Planning for a psychiatric COVID-19–positive

unit : Identifying key decision points is critical

Publish date: May 15, 2020 By  Erick H. Cheung, MD , Thomas B. Strouse, MD , Luming
Li, MD

Reports have emerged about the unique vulnerability of psychiatric hospitals to the
ravages of COVID-19.

Dr. Erick H. Cheung

In a South Korea psychiatric hospital, 101 of 103 patients contracted SARS-CoV-2

during an outbreak; 7 eventually died.1,2 This report, among a few others, have led
to the development of psychiatric COVID-19–positive units (PCU). However, it
remains highly unclear how many are currently open, where they are located, or
what their operations are like.

Early in the COVID-19 pandemic, it became clear to us that, as a public health

measure, it would be necessary to test all patients for COVID-19 who were being
considered for admission to our inpatient psychiatric units. We knew that we could
not allow a medically asymptomatic “covertly” COVID-19–positive patient to be
introduced to the social community of our inpatient units because of the risks of
transmission to other patients and staff.

In coordination with our health system infection prevention experts, we have

therefore required a confirmed negative COVID-19 polymerase chain reaction nasal
swab performed no more than 48 hours prior to the time/date of acute psychiatric
inpatient admission. Furthermore, as part of the broad health system response and
surge planning, we were asked by our respective incident command centers to
begin planning for a Psychiatric COVID-19–positive Unit (PCU) that might allow us
to safely care for a cohort of patients needing such hospitalization.

It is worth emphasizing that the typical patient who is a candidate for a PCU is so
acutely psychiatrically ill that they cannot be managed in a less restrictive
environment than an inpatient psychiatric unit and, at the same time, is likely to
not be medically ill enough to warrant admission to an internal medicine service in
a general acute care hospital.

We have identified eight principles and critical decision points that can help
inpatient units plan for the safe care of COVID-19–positive patients on a PCU.
RELATED
Coronavirus on the inpatient unit: A new challenge for psychiatry
1. Triage: Patients admitted to a PCU should be medically stable, particularly with
regard to COVID-19 and respiratory symptomatology. PCUs should establish clear
criteria for admission and discharge (or medical transfer). Examples of potential
exclusionary criteria to a PCU include:

 Respiratory distress, shortness of breath, hypoxia, requirement for

supplemental oxygen, or requirement for respiratory therapy breathing
treatments.
 Fever, or signs of sepsis, or systemic inflammatory response syndrome.
 Medical frailty, significant medical comorbidities, delirium, or altered
mental status;
 Requirements for continuous vital sign monitoring or of a monitoring
frequency beyond the capacity of the PCU.
Discharge criteria may also include a symptom-based strategy because emerging
evidence suggests that patients may be less infectious by day 10-14 of the disease
course,3 and viral lab testing is very sensitive and will be positive for periods of time
after individuals are no longer infectious. The symptom-based strategy allows for
patients to not require retesting prior to discharge. However, some receiving
facilities (for example residential or skilled nursing facilities) may necessitate
testing, in which case a testing-based strategy can be used. The Centers for Disease
Control and Prevention provides guidelines for both types of strategies. 4

2. Infection control and personal protective equipment: PCUs require

modifications or departures from the typical inpatient free-ranging environment in
which common areas are provided for patients to engage in a community of care,
including group therapy (such as occupational, recreational, Alcoholics
Anonymous, and social work groups).

 Isolation: PCUs must consider whether they will require patients to isolate

to their rooms or to allow modified or limited access to “public” or
“community” areas. While there do not appear to be standard
recommendations from the CDC or other public health entities regarding
negative pressure or any specific room ventilation requirements, it is
prudent to work with local infectious disease experts on protocols.
Important considerations include spatial planning for infection control areas
to don and doff appropriate personal protective equipment (PPE) and
appropriate workspace to prevent contamination of non–COVID-19 work
areas. Approaches can include establishing clearly identified and visually
demarcated infection control “zones” (often referred to as “hot, warm, and
cold zones”) that correspond to specific PPE requirements for staff. In
addition, individuals should eat in their own rooms or designated areas
because use of common areas for meals can potentially lead to aerosolized
spread of the virus.
  Cohorting: Generally, PCUs should consider admitting only COVID-19–
positive patients to a PCU to avoid exposure to other patients. Hospitals and
health systems should determine protocols and locations for testing and
managing “patients under investigation” for COVID-19, which should
precede admission to the PCU.
 PPE: It is important to clearly establish and communicate PPE
requirements and procedures for direct physical contact versus no physical
contact (for example, visual safety checks). Identify clear supply chains for
PPE and hand sanitizer.
3. Medical management and consultation: PCUs should establish clear
pathways for accessing consultation from medical consultants. It may be ideal, in
addition to standard daily psychiatric physician rounding, to have daily internal
medicine rounding and/or medical nursing staff working on the unit. Given the
potential of COVID-19–positive patients to rapidly devolve from asymptomatic to
acutely ill, it is necessary to establish protocols for the provision of urgent medical
care 24/7 and streamlined processes for transfer to a medical unit.

Clear protocols should be established to address any potential signs of

decompensation in the respiratory status of a PCU unit, including administration of
oxygen and restrictions (or appropriate precautions) related to aerosolizing
treatment such as nebulizers or positive airway pressure.

4. Code blue protocol: Any emergent medical issues, including acute respiratory

decompensation, should trigger a Code Blue response that has been specifically
designed for COVID-19–positive patients, including considerations for proper PPE
during resuscitation efforts.

Dr. Thomas B. Strouse

5. Psychiatric staffing and workflows: When possible, it may be preferable to

engage volunteer medical and nursing staff for the PCU, as opposed to mandating
participation. Take into consideration support needs, including education and
training about safe PPE practices, processes for testing health care workers, return-
to-work guidance, and potential alternate housing.
 Telehealth: Clinicians (such as physicians, social workers, occupational
therapists) should leverage and maximize the use of telemedicine to
minimize direct or prolonged exposure to infectious disease risks.
 Nursing: It is important to establish appropriate ratios of nursing and
support staff for a COVID-19–positive psychiatry unit given the unique work
flows related to isolation precautions and to ensure patient and staff safety.
These ratios may take into account patient-specific needs, including the
need for additional staff to perform constant observation for high-risk
patients, management of agitated patients, and sufficient staff to allow for
relief and break-time from PPE. Admission and routine care processes
 should be adapted in order to limit equipment entering the room, such as
computer workstations on wheels.
 Medication administration procedures: Develop work flows related to
PPE and infection control when retrieving and administering medications.
 Workspace: Designate appropriate workspace for PCU clinicians to access
computers and documents and to minimize use of non–COVID-19 unit work
areas.
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.