Experience of Managing COVID-19 in an Inpatient Psychiatric Setting

Dr B Harman-Jones (Psychiatry Trainee)
Dr M Aamer Sarfraz (Consultant Psychiatrist & DME)

Abstract

The COVID-19 pandemic has presented unique challenges to psychiatric inpatient services. The Medical Education Department at Kent and Medway NHS and Social Care Partnership Trust developed specific guidance for clinicians working in this setting during the pandemic. These were distributed and presented locally, and helped to guide development of policy. In this article we present the major recommendations contained in this guidance.

Introduction

The COVID-19 pandemic has forced us to adapt to a previously unrecognisable way of life. Patients and staff have also been affected and united by this extraordinary narrative affecting every aspect of our lives. COVID-19 is the syndrome caused by human infection with SARS-CoV-2, a novel coronavirus believed to have originated in a “wet market” in Wuhan City, China, but this is as yet unconfirmed.1,2 It is likely that person-to-person transmission of the virus was occurring in December 2019, and probably earlier.3 Coronaviruses are enveloped, single-stranded RNA viruses held in a natural reservoir in bats. Some cause disease in humans such as the common cold, SARS, and MERS, and are known to acquire the ability to infect human hosts by acquiring mutations through intermediate species.1,2

The incubation period of SARS-CoV-2 infection is between 1 and 14 days, with a median of 5-7 days.3 Transmission during the incubation period is possible, and was reported in 12.6% of cases in China.3 Transmission occurs via two major routes: mucosal contact with respiratory droplets, and contact with contaminated surfaces.4 Respiratory droplets are particles >5μm in diameter produced by coughing or sneezing, and can move over short distances.4 After a surface is contaminated, viability of the virus varies depending on surface type, with one study showing this is up to 72 hours on plastic, up to 48 hours on stainless steel and up to 8 hours on copper.4 Airborne transmission has not been reported, however this may be possible via aerosol-generating procedures.3 SARS-CoV-2 has also been detected in blood, cerebrospinal fluid, urine, saliva, tears, conjunctival secretions, and faeces, but it is unclear if contact with these constitutes viable routes of infection.3

The mechanism of infection by SARS-CoV-2 is via binding to human ACE-2 receptors via the “spike” receptor, which is structurally different to the spike protein found in SARS-CoV (the virus causing SARS) and may confer greater higher binding affinity.3 High ACE-2 expression is found in the lungs, heart, oesophagus, kidneys, bladder, and ileum, which may confer higher susceptibility of these organs to the disease.3 SARS-CoV-2 may also downregulate ACE-2 which may lead to a toxic accumulation of vasoconstricting angiotensin-II, which may contribute towards the development of ARDS and myocarditis.3

Due to the complexity of the situation, it was quickly recognised by the Medical Education Department at Kent and Medway NHS and Social Care Partnership Trust that specific guidance was required to enable clinicians to work confidently, effectively and safely during the pandemic. National-level guidance was quickly devised, but was inevitably generic, and could not provide the level of detail necessary to cover the nuances and unique operational challenges presented by psychiatric inpatient work. Psychiatrists required bespoke guidance, which we set out to develop. In this article we present the major aspects of this guidance.

Method

National-level guidance for managing COVID-19 was reviewed by clinicians with knowledge of inpatient psychiatry and formulated into themes which would form the basis for our guidance. Relevant details were verified and re-presented in a slideshow format, with additional detail relevant to inpatient psychiatry researched and incorporated appropriately. After review, this document was then distributed electronically via email as a PDF file. Additionally, the Medical Education Department organised and led video conferences for consultants and junior doctors, explaining and detailing the guidance, and answering any questions. Specialist support for these video conferences was provided by the involvement of a respiratory physician. These conferences were well-attended, well-received, have facilitated helpful information sharing between clinicians, and guided the development of formal policy by the Trust.

Results

Due to the specific implications of unmitigated spread of COVID-19 on a psychiatric ward, it is important to take precautions when assessing possible cases in this setting. These include:

  • Assessing patients in a single occupancy room only. Patients should wear a fluid-resistant surgical mask while moving to the single room 5 and maintain a distance of two metres from others while doing so.
  • Use of appropriate personal protective equipment must be used as if the patient has COVID-19.
  • Avoiding contact with the individual as much as possible – and avoiding using a stethoscope if possible due to risk of viral contamination. Added respiratory sounds are rarely found in COVID-19 and so chest auscultation is not likely to add important diagnostic information.3

Priorities of assessment in the psychiatric setting are to determine if COVID-19 is suspected, and if the patient is acutely unwell and requires transfer to acute hospital. Additionally medical staff must review for possible red flags indicating other pathology, and consider differentials as appropriate.

Diagnostic features are described in Table 1. Key features include fever, cough, dyspnoea, and altered sense of smell or taste. However, the presentation can be variable and special care must be taken to spot a potentially atypical presentation in some groups, particularly the immunosuppressed.

If COVID-19 is suspected, then the patient must be immediately placed into respiratory isolation, which in a psychiatric inpatient setting will most commonly be in their bedroom. However, if on assessment the patient appears acutely unwell, then staff must consider if it is more appropriate for the patient to be transferred to an acute general hospital. In such an instance, immediate stabilising interventions such as high-flow oxygen, airway adjuncts, and nebulised bronchodilators are possible, but the use of any of these should always be in the context of escalation of care. A protocol for the process of transfer to the local acute general hospitals was developed, and is shown in Figure 1.

Key

Fever
Cough (usually dry)
Dyspnoea
Altered sense of smell/taste

Other common features

Fatigue
Myalgia
Anorexia
Sputum production
Sore throat

Uncommon features

Conjunctivitis
GI symptoms
Confusion
Dizziness
Headache
Haemoptysis
Rhinorrhoea/nasal congestion
Chest pain
Cutaneous manifestations
Bronchial breath sounds
Tachypnoea
Tachycardia
Cyanosis
Crackles/rales on auscultation

Table 1 – Diagnostic features of Covid-19

Taken from BMJ Best Practice. Coronavirus disease 2019 (COVID-19). 2020. Available at: https://bestpractice.bmj.com/topics/en-gb/3000168#important-updat 3

Figure 1 – Protocol for transfer to acute hospital

Figure 1 – Protocol for transfer to acute hospital

Infection control

Precautions against the transmission of COVID-19 work by disrupting the two major routes of transmission: respiratory droplets and contact with contaminated surfaces. Measures include respiratory isolation of cases, alterations to contact between all people (social distancing), hand hygiene at key points, and use of personal protective equipment (PPE) at key points. Guidance on the use of PPE is setting-specific and changes frequently; therefore readers are directed towards government sources for the latest guidance. Additionally the correct technique for PPE use is important, and instructional guides are available from these sources.

While it does not appear that airborne virus constitutes a viable route of transmission,3 the risk is higher when using certain “aerosol generating” procedures that are common in healthcare settings.4 These include cardiopulmonary resuscitation, and the use of continuous positive airway pressure machines. Therefore, there are additional infection control precautions that must be followed by staff when these procedures are conducted.

Certain groups in the population are being advised to “shield” from COVID-19, because they would be at increased risk compared to the general population if they were to contract the illness. In practice, this means staying at home and not leaving for any reason.6 It is important to recognise that these individuals suffer from a wide variety of medical conditions, which could also affect inpatients admitted to psychiatric units. Therefore it would be important to explore the past medical history of all new and existing inpatients and consider what extra precautions would need to be put in place if shielding is required. The Infection Control Department should be consulted in such an instance but these measures may include provision of PPE for the patient rather than staff, and respiratory isolation even in the absence of any symptoms.

Management of COVID-19 itself

Generally speaking, COVID-19 is manageable in a home setting if there are no severe features and there are no risk factors. If severe, hospital admission is recommended as the use of high-flow nasal oxygen, non-invasive ventilation, mechanical ventilation, or extracorporeal membrane oxygenation would likely be required.

While technically constituting a “healthcare setting”, inpatient psychiatric units do not have the same capacity to manage physical health problems as acute general hospitals. There is no capacity to administer oxygen on a less than emergency basis, no capacity to administer intravenous medication, it is difficult to take regular physical observations from patients and maintain continuous observation, and mental health nurses are not specifically trained in managing physical health problems. Therefore, COVID-19 patients being cared for in these settings should be considered as if they were at home, and a low threshold maintained for transfer to acute general hospital.

The management of the vast majority of cases, and certainly those appropriately cared for in a psychiatric setting, centres around alleviating symptoms of the illness, and maintaining infection control. It is sensible to encourage good hydration but it should be noted that too much fluid can worsen oxygenation.3 Patients in respiratory isolation are likely to be less mobile than usual, and the illness may specifically make patients bedbound and dehydrated due to fever. Special attention should therefore be paid to the risk of venous thromboembolism and prescription of prophylactic low molecular weight heparin if appropriate. This is something for which medical staff have a unique responsibility in a psychiatric setting, in contrast to other healthcare environments where nurses tend to be more involved in these risk assessments.

Antipyretics are recommended for reduction of fever.3 Paracetamol and NSAIDs should not be routinely prescribed to all new inpatients in the absence of the disease, because this may mask COVID-19 symptoms and lead to late identification of cases. If cough is distressing, advise patients to avoid lying on their back as this makes coughing ineffective.3 Simple measures such as a teaspoon of honey can be effective.3 Some sources recommend oral opioids to suppress cough,3 but we would suggest this be undertaken with caution in a psychiatric setting.

Breathlessness can be addressed by keeping the room cool, and by encouraging relaxation, for example using breathing techniques, and changing body positions. Psychiatric nurses are uniquely placed to use their skills here and this should be encouraged where possible and safe. Inhaled bronchodilators could be considered if there is wheeze. It would seem prudent to use inhalers in the first instance and then move to nebulised medication if necessary, because of greater availability and the closer contact required to provide nebulised therapy.

There is evidence that vitamin D supplementation is protective against respiratory tract infection.7 This may be particularly important in a psychiatric setting, as people with psychosis, for example, are known be particularly vulnerable to vitamin D deficiency. Adults are already advised to take vitamin D 10 micrograms/day from October to March, but during the pandemic adults are being advised to continue this through the spring and summer if they have limited contact with sunlight.8 It would therefore be sensible to prescribe this for all inpatients if not contraindicated. Additionally, a vitamin D level on admission bloods is valuable as if found to be insufficient or deficient, the patient would require more vitamin D than provided by this supplementation alone.

One problem that is likely to disproportionately affect medical staff dealing with COVID-19 in a psychiatric inpatient setting is patients refusing to comply with respiratory isolation. The Mental Health Act does not allow restrictive practices to be applied because of a physical health issue. Chapter 26 of the Mental Health Act Code of Practice 2015,9 which governs the use of restrictive interventions under the Mental Health Act, should be followed wherever possible. Only where there is what is termed a “cogent reason” for departure from the Code should this be undertaken.10 It is necessary to seek specialist advice on what would constitute a cogent reason, and in our Trust a specific Ethical Advisory Committee has been devised to consider such proposals.

Implications for psychiatric treatments

Beyond the management of the disease itself, the implications of COVID-19 on the provision of psychiatric treatments are wide-reaching. The capacity for monitoring of patients is likely to be greatly reduced during the pandemic. This makes routine physical health checks, for example for patients starting antipsychotic therapy, more logistically difficult than usual. Therefore, we would encourage all clinicians to carefully consider the risk:benefit ratio in embarking on new medications during the pandemic. Clearly, there will be situations where this is not avoidable and the benefits of new medications greatly outweigh the risks. However, if a medication is likely to provide only more modest benefits, the risks of not being able to carry out physical health monitoring as readily may tip the balance in favour of delaying commencement of medication at this time.

The pandemic makes the choice of medication even more important than usual. Many psychotropics, especially benzodiazepines, can cause respiratory depression, and should be used with caution in suspected or confirmed COVID-19.10 The use of medication for rapid tranquilisation is especially risky as patients are agitated and any existing respiratory difficulties are likely to be exacerbated. Additionally the use of restraint presents another respiratory risk factor. Short-acting medication is preferred to longer acting due to the risk of rapid physical deterioration when administered. Lorazepam would be the preferred benzodiazepine as it has a shorter half-life.10

Particular care should be taken with patients on clozapine. Community titrations will be unavoidably more risky during the pandemic, therefore, we would suggest a lower threshold for inpatient titrations than usual. Clozapine should be stopped if patients are experiencing severe respiratory symptoms due to COVID-19, with particular care when restarting the medication as re-titration may be required. Patients with respiratory symptoms may reduce their cigarette intake, which may increase the clozapine level. Therefore, smoking status should be closely monitored. Additionally, serious side-effects may be missed by mistaking them as effects of COVID-19. If patients are experiencing flu-like symptoms, neutropenia must be suspected, and if experiencing symptoms of myocarditis (e.g. chest pain, shortness of breath), this is also no less likely than usual and should be suspected.

Patients on long-acting injectable antipsychotics are also affected. Capacity for community administration may be reduced, and it may be helpful to consider increasing the interval between dosing where possible. Alternatively, clinicians could consider switching to an alternative medication which allows less frequent dosing, e.g. from risperidone LAI to paliperidone palmitate 1-monthly, or from paliperidone palmitate 1-monthly to paliperidone palmitate 3-monthly.

Lithium presents additional challenges. If patients are experiencing fever, dehydration may occur which may precipitate lithium toxicity. Therefore, monitoring for symptoms of lithium toxicity should be intensified where COVID-19 is suspected or confirmed, and plasma levels obtained urgently if suspected. If confirmed, the management of lithium toxicity in COVID-19 would be no different than at other times, although involvement of general medical colleagues would be prudent due to the increased complexity of the situation.

The emergency Coronavirus Bill makes provision for emergency amendments to the Mental Health Act, specifically: Mental Health Act assessments, extensions to periods of detention permitted under Sections 5, 135 and 136, SOAD requirements for giving medication without consent, and alterations to some forensic sections.11 However, at the time of writing, these amendments are not in force, and will only be enacted if the circumstances necessitate this.

Finally, not even the fundamentals of psychiatric practice are untouched by the pandemic. Prior to the current situation, most psychiatrists had never considered using remote consultations on a regular basis. There is a widely-held perception that this type of interaction is of lower quality than that allowed by seeing patients face-to-face, which is considered particularly important in psychiatry. However, now “telepsychiatry” has become mainstream almost overnight, and many clinicians have been surprised at how well it can work, with even psychotherapy using this approach being well-received.12 The term refers specifically to the use of video conferencing to conduct consultations, but clinicians have also been using the telephone as it can be more accessible. For some adults with certain conditions such as PTSD or panic disorder, it may actually be preferable to face-to-face contact.12 Telepsychiatry has been officially supported as a validated and effective practice by the American Psychiatric Association, who have published the “Telepsychiatry toolkit”, which although US-specific, contains many useful tips on using the approach in practice.12

Discussion

A particular focus for our guidance was on the interface between psychiatric inpatient units and local general medical hospitals, and the prompt recognition of the acutely unwell patient requiring transfer. The management of patients with COVID-19 not requiring transfer to such a setting was detailed, with guidance towards evidence-based practical measures that could be deployed considering the somewhat limited resources available. Particular guidance was necessary on the management of patients detained under the Mental Health Act and measures if these patients refused to comply with isolation measures. Finally, the implications of the pandemic on the management of psychiatric conditions and the use of psychotropic medications were discussed.

We believe our approach was innovative in a number of ways. Firstly, the Medical Education Department recognised early on in the pandemic that the application of national-level guidance was going to be problematic in a psychiatric inpatient setting. We took the initiative to commission the development of this guidance which was completed expeditiously and shared promptly with clinicians. Distribution was purely electronic in order to maximise reach and comply with social distancing requirements. Interactivity was introduced using the innovative method of video conferencing on a large scale, which also took a multiagency approach by the involvement of a respiratory physician. We also took feedback throughout the development process, releasing a number of updates to the guidance based both on clinician feedback and developments in research. Finally, because the pandemic has reduced the potential for clinicians to engage in continuing professional development activities, our approach sought to address this need by providing broad and balanced coverage on the relevant clinical, professional and academic aspects.

References

[1] Khan et al. J. Clin. Microbiol 2020; doi:10.1128/JCM.00187-20.

[2] Tang X, Wu C, Li X, et al. On the origin and continuing evolution of SARS-CoV-2. Nat Sci Review. 2020 Mar 3 [Epub ahead of print].

[3] BMJ Best Practice. Coronavirus disease 2019 (COVID-19). 2020. Available at: https://bestpractice.bmj.com/topics/en-gb/3000168#important-updat

[4] Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland and Public Health England. Guidance for infection prevention and control in healthcare settings, Version 1.1. 27 March 2020.

[5] Public Health England. COVID-19: investigation and initial clinical management of possible cases. 30 March 2020. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-initial-investigation-of-possible-cases/investigation-and-initial-clinical-management-of-possible-cases-of-wuhan-novel-coronavirus-wn-cov-infection

[6] Public Health England. Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19. 30 March 2020. Available at: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

[7] Martineau AR, et al. BMJ 2017;356: i6583.

[8] BBC. Coronavirus: Should I start taking vitamin D? 23 April 2020. Available at: https://www.bbc.co.uk/news/health-52371688.

[9] Department of Health. Mental Health Act 1983: Code of practice. 2015. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF

[10] NAPICU. Managing acute disturbance in the context of COVID-19. 2020. Available at: https://napicu.org.uk/wp-content/uploads/2020/03/COVID-19_guidance_appendix.pdf

[11] HM Government. The Health Protection (Coronavirus) Regulations 2020. 2020. Available at: http://www.legislation.gov.uk/uksi/2020/129/contents/made

[12] American Psychiatric Association. Telepsychiatry Toolkit. 2020. Available at: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit