Patients running rampant- unmasked, hand unwashed, undistanced. You stand in the nurse’s workstation, watching the chaos ensue while holding the positive COVID test results in your hands. The world slows as you think, “How am I ever going to control this one?”
This scene is unfortunately ever present in our current health system. Since March 2020, the COVID-19 pandemic has put constant pressure on the medical system, uniquely affecting health care facilities with limited resources. Inpatient psychiatric hospitals present unique challenges as patients may struggle to maintain personal hygiene, consistently wear masks, or maintain social distancing in group settings. Additionally, psychiatric patients often have multiple unmanaged medical conditions and are less likely to have received a COVID-19 vaccination. These individuals have a significant risk of death due to their psychiatric and medical conditions, with a two to three times higher mortality rate than the general life expectancy. At the Mount Sinai Campus of St. Francis Hospital in Hartford, CT, the inpatient psychiatry unit has had considerable difficulties during the pandemic. The hospital was built in 1923 and does not have air-tight doors, negative pressure rooms, HEPA filtration symptoms, or other environmental necessities to promote infection control.
General hospital policy calls for the isolation of suspected or confirmed patients with COVID-19. This entails a private room, often in a dedicated wing, COVID-19 rapid antigen testing, and signage denoting the patient’s infectious status with PPE requirements. This strategy has shown varying levels of success, especially during COVID-19 surges. During the Omicron surge in January 2022, we noticed several challenges in maintaining infection control within our institution. The facility has demonstrated unprecedented demand for psychiatric beds since the beginning of the pandemic, causing there to rarely be an unfilled bed. Patients are allowed to freely move throughout the halls, eat meals, and attend group therapy sessions together in the same room. Coupled with inconsistent mask-wearing, this may facilitate increased infection transmission. Moreover, many of these patients have not received the full course of COVID-19 vaccinations, leaving them and others exposed to infection. Finally, given the increased demand for beds at inpatient and extended care psychiatric facilities, patients in psychiatric units may experience delays to discharge, leading to extended stays and potentially increased exposure to infection.
COVID-19 safety guidelines must be considered and implemented in inpatient units, including psychiatric floors. Many patients are unable to follow established COVID-19 protocol, including mask-wearing, social distancing, maintaining personal hygiene, and vaccinating pose a risk to themselves and patients and providers who come into contact with them. While it is important to consider the safety of others around the patients, it is essential also to consider patient autonomy. Just as providers cannot force treatment on a patient, patients cannot be forced to follow these safety guidelines. Ultimately, we can only make strong recommendations and reminders. In psychiatric units especially, this line blurs as providers rarely enforce these rules in an attempt to preserve the fragile relationship between patients and providers, as well as the risk of causing significant patient agitation.
As mentioned above, providers in our hospital had unique challenges during the pandemic. The Omicron variant “wave” overwhelmed testing capabilities and call centers everywhere, including the Trinity Health call center. As of January 3rd, Connecticut was having 1,457 cases of confirmed COVID daily, sustaining over 20 percent test positivity rate for much of January. This resulted in employees who were exposed to COVID or had symptoms being unable to receive timely work instructions or testing. In addition, staffing was stretched to its limit as many individuals were unable to safely report to work, often increasing the threshold that testing had to fall back to.
We present our recommendations now as COVID-19 moves toward endemicity. We emphasize the importance of having collaborative medical professionals who can be instrumental in managing comorbidities, acute illness, and vaccination. When individuals enter the facility, they should be offered the opportunity to have any missing COVID vaccination that they may qualify for, though we recognize that patients may not always be able to consent to this immediately upon entry, depending on their mental status at the time. Testing and vaccination should again be offered to patients upon discharge and ensure appropriate psychiatric and medical follow-up.
We note that vaccinations are not an instantaneous solution as significant efficacy takes up to two weeks, but given the large rate of return to both our as well as other outpatient/inpatient facilities signifies the important opportunity for public health that will help these individuals as well as those who care for them. Moreover, providers also require adequate testing, and health care workplaces either need to be provided an adequate number of COVID-19 tests to keep their workers safe during surges, or there must be a consideration of the types of tests that are adequate for confirming COVID-19 infection and safely returning to work. Reliable telehealth services should be available to mitigate the mental health burden and social isolation of exposed/infected patients and to lessen the burden on the health care system in cases where health care providers have been infected or exposed and are temporarily unable to see patients in person.
The authors thank Dr. Mahreen Raza, the psychiatrist in the Mount Sinai Campus of St. Francis Hospital in Hartford, for valuable discussion and comments on this case.
Anoush Calikyan. Hank Weinstock, and Ania Poteraj are medical students.
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