The Impact of Visitor Identification Policies on Hospitalized Children and Families

A new father anxiously arrives at the hospital to visit his newborn daughter, a premature infant transferred to the NICU. On arrival, hospital security asks the child’s father to present a valid form of identification (ID) before entering the premises. Originally from Mexico, the father presents his expired Mexican passport. This is not a permitted form of identification on the hospital list, and security asks him to present an alternative form of ID. He presents a Mexican consulate card with his photo and name on it, but this is also not permitted. Security asks the father to drive to the Mexican consulate, about 35 miles away, to renew his passport to gain access to the hospital to see his sick newborn daughter. The father worries that the passport may take weeks to renew. He also fears the potential consequences of bringing an expired passport to the consulate office and worries he will lose his job if he misses work to request a new passport. Ultimately, the father waits until his daughter is discharged from the hospital months later to finally meet her.Unfortunately, this case is not unique, as similar scenarios occur in hospitals throughout the United States regularly: a grandmother unable to relieve her exhausted daughter to help with a hospitalized grandson, an aunt not permitted to visit her nephew admitted for weeks of intravenous antibiotics, a homeless teenager unable to visit his girlfriend and newborn daughter after delivery, a grandfather turned away from visiting his granddaughter dying of cancer. In each of these cases, loving caregivers, defined as parent or other primary adult in a child’s life, were denied access to visit a hospitalized child because they did not have a valid form of ID accepted by the hospital.Hospital safety measures are crucial to ensure visitors pose no risk of harm to patients, families, and hospital staff. Institutions must grapple with how to create family-centered and equitable policies and ensure employee wellbeing and safety. Verification of identity may be enacted with the intent to protect patient and caregiver privacy, restrict unauthorized access to sensitive areas, minimize the risk of theft, and reduce the potential for disturbances or altercations within the premises. Additionally, it aids in the accurate tracking of visitors, enabling hospital authorities to maintain a record of individuals entering and exiting the facility. This information can be invaluable in case of emergencies, a need for contact tracing, or any unforeseen incidents that may require retrospective investigation. The Joint Commission’s accreditation requires hospitals to have a plan of security and process to identify everyone who enters their facilities.1 Therefore, ID requirements should support compliance with these health care regulations and policies. However, in an informal survey of multiple freestanding children’s hospitals (13 in total) varying in geographic location and size, there was large variability in requirements of inpatient visitors.Examples of inpatient visitor policies from an informal survey:No ID document requirement, but visitors need a pin number for entry that is only provided by the child’s primary caregiver.Required document with visitor’s name and date of birth (can be nongovernment-issued and/or expired).Required document with visitor’s name, date of birth, and photo (can be nongovernment-issued and/or expired).Required government-issued document only (unexpired).The American Academy of Pediatrics supports family- and patient-centered care and recommends that “families should be strongly encouraged to be present during hospitalization of their child, and pediatricians should advocate for improved employer recognition of the importance of family presence during a child’s illness.”2 The hospitalization of a child is often one of the most stressful times of a primary caregiver’s life. This stress not only comes from having a sick child, but also navigating the logistics of how to stay with them in the hospital, which may involve finding childcare for other children at home, taking time away from work, and having other caregivers come to the hospital in their stead. Visitation from caregivers is essential for the well-being and emotional health of not only the child, but also their caregiver during hospitalization. Caregiver participation in their child’s medical treatment has numerous positive effects, including reduction in child anxiety and pain, improvement in the child’s sleep, and promotion of quality of care through advocating for the child’s needs.3–5 Denying access to visitors causes distress and anxiety for both the child and caregiver, which may negatively impact the caregiver’s ability to be fully participatory in their child’s care and communicate with the members of the medical team.Certain populations experience a higher risk of being denied access to visit their family members in hospitals that require unexpired government-issued IDs. These includes those without a mailing address, transgender individuals awaiting IDs that match their identify, and victims of theft.Those experiencing homelessness face numerous obstacles in acquiring government IDs, as noted in studies and interviews conducted by the US Government Accountability Office.6 Challenges include lack of secure storage for personal documents, leading to loss or theft, and difficulty replacing lost IDs. Providing a residential address for ID applications poses further difficulty, along with financial constraints, limited access to transportation, and limited access to technology for application processes.Undocumented immigrants are another population at risk for being denied visitation because of lack of valid ID and may be one of the biggest populations affected. Defined as those who enter the United States without legal permission or those who fail to leave the United States when their permissible time ends,7 undocumented immigrants represent 3% of the US population.8 An estimated 4.4 million US citizen children live with at least 1 undocumented parent, and 6.1 million US children live with at least 1 undocumented family member.9 Nineteen states and the District of Columbia allow undocumented immigrants to apply for a driver’s license, but the remainder of states do not, making it very difficult to obtain a government-issued ID.10 In many states, even people who have temporary legal permission to be in the United States (for example, asylum-seeking populations) are not permitted to obtain a driver’s license until they are granted a work permit. Children with undocumented immigrant parents face several barriers in access to care, including poverty, preferring a language other than English, job insecurity, lack of transportation, racism, discrimination, and immigration-related fear.11 Immigration-related fear likely prevents many undocumented families from escalating the issue when their family members are denied visitation, and the true scope of this issue is unknown.11–13 Additionally, given that a large portion of children in immigrant families live in multigenerational households, where family members other than parents share a large portion of the childrearing responsibility,14 allowing visitation from caregivers is especially important to reduce fear and stress.Keeping our patients safe while providing the support they need can be challenging. Organizations such as the American Academy of Pediatrics and the Joint Commission should provide specific guidance on how to identify everyone who enters hospitals to ensure that all loving family members and caregivers are able to support a hospitalized child in their time of need.Additionally, we recommend that pediatricians advocate on behalf of populations facing barriers related to ID requirements by taking the following steps.Inquire about your hospital-specific visitor ID policy. Ideally, policies should ensure hospital accessibility for all individuals who support the hospitalized child in a safe and beneficial manner, working collaboratively with caregivers, hospital security, and administration. Each family’s definition of caregiver may vary based on family structure. ID policies should be transparent and easily accessible, with a clear process for exceptions for caregivers who are unable to present an accepted ID, both during the day and at night.Ensure that policies emphasize a family-centered and empathic approach. Escalation of concerns to leadership in the process of ID verification may be distressing to people without a valid ID. Thus, the established process should be as seamless and respectful as possible, and ideally include a partnership with social work. There should be established, short-term mechanisms to help caregivers without IDs see hospitalized children, as well as longer term options to help family members go through official processes to obtain a valid ID.Ensure that entry points in your hospital have easy access to interpreter services and multilingual signage, which promotes inclusivity and allows visitors to properly communicate with staff.For hospitals with more stringent ID policies, partner with important collaborators to create an inclusive policy (which may include incorporation of pin numbers/codes needed for entry, acceptance of a broader range of IDs from foreign countries, or other forms of US-based ID that include name and date of birth (± photo). Collaborators may include senior security personnel, nursing leadership, social workers, patient/family advocacy staff, Diversity, Equity, and Inclusion officers, department leadership, administrative staff, quality officers, and support from the risk management and legal offices.The presence of caregivers at the bedside of a hospitalized child is fundamental for their well-being. It not only supports the child’s emotional and psychological health, but also facilitates better medical care, enhances caregiver engagement in the treatment process, and preserves the familial bond during a difficult period. Therefore, health care institutions and pediatricians should implement safe and inclusive visitor ID policies to ensure caregiver access to support hospitalized children.We express gratitude for the patient families who inspired this perspectives piece. We also thank Dr Jimmy Beck for his contributions and support.