key: cord-1016334-45ckkv01 authors: Barnett, Brian; Esper, Frank; Foster, Charles B. title: Keeping the wolf at bay: Infection prevention and control measures for inpatient psychiatric facilities in the time of COVID-19 date: 2020-07-12 journal: Gen Hosp Psychiatry DOI: 10.1016/j.genhosppsych.2020.07.004 sha: 693bcda876b2c376072404334f34de0d5c1f1c3a doc_id: 1016334 cord_uid: 45ckkv01 nan J o u r n a l P r e -p r o o f design is particularly problematic for preventing COVID-19 dissemination, since viral spread from asymptomatic or pre-symptomatic individuals is common [10] . The inpatient psychiatric population itself poses several challenges to infection control as well. Patients are frequently admitted to psychiatric facilities directly from areas at high risk for COVID-19 dissemination, such as hospitals, correctional facilities, nursing homes, emergency rooms and homeless shelters. Due to cognitive limitations and severe mental illness, many patients also struggle with attending to activities of daily living, such as bathing and hand hygiene [11, 12] . Agitated patients and those experiencing psychosis are often unable to comply with infection prevention measures, reducing their efficacy. Due to limited resources and fewer infection prevention personnel, infection prevention is often undervalued and consequently less of a priority within psychiatric facilities than in general hospitals [12] . Hand washing is also likely to be less frequent among staff in psychiatric facilities, since they have fewer physical interactions with patients than staff in general hospitals [11] . Furthermore, in many facilities, dispensers for alcohol-based hand sanitizers are not available in care delivery areas for patient safety reasons. The need to restrain agitated patients also means that staff come into direct contact with patients in chaotic conditions, increasing their chances of becoming infected. Current COVID-19 prevention and control efforts have been hampered by poor access to testing at many facilities, which delays the transfer of patients who develop symptoms after admission and eventually test positive. Personal protective equipment (PPE) shortages also continue to be so problematic that the American Psychiatric Association and other mental health organizations have requested assistance from Vice President Pence [13] , though there has been no public response to their request. These difficulties greatly increase the risk of multiple inpatient psychiatric providers requiring quarantine or isolation after exposure to an infected patient, straining an already depleted workforce. Facilities are also experiencing barriers discharging patients, increasing length of stay and the chance affected individuals could be caught in an outbreak. Outpatient services, including partial hospitalization J o u r n a l P r e -p r o o f and intensive outpatient programs, have been severely curtailed in the wake of the pandemic, complicating discharge planning. While telepsychiatry services have expanded rapidly, they have not fully compensated for lost community capacity and are not accessible to patients without cell phone or computer access, which includes many individuals who are homeless or have serious mental illness. There are also anecdotal reports of sober homes and homeless shelters closing, as well as nursing homes and similar facilities refusing to accept new residents or allow current residents to return following a psychiatric hospitalization, due to concerns about these individuals seeding COVID-19 outbreaks in their facilities. o Some facilities require that all patients test negative for COVID-19 prior to admission. In this case, for those symptomatic patients refusing testing prior to admission, the safest approach is to manage them as if they were infected. However, since they may not actually be infected, they should be treated on a medical floor rather than a dedicated COVID-19 psychiatric facility if possible due to the high risk of exposure at the latter. For asymptomatic patients refusing testing, making an exception to allow for admission may be reasonable, since early peer reviewed [16, 17] and non-peer reviewed data [18, 19] J o u r n a l P r e -p r o o f indicate COVID-19 prevalence is low among a variety of populations receiving hospital based care, particularly among patients not exhibiting symptoms consistent with infection [17, 18] . However, in areas experiencing significant COVID-19 outbreaks this approach may not be appropriate. COVID-19 antibody testing could help minimize the frequency of these challenging scenarios in the future, since patients refusing the nasopharyngeal swab currently required for COVID-19 testing may be willing to submit to a serologic antibody test. However, at this time antibody tests should not be used as the sole test for diagnostic decision-making due to uncertainty regarding interpretation [20] .  Test the patient for COVID-19. If patient refuses testing, they should be managed as if they have tested positive.  Upon notification of a positive test result, or if a patient under investigation requires a higher level of care or cannot be appropriately isolated before results are available, the patient should be transferred to a medical facility or a dedicated COVID-19 psychiatric facility. If the patient tests negative and symptoms persist in the absence of another identifiable cause, repeat testing should be performed due to poor sensitivity of some tests.  Outbreak response measures will need to be implemented and may include testing and quarantining exposed patients.  Follow CDC guidance on monitoring and work restrictions for staff who are potentially exposed [21] , as well as work restrictions and return to work criteria for staff who develop confirmed or suspected COVID-19 [22] . J o u r n a l P r e -p r o o f  Homeless patients may need to complete quarantine in the psychiatric facility or another hospital affiliated site as a public safety measure. Coordination with public health officials is essential in this situation. Despite significant and unique challenges, inpatient psychiatric facilities are rapidly adapting to meet the demands of operating amid the COVID-19 pandemic. This is particularly important given signs of widespread psychological distress stemming from the pandemic [23] , which could soon lead to increased utilization of inpatient psychiatric facilities. By sharing infection prevention and response measures and strategies to overcome barriers to their implementation, psychiatric facilities can ensure the continued delivery of safe, effective care to their patients during these unsettling times. 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