Infrastructure Differences Between Psychiatric Units and Medical/Surgical Units

In many parts of the country, there is a scarcity of psychiatric inpatient beds. As such, it is essential for these units to remain operational and safe during this pandemic in order to meet the needs of the patients these inpatient units serve.

Inpatient psychiatric units differ from medical and surgical units in several ways [4••]. Even within inpatient psychiatric units, there are differences in terms of infrastructure [5]. Some inpatient psychiatric units are part of free-standing psychiatric hospitals with their own emergency departments. As a result, such units may not readily have access to specialty medical care if someone contracts COVID-19. Outbreaks in a free-standing facility have the potential to cause a partial or even complete shutdown of the facility [6]. Other inpatient psychiatry units may be co-located [either in the same building or on the same campus] with medical and surgical as well as intensive care units and may be better equipped to deal with an outbreak. Psychiatric units are oftentimes locked units and there are some advantages and disadvantages associated with this fact. When considering controlling the spread of COVID-19, one advantage of having a locked unit is that patients cannot walk out of the unit and inadvertently contribute to the spread of the infection. On the other hand, the patients and staff might feel cut off from the rest of the building and be at risk of adverse effects of isolation [7].

Inside the units, psychiatric facilities also have key differences from other medical units [1•, 8]. Unlike on general medical floors, psychiatric patients often spend a significant amount of time outside their rooms participating in group activities or socializing with peers. It would be unethical to confine patients to their rooms, which would be considered seclusion. One major characteristic of psychiatric units is the free movement in the hallways as well the availability of community areas so that patients can participate in group therapy activities [9]. Many disciplines offer group-based interventions on inpatient psychiatry units—occupational therapy, recreational therapy, pharmacy, music therapy, social work, and nursing. Group therapy is considered an integral part of psychiatric treatment, and thus, there are greater risks of transmission between patients and staff. While some psychiatric units have single occupancy rooms, many units have shared rooms and bathrooms, leading to increased risk of viral transmission. To reduce the risk of self-harm by patients, psychiatric units are designed to be ligature-proof and often lack equipment found in other units such as television sets in patient rooms, leading patients to congregate in common areas where a TV is available[5]. Due to the ligature-proof nature of psychiatric units, it is more difficult to keep patients masked as cloth masks could be used as ligatures by some patients. Most psychiatric units lack specialized equipment such as telemetry and negative-pressure rooms. Some psychiatric units are specifically designed to treat patients with comorbid medical and psychiatric conditions. However, the vast majority of psychiatric units have limited capacity to treat patients with any substantive general condition. For this reason, such inpatient psychiatric units may not be able to have patients needing more involved general medical care such as intravenous lines or indwelling catheters.

Differences Between Psychiatric Patients and Patients on Other Units

Psychiatric patients are often vulnerable to contracting COVID-19 because of many factors such as crowded living conditions, homelessness, poor social support, and untreated medical conditions such as diabetes and hypertension [4••]. These patients often do not seek help when ill and may need to be brought to a treatment facility and hospitalized involuntarily. The pandemic itself has contributed to worsening mental health [10, 11], especially in people with depression, anxiety, and even paranoia. Cognitively impaired patients and patients with intellectual disabilities may be unable to comprehend the safety precautions in effect on the unit. There are also challenges related to the acutely agitated or behaviorally disinhibited patients. This may make it difficult to enforce use of masks, hand hygiene, physical distancing, and other measures to reduce the risk of viral transmission[6].

Differences in Staff Functioning on Psychiatric Units and Other Issues

Psychiatric units have interdisciplinary rounds which traditionally involve close contact between multiple team members. In academic medical centers, the presence of trainees and students makes it even more challenging to plan for physical distancing. Restricting students and residents on the psychiatric units risks compromising their ability to learn hands-on clinical skills [1•, 12]. The pandemic is also likely to lead to the lack of qualified physicians and staff available to meet the demands of psychiatric units because of expanding patient loads.

Another consideration related to social distancing is that there are regulatory requirements to conduct visual checks on patients every 15 min. Meeting this patient need frequently requires staff to come in close proximity of patients. Some patients with psychiatric illnesses may need sitters for elevated suicide risk or self-harm or because of the inability to take care of their activities of daily living, again increasing the risk of transmission.

There are other challenges that COVID-19 brings to psychiatric care on an inpatient unit that pertain to discharge planning. For example, once psychiatrically stabilized, patients may encounter difficulties with being discharged home to self-quarantine. For homeless patients, there is the likelihood of difficulty in finding placement—shelters and step-down units may be closed or functioning at reduced capacity as a result of the pandemic. In addition, family members may be unwilling or unable to provide a place for patients to self-quarantine after discharge [4••]. Visitor restrictions in place in many facilities can lead to isolation and worsening of psychiatric illness for some patients who derive benefits from visitors. Finally, there are ethical issues related to patients’ capacity to accept or decline treatment and/or vaccination. Psychiatric patients, especially those with cognitive impairment, may not have the capacity to weigh the risks versus the benefits of getting treated for COVID-19 and/or getting the vaccine when it becomes available to them. At such times, the healthcare team may need to consider seeking court-ordered forced treatment or vaccination.

The unique challenges presented to psychiatric care by COVID-19 begin in the emergency department (ED), where psychiatry patients are screened prior to admission. The main challenge is the time psychiatry patients need to wait in the ED pending their COVID-19 testing results. Notification of a patient’s COVID status is necessary to identify safe and durable disposition. There can be disposition challenges when attempting to find an appropriate place for care for COVID-positive patients who are medically stable yet require psychiatric hospitalization. Therefore, our institution established specific infection control measures to be used for psychiatric admissions through the ED.