Visiting hours for hospitalized patients have traditionally been restricted to set periods during the day and limited in duration. However, the situation is slowly changing towards a more open approach to family visits, even in wards where visits are often most restricted, such as intensive care units (ICUs). As just a few examples of this general change in attitudes towards visiting, many American hospitals have now completely removed restricted visiting hours; a campaign of extended visiting hours was launched in France a few months ago; and a bill is currently being discussed in Italy to expand hospital visits.

by Prof Jean-Louis Vincent

Why restrict hospital visiting?
The reasons behind restrictive visiting are not very clear or, in today’s context, very credible. The fear of transmission of infection was perhaps the earliest reason for restricting visits, but with improved infection control measures, this concern is generally unfounded. Other suggested reasons include the need for patient to have adequate rest periods and the belief that visitors interfere negatively with medical and nursing care.

Because sick patients need rest?
It was widely believed that having periods of the day without visiting would ensure that patients had sufficient periods of rest, without disturbance from visitors. However, the need for sick patients to rest is often exaggerated. Indeed, this idea is now rather out-of-date, even for the sickest of patients. Although patients must clearly not be exhausted by their visitors, too much rest can encourage muscle weakness and prolong convalescence. When a family member says “doesn’t he/she need to rest Doctor?”, I often reply “certainly not; in fact you should wake him/her up!”. The current trend is to encourage physical and intellectual stimulation for all patients.
Of course patients need some time to sleep and rest, as we all do, but this can be determined on an individual basis, preferably after discussion with the patient, rather than being enforced at fixed times by restricted visiting hours. Moreover, the presence of a loved one in the room does not necessarily prevent restorative sleep. Rest is also important for family members and it is sometimes necessary to remind them to take a break, particularly at night. In any case, access to hospitals is generally limited during the night, for security reasons.
Because visitors interfere with patient care?
The presence of visitors was often believed to interfere negatively with medical care. Visiting hours were therefore concentrated on periods of the day during which patients were least likely to be undergoing medical consults or examinations. However, hospitals of today function almost continuously or at least with considerably more extensive hours than in the past, notably for laboratory and radiological investigations, making it difficult to predict when examinations and rounds are most likely to take place.
The presence of visitors was also often believed to hinder good nursing care, and perhaps much restricted visiting was devised for the benefit of nurses, rather than  the patient. Nurses often complained that they were unable to perform the necessary care in the best possible way, because they were bothered by the presence of relatives, sometimes numerous and noisy, who asked a lot of questions, and were even critical of the care being provided!
However, it is now widely believed that extended visiting hours can be beneficial not only for the patient and visitors, but also for the staff. Staff members, especially nurses, are often initially reluctant to the proposed change to more extensive or unlimited visiting, concerned that it will increase their workload. But this is not necessarily true, and is in fact often the reverse. Allowing visitors to be present at different times during the day enables them to understand better the work of the nurses, doctors and other healthcare personnel. When visiting hours are restricted, nurses often make use of the visiting periods to have a small break, to catch up or even have a joke with their colleagues. This can sometimes give visitors the impression that nurses have nothing to do, or are not really concerned about looking after the patients under their care. By arriving at different times of the day and staying for longer periods, family members can better appreciate hospital life and realize that nurses also need some time for relaxation and distraction, thus reducing the risk of conflicts between family members and staff. Extending visiting hours also reduces the number of telephone calls from relatives asking after their loved one, thus freeing up nursing time.

Let’s welcome visitors
Importantly, fixed visiting hours can discourage relatives from visiting a patient. For example, it can be difficult for family members who are working to request time off during the day to be able to observe the fixed visiting hours; sometimes family members simply forget (or are unaware of) the specified times, especially when units have different hours on different days of the week, and have to go home having missed the allocated slot; similarly, visitors who have to travel some distance to visit their loved one may be put off by the risk of being late and missing the fixed visiting period. Finally it is sometimes just easier to say, “I’ll visit when they’re better and out of hospital…”
Rather than being made to feel that they are the enemy and not welcome, relatives should be encouraged to visit and be involved. We must not talk about “them” and “us”. The patient must be at the centre of our preoccupations at all times and we must all work together to ensure he/she has the best possible chances of a good recovery without complications. Family members and loved ones form part of the patient’s immediate supportive environment and can form a useful bridge between the patient and hospital staff. They can also play an active role in patient surveillance, for example by indicating to staff if there is a problem that has not been noticed or that the patient may not want to report. In certain American hospitals, pamphlets are now available to explain how relatives can identify and report important signs of deterioration, for example, confusion that wasn’t there before or a small change in respiration that has gone unnoticed. 
Family members can even sometimes contribute directly to some aspects of patient care, for example helping with feeding, washing or dressing. Indeed, these practices are commonplace in countries with limited resources, where family members never leave the bedside. In western society, however, patient care has been completely transferred from the family to professional carers, which can sometimes lead to the patient feeling patronized or being treated like a child.
The hospital structure is also changing to be more welcoming for visitors. Instead of a few folding seats at the end of the corridor for relatives waiting while the patient is examined or comes back from an examination, many hospitals have now introduced reception rooms where relatives can stay as long as they wish, in comfortable conditions. In the United States in particular, hospitals have set up small kitchen-lounges where families can rest, prepare a meal in the microwave or watch television… and why not socialize, chat, share experiences with relatives of other patients.
Indeed, the hospital is no longer a detached world, which we are somewhat hesitant or even scared to enter. Hospitals are increasingly user friendly and should be seen as somewhere positive and welcoming. After all, many hospitals now have a cafeteria (if not a restaurant), small shops, a bank, a post-office, pleasant gardens… creating the idea that hospitals can be part of everyday life, and indeed are for the many patients and visitors that pass through the doors daily. Visitors can make use of these areas when their relative is undergoing an examination or receiving nursing care.

Family presence during interventions?
As families spend more time visiting their loved ones in hospital, the chances that they will be present when an intervention is needed are increasing, perhaps particularly on high acuity wards. But should they be allowed to stay in the room? Perhaps yes for a simple blood test or changing of a dressing, but what about during cardiopulmonary resuscitation (CPR)? This issue continues to raise considerable debate, not least because the patient needing CPR cannot be asked if they mind. Although some staff members find having family members present adds stress to an already complex situation, studies have suggested that the presence of a relative can help a surviving patient understand what has happened and, if the patient dies, having been present can reassure the family member that everything possible was done. This is an area where attitudes are changing and, if a family member wishes to be present during CPR, this request should not be refused.

The rights and responsibilities of visitors ….
Clearly, although visitors have the right to see their loved ones in hospital, they must also abide by certain rules. They must leave the room when asked to do so by the hospital staff and should not interfere with patient care. They should not slow the work of the nursing or medical staff by asking repetitive, unnecessary questions or by engaging in prolonged conversation. Importantly, too, visitors are there to visit only their relative/loved one and must not look, even surreptitiously, into the rooms of other patients!

… and the rights of the patient
On reflection, rather than asking whether visiting the sick patient is allowed, the question should rather be the reverse, whether the patient is allowed to see his/her relatives? Limiting hospital visits is generally harmful for the patient and opening up visiting is reported to improve patient satisfaction. By bringing news from the outside world, family, friends, pets, … visitors can stimulate a patient’s intellect and interest, helping promote a quick recovery. There is nothing worse than lying in bed all day just looking at the ceiling… But, it is important to consider the patient’s viewpoint when considering visitor access. For example, some patients may prefer to have only close family members visit, feeling embarrassed about less well-known friends and relatives seeing them unwell, and others may prefer not to discuss their condition when family members are present for fear of upsetting them. Patients have the right to see visitors whenever they wish, but should not have visiting forced upon them.

Conclusion
It is not so long ago that, when visiting a patient in hospital, an often rather officious nurse would announce the end of visiting hours and insist you leave your loved one. Such strict practices have become less common and there is much more flexibility, particularly on general hospital wards. We need to go further and extend open visiting to all areas of the hospital, including ICUs, where visiting still remains, in general, more restricted. In many cases, we should be actively inviting relatives to visit more and to stay longer, especially when the patient has few visitors and feels isolated. Visiting is humane and good for the patient.
If you still have restricted visiting hours at your hospital, I am sure this will change in the near future. I am not convinced that there should be a law on this subject, whether in Belgium, Italy or elsewhere, but rather a collective effort needs to be made to change our mentality related to visiting hours and thus improve the quality of care for our patients.

Suggested reading
Giannini A, et al. What’s new in ICU visiting policies: can we continue to keep the doors closed? Intensive Care Med 2014; 40: 730-33
Jabre P, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med 2013; 368: 1008–18.
McAdam JL & Puntillo KA. Open visitation policies and practices in US ICUs: can we ever get there? Crit Care 2013; 17: 171
Shulkin D, et al. Eliminating visiting hour restrictions in hospitals. J Healthc Qual 2014; 36: 54-7

The author
Jean-Louis Vincent, MD, PhD
Dept of Intensive Care, Erasme University Hospital, Université libre de Bruxelles,
Route de Lennik 808, 1070 Brussels,
Belgium
jlvincent@intensive.org

Earlier this year the American Medical Association (AMA) published an article entitled ‘Lower costs by going green!’ aimed at the healthcare sector.  They note that, in the USA, 9 – 10 percent of the nation’s total carbon dioxide emissions are generated by the health care industry – and the USA is not alone in this high carbon footprint.  In Europe the average emissions is estimated to be about 5 percent.  Cleary there is a margin for improvement.  The AMA article makes practical, money and energy saving proposals aimed at the small medical practices.  The question arises as to how this could be achieved in the larger hospital environment.  There is a trove of excellent suggestions for building new energy efficient and environmentally friendly hospitals – but what of existing hospitals?
A very useful source of information is the Global Green and Healthy Hospitals (GGHH) community.  The community of almost 1000 members have the aim to transform the health sector and foster a healthy future for people and the planet.  To achieve this aim GGHH brings together hospitals, health systems, and health organizations from around the world under the shared goal of reducing the environmental footprint of the health sector.
To achieve their aims, they suggest a 10 goal strategy: Leadership -making environmental health, safety and sustainability key organizational priorities;  substituting harmful chemicals with safer alternatives; to reduce, treat and safely dispose of healthcare waste; to reduce water consumption, as well as to source, purchase and serve sustainably locally grown, healthy food. Other goals include implementing energy saving strategies; safely manage and dispose of pharmaceuticals; transportation planning, building efficiency design; and purchasing safe and sustainable products.   
GGHH points out that there is not one model of green and healthy hospital but indicate that many health systems around the world are already taking steps to reduce their environmental footprint contributing to public health while at the same time saving money.    Initiatives such as the ‘Health Promoting Hospital Network’ originating in Europe and with the support of the World Health Organisation, is developing a set of sustainability criteria.  Such initiatives and conferences of greening the health sector are emerging in countries as diverse as Argentina, China, India, South Africa and Sweden – to name a few.
The Global Green and Healthy Hospitals agenda sets out to support these existing efforts around the world to promote greater sustainability and environmental health.  European hospitals would do well to align themselves with this community, reducing the European healthcare contribution to the carbon footprint, as well as, in many cases, saving money –immediately and in the future.

Healthcare, like other services, requires getting appropriate expertise to the place where it is needed at the right time. Requirements like these become critical when a patient faces a sudden and unpredictable life-threatening condition. The latter is a near-routine occurrence in a hospital’s intensive care unit (ICU). Still, a host of factors make it impossible for clinicians to be present at every point in the ICU, all the time.

Early acceptance of robotic telepresence
Such shortcomings are sought to be addressed by ICU robots, one of the latest applications in the emerging field of ‘robotic telepresence’. The use of ICU robots, also referred to as teleoperated medical devices, is growing rapidly as a supplement for patient care in the ICU. In its early stages, healthcare providers were overwhelmingly convinced of their potential. In September 2012, for example, a survey of over 10,000 ICU robotic interventions in the journal ‘Telemedicine journal and e-health’ found 100 percent of practitioners considered the robot to improve both patient care and patient satisfaction.

Autonomous, optimised for ICU, hospital environment
ICU robots essentially provide access for physicians and other specialists to implement a variety of medical procedures round-the-clock, while reducing delays for difficult admissions or procedures.
The robots can be pre-programmed to drive on their own around an ICU, or this mode can be overridden and controlled by an individual, located on the premises, at a facility near by or thousands of kilometres away, via a keyboard or joystick.
The robotic sensors are optimized to perform in a hospital environment, enabling the robot to identify and avoid things like IV lines, cables and glass doors.

Plug-and-play for medical devices
The robot itself contains combinations of display types, microphones, speakers and cameras; these have pan-tilt and zoom capabilities, and are powerful and manoeuvrable enough to permit physicians to view fine details and listen to the smallest sounds.
Typical accessories in an ICU robot include an integrated electronic stethoscope to allow physicians to listen remotely to heart and lung sounds using earbuds. However, most Class II medical devices can be plugged into the robot, which streams data back in real time. On the other side, robots can also access digitized medical records of patients.
Recent innovations include a smartphone application, enabling physicians to access the robot’s camera. Another is ‘point and click’ navigation, by virtue of which a user can simply click somewhere on a map of the hospital and the robot gets itself there.

UCLA pioneers ICU robot
The history of ICU robotics dates to 2005, when the University of California at Los Angeles (UCLA) Medical Center became the world’s first hospital to introduce a robot in its neurosurgery intensive care unit under a US military-funded pilot project. The UCLA pilot saw intensivists (clinicians specialized in the care of critically ill patients) monitoring patients from their homes and offices.

The robot was RP-6, developed by California-based InTouch, a company known for its ‘auto-drive’ robotics technology used in defence and public safety. Controlled by a webcam and joystick over a broadband connection, the 65 inch (166 cm) wheeled robot boasted 8-hour runtime from a single charge. Onwards from 2006, InTouch offered hospitals an option to rent the RP-6 for USD 4,000 a month, or buy it outright for USD 120,000. Its earliest customers included Detroit Medical Center and Baltimore’s Sinai Hospital.

The iRobot-InTouch Health Alliance
Meanwhile, another US company iRobot (vendor of the robotic household vacuum, Roomba) set up a Healthcare Robotics division in 2009.
In 2011, iRobot and InTouch Health announced an alliance targeting healthcare. The next year they unveiled the RP-VITA (Remote Presence Virtual + Independent Telemedicine Assistant), a robot which went beyond simply providing remote interactive capability between a clinician and patients to a hugely-enhanced navigation capability, based on sophisticated mapping and obstacle detection and avoidance technologies tailored to a hospital environment. Its aim was to free the clinician for clinical tasks.

FDA clearance
The most revolutionary capability of RP-VITA was autonomous navigation, which was submitted to the the US Food and Drug Administration (FDA) for 510(k) approval. In January 2013, the FDA cleared RP-VITA, making it the first autonomously navigating telepresence robot in healthcare, with clearance for use before, during and after surgery and for cardiovascular, neurological, prenatal and psychological as well as critical care. 

Demand driven by range of factors
The key drivers of demand for ICU robots today include time factors (urgency in ICU cases) and access (unavailability of ICU expertise) in remote areas. Both these are compounded by staff shortages.
There are fewer than 6,000 practising intensivists in the United States today and more than 5 million patients admitted to ICUs annually. A few years ago, Teresa Rincon, chair of the Tele-ICU Committee of the Society of Critical Care Medicine (SCCM) noted that the number of intensivists in the US was “not enough for each hospital to have one.” Indeed, it is estimated that only about 37 percent of ICU patients in the US receive intensivist care, although trained intensivists in the ICU correlates to better outcomes and decreased length of stay – both in the ICU and hospital.

The challenge of coma
In terms of urgency,  the SCCM notes that up to 58% of emergency department admissions in the US result in an ICU admission. 
Following admission, one of the major drivers of demand for ICU robots is coma. The reliable assessment of comatose patients is always critical. A hospital needs to quickly identify clinical status changes in order to determine and implement appropriate interventions.
In January 2017, the prestigious Mayo Clinic published results from a 15-month study of 100 patients, which is reported as the first to look specifically at telemedicine in assessing patients in coma. The results suggest that patients with depressed levels of consciousness can be assessed reliably through telemedicine.
Another urgent complication is delirium. Delirium incidence has been estimated at over 80% in critically ill patients. This is accompanied by a threefold increase in mortality risk, according to an oft-cited study in an April 2004 issue of the ‘Journal of the American Medical Association’.

Clinician availability
Medical emergencies like coma and delirium require the presence of highly qualified clinicians, but as discussed previously, real-life constraints limit their availability round-the-clock.
Access is another crucial consideration. Most hospitals simply lack the patient volume to employ full-time intensivists in fields like neonatology, while their availability is limited for the same reason in remote rural locations. 

The tele-ICU
The first attempts to address such challenges were centred on telemedicine or Tele-ICU care, involving continuous surveillance and interactive care by offsite clinicians. This was achieved by video observation of the patient and interrogation of equipment, along with instructions conveyed to other ICU staff.
Although more studies are needed, there is evidence of an association of the Tele-ICU with lower mortality and shorter length of stay in both the ICU as well as the hospital.  Another benefit is that a Tele-ICU enables stricter adherence to guidelines.

US leads the way
Europe was a relative latecomer to ICU telemedicine, with a near-total focus on teleconsultation and almost-total reliance on the US experience.
For example, Britain’s NHS refers extensively to US studies on ICU telemedicine in its own Technology Enabled Care Services (TECS) Evidence Database, while the University of Pittsburgh Medical Center has opened a Tele-ICU centre in Italy, which allows US physicians to perform remote consults for Italian ICU patients.

From telemedicine to robotics: business model turned around
In many senses, ICU robotics have been a natural successor to the Tele-ICU, albeit with a significant reversal in its operating model.
The Tele-ICU functions centrally. Rooms are hard-wired with high-resolution cameras and transmit data to a remote command centre staffed by an intensivist (tele-intensivist). The intensivist, who typically covers multiple ICUs, has access to the same clinical information (e.g. vital signs, lab values, notes, physician orders etc.) as the ICU bedside team consisting of nurses, respiratory therapists, non-ICU physician and transfers instructions to them via a two-way communication link. Robotics, driven by advances in technology and mobility, have made it possible for the Tele-ICU care model to become decentralized. The ICU robot is controlled wirelessly by the tele-intensivist, who is freed from a dedicated command centre, and can indeed be just about anywhere. The robot moves from room to room, examining patients based on instructions from the intensivist and interacting as required with staff. The latter interaction is now seen to be far more efficient, since it occurs only after the intensivist has given instructions on the procedures which need to be performed on a patient.

The cost factor
ICU robots seem to also address another major  limitation of Tele-ICU, namely cost. Most studies on Tele-ICU have found that though the technologies deployed have been adequate, they have also been much too expensive.
In the US, some hospitals collided with reality, quickly and harshly, “removing tele-ICUs after outcomes failed to justify the costs.” A study in December 2009, in the prestigious ‘Journal of the American Medical Association’ also questioned a key maxim of the Tele-ICU, pointing to evidence that remote monitoring of patients in ICUs was not associated with an overall improvement in the risk of death or length of stay in the ICU or hospital.
Perspectives have been similar in Europe. For example, a Dutch study published in 2011 in the ‘Netherlands Journal of Critical Care’  concluded that hospitals were unlikely to see the “enormous” investment entailed by a tele-ICU as being cost-effective. Concerns about Tele-ICUs were also echoed the same year in Canada, where critical care clinicians, writing in the ‘Journal of Critical Care’ expressed scepticism regarding the ability of a Tele-ICU to address challenges of human resource limitation or even deliver quality care.

The personal touch
While a conclusive answer to the question of cost-effectiveness of OCU robots will require a larger user base, one powerful advantage seems to be the ability to target the eventual subject of the healthcare process, the patient. According to Paul Vespa, a neurosurgeon at UCLA’s David Geffen School of Medicine patients “interact with the robot as if it is a person.”

Steps to realize full potential
Before there is growth in numbers of ICU robots, some of the factors which will need to be addressed have been identified in a ‘Journal of Critical Care’ article in December 2013 by the Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City, US.
These consist of formal training and orientation, identification of roles, responsibilities, and expectations, needs assessment, and administrative support and organization. Failure to adopt these, say the authors, will mean ICU robots may not see their full potential realized.