6. Restraints and management of agitated patients: PCUs should develop plans for addressing agitated patients, including contingency plans for whether seclusion or restraints should be administered in the patient’s individual room or in a dedicated restraint room in the PCU. Staff training should include protocols specifically designed for managing agitated patients in the PCU.
7. Discharge processes: If patients remain medically well and clear their COVID-19 PCR tests, it is conceivable that they might be transferred to a non–COVID-19 psychiatric unit if sufficient isolation time has passed and the infectious disease consultants deem it appropriate. It is also possible that patients would be discharged from a PCU to home or other residential setting. Such patients should be assessed for ability to comply with continued self-quarantine if necessary. Discharge planning must take into consideration follow-up plans for COVID-19 illness and primary care appointments, as well as needed psychiatric follow-up.
8. Patients’ rights: The apparently highly infectious and transmissible nature of SARS-CoV-2 creates novel tensions between a wide range of individual rights and the rights of others. In addition to manifesting in our general society, there are potentially unique tensions in acute inpatient psychiatric settings. Certain patients’ rights may require modification in a PCU (for example, access to outdoor space, personal belongings, visitors, and possibly civil commitment judicial hearings). These discussions may require input from hospital compliance officers, ethics committees, risk managers, and the local department of mental health and also may be partly solved by using video communication platforms.
Dr. Luming Li
A few other “pearls” may be of value: Psychiatric hospitals that are colocated with a general acute care hospital or ED might be better situated to develop protocols to safely care for COVID-19–positive psychiatric patients, by virtue of the close proximity of full-spectrum acute general hospital services. Direct engagement by a command center and hospital or health system senior leadership also seems crucial as a means for assuring authorization to proceed with planning what may be a frightening or controversial (but necessary) adaptation of inpatient psychiatric unit(s) to the exigencies of the COVID-19 pandemic.
The resources of a robust community hospital or academic health system (including infection prevention leaders who engage in continuous liaison with local, county, state, and federal public health expertise) are crucial to the “learning health system” model, which requires flexibility, rapid adaptation to new knowledge, and accessibility to infectious disease and other consultation for special situations. Frequent and open communication with all professional stakeholders (through town halls, Q&A sessions, group discussions, and so on) is important in the planning process to socialize the principles and concepts that are critical for providing care in a PCU, reducing anxiety, and bolstering collegiality and staff morale.
References
1. Kim MJ. “ ‘It was a medical disaster’: The psychiatric ward that saw 100 patients with new coronavirus.” Independent. 2020 Mar 1.
2. Korean Society of Infectious Diseases et al. J Korean Med Sci. 2020 Mar 16;35(10):e112.
3. Centers for Disease Control and Prevention. Symptom-based strategy to discontinue isolation for persons with COVID-19. Decision Memo. 2020 May 3.
4. He X et al. Nature Medicine. 2020. 26:672-5.
Dr. Cheung is associate medical director and chief quality officer at the Stewart and Lynda Resnick Neuropsychiatric Hospital at the University of California, Los Angeles. He has no conflicts of interest. Dr. Strouse is medical director, UCLA Stewart and Lynda Resnick Neuropsychiatric Hospital and Maddie Katz Professor at the UCLA department of psychiatry/Semel Institute. He has no conflicts of interest. Dr. Li is associate medical director of quality improvement at Yale-New Haven Psychiatric Hospital in Connecticut. She also serves as medical director of clinical operations at the Yale-New Haven Health System. Dr. Li is a 2019-2020 Health and Aging Policy Fellow and receives funding support from the program.