablets in a safe way.

Virtual visiting should continue where possible. There is immense value in cards, phone calls, e-mails, social media as well as video calls.

We have updated this guidance to assist health boards and trusts in striking a balance between allowing visiting with a purpose, whilst maintain robust infection control measures. The safety of patients, visitors and staff must be paramount.

This guidance is being kept under review and will change as the pandemic status alters.

The guidance remains that health boards and trusts should not return to “business as usual” in relation to visiting.

Visiting, with agreement from the ward sister/charge nurse/nurse in charge, can be facilitated as follows; as long as visitors do not have any symptoms of COVID-19 or are recovered from COVID-19 and have not been knowingly exposed to someone with COVID-19 in the past 14 days:

Within non-COVID-19 areas and services:

• one parent guardian, or carer at the bedside at a time for paediatric inpatients and neonates
• patients who are in the last days of their life - this can be up to two visitors at a time, for a specified amount of time, from the same household or part of an extended household.  If not from same household or not part of an extended household they should visit the bedside separately and maintain distance outside of the clinical area.
• a birthing partner for women in labour, preferably from the same household or part of an extended household
• in general, one visitor at a time for a patient with mental health needs, learning disability or cognitive impairment, where lack of visiting would cause distress or it is required as a reasonable adjustment to support access to health assessment or intervention. However the number and frequency of visitors should be considered on an individual basis in light of the patient’s/service user’s needs, care plan and in consultation with their support staff or carer
• children and young people may visit a parent/guardian/carer or sibling in a healthcare setting and should be accompanied by one appropriate adult.
• people with long term conditions which necessitate increased length of stay in a healthcare setting or people with specific care and well-being needs that the visitor/carer actively contributes to, for example, feeding, supporting communication needs and supporting rehabilitation. The health and well-being of these patients may benefit from seeing appropriate visitors, as their length of stay is over many weeks.  This should be documented in their care plan.

COVID-19 confirmed and possible infectious areas (assessment areas):

• Infection Prevention and Control (IP&C) procedures in these areas must be clear and any visitors must be made aware of the risks and advised of IP&C measures in place including the use of any PPE required during their visit
• end of life COVID-19 patients may receive visitors during their last days of life, if permission is sought in advance from the ward sister/charge nurse/nurse in charge. This may be up to two visitors, one at the bedside at a time, for a specified amount of time, preferably from the same household or part of an extended household.
• people who were formerly shielding or who are otherwise clinically vulnerable should avoid hospital visits wherever possible. Where a hospital visit is deemed essential, for example to visit a loved one in the last days of life, hospitals should provide medical masks.
• all permitted visitors must adhere to hand hygiene and infection control precautions on arriving and leaving the area.

It is recognised that guidance cannot foresee all requests for visiting nor all patient circumstances. Therefore, health boards and trusts do have the discretion, when operating the guidance, to agree to visiting requests that are not outlined in any of the categories set out above where they are satisfied the benefits to the well-being of the patient or visitor in agreeing a visit outweigh the infection control risks and any other practical difficulties in facilitating access.

It is important that all visitors have agreement from the ward sister/charge nurse/nurse in charge before travelling for each visit.  It may not be possible for visitors to see their loved ones every day and agreement for one visit should not be taken as agreement for further visits. This should be made clear to the visitor.

Staff should treat all requests from visitors with compassion and empathy whilst ensuring the patient’s best interests are met.  Face-to-face visiting should be with a purpose ie not just a social occasion. It is to improve the well-being and aid the recovery of a patient or benefit the well-being of a visitor e.g. a visit from a young person who is distressed at not being able to see their parent, guardian or carer. 

Advice can be sought from the Infection Prevention and Control team if required. All visits need to be risk assessed and Annex 1 provides a checklist of questions to aid decision-making for visits.

Scientific evidence suggests that the virus survives less well in sunlight. This means that the risk of transmission is thought to be greatly reduced when outdoors.   

If health boards and trusts are in a position to support outdoor visits, for example in the grounds or gardens of the healthcare setting, such visits should be made in accordance with social distancing guidance. Visitors should maintain the 2 metres distance from patients/service users, staff and other visitors at all times. 

Health boards and trusts may offer outdoor visits if they feel in certain circumstances that such visiting arrangements would be appropriate and possible to arrange.  Annex 1 provides a checklist to aid staff in considering visits.

It may be necessary for visitors to accompany patients/service users to scheduled appointments in a healthcare setting. This may be in the following situations, which are by no means exhaustive:

• individuals with a mental health issue, dementia, a learning disability or autism, where not being accompanied would cause the patient/service user to be distressed. Where possible, visits for such service users should be considered on an individual basis in light of the patient’s/service user’s needs, care plan and in consultation with their support staff or carer
• individuals with cognitive impairment who may be unable to recall health advice provided
• where the treatment/procedure is likely to cause the patient distress and the visitor can provide support

Appointment letters and websites should provide advice and contact details for visitors to request approval to accompany patients (where appropriate). The letters may include advice on:

• the need to adhere to social/physical distancing as well as hand hygiene and infection control precautions on arriving and leaving the appointment
• people who were formerly shielding or who are otherwise clinically vulnerable should not accompany patients unless essential. Where this is deemed essential, hospitals should provide medical masks. 
• all visitors aged 11 or over are required to wear a face covering in indoor public areas unless they have a health or disability reason for not wearing one. Read further guidance on face coverings and exemptions

All requests to accompany patients need to be risk assessed and Annex 1 provides a checklist of questions to aid decision-making for visits. Guidance on accompanying pregnant women to pre-planned antenatal appointments is provided at Annex 2.

It may also be necessary for visitors to accompany patients/service users to unscheduled appointments, for example to Emergency Departments.  If via ambulance this will need to be at the discretion of ambulance/emergency department staff and requests should consider the individual patient’s/service user’s needs and the support which can be provided by the visitor to help them understand their treatment and/or alleviate their distress.

Staff should treat all requests for face-to-face visits with patients compassionately and with empathy whilst ensuring the patient’s best interests are met.  Indoor visiting should always be by appointment for one visitor at a time for a limited time period unless the patient/service user is in the last days of their life. 

Consideration should be given as to whether or not outdoor visiting is an option for the patients. If it is, an offer should be made for outdoor visiting in accordance with social distancing guidance.   

All requests and offers for visits need to be risk assessed and the following considerations will aid decision making:

• Does the patient/service user meet the exceptions to visiting for patients not infected with COVID-19?

If not:

• Is the request for visiting with a purpose? ie not a social occasion but to improve the well-being and aid the recovery of a patient or benefit the well-being of a visitor
• Would the patient’s/service user’s health and well-being benefit from seeing an appropriate visitor? 
• Is the patient/service user COVID-19 free and placed on a COVID-19 free ward
• What is the COVID-19 situation in the healthcare setting?  Visiting will need to be suspended if an outbreak or increased numbers of patients with symptoms of COVID-19 (or other infection) occurs in the healthcare setting.
• Has the patient/service user already received a face-to-face visit from another relative?  Visits should preferably be with people from the same household or part of an extended household and ideally be limited to one household/extended household in any given week, however visiting arrangements should take into account individual circumstances - multiple adult children may each be living in separate households for example.  The aim here is to limit the number of contacts as far as possible whilst ensuring compassionate arrangements for visiting.

Practicalities and location of visit

• Has provision been made to ensure all chairs and equipment are cleaned between visits?
• Can hand sanitiser be provided for the visitor at a fixed point?
• Can the visit be facilitated outdoors, such as a garden? 
• Do staffing levels support outdoor visiting?
• If the visit cannot be facilitated outdoors, is there a separate side room in the healthcare setting which can be used?
• How will the visitor safely journey from the car park through the building to and from the patient’s/service user’s location? 
• For outdoor visiting, consider how the visitor will safely journey from the car park to the outdoor location.
• Is there sufficient signage to the patient’s/service user’s indoor or outdoor location as well as social distancing reminders?
• Will the visitor need to be escorted to the patient’s/service user’s indoor or outdoor location?
• Have any other visits been arranged at the same time in the side room or outdoor location?
• Is there facility for a designated, well sign-posted “visitor toilet” near to the visiting location?
• How will visitors of different patients/service users be managed to prevent too many visitors at one time in a location.

Questions to discuss with the visitor

• Has the visitor considered other methods to maintain regular contact with their loved one?  For example, phone calls, e-mails, social media and video calls.
• Is the visitor self-isolating?  Do they have COVID-19 symptoms?  People who have COVID-19 symptoms or are required to self-isolate, including as an identified contact of a positive case under Test, Trace and Protect Strategy must stay at home and are not permitted to visit.
• Does the visitor understand that if they arrive and are displaying any symptoms consistent with COVID-19 they will be asked to leave immediately? 
• Does the visitor understand that visiting may have to be suspended if an outbreak or increased numbers of patients with symptoms of COVID-19 (or other infection) occurs in the healthcare setting?
• Does the visitor understand that agreement for this visit does not mean they may see their loved one every day?  Agreement will need to be sought for subsequent visits.
• Is the visitor able to travel to the healthcare setting? 
• Does the visitor understand the need to maintain the 2 metre social distance from patients/service users, staff and other visitors at all times in the healthcare setting or outdoor location?
• Does the visitor understand that they will need to listen and adhere to staff advice on hand hygiene and infection control precautions on arriving and leaving the area?
• Does the visitor intend to bring a young child or toddler?  This should be discouraged due to the difficulty of maintaining social distancing.
• Does the visitor understand that if they were formerly shielding or are otherwise clinically vulnerable, they should avoid hospital visits? Where a hospital visit is deemed essential, for example to visit a loved one in the last days of life, hospitals should provide medical masks.
• Does the visitor understand that all visitors aged 11 or over are required to wear a face covering in indoor public areas unless they have a health or disability reason for not wearing one. Read further guidance on face coverings and exemptions.
• Does the visitor understand that food and drink may not be shared and gifts/flowers are discouraged?
• Does the visitor to the outdoor location understand that they may not enter the healthcare setting unless they wish to use the designated “visitor toilet”?
• Does the visitor understand that outdoor visits are weather dependent and may be cancelled at relatively short notice if there is no alternative visiting area?

Previous guidance on visiting to maternity hospital settings during the COVID-19 pandemic has been that a woman could be accompanied by one birthing partner and only during active labour and at birth.  However, evidence not only supports the presence of birth partners in labour and birth in improving outcomes for women and infants but also highlights that infant bonding and attachment with parents, increases in the periods around birth. Also, we are aware that lack of opportunities for partners to attend appointments such as ultrasound scans have caused distress for families at this time.

Guidance for pregnant women attending hospital settings for specific pre-planned antenatal appointments

The guidance outlines situations where the woman can be accompanied by her partner/nominated other.  This guidance cannot foresee all requests for accompanying pregnant women and reference should be made to the exceptionality paragraph in the main guidance.

The revised guidance is applicable to women when attending the maternity hospital for the following reasons:

• 12-week pregnancy dating scan
• early pregnancy clinic
• anomaly scan
• attendance at Fetal Medicine Department

Key policy principles

Women can be accompanied by their partner or nominated other, preferably from the same household or part of an extended household, to any of the above except in outbreaks of the COVID-19 pandemic in a hospital setting.  There may be occasions in individual health boards that visiting, for specific reasons, may be limited further than outlined in this guidance. This will most likely be to reduce the number of people in any one area to comply with social distancing rules. In this scenario, clear explanations will be given to women and their partner/nominated other.

Members of the public who are experiencing the symptoms associated with COVID-19 should not visit maternity hospitals. Pregnant women with symptoms of COVID-19, or have tested positive or are self-isolating, should be advised to phone their maternity service to discuss the rescheduling of their appointment. 

Appointment letters and health board websites should provide advice and contact details for visitors to request approval to accompany patients (where appropriate).  The letters may include advice on:

• the need to adhere to social/physical distancing as well as hand hygiene and infection control precautions on arriving and leaving an appointment
• people who were formerly shielding or who are otherwise clinically vulnerable should not accompany patients unless essential. Where this is deemed essential, hospitals should provide medical masks.

• All visitors aged 11 or over are required to wear a face covering in indoor public areas unless they have a health or disability reason for not wearing one. Read further guidance on face coverings and exemptions.

Consideration should be given to the principles in the main guidance on accompanying patients to scheduled healthcare appointments.  This may be in the following situations, which are by no means exhaustive:

• women with a mental health issue, a learning disability or autism, where not being accompanied would cause them to be distressed
• women with cognitive impairment who may be unable to recall health advice provided.
• where the treatment/procedure is likely to cause the woman distress and the partner/nominated other can provide support

All requests to accompany patients need to be risk assessed and Annex 1 provides a checklist of questions to aid decision-making for visits. 

This guidance should be read in conjunction with Annex 1 above: Considerations for visiting in non-COVID-19 healthcare settings.

Hospices place family and carers care at the heart of good palliative care. Being able to share time with friends and family at the end of life contributes, not only to the wellbeing of the patient, but also to their loved ones. Where possible all visiting requests are met with sensitivity and understanding, particularly during the last days of life, where death is imminent.

As a result of the numbers of people affected by coronavirus pandemic, hospices are having to do things a little differently.

Hospices want to provide families and loved ones with the opportunity to visit COVID-19 positive patients and others receiving end of life care. In order to do this, they must consider that prevention and control of infection, is supported by detailed risk assessment and careful planning, to ensure the health and safety of patients, visitors and staff. Hospices will need to continue restricting the number of visitors if this is necessary, to comply with social distancing measures.

Revised guidance on hospital visiting during the coronavirus outbreak (effective from 20 July), is, where relevant, also applicable to hospices. The guidance sets out that, where patients are in the last days of their life, up to two visitors may be allowed at a time, for a specified amount of time, from the same household or part of an extended household. If not from the same household or not part of an extended household, they should visit the bedside separately and maintain distance outside of the clinical area.

Agreement, in advance of any visit to a hospice, should be sought from the hospice manager, before a visit is made.

• Virtual visiting is encouraged and supported where possible, but in the case of face-to-face visiting, this needs to be agreed in advance and outdoor visits may be offered if appropriate. Hospices should consider local situations, including COVID-19 outbreak status and the unique structure of each hospice.
   
• All visitors to health and care facilities must wear face coverings: Guidance in relation to the new measures, including reasonable excuses for not wearing face coverings.
   
• Risk should be balanced against:
  • the benefits to individual wellbeing of having visitors;
  • the extent of harm experienced by a patient or by a visitor from a lack of visitation, particularly for people in the final hours or days of life;
  • the provisions and needs outlined in an individual’s care plan.
     
• Hospices have discretion to meet the individual needs of patients and to deliver family centric care, at a time when the presence of family or friends will be particularly important.
   
• This individualised and flexible approach must take into consideration a patient’s wishes, proximity to death, rights, family needs and any cultural or religious needs. Patients should be involved in this approach as far as possible. These discussions should be documented within the patient’s notes so that there is a written record.
   
• Hospices may apply different rules for different patients, in particular for people in the final hours or days of life. Planning should be done in advance in cases where this is possible. Information and decisions should be shared quickly with patients, families and staff.
   
• The approach to making decisions on visiting, including factors taken into consideration for a decision and the decision making process, should be outlined in a visiting policy, which is distributed to patients and families.
   
• For hospices with an In-Patient Unit (IPU), it is important to provide clarity and gain consensus with the IPU team on its visiting policy.
   
• It is recommended hospices enable pre-booking and recording of visits, avoiding ad-hoc visits where possible.
   
• Supporting children to visit loved ones can be a key part of their bereavement support.
   
• In the event of an outbreak in a hospice and/or evidence of community hotspots or outbreaks, hospices may rapidly impose visiting restrictions to protect patients, staff and visitors. In this situation, hospices should set out alternative options to maintain social contact and keep families updated.
   
• Local lockdown rules should also be taken into consideration before arranging any visit. 
   
• This guidance is being kept under review and is likely to change as the pandemic status alters.