A Virtual Inpatient Psychiatry Unit in a Multicampus Health Care System During the COVID-19 Pandemic

To improve care efficiency and patient access, the general medical and psychiatry teams in a multicampus health care system worked together to care for patients in this virtual inpatient psychiatric unit. COVID-19–positive patients under a psychiatric emergency hold across eight hospital campuses were admitted to the medical unit and the virtual inpatient psychiatry unit simultaneously. While receiving care from the general medical team, a patient was also receiving virtual psychiatric care provided remotely by a multidisciplinary team of psychiatrists, nursing staff, social workers, and case managers.

This unit was developed in a multicampus health care system headquartered in Central Florida. It was implemented across eight hospital campuses, which all have emergency room services and medical floors. The largest campus has an acute inpatient 44-bed psychiatric unit that is designated as a “Baker Act receiving facility.” During the COVID-19 surge in 2021, when patients placed under the Baker Act with COVID-19–positive status could not be admitted to a psychiatric facility, our team began using preexisting telepsychiatry services to develop this virtual unit for COVID-19 patients.

Because of the scarcity of psychiatrists, the psychiatry teams could not be physically present at each campus. In 2016, the health care system’s psychiatry service was awarded an internal innovation grant to develop and provide telepsychiatry consultation services. Before the pandemic, these services were mainly provided to hospital campuses in outreach areas, with some use of this mode of delivery on the main hospital campus. At the onset of the COVID-19 pandemic, the system already had a fully functional telepsychiatry service in place, which the team used to care for COVID-19 patients placed under the Baker Act in order to ensure safety while continuing to provide psychiatric care.

The psychiatry team consisted of the attending psychiatrist, nursing staff, social workers, and case manager. Serving as a liaison between the general medical and psychiatry teams, psychiatric nursing staff closely coordinated with medical unit nursing staff to ensure delivery of the psychiatric aspects of care, including deescalation and monitoring of the procedural aspects of the Baker Act. Case managers and social workers found placement options for those who continued to require inpatient psychiatric hospitalization but could be taken out of COVID-19–imposed quarantine. The staff explored outpatient resources for substance use treatment, psychiatric care, therapy, and coordinating care with families of patients who were ready for discharge.

The unit followed a sequence of patient admission, 72-hour hold, and discharge. Admission occurred in one of two ways. Either a patient was admitted through emergency services and placed under the Baker Act (e.g., a patient with a primary psychiatric illness, such as severe depression or suicidal ideation) or a patient had already been admitted to the hospital and was then placed under the Baker Act (e.g., a patient presenting with a general medical condition, such as exacerbation of chronic obstructive pulmonary disease, was admitted to the medical floor and then reported severe depression or suicidal ideation). This unit ensured that COVID-19–positive patients placed under the Baker Act did not need to wait for placement and would get psychiatric care as quickly and efficiently as possible. These patients were included in a virtual inpatient patient list, which covered the eight hospital campuses and was regularly updated and shared among the members of the psychiatry team. Patients with COVID-19–positive status, including those who were asymptomatic, were admitted to medical floors that could adhere to infection control guidelines. The patients’ other general medical conditions were managed by the medical team consisting of a primary hospitalist, nursing staff, and case manager on the floor.

During the 72-hour hold, patients who tested positive for COVID-19 were admitted to the general medical unit. A patient received the initial visit by the multidisciplinary psychiatry team, followed by continued daily virtual visits by this team.

Standard Baker Act admission procedures for patient safety were followed. A one-to-one observation status was arranged for every patient. The patient’s room was modified to remove objects like sharps containers that would pose a potential safety hazard. The same safety precautions as in psychiatric units were followed for food trays. Patient belongings were stored in a secure location with the help of the unit charge nurse. During pre- and midshift briefings conducted by the charge nurse together with psychiatry nursing staff, nursing staff on the general medical unit were regularly updated on and reminded of personal safety precautions when caring for patients admitted under the Baker Act.

Patients were assessed and treated by the admitting general medical team in person and received treatment for COVID-19 and other general medical conditions as applicable. Moreover, a telepsychiatry device, consisting of a tablet connected to speakers and attached to a stand with wheels with an adjustable angle for optimal two-way video and audio communication, was utilized for virtual psychiatric visits and consultations. Microsoft Teams was used as a HIPAA-compliant and secure videoconferencing software. The multidisciplinary psychiatry team would meet virtually every morning to discuss each case and formulate a tentative treatment plan. The team would then meet with each patient virtually. For new patients, the attending psychiatrist would take a thorough history, do a mental status examination, obtain collateral information from family members, and engage in shared decision making by discussing the treatment plan with the patient. Psychotropic medications were started as applicable to stabilize psychiatric illness, and patients were closely monitored for adverse effects or drug interactions. For patients unable to participate meaningfully in rounds, information about their behaviors was obtained from nursing and observation staff. Follow-up evaluation for each patient was conducted daily, and medications were titrated as required to manage symptoms. The team would also discuss plans with patients for future care. Apart from psychiatric medication management, patients had access to chaplain visits.

After the 72-hour hold, patients were discharged in one of two ways. Patients were transferred to a traditional Baker Act receiving facility when COVID-19 management or isolation was no longer needed but psychiatric hospitalization was still required. Alternatively, patients were discharged by the psychiatric team when they had received adequate treatment for acute psychiatric illness during their hospitalization, leading to the Baker Act requirements being lifted. In this case, patients were connected with outpatient psychiatric resources. For a subset of patients, who continued to need both COVID-19 isolation and acute psychiatric care, Baker Act provisions were continued by asking the court to grant an extended period for inpatient psychiatric care.