COVID-19 – Strict Patient Safety (Visitor) Policy
Last Update: December 24, 2020
I. Policy Author
Please contact Brian Cassel, firstname.lastname@example.org, with any questions related to this policy.
The COVID-19 pandemic continues with predictions for necessary, continued modifications to clinical practice operations. Based on community transmission rates, state and county public health information, and hospital conditions we are implementing modifications to the Strict Patient Safety Policy, originally established on 3/20/20.
Means, with respect to an individual, a physical or mental impairment that substantially limits one or more major life activities of such individual; and a record of such impairment; or being regarded as having such an impairment. This shall not apply to impairments that are transitory and minor. A transitory impairment is an impairment with an actual or expected duration of 6 months or less.
Designated Support Person
Individual who is chosen by the patient to be physically present at the hospital to support the patient. A Designated Support Person is not limited to patients with disabilities. The Designated Support Person must be 18 years of age or older. The Designated Support Person is knowledgeable about the management and care of the patient. This person may be a friend, family member, personal care assistant or disability service provider; and may or may not be legally authorized to make decisions for the patient.
Defined as the period of time from midnight one day until midnight the following day
IV. Patient Safety Measures
A. In UMMS Inpatient Facilities
- UMMS has adopted a strict patient safety (no visitation) policy with the following exceptions: 1) individuals with disabilities, 2) women presenting for delivery, 3) pediatric patients and 4) patients at the end of life. No general visitation for adult inpatients will occur at this time. See sections C and D for details of allowed visitations, as well as exceptions by patient category.
- Consistent with the COVID-19: UMMS Policy for Expanded PPE and Universal Masking During Community Spread of COVID-19, every person in any UMMS facility is expected to be wearing some type of mask at all times.
- Masks must be worn at all times while in the hospital and must be worn above the nose and below the mouth. Cloth masks (without exhalation valves) are acceptable for visitors.
- Each hospital should establish a process to escalate visitor refusal to wear masks to designated hospital leadership.
- In the event that an authorized representative of a patient in the Emergency Department (ED) refuses to mask, the refusal will be immediately escalated, per the defined hospital process.
- If the authorized representative continues to refuse to mask, he or she will be asked to leave after medical screening is complete.
- All persons visiting patients who are COVID-19+ or Persons Under Investigation (PUIs) for end of life, must have reviewed the Acknowledgement of Risk Form, which will be signed by designated hospital staff prior to patient visitation.
- For patients who are undergoing asymptomatic COVID-19 screening and have not been deemed PUI or COVID-19+, visitation that is necessary for designated exceptions shall occur only after initial admission testing for a patient has been completed and their COVID-19 status is known.
- The Designated Support Person must be 18 years of age or older. No individuals under the age of 18 will be allowed to enter the facility unless the individual is the parent or guardian of a hospitalized patient.
- During this time, only two Designated Support Persons per disabled patient may be identified for visitation privileges (per Maryland regulation). These two Designated Support Persons (DSP) may change during the course of the patient’s hospitalization by calendar day, but not more frequently. Designated Support Persons, like all members of the UMMS community, are required to follow all Infection Prevention policies established by the hospital. These practices may prohibit the Designated Support Person from entering certain areas of the hospital.
- The Designated Support Person must adhere to the facility’s check-in process upon entry. They will be screened for symptoms of COVID-19, travel and gatherings and may be required to have a temperature screening as well, per facility protocol. If it is determined that the Designated Support Person is exhibiting symptoms associated with COVID-19, he or she will not be permitted to enter the facility.
- Frequent entry and exit from the hospital will be discouraged. Hospitals may not allow visitors who leave to return in the same day unless approved for overnight stay.
- Visitors should not eat or drink inside patient rooms or other patient care areas.
B. Outpatient Appointments/Procedures
- One Designated Support Person may accompany a patient who is not a PUI or COVID-19+, if their support is needed to facilitate care of the patient during an ambulatory visit, procedure or same-day surgery. If there are waiting room space constraints, staff will work with the patient and their Designated Support Person to determine optimal waiting arrangements.
- The Designated Support Person should be 18 years of age or older. Patients should be strongly discouraged from having individuals under the age of 18 accompany them to an office visit at the time the visit is scheduled. Exceptions include:1) if the patient is a minor and the accompanying individual is a parent or guardian, or 2) if the accompanying individual is the infant of a nursing mother.
- If the patient is accompanied by an individual under the age of 18, the practice shall inform the patient that the accompanying minor must (1) stay in close proximity to the patient at all times; (2) avoid being within 6 feet of another person; and (3) if, the minor is able, must wear a mask for the duration of the visit.
- For all other situations where a patient presents with a minor Designated Support Person, the practice should consider whether the visit can be rescheduled and conducted through a telehealth visit, to occur within a reasonable and appropriate time period. The provider and patient should work together to decide the appropriateness and feasibility of a telehealth visit.
- Designated Support Persons who are visiting, like all members of the UMMS community, are required to follow all Infection Prevention policies established by the hospital.
- They must adhere to the facility’s check-in process which will include screening for symptoms of COVID-19 and may include temperature screening, per facility protocol. They must remain with the patient or in the designated waiting area at all times. They may not be permitted to remain in the facility if waiting room restrictions create the potential for an unsafe environment of care or work for patients, staff and/or providers.
- They should not eat or drink in patient care areas during outpatient visits occurring inside UMMS facilities.
- Patients with disabilities have the right to have a Designated Support Person present, in accordance with the Maryland Department of Health.
- Patients with disabilities who require support are allowed one Designated Support Person at their bedside at all times. Overnight stays may be allowed for these patients.
- If the patient and Designated Support Person are unable to comply with the hospital's Infection Prevention measures, the patient may propose other reasonable accommodations that also comply with the hospital's measures and will not adversely impact the health of staff and other patients. All proposed accommodations shall be reviewed by an identified Infection Prevention lead at the local facility. Approval of any proposal is at the sole discretion of the designated Infection Prevention lead.
- Designated Support Persons for patients who are COVID-19+ or PUI must have reviewed the Acknowledgement of Risk Form, which will be signed by designated hospital staff prior to patient visitation.
- Communication with Designated Support Persons
- If a patient with disabilities does not have a Designated Support Person present at the hospital, staff shall make reasonable efforts to communicate relevant information with a patient's designated representative, in alignment with patient privacy requirements. Effort shall be made to communicate in advance of admission, if possible.
- The hospital shall inform the patient and any Designated Support Persons, friends, family members, personal care assistants or disability service providers of this policy.
- Religious Accommodations
- For patients who are PUI or COVID-19+, an exemption shall be granted for the patient to receive religious services in compassionate care circumstances or at end of life.
- Patients in non-COVID-19+ units, who are neither PUI, nor COVID-19+, may receive religious services from clergy of the patient’s choice at any reasonable time, if it can be provided without disruption to the clinical care of the patient or other patients on the unit or in the room.
- All clergy must abide by hospital policies and procedures relating to patient visitation, will be screened for symptoms of COVID-19, and may be required to have temperature screening as well, per facility protocol. They also must have reviewed the Acknowledgement of Risk Form for COVID-19+ patients or PUIs, which will be signed by designated hospital staff prior to patient visitation.
- Other Exceptions
- Patients undergoing emergency surgery related to a traumatic event.
- If the patient’s care team requests the visitor to be a part of scheduled care partner training for patients with rehabilitation or cognitive needs.
- For patient and care partner discharge education when in-person bedside education is medically necessary as determined by the patient’s treatment team.
- Patients who are prisoners may require up to two guards at the bedside at a time.
D. Allowed Individuals by Category
|Type of Inpatient Setting||Number of Designated Support Persons|
|COVID-19+ or PUI Adult Inpatients||
|Adult Inpatients (Non-COVID-19+ or Non-PUI)||
(for example, semiprivate rooms, bays (e.g.,PACU), ED waiting rooms)
|Individuals With Disabilities||
|Behavioral Health Units and Inpatient Rehabilitation Units||
(patients in private rooms)
|Obstetrics/Labor and Delivery||
|Pediatrics and Neonates||
|End of Life PUIs or COVID-19 Patients||
|End of Life non- PUI or COVID-19 Patients||
|Patients Requiring Aerosol-Generating Procedures||
|Outpatient Appointments and Procedures||
E. As a reminder, all visitors must follow the standard rules of the respective UMMS facility:
- Visitors may not smoke in any area within or outside of the facility.
- Visitors may not give patients any nicotine-related items, medications/drugs not prescribed by the patient’s physician, or weapons of any type.
- Visitors must follow the directions of UMMS staff members.
- In order to create a healing environment, visitors must comply with respectful and quiet conduct towards all patients, other visitors and staff at all times.
- Violation of any UMMS facility policy will result in the visitor being removed from the premises, and the visitor may be barred from any further visits.
V. Supportive Information
A. Communication and Education
- This policy will be communicated to the appropriate UMMS personnel via the following channels.
- The policy will be placed within PolicyStat on the intranet.
- Re-education and revisions will be communicated via Medical Staff, Patient Care Service, and staff meetings and publications as needed.