key: cord-0948293-ffrdbvox authors: Sarcevic, Nermica; Popiel, Maryann title: Maintaining a Bronx inpatient psychiatry service at full capacity during the COVID‐19 pandemic date: 2021-03-02 journal: Perspect Psychiatr Care DOI: 10.1111/ppc.12751 sha: f4e13eb38e89da81de202a9a01147ae5728403ef doc_id: 948293 cord_uid: ffrdbvox PURPOSE: The purpose of this article is to present an overview of rapidly transformed workflows on our inpatient psychiatry service during COVID‐19 pandemic outbreak in New York. CONCLUSION: Rapidly transformed workflows, staffing patterns and discharge policies, as well as programs addressing the emotional and social needs of our staff enabled us to not only run our service without interruptions and maintain full inpatient census but also prevent the spread of COVID‐19. PRACTICE IMPLICATIONS: The challenges we faced and lessons we learned can be easily applied to other inpatient psychiatry services as we anticipate the second surge of COVID‐19 infection. Data from Italy indicated that in the early phase following the COVID-19 epidemic onset, there was a marked reduction in voluntary psychiatric admission rates; however, there was no noticeable Nermica Sarcevic and Maryann Popiel contributed equally to this study. reduction in involuntary admissions. 3 More than 90% of Jacobi inpatient psychiatry admissions are involuntary; therefore, we did not expect any significant decline in our census. Inpatient psychiatric care is a necessary component in our continuum, especially during a time of limited access to outpatient care and community resources. This was compounded by other stressors of the pandemic-fear of virus exposure, financial insecurities, food insecurities, and social isolation, all of which have the potential to exacerbate mental illness. With the surge of COVID-19 positive patients at Jacobi, early crisis planning considered transforming a portion of our Inpatient Service into a medical unit. We realized that such a decision could result in overcrowding of our CPEP and lead to increased virus exposure of those patients and staff, limiting our ability to respond appropriately to the acuity of the patients in that setting. Without a fully functioning inpatient service, our outpatients who required hospitalization might need to be transferred to a different hospital system. We were therefore challenged with the task of keeping our inpatients and inpatient staff safe to allow us to operate the service at full capacity. Through rapidly evolving improvement cycles and lessons learned at each juncture, as well as guidance from Center for Medicare and Medicaid Services, 11 New York State Office of Mental Health, 12 and New York City Department of Health and Mental Hygiene, 13 we created a safe and effective standard workflow. Our approach prevented the spread of the COVID-19 virus throughout our inpatient psychiatry service as was witnessed in many other New York City hospitals. This manuscript is designed to share our guiding principles behind this work flow, measures undertaken to overcome obstacles as well as our current standard work protocols. Because patients can be contagious yet asymptomatic, a new admission screening process with diagnostic testing was required to determine COVID-19 status. This testing had limitations: inconsistent availability, 24-72-hour lag for standard test results, modest test sensitivity leading to false negatives and variations in testing accuracy due to sample collection and symptom duration. 17 Obtaining a detailed history from patients presenting to our CPEP was challenging due to their impaired mental status, inability to cooperate, or unawareness of exposure. With these factors in mind, a new comprehensive screening process at triage was developed. All patients were screened for the following: the presence of respiratory symptoms (cough, shortness of breath, chest pain), myalgia, fever (subjective or objective), presence of gastrointestinal symptoms (i.e., diarrhea), loss of taste and smell, decreased oxygen saturation, abnormal vital signs, abnormal laboratory tests, and exposure to COVID-19 within last 2 weeks. The presence of any one of these signs and symptoms was considered a positive screen. Patients who screened positive were placed in isolation and tested for COVID-19 before being admitted to an inpatient unit. We converted our Extended Observation Bed (EOB) Unit within the CPEP into a person under investigation (PUI)/COVID-19 isolation area for this purpose. Our EOB Unit has six single bedded rooms which allowed isolation for up to 72 hour until these testing results were obtained and a decision regarding a final disposition could be made. Asymptomatic patients with laboratory abnormalities (i.e., leukopenia/lymphopenia, abnormal differential, abnormal liver function tests, increased creatinine) were also isolated and tested for COVID-19 before being admitted to the inpatient unit. If COVID-19 testing was negative but laboratory abnormalities were present in an asymptomatic patient, a medical consult was obtained to determine further steps and the need for retesting. 15 Once COVID-19 testing became widely available, we started testing all admissions to the inpatient service. To prevent COVID-19 infection spread on the non-COVID-19 units, we had to address issues specific to all sources: patients, staff, environment, and visitors. Single room occupancy was utilized when inpatient census allowed. Patients were allowed to remain in their rooms throughout the day. Additional dining space was created and dining in patients' bedrooms was allowed to ensure social distancing during mealtime. Groups they were transferred to a medical unit. A roommate of a newly diagnosed COVID-19 patient was also immediately isolated, tested, and closely monitored for the development of COVID-19 symptoms. Staff exposed to a newly diagnosed patient were required to closely self-monitor for symptoms. Staff was required to take their temperature twice a day and selfmonitor for COVID-19 symptoms. Flexible work scheduling was implemented to decrease staff exposure and allow adequate time for rest and self-care. Staff with increased risk, including immunocompromised individuals, were offered the opportunity of working remotely. Staff entering units was limited to essential direct care members only and staff rotation between units was avoided whenever possible. Initially, all staff was provided with surgical masks and staff treating COVID-19 positive patient or PUIs were provided with full PPE. Once a sufficient supply became available, all staff members were provided with N95 masks. Telepsychiatry was introduced, allowing remote work, both from home and on-site. Treatment team meetings were held virtually. Virtual on-site departmental huddles were held daily to assess the current situation and identify urgent issues and needs. Our hospital-wide Helping Healers Heal Program and Psychology Support Team offered support to staff dealing with emotional distress related to the pandemic. 16 Housing arrangements within the hospital or at local hotels were offered to staff concerned for potentially infecting their families. SARCEVIC AND POPIEL | 3 Disinfection of the items and spaces used frequently, including communal phones, doorknobs, and shared computers was performed each shift by departmental coordinating managers and hospital housekeeping. Terminal cleaning of patient rooms following discharge or transfer of COVID-19 positive patients was performed by hospital housekeeping before the room was reutilized. Restriction of visits from families, outside agencies, and all items brought from outside was instituted at the beginning of the pandemic. iPads were used to allow contact with families and conduct meetings with outside agencies, minimizing the potential negative impact of these restrictions on patients, their treatment, and discharge planning. Efficient, safe inpatient discharge immediately upon psychiatric stabilization was critical in preventing unit overcrowding and ensuring an adequate number of available beds. We faced many challenges in achieving this goal. Family and outside providers/agencies, who were typically involved in confirming a patient's readiness for discharge were not allowed to visit our units. Many outpatient clinics were closed to new patients and were not providing face-to-face visits for established patients. There was a marked decrease in access to substance use clinics, in a time when patients were at even higher risk of relapse due to the stress of the pandemic. Primary care follow-up of patients with complex medical conditions was limited due to the change of workflows in response to the COVID-19 surge. Many patients faced housing challenges including not being able to return home due to their COVID-19 status, and concerns about exposure to COVID-19 if going to a shelter, nursing home, residence, or other congregate settings. The referral process to many residential settings was suspended. There was a threat of increased disengagement, noncompliance, and rapid relapse due to the changes in healthcare delivery in the community. We quickly established multiple new discharge workflows. The importance of a comprehensive risk assessment and identification of patients at heightened risk for suicide, violence, and serious complication of their medical illness was recognized. For these patients, the inpatient team remained in contact after discharge and continued to assess risk and provide follow-up via telehealth until a community-based provider could assume treatment responsibility. Inpatients were engaged in the development of a personal safety plan to identify their early warning signs of relapse or self-harm and utilize measures that would mitigate their risk. Family members were involved in safety planning via telehealth to enhance social support upon discharge when deemed to be safe. Long-acting injectable medication utilization was increased whenever possible to improve compliance. Given limited outpatient care and new risks with travel, some patients were given a month's supply of outpatient medications upon discharge. If the lethality potential of this approach was too high for a given patient, smaller quantities were given on discharge and a prescription was transmitted to the community pharmacy with a later release date to prevent medication accumulation. Educational material, emphasizing the importance of social distancing, face covering, and hand hygiene was also provided to patients upon discharge. This was not only to keep our patients safe but to assist them in feeling prepared to attend their outpatient appointments when these became available. We faced staffing shortages due to isolation or quarantine, lack of child care, or medical conditions leading to inability to work on-site. Telepsychiatry should be utilized whenever possible to allow remote work. With school closing, a number of staff members faced child care issues. Although this was recognized at the start of the pandemic, we were not able to assist in an organized fashion. Child care issues can only be resolved at the organizational level, and this should be one of the top priorities to prepare for the next wave. There was a delay in providing surgical masks to all psychiatry inpatients due to supply chain issues, concerns for ligature risk and injury from metal nose strip, and infection control issues (patients in congregate settings might exchange masks accidentally). An adequate supply of safe masks for our patients needs to be ordered and distributed. Patient educational groups that emphasize the importance of wearing masks and social distancing need to be held frequently. Staff faced catastrophic stressors, which included: witnessing an unprecedented volume of sick and dying patients, fear of infecting themselves and their family members as well as concern about the health and prognoses of family and coworkers who had fallen ill. In spite of available resources for staff's emotional support, only a limited number of staff members utilized them. Ongoing monitoring is crucial in identifying those who are at risk for the development of mental health issues and ensuring that they are aware of available resources. An organized system for reaching out to staff members who have fallen ill and providing support during that time should be established. Deployment of a "battle buddy" system 17 as a psychological resilience intervention could be the most practical way of providing support, monitoring stress, and reinforcing safety procedures with little to no cost and very short start-up time. Ensuring adequate PPE supply, training on how to recognize the signs and symptoms of COVID-19 infection and knowledge about basic strategies to mitigate the spread of disease is pivotal in preparing the workforce and improving staff engagement. The constant influx of new information and guidelines, supply and testing availability updates, and continued need for change led to confusion and frustration. Attention to timely staff updates with transparency and accuracy of information through daily huddles at all levels (from hospital leadership to unit), email blasts, and overhead announcements mitigate confusion and mistrust. The latest advisories and most recent studies should be utilized in developing a flexible and adaptable operational system. Out of 233 BHS patients tested between March 18, 2020 and June 11, 2020, 32 (13.6%) were positive, confirming that BHS should be considered a high-risk area. During the same period, our admissions increased by 6.5% compared to the same period in 2019, reinforcing the need to keep our inpatient service fully operational. Through teamwork, open communication, workflow adjustment, and flexibility, we were able to achieve this goal while providing comprehensive and safe psychiatric care for our patients. The next wave of COVID-19 will coincide with flu season, putting more stress on the healthcare system. 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CMS.gov New York State Office of Mental Health. Treatment planning and documentation standards for article 28/31 hospital psychiatry providers during emergency period issues. omh.ny.gov Guidance for Healthcare Workers Self-Monitoring and Work restriction in the Presence of Sustained Community Transmission of Coronavirus Disease COVID-19 testing and patients in mental health facilities Laboratory abnormalities in patients with COVID-2019 infection Second Victim: Helping healers heal-Support for staff following stressful or traumatic events. NYC Health and Hospitals/Jacobi Support Resources Battle buddies: rapid deployment of a psychological resilience intervention for health care workers during the coronavirus disease 2019 pandemic Maintaining a Bronx inpatient psychiatry service at full capacity during the COVID-19 pandemic The authors declare that there are no conflict of interests. The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0002-9058-9589Maryann Popiel https://orcid.org/0000-0003-0780-8259