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Visiting with a purpose.

The Health Protection (Coronavirus Restrictions) (No. 5) (Wales) Regulations 2020 as amended set out the number of persons who are permitted to gather together in regulated premises, which is defined to include hospital premises and hospices. This Guidance does not change those Regulations but provides advice in the context of what is considered to be appropriate in terms of visitor numbers to maintain infection prevention and control in hospital and hospice settings during the pandemic.

This guidance supersedes NHS Wales visiting guidance of 25 March, 20 April, 20 July and 30 November.

The following is a summary of the changes made to the 30 November guidance:

  • The Health Protection (Coronavirus Restrictions) (No. 4) (Wales) Regulations 2020 as amended have been repealed and replaced by the No 5 Regulations.
  • Reference to the All Wales Standards for Accessible Communication and Information for People with Sensory Loss added.
  • Up to two parents, guardians, or carers at the bedside at a time for paediatric inpatients and neonates subject to local determination, and following a risk assessment including the ability to maintain social distancing.
  • Link to guidance on extended households updated.
  • Lateral Flow Device testing for hospices  added to Annex 3.
  • Principles organisations to consider regarding hospital visiting added as Annex 4.

Summary

  • 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.
  • In order to comply with the 2 metres social/physical distancing measure it is still necessary to restrict the number of visitors.
  • 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 and agreement for visiting based on the best interests of the patient/service user or the well-being of the visitor.

Guidance

The Welsh Government supports a person-centred, flexible approach to visiting.  However, Wales is still in a phase of sustained community transmission of COVID-19 and our first priority is the prevention and control of infection in our healthcare settings.  This is to ensure the health, safety and well-being of patients/service users, staff and visitors themselves. 

Welsh Government guidance currently states that 2 metres social/physical distance needs to be maintained as one of the key measures to help prevent the transmission of COVID-19. Insofar as possible, this measure needs to be maintained in a healthcare setting. To adhere to the social distancing measure, it is still necessary to restrict the number of visitors in healthcare settings. 

The importance of continuing to support the well-being both of patients/service users and their families and loved ones during this difficult time is fully appreciated. It is recognised health boards and trusts have been innovative in finding alternative ways to enable patients/services users to maintain contact with their relatives and friends through virtual visiting using mobile phones, tablets etc and this should continue where possible. There is immense value in cards, phone calls, e-mails, social media as well as video calls.

Therefore, this updated guidance aims to assist health boards and trusts to strike a balance in terms of the visiting principles between allowing visiting with a purpose and the clear need to maintain robust infection prevention and control strategies at this stage in the pandemic, for the safety of patients, visitors and staff.

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.

Some people may require essential support assistants for specific additional support, for example a support worker or British Sign language or foreign language interpreter. Essential support assistants are not to be classed as visitors in the traditional sense. In some circumstances, where people receive care and support from a family member or partner they may nominate this person as their essential support assistant. 

All visitors aged 11 or over are required to wear a face covering in indoor public areas unless they have a reasonable excuse not to wear a face covering, for example if you have a health or disability reason for not wearing one. Read further guidance on face coverings and exemptions. In so far as possible, visitors should also maintain 2 metres physical distancing whilst on the hospital premises.

Visiting, with agreement from the ward sister/charge nurse/nurse in charge or via the health board’s arrangements for visiting, can be facilitated as follows; as long as visitors:

  • do not have any symptoms of COVID-19 and are awaiting the outcome of a test
  • have not tested positive for COVID-19 and are still within the self-isolation period and are therefore still recovering from COVID-19
  • have not been told to self-isolate by NHS TTP (Test, Trace Protect) Service
  • have not been knowingly exposed to someone with COVID-19 in the past 10 days
  • do not live with any household members who currently have COVID-19 symptoms and are awaiting the outcome of a test, or have been tested positive and are currently self-isolating, or have been told to self-isolate by NHS TTP Service
  • have not returned from overseas travel in the last 10 days from a non-exempt country and are required to be in quarantine

Within non-COVID-19 areas and services:

  • Up to two parents, guardians, or carers at the bedside at a time for paediatric inpatients and neonates subject to local determination, and following a risk assessment including the ability to maintain social distancing.
     
  • 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. See current guidance from 7 June 2021 for extended households. You will also need to check our Alert levels page for the latest information.
  • Essential support assistants and partner support visitors may support women in a maternity unit/hospital setting in accordance with the defined risk assessed levels of restrictions, in accordance with Annex 2.
     
  • In general, one visitor at a time for a patient with mental health needs, dementia, 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. Currently guidance from 7 June 2021 for extended households can be found here, you will need to check our Alert levels page for the latest information.
     
  • People who were formerly shielding or who are otherwise at increased risk from the virus 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. 

Exceptionality 

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.

Agreeing visits

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 and 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, for example a visit from a young person who is distressed at not being able to see their parent, guardian or carer. All visitors aged 11 or over are required to wear a face covering in indoor public areas unless they have a reasonable excuse not to wear a face covering. For example, if you have a health or disability reason for not wearing one. Read further guidance on face coverings and exemptions.

If the ward sister/charge nurse/nurse in charge is unsure, 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.

Outdoor visits for patients not known to be infected with COVID-19 

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 Welsh Government 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.    

Accompanying patients to scheduled healthcare appointments

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.
     
  • Some people may require essential support assistants for specific additional support, for example a support worker or British Sign language or foreign language interpreter. Essential support assistants are not to be classed as visitors in the traditional sense. In some circumstances, where people receive care and support from a family member or partner they may nominate this person as their essential support assistant
     
  • 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:

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 and Annex 4 on Lateral Flow Device testing principles.

Accompanying patients to unscheduled healthcare appointments  

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.

Annex 1: Considerations for visiting in non-COVID-19 healthcare settings

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 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 Welsh Government 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? That means it is not a social occasion but to improve the well-being and aid the recovery of a patient or benefit the wellbeing 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. Currently guidance from 7 June 2021 for extended households can be found here, you will need to check our Alert levels page for the latest information.

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?
     
  • The expectation is that visitors would provide their own face coverings, but in the event a visitor arrives without one, they should be provided with one.
     
  • 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? 

Essential messages to convey to all visitors

  • Remind the visitor of the option of other methods by which they can maintain regular contact with their loved one, for example, phone calls, e-mails, social media and video calls.
     
  • Ensure the visitor is made fully aware of what is required with regard to their present health and COVID-19. If they have COVID-19 symptoms they should be self-isolating.  All visitors should be made aware that they must stay at home and are not permitted to visit if:
    • they personally have COVID-19 symptoms, are awaiting the outcome of a COVID-19 test,  are required to self-isolate (including as an identified contact of a positive case under the NHS Test, Trace and Protect Strategy):
    • or, if they live with any household members  who have COVID-19 symptoms (and who are therefore self-isolating), or have COVID-19 symptoms, are self-isolating and are awaiting the outcome of a COVID-19 test.
    • or, they have returned from overseas travel in the last 10 days from a non-exempt country and are required to be in quarantine
  • Ensure the visitor understands that if they arrive and are displaying any symptoms consistent with COVID-19 they will be asked to leave immediately.
     
  • Ensure 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.
     
  • Ensure the visitor understands 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.
     
  • Ensure the visitor is made aware it is their responsibility to arrange their own travel to the healthcare setting. 
     
  • Ensure the visitor understands 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.
     
  • Ensure the visitor understands that they will need to listen and adhere to staff advice on hand hygiene and infection control precautions on arriving and leaving the area and the consequences of not doing so.
     
  • Ensure the visitor is discouraged from bringing a young child or toddler along to the visit  due to the difficulty of maintaining social distancing.
     
  • Ensure the visitor understands 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.
     
  • Ensure  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 reasonable excuse not to wear a face covering. Read further guidance on face coverings and exemptions. Ensure the visitor been made aware of the need to bring their own face covering with them and the consequences of not doing so (visit unable to go ahead).
     
  • Ensure the visitor understands that food and drink must not be shared and gifts/flowers are discouraged.
     
  • Ensure the visitor to the outdoor location understands that they may not enter the healthcare setting unless they wish to use the designated “visitor toilet”.
     
  • Ensure the visitor understands that outdoor visits are weather dependent and may be cancelled at relatively short notice if there is no alternative visiting area.

Annex 2: Framework to assist NHS health boards to assess visitor access for partners, visitors and other supporters of pregnant women in Welsh maternity services during the COVID-19 pandemic

Purpose of this Framework 

This framework is designed to assist NHS health boards in Wales to flexibly adapt access for partners, visitors and other supporters of pregnant women in maternity services according to local viral transmission rates. It applies to inpatient and outpatient settings. It does not apply to women who have tested positive for COVID-19 for whom there is a defined pathway in each health board. 

Background 

This framework has been informed by the guidance provided to NHS England from the Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) and the subsequent published framework by NHSE (September 2020). It has been reviewed to ensure it meets advice and guidelines in operation in Wales with the support of key stakeholders from Health Boards in Wales. Visiting is challenging during a pandemic, and the priority must be the safety of all service users (including pregnant women), staff and visitors.   

Health Boards must tailor policies to the local situation and be innovative in the way that visiting access is enabled. In periods of high local COVID-19 transmission rates and/or variants of concern health boards should revise guidance according to need, working with Maternity Service Liaison Committees, local staff representatives (including health and safety representatives), other professional groups (e.g. sonographers) as well as appropriate infection control and public health experts.  

Take a risk assessed approach   

We suggest that health boards undertake a risk assessed approach, following a meaningful and documented assessment, making any necessary changes according to local transmission of the virus to either relax or reinstate previous levels of restrictions.

Information to support health boards to risk assess visiting policies can be utilised in the Royal College of Midwives’ briefing ‘Reintroduction of visitors to Maternity Units across the UK during the COVID-19 pandemic' (rmc.org.uk).

More general information is available from the Health and Safety Executive.

Policies on permitting access to women’s partners, visitors or other supporters should be regularly reviewed, be tailored to your local context and take account of:  

  • current national pandemic risk and government policy
  • NHS recovery phases
  • local trends in COVID-19 incidence and prevalence
  • physical space in the maternity service, including in waiting areas and clinic rooms
  • the number of women expected to attend an outpatient scan or clinic, and the use of waiting areas which are shared with other services
  • the number of women expected in an inpatient maternity unit (e.g. a postnatal ward), distance between bed spaces and cots as well as flow through ward; and
  • staffing of the maternity clinic / unit

Mitigating the risk of transmission 

While clinical services are a potential source of viral transmission between service users (including pregnant women), staff and visitors, this risk can be mitigated by:

  • requiring all hospital staff, service users and visitors over the age of 11 to wear a face covering in indoor public areas unless they have a reasonable excuse not to wear a face covering. Read further guidance on face coverings and exemptions. 
  • facilitating good hand hygiene by signposting to hand-washing stations or alcohol gel
  • encouraging good respiratory hygiene through the ‘Catch it, Bin it, Kill it, Wash your Hands’ approach (e.g. using a tissue to catch coughs or sneezes and immediately disposing of this in a bin) and poster signage to reinforce messaging
  • ensuring 2-metre social distancing according to national guidance in healthcare settings
  • introducing one-way systems where feasible and proactively managing the risk of queues and pinch points;
  • staff using personal protective equipment (PPE), as directed by national guidance;
  • implementing government advice ensuring individuals who wish to visit or accompany women to hospital:
    • do not have any symptoms of COVID-19 and are awaiting the outcome of a test
    • have not tested positive for COVID-19 and are still within the self-isolation period and are therefore still recovering from COVID-19
    • have not been told to self-isolate by NHS TTP (Test, Trace Protect) Service
    • have not been knowingly exposed to someone with COVID-19 in the past 10 days
    • do not live with any household members who currently have COVID-19 symptoms and are awaiting the outcome of a test, or have been tested positive and are currently self-isolating, or have been told to self-isolate by NHS TTP Service
    • have not returned from overseas travel in the last 10 days from a non-exempt country and are required to be in quarantine
  • where possible, recommending that partners, visitors or other supporters should preferably be from the same household or part of an extended household as the woman. See guidance from 7 June 2021 for extended households. You will also need to check our Alert levels page for the latest information.
  • checking on arrival that partners, visitors or other supporters do not have symptoms suggestive of COVID-19 infection or other indications that require a self-isolation period (e.g. recent foreign travel to some countries, recent contact with an infected person) (see guidance on self-isolation) and request that under circumstances, they leave the clinical premises and return home immediately
  • Lateral Flow Device asymptomatic testing is available for pregnant women and partner support throughout pregnancy. Further details are available from the local maternity unit;
  • for women admitted to a hospital or community birth centre, asking the woman to nominate her partner support and, if required, essential support assistant who can attend during her admission;
  • minimising the movement of visitors and service users around the premises;
  • not permitting children under the age of 16 to visit or accompany women to appointments; in exceptional circumstances, this can be discussed with the midwife/person in charge who should make an individualised decision;

Assessing restrictions of partners, visitors or other supporters to maternity inpatient services

Consideration should be given to the needs of women who require additional support to access maternity services and for whom reasonable adjustments may be required. 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.
  • Where a woman has specific communication needs and may require support to understand information.

Women with support needs such as those listed above may also require an essential support assistant to accompany them to appointments and when in a hospital setting.

Definitions of partners, visitors and essential support assistants 

Partner support

are persons nominated by the woman to accompany her during pregnancy, labour and birth and the postnatal period. They are not necessarily life partners, but may be other supportive persons such as relatives, friends or doulas. 

Visitors and other supporters

of pregnant women are other people who either visit a woman during her stay in hospital or a community birth centre, or accompany her to outpatient appointments. This may include her partner, a relative, a friend or a doula.

Essential support assistants

are individuals required by women with specific additional support needs, e.g. a support worker or interpreter. Essential support assistants are not to be classed as visitors in the traditional sense. In some circumstances where a woman usually receives care and support from a family member or partner they may nominate this person as their essential support assistant

It is anticipated the risk levels will be set by predominately following the overall health board’s risk levels. However, localised risk assessments should also be undertaken for individual maternity units/services. This risk assessment should be carried out on a multi professional basis.  

Essential support assistants, birth partners and visitors may support women in a maternity unit/hospital setting within these defined risk assessed levels of restrictions.

Assessing restrictions of partners, visitors or other supporters to maternity inpatient services
Risk Rating Labour and Birth Settings  Antenatal or Postnatal Inpatient settings  Maternity Outpatients  Ultrasound Appointments
Very High  Essential support assistant AND / OR partner support in active labour  Women to attend appointments alone. However essential support assistants able to attend to provide specified support. One nominated adult may accompany the woman attending where she requires familiar support for consultations which may cause her distress.  Women to attend appointments alone. However essential support assistants able to attend to provide specified support.  One nominated adult may accompany the woman attending where she requires familiar support for consultations which may cause her distress All scans: Women to attend scans alone. However essential support assistants able to attend to provide specified support. 
 
One nominated adult may accompany the woman attending where she requires familiar support for consultations which may cause her distress. 
High Essential support assistants AND / OR partner support in active labour  Women to attend appointments alone. However essential support assistants able to attend to provide specified support. 
 
One nominated adult may accompany the woman attending where she requires familiar support for consultations which may cause her distress. 
Women to attend appointments alone. However essential support assistants able to attend to provide specified support. 
 
One nominated adult may accompany the woman attending where she requires familiar support for consultations which may cause her distress

Specified scans:

Partner support to accompany the woman to the appointments specified below(1) where social distancing can be achieved 
 
All other scans:
As very high risk level

Medium Essential support assistants AND / OR partner support if national guidance on social distancing can be achieved in the local setting  Essential support assistants AND / OR partner support if national guidance on social distancing can be achieved in the local setting. Essential support assistants AND / OR partner support if national guidance on social distancing can be achieved in the local setting.

Specified scans:

Partner support  to accompany the woman to the appointments specified below* where social distancing can be achieved

 

All other scans:

As very high risk level

Low Phased reintroduction of usual birth policies,  if different to medium risk level Phased reintroduction of usual visiting policies, if different to medium risk level.  Phased reintroduction of usual visiting policies, if different from medium risk level Phased reintroduction of usual visiting policies, if different from medium risk level.

Considerations when arranging inpatient visiting opportunities 

Restricting the time allowed for a single visit, offering morning or afternoon visiting sessions for adjacent bed spaces, or operating a visit booking system are some approaches that will maintain social distance between visitors. 

You may need to tailor your approach across services if one section of the service (e.g. birthing units) has ample physical space but others (e.g. postnatal wards) do not. 

NHS Health Boards are also advised to keep and retain a list of women attending each clinic / health care setting so that she can be contacted to provide details of anyone who has accompanied her and provide their names and contact details, to aid the NHS Test, Trace and Protect Service if contact tracing is indicated 

Sample guidance for visitors to inpatient services is in the RCM’s briefing Reintroduction of visitors to Maternity Units across the UK during the COVID-19 pandemic.

Assessing restrictions for partner support for pregnant women to maternity outpatient services

We recommend a similar approach for assessment of restrictions for accompanying adults, including partner support, to maternity outpatient services and ultrasound appointments.

The measures to mitigate the risk of transmission also apply to adults accompanying women to maternity outpatient services in community and hospital settings. 

Women should be encouraged to attend their appointment on time and to wait outside the hospital if they arrive early. 

If it isn’t feasible for partners or other individuals to accompany the woman in the waiting area, consider whether it is practical for them to wait outside the hospital/clinic (or in their car). They can be called into the clinical area when the clinician is ready to begin the appointment. Take account of whether it is acceptable for the accompanying adults to enter the room later than the woman, or whether it is possible to organise services in a way that enables this (including a possible impact on the length of the appointment), and whether this will lead to overcrowding and prevent social distancing in the external waiting areas.

Pausing or reversing the reintroduction of visitors to maternity services

Pausing the reintroduction of visitors, or reversal back to more stringent restrictions, may be warranted in response to the local or national transmission risk, or if a recent increase in the number of visitors was unsafe. 

The decision-making process for pausing or reversal should be clearly recorded. Discuss your reasons with local Maternity Services Liaison Committees and staff-side representatives. Consider sharing why you’ve made the decision, to help assure women and visitors that the leadership team has considered all reasonable approaches and adjustments but finds the practice unsafe.

Informing the Welsh Government

Health Boards should inform the Office of the Chief Nursing Officer immediately prior to changing their approach to visitor access to maternity services. Please email OCNOMailbox@gov.wales

Annex 3: Considerations for visiting in non COVID-19 hospice settings

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. All visiting requests should be met with sensitivity and understanding and accommodated where possible particularly during the last days of life.

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, wherever possible. 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 (June 2021), 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 social distancing outside of the clinical area. See guidance from 7 June 2021 for extended households. You will also need to check our Alert levels page for the latest information.

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.
  • Lateral Flow Device asymptomatic testing is available for visitors and visiting professionals in hospice inpatient unit settings. Further details are available from the hospice when arranging visiting. 
  • All visitors to health and care facilities must wear face coverings. See guidance in relation to the new measures, including reasonable excuses for not wearing face coverings.
  • Risk should be balanced against:
    • the benefits to individual well-being 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.
  • This guidance is being kept under review and is likely to change as the pandemic status alters.

Annex 4: Principles for organisations to consider regarding hospital visiting

The guidance suggests ‘that Health Boards (HBs) undertake a risk assessed approach, following a meaningful and documented assessment, making any necessary changes according to local transmission of the virus to either relax or reinstate previous degrees of restrictions.’

The guidance also identifies that visiting for individuals may be assessed and facilitated by the relevant ward manager on a case by case basis within the framework.

Whilst the importance of visiting to maintain wellbeing for individuals, especially those with a mental health issue, dementia, a learning disability or chronic illness is well understood and accepted, it must be remembered that a large proportion of transmission of COVID-19 within hospitals has been nosocomial and has occurred when the community rate of transmission is high.

It is therefore recognised that HBs will need to tailor protocols on visiting within specific hospitals and care settings according to local variables such as community transmission rate and the existence of highly transmissible Variants of Concern (VoC).

This annex sets out some principles for organisations to consider to assist with making decisions as part of this risk assessed approach within a national framework.

Hierarchy of controls

The primary consideration for HBs in excluding COVID-19 infection from hospital sites should always be the implementation and maintenance of the ‘Hierarchy of Controls’; these being in order of priority - elimination, substitution, engineering controls, administrative controls and personal protective equipment (PPE).

Therefore Health Boards should work to develop reliable systems for the exclusion of symptomatic individuals and to ensure that environmental modifications and signage are in place to enable social distancing and to manage the risk of queues and pinch points.

There should be sufficient hand-washing/hand sanitiser stations and cleaning products to ensure good and frequent hand and respiratory hygiene opportunities and, if necessary, the provision of appropriate face coverings and PPE.

Patient vaccination guidance

There is growing evidence of the efficacy of the vaccination programme in preventing the hospitalisation and death of patents with COVID-19. The vaccination of elderly and clinically vulnerable people is well advanced and data presented on the Public Health Wales Tableau database for 8 June 2021 indicate that 95.4% of Health Care Workers have also received at least the first dose of vaccine.

On 3 March 2021 the joint CMO/CNO letter ‘Consideration of vaccinating patients in eligible priority cohorts at or around admission and for inpatients’ recommended vaccination for elective, emergency and admitted hospital patients within eligible cohorts. Most of these cohorts will now have received both doses.

The letter gave examples of how HBs were asked toput arrangements in place to enhance deployment of the COVID-19 vaccination programme including:

  1. Offering at least one COVID vaccination, where practical, to elective admissions who are in the eligible cohorts, preferably more than two weeks prior to admission.
  2. Offer COVID vaccination to emergency admissions who test negative at admission and who are in the eligible cohorts currently being offered vaccination, if they are deemed clinically suitable/fit for vaccination.
  3. Offer COVID-19 vaccination to current inpatients who are in the priority groups being immunised, where practical.
  4. For those who have received the first dose of the vaccine, which may have been given in the community or in hospital, if their second dose is due while they are in hospital, this needs to be facilitated if they are deemed clinically suitable/fit for vaccination.

Considerations on the use of testing

Testing is being used to screen visitors to other closed settings with vulnerable residents and so can be considered for hospitals.

There are two perceived benefits from the introduction of testing for hospital visitors:

  • the exclusion of infectious visitors if the test is positive
  • the provision of reassurance if the test is negative

There are a range of different testing technologies that may be employed, including lateral flow devices (LFD) and point of care (POC) devices. Each of these has different characteristics and costs.

In making decisions about testing in the suite of measures to promote safer hospital visiting, it is important that Health Boards understand the context within which testing takes place. To take the case of LFDs:

  • For the week of 23 to 29 May 2021, the COVID-19 infection survey estimates that community COVID-19 infection rates in Wales were around 1 person in 1,050 (95% credible interval: 1 in 2,910 to 1 in 520), or an estimated 2,900 people during this period.
  • It is now understood that at this low prevalence the vast majority of positive LFD tests will be false results. This would mean that an individual who tests positive with an LFD might still only have a less than 5% chance of actually being infectious.  The reliability is likely to be further reduced when the test is self-administered without supervision.
  • At low prevalence, there is a high chance of inappropriately excluding individuals with positive LFD results from visiting, with potentially distressing and harmful consequences where the person they planned to visit is critically ill or at the end of life.  Also visiting is denied to those that do not take a test.
  • The reliability of a positive test increases as community prevalence increases, suggesting a more useful role for LFD testing if community rates are high.
  • It should also be noted that LFDs are not 100% sensitive, so may miss around 30% of those that are truly infectious.  This is further justification for continuing the other measures in the hierarchy of controls.
  • It is recognised that there will be circumstances when a local risk assessment is thought to suggest a benefit to LFD testing of visitors, perhaps for immuno-compromised patient cohorts.

The latest guidance Visits to care homes: guidance for providers (updated 6 August 2021) advises that all indoor care visitors are tested, via supervised testing, prior to entry. The care home guidance document is also clear in stating that ‘The expectation is that risk assessed visits, including indoor visits, will be supported’ and that the emphasis for providers should be on ‘how’ rather than ‘whether’ visits should take place.

In comparison, the document ‘Hospital visiting during the coronavirus outbreak: guidance’ (November 2020) frequently reiterates that ‘visiting should be with a clear purpose and agreement for visiting based on the best interests of the patient/service user or the well-being of the visitor.’

As restrictions are relaxed and hospital visiting ceases to be only ‘visiting with a purpose’ Health boards may consider whether the implementation of LFD or POC testing, supplemented by Polymerase Chain Reaction Rt-PCR  lab based testing to confirm positives, is required in addition to the ‘Hierarchy of Controls’ to assist in the initiation of more routine hospital visiting.

The main options through which Health Boards could utilise testing if they make it a requirement are:

  • supervised testing in-situ at the hospital site
  • self-testing at home.

There are practical considerations that should be taken into account when choosing the most appropriate channel:

  • For supervised testing in-situ: Do hospitals have staffing and estate capacity to ensure supervised testing for all visitors on the same day as the visit and to provide sufficient room for social distancing whilst awaiting results?
  • For self-test at home prior to visiting: questions about the accuracy of unsupervised tests have been raised, Health Boards will also want to consider validation of the process and the ability to record the results of all tests. Ideally, visitors should be engaging in regular testing and will have had at least two negative tests before visiting. Visitors will also need clear guidance on how and where they can access LFDs.

There are also potentially large financial and ecological costs associated with widespread deployment of further testing which should be taken into consideration.

Parents and partners

The hospital visiting guidance does recognise the special circumstances of partners of women in maternity services to attend pregnancy appointments and inpatient admissions and allows up to two parents, guardians or carers at the bedside at a time for paediatric inpatients and neonates subject to local determination, and following a risk assessment including the ability to maintain social distancing. The principle of local risk assessment still applies as outlined, but it is recognised that there may be a useful role for regular LFD testing to facilitate access to partner/parent support throughout pregnancy/ birth/ postnatal and in provision of support to children. There could also be opportunities to utilise Point Of Care devices to test parents and partners.

Parents of children in hospital and pregnant women and their identified support partner in maternity services are now able to access LFD test packs by collecting test kits from their closest community collection point or by ordering test kits direct to their home.

Conclusion

Implementation of the hierarchy of controls remains the primary means of preventing the entry and spread of COVID-19 to hospital. Protocols and procedures for social distancing, environmental cleaning and IPC, including thorough and frequent hand-hygiene by visitors and wearing of face coverings and use of PPE, where appropriate, must be reviewed and evaluated on a regular basis.

Health Boards and Trusts should consider how vaccination for emergency, elective and in-patients can be deployed to enhance the safety of hospital visiting, and if the benefit outweighs the disadvantage.

The role of visitor testing as part of a risk assessed approach must be considered in the context of current community transmission rate, the local presence of VoC, the vulnerability of particular patient groups and the circumstances and purpose of the visit.

Footnotes: Principles for organisations to consider regarding hospital visiting

(1) early pregnancy assessment unit scan (EPAU)/early pregnancy dating scan (11 weeks + 2 days to 14 weeks + 1 day)/fetal anomaly scan (18 to 20 weeks + 6 days)/attendance at Fetal Medicine Department.

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