key: cord-0693838-jbvsbslp authors: Levitt, Gwen; Weller, Jennifer A.; Pandurangi, Ananda; Thippaiah, Srinagesh Mannekote title: Impact of SARS-CoV-2 Infection and Implementation of Infection Prevention and Control (IPC) Measures on Inpatient Psychiatric Units date: 2021-09-20 journal: Asian J Psychiatr DOI: 10.1016/j.ajp.2021.102868 sha: 0c1e7a82ee4975e17e5d2716ef413d2bc17fa2d0 doc_id: 693838 cord_uid: jbvsbslp Psychiatric patients on inpatient care are at high risk of acquiring and transmitting communicable diseases such as SARS-CoV-2 (COVID-19). The authors conducted a retrospective review of the medical records of COVID-positive inpatients at Valleywise Health Medical Center, Arizona, USA from March to June 2020. The authors examined a cohort of COVID-positive inpatients admitted early in the pandemic to assess the ways in which the virus and infection prevention and control (IPC) measures affected patients at a large psychiatric hospital. Data was gathered for demographics, psychiatric diagnoses, COVID-19 symptoms, medical co-morbidities, and length of stay. Initial and revised hospital policies and procedures, and emergent challenges in managing this highly contagious disease in the inpatient psychiatric setting, were examined by review of relevant documents and direct observation by board certified psychiatrists who provided direct care. Significant challenges were encountered in balancing the need for a therapeutic milieu and compliance with IPC measures. During the study period, 39 patients and 15 staff members became COVID-positive. Within the covid staff, all but one had provided direct care to COVID-positive patients. Overall, behavioral health facilities were largely successful in identifying and quarantining COVID-positive patients. The hospital’s IPC policies/procedures were constantly updated to meet new guidelines and knowledge about the virus, which may have lowered transmission rates and mitigated potential complications. While basic quality and safety of providing psychiatric care were preserved, individual and group therapies’ formats and provision of a therapeutic milieu were altered and may have adversely affected patient care and/or contributed to doubling the length of stay. Inpatient psychiatric facilities face unique challenges in addressing contagious illnesses such as measures are critical in preventing the transmission of illnesses such as COVID-19 (Peters et al., 2018) , yet these strategies could constrain the therapeutic milieu and traditional inpatient psychiatric care. Staff and patient mobility, communal living, and patient symptoms and behaviors may interfere with adherence to IPC measures, quarantine protocols, and social distancing (Moreno et al., 2020) . As outlined by Li (2020) , the physical layout of psychiatric facilities encourages social interaction. Patients and staff move between units for optimal utilization of staff and beds, as well as activities, which can prevent containment of an infectious illness (Li, 2020) . Individuals with a serious mental illness (SMI) are more susceptible than the general population to COVID-19 for medical and psychosocial reasons (Yao, Chen, & Xu, 2020) . In this retrospective study and a naturalistic review, the authors review the experience of a large health system early in the pandemic. We describe preventative measures implemented and challenges faced by staff and patients during the study period. We make suggestions about improvements for future challenges. Facilities, Locations, and Units: VHMC in Arizona is a government-supported medical center with three inpatient psychiatric facilities (356 beds). Units include 342 adult beds, one medical/geriatric unit (23 beds), and one adolescent unit (14 beds). One unit at the main hospital (22 beds) treats patients with significant medical comorbidities. The units are locked, and have single and multi-bedded rooms. Study period: Retrospective data on COVID-positive patients was collected for a 10-week period (March 28 to June 6, 2020) during the "first wave" of the pandemic in USA. Observations of care models and IPC protocols were made during that period and a post-study period and updated often. This time frame was selected to study the initial effects of the pandemic. A nursing administration log was utilized to identify COVID-positive patients at the three facilities. the authors reviewed electronic medical records of identified patients, collecting patient demographics, admission date, COVID-19 test date, length of stay (LOS), psychiatric and medical diagnoses, and clinical outcomes. Hospital administration provided an anonymous list of COVID-positive staff. The authors reviewed IPC policies and measures implemented during the study period. Covid-19 Patients: Thirty-nine patients tested positive for COVID-19 during the study period. Thirty-four (87%) were male and five (13%) were female. The age range was 18 to 73 years, with an average of 42.5 years. Twenty patients (51%) were white, nine (23%) were Black, and 10 (26%) were Hispanic. Patients received psychiatric medications as usual. Most therapeutic interventions in the facilities are provided in a group format. Due to the pandemic, groups were stopped. The average LOS was 46 days, more than double the average LOS prior to the pandemic. Five patients remained hospitalized at the conclusion of the study period (see Table 1 ). The first COVID-positive patient (P1) was identified on March 29, 2020 within 24 hours of admission. The first staff member tested positive on April 2, 2020. On April 15, a second patient (P2) tested positive on a different unit. By April 17 and 18, there was a rapid increase in COVID-positive patients and staff (see Figure 1 ). In April and early May, several units at two other locations were quarantined when COVID-positive patients were identified. Four male patients required physical restraints and involuntary medication for severe agitation and dangerous behaviors after repeated requests to remain in quarantine failed. COVID Symptoms: Of the 39 COVID-positive patients, 33 (84%) had mild cold-like symptoms for one to two days that required minimal interventions (see Table 2 ). A temperature of at least 100.4 F was noted in 11 (33%) patients. Ten (28%) patients had temperatures below 100.4 F. Symptoms included cough, headache, nausea, earache, sore/scratchy throat, nasal congestion, and chills. Three (8%) patients required transfer to medical units. A 43-year-old male required a ventilator and suffered multi-system medical complications. He remained medically hospitalized after the study concluded and was eventually discharged to a nursing facility. Bacterial pneumonia was diagnosed in two patients; neither required ventilation and both recovered fully. Medical Comorbidities: Preexisting hypertension in 16 patients (41%) and diabetes in 10 patients (25%) were noted. Known lung disorders (e.g., chronic obstructive pulmonary disease, asthma, history of pneumonia or tuberculosis) were recorded in 22 (56%) patients. Obesity was noted in four (10%) patients. Other comorbidities included hepatitis C in two patients (5%) and cardiac issues in three patients (8%). Sixteen (41%) patients had no comorbid medical conditions. Six patients (15%) had at least one known COVID-related medical comorbidity, nine patients (23%) had two comorbidities, and six patients (15%), all males, had three (see Table 3 ) (SAMSHA 2020, BMJ June 2020). . Patient 1 (P1) and/or P2 were the likely epicenter. P1 tested positive on admission and P2 tested positive several days after admission after two negative tests on the medical floor. P2 likely contracted COVID-19 on the medical floor. The third patient (P3) tested negative on admission to psychiatry but required an emergency room visit several days later. On his return, he tested positive. P3 was likely exposed prior to admission or in the emergency room. In rapid succession, 13 patients on the unit where P2 and P3 were housed contracted COVID-19 (see Figure 1 ). Although efforts were made to assign staff to the same unit, there were times when staff were deployed elsewhere, potentially contributing to spread of the virus. The hospital response plan for COVID-19 began in mid-March of 2020 and evolved daily. Many modifications were recommended by VHMC Infection Control and Arizona Department of Health Services. Restriction of Personal Visits: The hospital prohibited visitors. As noted by Fagiolini, Cuomo, and Frank (2020), lack of contact with their loved ones may have increased patient stress. Visitor restrictions also affected treatment planning. Case managers stopped meeting in person with treatment teams and patients for discharge planning. Teleconference platforms were utilized instead. Mental health court hearings were conducted by phone. Cell phones, normally prohibited, were provided for quarantined patients to communicate with supportive others. Preventive Measures by Staff: Hospital staff were required to wear face masks. Each facility designated one entrance at which nurses took temperatures and screened staff as they entered. This process has been described by (Ying, Yang, & Jianming, 2020) . The screening caused a bottleneck of staff and increased the potential for viral transmission. Subsequently, staff were asked to take their own temperatures and attest to asymptomatic status. A drive-up testing station was set up for staff who suspected exposure to COVID-19 (Bradley et al., 2020) . Due to initial shortages of personal protective equipment (PPE), staff were issued one surgical mask to wear in contact with patients. Cloth masks were allowed at other times. Staff wore the same surgical mask until soiled or torn. In late June, staff received a reusable face shield and were required to wear it with a mask on patient units. Enough surgical masks then became available for daily changes. Creation of "Admissions Observation Units" (AOUs) and Admissions Protocols: In March and April, Admissions Observation Units were created, decreasing bed capacity by 30. These units, with one patient per room, were used for all new admissions. All AOU patients were quarantined (AugensteinTara et al., 2020). Once patients tested negative, they were moved to a general psychiatry unit. If positive, they went to a COVID-designated medical unit. Revision of IPC Protocols: As more was learned about COVID-19, admission protocols were modified to minimize exposure and transmission. Initially, patients were transferred off AOUs after testing negative for COVID-19. Protocols were changed as we learned of the 14-day incubation period, the potential for false negative results early in the infection, and the observation that several patients converted from negative to positive status. Patients were required to test negative and be free of symptoms for 72 hours before transfer to a general unit. Staff working on AOU and COVID units were required to wear full PPE. Social distancing was enforced (CDC, 2020; Lauer et al., 2020) . Portable hand washing stations were provided. Videoconferencing was utilized to evaluate quarantined patients to avoid direct contact and to decrease PPE use during nationwide shortages (Turer et al., 2020) . Group activities were halted. Common areas were reconfigured to create more space. Meals were delivered to the units rather than using the dining hall. Utilization of Videoconference: Cell phones were provided to patients in quarantine with access limited to pre-selected internet sites. Providers interacted, when feasible, virtually with quarantined patients (see (Reay, Looi, & Keightley, 2020) . There were challenges with internet connectivity, consistency of access, and audio/video quality due to increased need for wireless access. (2020), it is difficult to encourage patients to cover a sneeze or maintain social distance. The importance of hand washing may be difficult to impress on a person with acute psychiatric symptoms. Many psychiatric facilities use non-alcohol-based hand sanitizer considered ineffective against COVID-19 (Berardi et al., 2020) . Our facilities changed products and monitored patient access to it. Psychiatric patients may have compromised ability to maintain personal hygiene and require reminders. Some patients avoid changing clothing or bed linens, or showering, due to altered thoughts, paranoia, depression, or forgetfulness. Patients may become anxious when staff attempt to assist them with activities of daily living (Wang et al., 2020) . Face masks obscure the mouth, muffle the voice, and impersonalize the wearer. Patients experiencing acute psychosis, cognitive deficits, or mania may have difficulty interacting with masked staff (Bojdani et al., 2020) . They may believe that staff are trying to hide their identity. Patients with cognitive or hearing impairments may struggle to understand masked staff. Some patients cannot identify who is speaking (Wang et al., 2020) . A mask or full PPE can make it hard to interpret the emotions of the wearer (Pal, Gupta, Parmar, & Sharma) . Full PPE can create uncertainty and fear in psychiatric patients. It may signify that something serious or medically dangerous is happening, that the patient must be very sick, or that staff intend to perform an undesired medical procedure on them (Veluri, 2020) . It is therefore important that staff and physicians introduce themselves frequently, clarify their roles and reasons for the precautions, to allay patient fears and paranoia. Staff must ensure that patients wear their masks properly. Some patients cannot tolerate the sensation of the mask, refrain from touching it, or keep both nose and mouth covered. Some psychiatric patients may refuse to wear a mask. Constant directives from staff may cause patients to experience undue anxiety or feel controlled, which is countertherapeutic from a psychiatric perspective and necessitates increased use of "as needed" (PRN) medication. Frequent patient education in a supportive manner, on masks, sanitizing and physical distancing is essential. When one patient is under investigation or tests positive for COVID-19, the entire unit must go on quarantine. Patients cannot be moved unless it is for discharge. Hospital safety policy requires staff to monitor inpatients every 15 minutes, so room doors are opened; this action may increase viral transmission. Some patients become agitated or aggressive when confined. On a psychiatric unit, locking a patient behind a door is considered a form of restraint and necessitates direct continuous observation. Quarantine can pose an ethical dilemma if used to isolate a patient for IPC measures as opposed to harmful behaviors (Brody, Parish, Kanellopoulos, & Russ, 2020; Giallonardo et al., 2020; Russ, Sisti, & Wilner, 2020) . Another dilemma arises when patients refuse COVID testing and must quarantine for 14 days or until agreeing to be tested. These challenges were addressed by repeated education, reassurance, and support by staff. Testing in Psychiatric Facilities: Testing for COVID-19 is critical for identification, tracking, and containment (Van Beusekom, 2020). Initially, due to severe shortages, tests could only be obtained from the Health Department. It took up to seven days to obtain results. In early April 2020, VHMC obtained testing kits and created a screening protocol for the highest-risk patients, with results in 48 hours. On April 29, 2020, VHMC obtained the rapid COVID-19 test (12-hour results) and gave it to all psychiatric admissions regardless of observable symptoms (discussed in Zhang et al., 2020) . In the early part of the study, delays in results likely contributed to longer LOS. Remote Interviewing: Staff held a video device during interviews for patients who were too psychiatrically or medically compromised to manage them safely or correctly. This close contact between staff and patient increased risk of viral transmission. Some patients were suspicious of the technology, believing the interview was recorded or broadcast. Due to the small screen, providers could see only the patient's face and had difficulty assessing full range of affect, and physical issues such as oral TD, grimacing etc. Nearby noise was a significant interference. For some patients, difficulty locating the source of the voice was disorienting and frightening. Providers needed to be aware of these sensitivities and address them with the patient. Prior to the pandemic, patients met with providers in small interview rooms. During the pandemic, patients not on quarantine were interviewed in the dayroom. This practice interfered with privacy. This change affected some patients' willingness to discuss symptoms or sensitive issues relevant to treatment. Discharge planning and family meetings occurred by phone. Because outpatient providers and family could not visit, it was difficult to fully ascertain treatment response and/or readiness for discharge. Legal preparations and proceedings were conducted via teleconference, which increased patients' difficulties understanding court proceedings. Recognizing these difficulties, some legal advocates wore PPE and met face-to-face with non-quarantined patients. By May 19, 2020, Maricopa County documented a COVID positivity rate in the general population of 5.9%. By June 15, 2020, this rate increased to 8.56% (Data Dashboard 2020). This 39-patient cohort represented 11% of the total psychiatric inpatient population at VHMC during the study period. The rate of hospitalization in Maricopa County for treatment of COVID-19 was 10% on June 15, 2020 (Data Dashboard, 2020). This statistic is consistent with the rate found in the study cohort and with a rate of 10.9% in a comparable New Jersey psychiatric facility (COVID-19, 2020) . According to the Arizona Data Dashboard, in May 2020, one-half of the general population testing positive for COVID-19 were 20 to 44 years old (Data Dashboard, 2020). In Arizona, 18% of the COVID-positive general population was white, 26% was Hispanic, and 3% was Black; . 52% were female and 48% were male. Nearly one-fourth (24%) of Arizona's COVID patients reported chronic medical conditions including diabetes, cardiac disease, hypertension, COPD, and chronic renal or liver disease. In the study cohort, the percentages of Hispanic (21%) and Black (29%) patients were similar to the general population. The cohort had more male patients than the state statistics because the initial COVID outbreak occurred on an all-male unit. The cohort had more than twice the number of patients (56%) with COVID-19-related medical comorbidities than Arizona state statistics. This finding is not surprising, because SMI patients are at high risk for medical complications and die approximately 25 years earlier than the general population (Park, Svendsen, & Foti, 2020) . The study's facilities serve primarily SMI patients who are indigent and have medical comorbidities. These factors might have affected the early spike in cases. Early in the study period, there was a sharp rise in positivity after the first three COVID patients. With constantly evolving information about COVID-19, implementation of tighter IPC measures, and availability of rapid testing, the rate of infection decreased. These changes suggest the efficacy of implemented measures. Dedication of staff applying IPC measures with fidelity cannot be understated. Only three patients developed significant complications, and only one patient remained in serious condition at the conclusion of the study period. For patients and staff, the biggest challenge was quarantine status. Inpatients required constant direction and support to maintain isolation. Boredom was a significant problem. Most patients expressed more concern about the no-visitor policy than about the virus. Many community placements refused COVID-19-positive or exposed patients, thwarting discharge plans. A Perspective from Asian Countries Experience: Asia accounts for 58% of the world population, and approximately 15 percent of COVID cases and deaths, while the USA and Europe each account for 30-40 percent. Thus, infection rates and outcomes appeared better in Asian countries. This may be attributed to younger population , centralized and coordinated health care strategies, relative lower number of older people (Tandon, 2021a) . It could also be partly due to systematic under reporting of the cases (Samaddar, Gadepalli, Nag, & Misra, 2020) . In India for example, there was successful prevention of COVID alpha and lower morbidity in the initial wave of pandemic but there was a catastrophic upsurge of cases and fatalities in India in spring 2021 due to delta variant of COVID virus which affected younger and older persons alike. Similar drastic increase in cases were recognized in other South Asian countries such as Nepal, Afghanistan, and Bangladesh (Bhutta et al., 2021) . Both in Asia and Europe/America, the pandemic revealed the strengths and exposed the weaknesses of the health care systems, highlighting the importance of a coordinated global response, sharing resources, sharing accurate information and clear communication among the various international governments and community/organizations (Tandon, 2021a) . Treating psychiatric patients in inpatient settings is particularly challenging is middle-and low-income Asian countries. Furthermore, the COVID pandemic has led to unpredictable consequences and impact on hospital care of psychiatric patients. In Turkey, ten percent of patients required psychiatric consultation in COVID units. Such consultation needs to keep in mind that Covid-19 may be associated with increased neuropsychiatric disorders and more negative outcomes of the disease (Turan et al., 2021) . In Iran, 83% percent of patients expressed readiness to be treated. However, only 16.7% of the respondents showed interest in visiting COVID patients more than once (Shariati, Eftekhar Ardebili, & Shalbafan, 2020) . Interestingly, across the globe significant number of studies report a modest reduction in total suicide rates since the pandemic began. No significant net increase in suicide rates have been reported during the first year of the COVID-19 pandemic (Tandon, 2021b) . In Japan, inpatient hospitalizations are also reportedly reduced by about 2% lower for each reported month (Usuda, Okazaki, Tsukie, & Yamanouchi, 2021) . However, the seclusion rates within the inpatient population reportedly increased by 0.4-0.7%. This could possibly be due to the psychiatric hospitals having no choice but isolating patients with suspected COVID-J o u r n a l P r e -p r o o f 19 patients (Usuda et al., 2021) . It should be remembered that such numbers may change in either direction, as the virus mutates, illness rates increase (or decrease with more vaccinations) and as we learn more about the impact of the pandemic through more studies and publications. Infection control, even prior to the pandemic, was daunting for psychiatric facilities, especially the population served at systems like VHMC reported here. Overall, VHMC was largely successful in identifying and quarantining patients. The risk of contracting the virus was high, and the facilities' actions may have decreased cases and mitigated complications. Despite the challenges and restrictions, psychiatric care was provided safely to all patients and no patient was denied care. It is difficult to quantify the negative impact of IPC protocols and procedures on patients' psychiatric symptoms and recovery. Isolation, detachment, and loneliness, lack of group activities and in-person sessions may have adversely affected illness course. For several patients, use of physical restraints and involuntary medication was a regrettable result of enforcing quarantine. Increased LOS for discharge-ready patients was frustrating and even demoralizing. Use of telemedicine may have impacted the quality of assessments in ways that are still unknown. It remains unclear if overall treatment and patient satisfaction were affected by imposed measures. 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J o u r n a l P r e -p r o o f Table:1 Table: 2 Table:3 Table:  While basic quality and safety of providing psychiatric care were effectively preserved, but the risk of transmission was high and spread of the illness to other patients and staff was rapid. Therapeutic treatment modality formats were altered and may have adversely affected patient care and/or contributed to doubling the length of stay.