The impact of COVID-19 changed utilization and delivery of healthcare services, requiring an abrupt shift in treatment and staffing models 1Loades M.E. Chatburn E. Higson-Sweeney N. et al.Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19.,2Bojdani E. Rajagopalan A. Chen A. et al.COVID-19 pandemic: Impact on psychiatric care in the United States.. This is particularly salient in youth acute and intensive treatment services (AITS), including inpatient psychiatric hospitals (IPH), intensive outpatient programs (IOP), and partial hospitalization programs (PHP), due to challenging issues of maintaining high quality care and a safe, therapeutic milieu during increased demand for acute services;3

Leeb, RT, Bitsko, RH, Radhakrishnan, L, Martinez, P, Njai, R., Holland, KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. Available at https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm. Accessed 2/17/2021.

all while limiting transmission of COVID-19 on locked units, in close quarters, and for youth traveling back and forth to day-programs. Over the past year, AITS adapted and evolved without the ability to pause services and plan, increase staffing, or allocate additional resources. This paper discusses themes of changes made based on over 20 facilities across the United States through the Acute, Intensive, and Residential Service Special Interest Group. These facilities include psychiatric inpatient units and day-treatment programs. We discuss lessons learned from these changes, the need for evaluating these changes, and application of these lessons in future crises.The most significant impact on AITS programming included changes to prevent COVID-19 transmission, a difficult task given the close contact of patients and staff in these milieu-based programs. These levels of mental health care, including milieu groups, require multiple patients and staff members to be present at the same time within close physical space, presenting unique challenges for AITS programs given social distancing guidelines. As a result, AITS made significant shifts in the provision of services and how patients in the emergency department (ED) are referred and admitted to these services. While some programs deferred patients to other areas of care until there were no concerns for COVID-19 (e.g., in the ED or medical floor beds), other programs modified, paused, or closed due to limited strategies for safe in-person care.

Modifications and Impact

Modifications to AITS admissions happened quickly in response to the pandemic. Several facilities decreased their patient census in order to implement social distancing guidelines, altered or eliminated shared inpatient rooms, modified group treatment areas, and created COVID-19 specific or quarantine rooms/units. At some hospitals, reduced census was accomplished by connecting patients and families to other intensive outpatient services rather than admitting to IPH and a push for quicker, albeit still safe, discharges from the ED. There was also effort to bypass the ED in order to reduce virus exposure by increasing the amount of direct admissions to IPH units. Assessments of risk, at times, were conducted via telehealth instead of in the ED as inpatient beds were full and attempts were made to keep psychiatric cases out of the ED.

New admission procedures included some level of screening or testing for COVID-19. However, facilities and programs differed on how patients were dispositioned after their screening/testing. Some facilities allowed for admission to their IPH units but patients were quarantined and staff wore personal protective equipment (PPE) during interactions until the patient tested negative; requiring patients to wait for a negative COVID-19 test to engage in milieu and program activities. Other facilities boarded patients in the ED or on a medical floor until the patient had a negative COVID-19 test result, and others did not admit patients if they came from a COVID-19 “hotspot” location. As the pandemic wore on and rates of cases rose, some units began embracing the influx of COVID-19 positive patients and created COVID-19 positive units or hallways on their inpatient service.

Some day-treatment programs paused services or closed due to the concern of having multiple patients and staff in close contact and shared group rooms. Other programs embraced telehealth options, becoming fully virtual or developing hybrid programs to reduce the amount of people on site each day. Others modified the number of patients admitted to the program, initiated daily screening of symptoms prior to entering the facility or required a negative COVID-19 test prior to enrolling in the program. Additionally, programs restructured the physical setting to allow for successful social distancing, decreased the length of the treatment day, and limited some program activities involving close contact. Some programs pivoted to a fully virtual service which minimized access to the traditional therapeutic milieu.

AITS care model changes focused on maintaining social distancing guidelines and donning PPE for staff, patients, and families. Milieus were adapted by reducing the number of patients in groups, removing furniture as necessary, posting and verbalizing reminders to socially distance, increasing cleaning, and reducing shared materials. Some programs divided units into separate “pods,” partitioned common areas, split group therapy into multiple rooms, and assigned seats to patients within common areas. Groups with leaders that came from outside the treatment setting (e.g., pet therapy) were discontinued while auxiliary groups (i.e., recreational therapy, etc.) were temporarily reduced to accommodate staffing changes. Most units experienced some difficulty maintaining these COVID-19 precautions due to the extended length of the pandemic, leading to reduced fidelity to these modifications.

All programs required staff and visitors to wear masks and many mandated eye protection for staff. Patients were provided and encouraged to wear masks with variable compliance. Visitation guidelines were commonly changed to reduce the number of visitors or suspend visitation completely (e.g., 1 to 2 caregivers per patient, COVID-19 symptom screening prior to entering the facility, etc.). Virtual family meetings, therapy sessions, and team meetings using technology that staff had not previously used as part of AITS were encouraged over in-person interactions. There was also variability in PHP and IOP treatment programming ranging from shifting to full telehealth, a hybrid model (e.g., three days a week in person and two days virtually), or no changes in programming other than the addition of staff and patient PPE.

Many programs altered staffing models. At some sites, direct care staff were furloughed or deployed to other positions. Staff reductions resulted in increased coverage demands. Additionally, staff were staggered (e.g., psychiatrists and social workers alternated in-person and virtual workdays to decrease the number of in-person providers at any given time), and many staff meetings moved virtually. Though virtual meetings allow greater flexibility and promote social distancing, reduced on-site attendance adversely impacted staff availability and immediate support for acute needs.

The full impact of the pandemic on staff remains to be seen, though over the past year, we know symptom screening requirements resulted in an increase in sick calls, and employees were required to stay home until their symptoms resolved and/or had a negative COVID-19 test. Therefore, staff who may have normally reported to work with a mild cold were unable to come to work, resulting in increases in sick time and coverage needs, and higher burn out due to limited staff pools6The threat of COVID-19 and its influence on nursing staff burnout.. The combination of absences due to mandatory furloughs and sick time resulted in an increased strain on both the system and individual staff members. As programs moved toward telehealth, boundaries between work and home life were blurred. Further, staff members are currently living through and are actively experiencing the same trauma of the pandemic experienced by patients and their families, adding to the strain and stress of providing mental health treatment.

Lessons Learned and Next Steps

In the current pandemic, we have had to alter treatment and staffing models in AITS with the dual goals of maintaining the standard of care for youth with the most acute and severe mental illness while minimizing COVID-19 exposures. Program modifications resulted in numerous lessons learned. These lessons involve an awareness and ability to make quick modifications related to program access; expansion of external resources; census, space and staff modifications; implementation of health and wellness strategies; and maximizing telehealth. Notably, these rapid changes to AITS care were made concurrent to providing mental health care to youth. AITS care could not stop, as the impact of COVID-19 has reinforced the fact that mental health care is essential.

With the onset of COVID-19, telehealth services emerged quickly. Programs were able to utilize technology to host virtual family therapy sessions and treatment team meetings. COVID positive patients who were quarantined to their treatment rooms were able to participate in therapy groups and individual therapy via telehealth. Treatment programs reported that this approach allowed families to access care where transportation would have historically been a barrier.

Future research on the impact of these modifications on patient- and service-level outcomes will be important in coming months, especially regarding the effectiveness of utilizing telehealth for providing mental health services in AITS. In addition, AITS providers are not excluded from impacts the pandemic may have on mental health, and it will be important to study the factors associated with provider functioning and well-being.

AITS provide essential interventions for our most psychiatrically vulnerable patients and cannot shut down, especially during a disaster. The adaptations reviewed in this article allowed continued service provision for the most severely ill, highest risk youth in a milieu environment despite an ongoing pandemic.

We hope these lessons are useful for persisting through the current pandemic, and to enhance preparedness for AITS facilities to pivot efficiently and effectively in response to future catastrophes to maintain high quality acute care, especially given the escalation of mental health needs during crises. Table 1

Table 1Lessons Learned From Pre and Post Pandemic Practices in Acute and Intensive Treatment Settings

Notes. IPH = inpatient psychiatric hospital; PHP = partial hospitalization program; IOP = intensive outpatient program; PPE = personal protective equipment; ED = emergency department; C/L = consultation/liaison; AITS = acute intensive treatment services.

ReferencesLoades M.E. Chatburn E. Higson-Sweeney N. et al.

Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19.

Journal of the American Academy of Child and Adolescent Psychiatry. 59: 1218-1239https://doi.org/10.1016/j.jaac.2020.05.009Bojdani E. Rajagopalan A. Chen A. et al.

COVID-19 pandemic: Impact on psychiatric care in the United States.

Psychiatry Research. 289: 113069https://doi.org/10.1016/j.psychres.2020.113069

Leeb, RT, Bitsko, RH, Radhakrishnan, L, Martinez, P, Njai, R., Holland, KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. Available at https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm. Accessed 2/17/2021.

Acute, Intensive, and Residential Service Special Interest Group. American Psychological Association Child and Adolescent Psychology Division. https://sccap53.org/special-interest-groups/current-special-interest-groups/acute-intensive-and-residential-service-special-interest-group/

American Academy of Child and Adolescent Psychiatry. Principles of Care for Treatment of Children and Adolescents with Mental Illnesses in Residential Treatment Centers. https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/principles_of_care_for_children_in_residential_treatment_centers.pdf (2010). Available at: https://www.aacap.org/AACAP/Member_Resources/Practice_Information/Inpatient_and_Residential_Health_Care.aspx. Accessed November 22, 2020.

The threat of COVID-19 and its influence on nursing staff burnout.

Journal of Advanced Nursing. 77: 832-844Article InfoPublication History

Accepted: June 25, 2021

Received in revised form: June 9, 2021

Received: December 29, 2020

Publication stageIn Press Journal Pre-ProofFootnotes

The authors have reported no funding for this work.

Author Contributions

Conceptualization: Leffler

Writing – original draft: Leffler, Esposito, Frazier, Patriquin, Reiman, Thompson, Waitz

Disclosure: Drs. Leffler, Esposito, Frazier, Patriquin, Reiman, Thompson, and Waitz have reported no biomedical financial interests or potential conflicts of interest.

Identification

DOI: https://doi.org/10.1016/j.jaac.2021.06.016

Copyright

© 2021 Published by Elsevier Inc. on behalf of the American Academy of Child and Adolescent Psychiatry.

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