Every day in the United States, about 180,000 patients receive mental health care in some 4,000 inpatient and residential psychiatric facilities. SARS-CoV-2 can spread fast in any place where people live together, and psychiatric hospitals have particular problems: patients arrive from other high-risk settings, and patients' complex needs make standard infection control hard to apply. This is how Wyoming's state psychiatric hospital handled its first cases in 2020.
The hospital
| Units | three very different ones — Adult Psychiatric Services, Medical Geriatric Psychiatric Services and Criminal Justice Services |
| Patients | all 19 or older, admitted from other health care, group residential and correctional facilities in the state |
| Beds | 104, about 65% of them in double rooms |
| Staff | about 300, mostly health care personnel |
Two positive transfers
| Date (2020) | What happened |
|---|---|
| Late March | the hospital begins testing some new admissions and patients with COVID-like symptoms; staff with symptoms are told to get tested through their own doctors. No cases found |
| April 3 | a private psychiatric hospital, planning to transfer one of its patients, gets a negative test for that patient; the second patient is never tested before transfer |
| April 13 | both patients, without symptoms, arrive at the state hospital from the private hospital, which has confirmed COVID-19 cases among residents and staff. Because of that outbreak, both are tested on arrival and isolated in separate rooms; staff exposed during transport or admission without full protective equipment are asked to self-quarantine |
| April 16 | both test positive |
| May 1 | a point prevalence survey tests everyone who agrees, 18 days after the pair arrived |
What the hospital changed
New admissions
- A dedicated admissions team screens and tests every new patient.
- New patients stay isolated in a single room until their result comes back.
- Anyone who tests positive goes to a separate ward, staffed by eight dedicated nurses who also do the housekeeping, for 2 weeks or until two negative swabs taken 24 hours apart. Existing patients who develop symptoms are handled the same way.
Everyone, reinforced from long-term care guidance
- cloth face coverings for patients who will wear them, and masks for staff at all times;
- frequent disinfection of COVID-19 patients' spaces and all communal areas;
- no group dining, or more space between diners;
- smaller group therapy sessions;
- no nonessential visitors or services;
- daily symptom and temperature checks for all patients and staff.
Adapted for psychiatric patients: ordinary face coverings have elastic and metal parts that could be used for self-harm or violence, so the hospital made its own — including face coverings made from socks, an item patients were already allowed.
The survey: all negative
With the Wyoming Department of Health and CDC, two-person teams in each unit asked everyone to take part, with oral consent (and a guardian's consent where a patient had one), a short questionnaire and a nasopharyngeal swab, tested at the Wyoming State Public Health Laboratory.
| Took part | Median age | |
|---|---|---|
| Patients — all | 46 of 76 (61%) | 57 |
| Adult psychiatric | 21 of 31 | 48 |
| Medical geriatric psychiatric | 16 of 21 | 62 |
| Criminal justice | 9 of 24 | 42 |
| Health care personnel — all | 171 of 282 (61%) | 43 |
| Clinical care | 137 of 238 | 41 |
| Housekeeping | 14 of 16 | 55 |
| Transport and security | 20 of 27 | 46 |
Patients had been in the hospital a median of 150 days. Of the staff who took part, 88% gave direct patient care, 57% had worked on more than one unit in the previous two weeks, and 5% had also worked at another health care facility. (Housekeeping, transport and security staff can give non-clinical direct care — helping patients move around, or stepping in if a patient turns violent.)
Answers about symptoms were too inconsistent to use: people often named symptoms unrelated to COVID-19 or put them down to existing conditions.
Every patient and staff member tested was negative — a sign that the expanded measures may have worked.
Problems particular to psychiatric facilities
From the hospital's experience and reports from other Wyoming facilities, the team listed the difficulties and possible answers.
| Problem | Possible answer |
|---|---|
| Admissions from high-risk places — homeless shelters, group homes, jails | test new patients and keep them off regular wards until results come back |
| Patients resisting screening, sometimes violently | explain why screening and testing matter, to counter misinformation and fear |
| Cohorting — patients must already be kept apart by age, gender, treatment needs and risk of violence | work hard to keep the virus out so COVID cohorting is not needed; if it spreads, isolate in single rooms, or share rooms with other COVID-19 patients where the other rules allow |
| Therapy needs closeness and cannot simply stop | smaller groups or one-to-one sessions, six feet apart, everyone covered, surfaces cleaned more often |
| Face coverings unsuitable or refused | modified coverings or fastenings, or approved items used as coverings |
| Cleaning products — patients may lick surfaces or try to swallow products | lock products away; staff hand out hand sanitizer in single portions |
| Physical and emotional strain on staff — frequent checks, restraining violent patients, turnover, stigma | plan surge staffing and flexible leave, protect staff at higher risk, and plan communications against stigma |
| Staff exposure — spitting, licking, thrashing, pulling off protective equipment; security and transport staff first on the scene | protective gear that allows free movement: goggles rather than glasses or face shields, respirators rather than surgical masks, Tyvek suits rather than gowns; utility belts for non-clinical staff |
| Open wards and shared bathrooms, built for observation | control symptomatic patients' access to communal areas; disinfect more |
| Rooms not built for medical care — often no electric outlets, for safety | plan transfers to acute care hospitals |
Closing admissions would lower the risk, but it would contradict these hospitals' purpose and leave patients stuck in acute care hospitals. Instead, the authors recommend that facilities plan for their own limits — and that states and counties plan across all high-risk facilities, with joint testing strategies, wider screening and community surveillance, because patients and staff move between them.
Limits
- The survey was one day's snapshot; very recent infections could have been missed.
- 39% of patients and staff were not tested — some patients were too unwell to take part, and some staff off duty may not have wanted to travel to the hospital. Missed cases would mean the true prevalence was higher.
- Answers may have been affected by cognitive disability or recall bias.
- It could not be proved that the measures were what prevented spread.
A point prevalence survey proved feasible in a psychiatric hospital, and the authors suggest it as an outbreak tool for this and other facilities.
Sources
Based on Callaghan AW, Chard AN, Arnold P, et al., "Screening for SARS-CoV-2 Infection Within a Psychiatric Hospital and Considerations for Limiting Transmission Within Residential Psychiatric Facilities — Wyoming, 2020," MMWR Morbidity and Mortality Weekly Report volume 69, number 26, Centers for Disease Control and Prevention; a work of the United States government in the public domain.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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