Challenges and Priorities in Responding to COVID-19 in Inpatient Psychiatry

For inpatient psychiatry, an important consideration is to screen patients diligently for respiratory symptoms and fever prior to admission. Although psychiatric facilities vary in whether they are a free-standing facility or an inpatient psychiatric unit attached to a medical center, all facilities should consider screening patients for COVID-19 symptoms prior to admission, as well as rescreening for symptoms throughout the hospitalization, because asymptomatic patients may develop COVID-19 after psychiatric admission.

Personal protective equipment should be used in cases where patients develop fever and respiratory symptoms, although its use should be minimized if patients do not meet both criteria, especially if personal protective equipment supplies are low. Clinical leadership should also consider having staff wear designated clothing, such as scrubs, during the workday to minimize transfer of the coronavirus on various surfaces. In addition, surfaces should be cleaned often, using recommended cleaning agents, such as high-content ethanol-based hand sanitizer for disinfecting oneself and surfaces (6). In addition, disinfection should be performed on items and spaces used frequently, including dining areas, doorways, common-use computers, and identification cards, which contain plastic and metal and can transmit COVID-19 (7).

To minimize risk for direct contact by outsiders exposed to COVID-19, visitor restrictions for family members, nonessential employees, and students can be an important decision point in order to protect essential staff and patients from exposure to additional outside individuals. However, social interactions and family meetings are important components of inpatient treatment. Thus, although decisions may be made to limit contact, doing so may affect the treatment course and how patients reconnect with family members and may cause significant anxiety among family members who are apart from loved ones. Similarly, limiting students from observing clinical processes may affect graduation requirements for those students.

Even with no pandemic, there is a national shortage of psychiatric providers (8). During the pandemic, the provider shortage will worsen as psychiatrists are exposed and become ill. Administrators and clinical leaders will need to identify strategies to address the shortage, including creation of back-up systems to include psychiatrists and providers who are credentialed at the facility, and they may need to find creative ways to increase staffing. Potential options for staffing include reducing team sizes and creating a back-up pool of providers who can truly practice physical distancing and become available if designated frontline providers become unable to provide care. Also, providers working in research and nonclinical administrative roles can be reassigned to clinical care as part of a back-up pool. In addition, telepsychiatry can be an important consideration for delivering inpatient services to minimize simultaneous exposure of a high number of clinical providers (9). Thus staff can still perform clinical care while minimizing their exposure to the hospital. Staff should self-monitor for symptom development and obtain testing if symptoms such as fever or respiratory symptoms are present. In addition, staff with higher risk, including pregnant, elderly, and immunocompromised individuals, may need to be sent home to work remotely during the pandemic period.

Limited published accounts are available on operational changes in response to COVID-19, especially in psychiatry. COVID-19 has an asymptomatic period, and thus some individuals may not have COVID-19 symptoms before being admitted (10). Designated isolation rooms may be helpful in grouping patients with COVID-19 symptoms, which may require closing one or more hospital beds if two or more patients are roomed together. After a patient develops COVID-19 symptoms, the patient should be immediately placed on precautions that require wearing a mask and gown and being isolated in designated rooms to minimize spread. If a psychiatric facility is connected to a medical center, steps should be taken to facilitate transfer to inpatient medicine or inpatient pediatrics for COVID-19 testing, because many psychiatric facilities have open milieu and would have difficulty isolating patients to avoid significant spread. Patients with subthreshold symptoms, such as only fever or only respiratory symptoms, should be monitored more closely for development of additional symptoms, including more frequent monitoring of vital signs and review of symptoms. Other medical conditions, such as viral influenza and routine causes of fever or respiratory symptoms, should be explored. Patients who develop COVID-19 symptoms should be monitored closely for imminent risk of suicide, homicide, and grave disability. If the patient is considered psychiatrically stable, he or she should be discharged to outpatient care and self-quarantine. Additional considerations should be made regarding the threshold for hospitalization. Psychiatric hospitalizations that are not absolutely necessary for acute safety concerns should be minimized.

Group therapy is an important component of inpatient treatment as part of the ecological milieu (11–13). Multiple individuals meet together with a trained facilitator to learn about psychological tools to address symptoms such as anxiety, depression, suicidal ideation, psychosis, and intense emotional lability and to facilitate education about psychiatric conditions. Such meetings reinforce treatment goals and provide positive supports. However, given that group therapy requires close contact, decisions to facilitate changes in group treatment may be needed, including limiting the number of individuals participating in a group and ensuring that physical distancing among individuals occurs. In addition, older patients with multiple medical comorbidities may be especially at risk in group settings with younger patients and may need to discontinue and minimize group therapy during a pandemic. However, limiting group treatment options and reducing group size may lead to social isolation and loneliness—factors that may have partly contributed to an individual’s hospitalization.