Management of the COVID-19-Infected Psychiatric Inpatients: Unique Infection Prevention Considerations and Evolving Strategies.

The authors make the case for expanding the national discussion of inpatient psychiatric beds to recognize and incorporate other vital components of the continuum of care in order to improve outcomes for individuals with serious mental illness. They review the varied terminology applied to psychiatric beds and describe how the location of these beds has changed from primarily state hospitals to the criminal justice system, emergency departments, inpatient units, and the community. The authors propose 10 recommendations related to beds or to contextual issues regarding them. The recommendations address issues of mental illness terminology, criminal and juvenile justice diversion, the Emergency Medical Treatment and Labor Act, mental health technology, and the mental health workforce, among others. Each recommendation is based on findings from publicly available data and clinical observation and is intended to reduce the human and economic costs associated with severe mental illness by promoting a robust, interconnected, and evidence-based system of care that goes beyond beds.

This study examined usage patterns of restraint and seclusion before and after the implementation of collaborative problem solving (CPS), a manualized therapeutic program for working with aggressive children and adolescents. The clinical setting was a 15-bed psychiatric inpatient unit for school-age children. A total of 755 children were hospitalized for a total of 998 admissions from fiscal years 2003 to 2007 (median age=11 years; 64% boys). Data were collected for three years before and 1.5 years after the six-month implementation of the CPS model of care. There were 559 restraint and 1,671 seclusion events during the study period. After implementation of the CPS model there was a reduction in the use of restraints (from 263 events to seven events per year, representing a 37.6-fold reduction, slope [beta]=-.696) and seclusion (from 432 to 133 events per year, representing a 3.2-fold reduction, beta=-.423). The mean duration of restraints decreased from 41+/-8 to 18+/-20 minutes per episode, yielding cumulative unitwide restraint use that dropped from 16+/-10 to .3+/-.5 hours per month (a 45.5-fold reduction, beta=-.674). The mean duration of seclusion decreased from 27+/-5 to 21+/-5 minutes per episode, yielding cumulative unitwide seclusion use that dropped from 15+/-6 to 7+/-6 hours per month (a 2.2-fold reduction; p for trend .01 or better for all slopes). During the early phases of implementation there was a transient increase in staff injuries through patient assaults. CPS is a promising approach to reduce seclusion and restraint use in a child psychiatric inpatient setting. Future research and replication efforts are warranted to test its effectiveness in other restrictive settings.

Back to table of contents Previous article Next article From the PresidentFull AccessCOVID-19 and Sensationalizing Inpatient Psychiatric SettingsJeffrey Geller, M.D., M.P.H.Jeffrey Geller, M.D., M.P.H.Published Online:9 Jun 2020https://doi.org/10.1176/appi.pn.2020.6b22In the years following World War II, Americans were exposed to just how deprived their public psychiatric hospitals were of even a modicum of decency, much less the capability to provide treatment to patients. Muckraking journalism, such as Albert Deutch's book Shame of the States (1948) and Albert Maisel's article in Life Magazine, "Bedlam" (1946), as well as a first-person account written as a novel, Mary Jane Ward's Snake Pit (1946), grabbed readers' attention.Over the subsequent 75 years, the more scurrilous the portrayal of the psychiatric hospital—both public and private—the greater its audience. Noteworthy are the book and then film versions of One Flew Over the Cuckoo's Nest and Girl Interrupted. Perhaps it should come as no surprise that the COVID-19 pandemic would bring out new portrayals of psychiatric inpatient settings failing miserably to keep patients safe and provide adequate treatment. Today's version of Dr. Kik, like his predecessor in the Snake Pit, fights for his patients against villainous administrators who fail to see past their own foolishness and greed to their tasks of meeting patients' needs.Is this a fair representation of American psychiatric inpatient services during the COVID-19 pandemic? Or does this sensationalism fall under the penumbra of what U.N. Secretary-General António Guterres has called a "pandemic of misinformation."A case in point is Masha Gessen's article in the April 21 New Yorker, "Why Psychiatric Wards Are Uniquely Vulnerable to the Coronavirus." There surely are characteristics of psychiatric patients and inpatient settings that pose unique challenges to efforts to contain the contagion of COVID-19. These have been covered previously in Psychiatric News. Gessen, in contrast, presents a drama of the crusading psychiatrist—usually the medical director—fighting the penurious administrators in a futile, Don Quixote–like struggle.Gessen wrote that she spoke to psychiatrists working on inpatient units in for-profit, nonprofit, and state hospitals, and they uniformly reported they were lacking testing, personal protective equipment (PPE), and seclusion protocols while having conflicts with hospital administrators. She named a few hospitals, including Western State Hospital in Washington, which had at least 27 staff and six patients who had tested positive for COVID-19 and one death in mid-April. She warned these numbers were low because testing was extremely limited. She mentioned Greystone Park Psychiatric Hospital in New Jersey, where 33 patients (10% of the inpatients) and 42 employees had tested positive, and four patients had died. She described one hospital that had revised patients' schedules to achieve social distancing, but this left patients with long hours with nothing to do except stay in nearly empty bedrooms where patients have no televisions, telephones, cell phones, tablets, or computers; some MP3 players were provided by the hospital, but there were not enough for every patient. A large state hospital with one staff death and nine patient deaths had to send patients to a nearby general hospital for testing. She was critical that some psychiatrists were improvising ways to deal with COVID-19 as they went along, as if they had other choices.After reading the article, I wondered whether it was really this bad everywhere. On a couple of psychiatry listservs that I'm on, I mentioned the New Yorker article and asked if anyone had a different story. These are the responses I received the first day:In a New England state, a university hospital unit had 14 of its 20 psychiatric beds filled but had no COVID-19 cases. The one state hospital had 165 of 180 beds filled and no COVID-19 patients, but the state hospital did have a COVID-19 unit set up and ready to go. PPE was no issue at the university hospital; it had been a major issue at the state hospital early on, but that was not the case by mid-April. In a Pennsylvania hospital with 64 of its 89 psychiatric beds filled, the hospital had converted rooms with two beds for adults into single rooms and one- and two-bed rooms for children. The hospital had no COVID-19 positive cases and no difficulties with PPE supplies. In Wisconsin, a 60-bed psychiatric hospital had three to five COVID-19 cases at any given time with no deaths. The hospital had all the PPE it needed. In the Central Plains states, there were two psychiatric hospitals of 200 and 250 beds and one 16-bed psychiatric unit that provided data, and none had had a COVID-19 positive case. At one of these hospitals, staff had procured their own masks and gowns. In California, at one hospital with psychiatric units' census totaling 48 beds, there had been no COVID-19 cases and no problems obtaining PPE.After barraging the reader with calamitous examples of failures in dealing with COVID-19, Gessen made some important points: (1) it is not a good idea for general hospital psychiatric units to push patients into state hospitals, causing them in turn to move patients to transitional facilities, which then prematurely discharge individuals to residential settings where they are at risk for coronavirus infection; (2) sending patients into communities at a "terrifying time" should be done with more caution than under more typical circumstances; and (3) running hospitals as if they are businesses sets up doctors to battle against hospital bureaucracies where the only potential winners are "the ones looking at this from a long-term financial-sustainability standpoint." These points would have been better made had Gessen described a more balanced, nuanced backdrop.Massachusetts, where I work, did not make the mistakes Gessen highlighted. A case in point: I have been spending about 40 to 45 hours a week at Worcester Recovery Center and Hospital (WRCH) throughout the pandemic. In mid-April there were 245 patients at WRCH (capacity 290) when all patients were tested for COVID-19. The results were a positive rate of less than 2%. That same week, the 114 residents at the Worcester Homeless Shelter were tested, and the positive rate there was 43%. During the first two weeks of May, all WRCH employees not previously tested were tested, and 1.5% were positive for COVID-19. Including all employees tested since March 30, the positive rate was 2.7% of about 1,100 employees tested. By the end of May, 16 of the 30 staff who had tested positive were back at work. There were no COVID-19–related deaths among patients or staff. These results were obtained by employing all manner of emergency protocols and procedures (see Psychiatric News, for details).Unlike the hospitals about which Gessen wrote, when WRCH patients spend time alone in their single bedrooms, they may have—and almost every patient has some of these—a cell phone, iPad, iPod, laptop, MP3 player, wireless headphones, television set, and other electronics. The Rehabilitation Department has continued to provide ongoing services and modify the parameters week to week depending on CDC, state public health, and other recommendations. Clinical meetings were a mix of staff in the room and staff joining by remote access such that the staff in the room could stay six or more feet apart. All staff and patients must wear masks. There are "huddles" that include administrators and clinicians, just administrators, and just members of single disciplines going on all day. These meetings are almost entirely remote.Fundamental to achieving a safe environment for patients and staff at WRCH has been both a high degree of shared sense of purpose and very frequent and effective communication between hospital administration and clinical staff, as well as strong support from the commissioner of mental health and her staff and the secretary of Health and Human Services and her staff.Due mainly to discomfort that gets twisted into prejudice and discrimination, psychiatric inpatient settings have long been the subject of parody, hyperbole, derision, and vilification. In his 1958 APA presidential speech, Harry Solomon remarked, "The large mental hospital is antiquated, outmoded, and rapidly becoming obsolete. … I do not see how any reasonably objective view of our mental hospitals today can fail to conclude they are bankrupt beyond remedy." Just over a century earlier, U.S. President Franklin Pierce, in perhaps the most poetic description of a state hospital ever, portrayed state hospitals as, "munificent establishments of local beneficence." There is no psychiatric hospital today that is either of these. And, no doubt, each patient's experience in a psychiatric hospital is unique.There's no good time to disparage psychiatric hospitals as a class, but the middle of the COVID-19 pandemic is a particularly bad time to do so. It is extremely irresponsible to discourage people who need inpatient psychiatric care to not get it. Some people won't go, and they will die because they didn't. ■ ISSUES NewArchived

Background: Uniform has traditionally been worn in psychiatric inpatient and other mental health settings, but there has been a move to non-uniform in recent years. Some services have made the change back to uniform, raising questions about the potential impact on patients and staff.<br/>Aim: To review the impact of uniform within a psychiatric inpatient or mental health setting.<br/>Method: Databases were searched for articles exploring the impact of uniform use using specified search terms. Articles were assessed for suitability with inclusion and exclusion criteria, critically appraised, then analysed for themes using thematic analysis.<br/>Results: 17 papers were included in the review. Thematic analysis identified five main themes and 29 subthemes. Main themes were Attitudes and interactions, A freer environment, Are you both nurses?, The 'ideal self' and There are more important things. A critical appraisal of the articles suggested issues with validity and reliability, which are discussed.<br/>Discussion: Studies identified that wearing non-uniform facilitated positive changes in both patients and staff. This raises the potential negative impact of uniform on both patients and staff, and the role of power imbalance in these settings is discussed. Further themes around identification of staff out of uniform were considered.<br/>Implications for practice: The use of uniform in mental health and psychiatric inpatient settings should be considered carefully, due to the potential negative impact, whilst also recognising the importance of staff identification and supporting professional identity.

Seclusion and restraint continue to be used across psychiatric inpatient and emergency settings, despite calls for elimination and demonstrated efficacy of reduction initiatives. This study investigated nurses’ perceptions regarding reducing and eliminating the use of these containment methods with psychiatric consumers. Nurses (n = 512) across Australia completed an online survey examining their views on the possibility of elimination of seclusion, physical restraint, and mechanical restraint as well as perceptions of these practices and factors influencing their use. Nurses reported working in units where physical restraint, seclusion, and, to a lesser extent, mechanical restraint were used. These were viewed as necessary last resort methods to maintain staff and consumer safety, and nurses tended to disagree that containment methods could be eliminated from practice. Seclusion was considered significantly more favourably than mechanical restraint with the elimination of mechanical restraint seen as more of a possibility than seclusion or physical restraint. Respondents accepted that use of these methods was deleterious to relationships with consumers. They also felt that containment use was a function of a lack of resources. Factors perceived to reduce the likelihood of seclusion/restraint included empathy and rapport between staff and consumers and utilizing trauma‐informed care principles. Nurses were faced with threatening situations and felt only moderately safe at work, but believed they were able to use their clinical skills to maintain safety. The study suggests that initiatives at multiple levels are needed to help nurses to maintain safety and move towards realizing directives to reduce and, where possible, eliminate restraint use.

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated $140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

Telemedicine and eConsults for Hospitalized Patients During COVID-19

A depressed patient with a left ventricular assist device (LVAD) due to heart failure presented a unique challenge for staff in an inpatient psychiatric facility. Although depression in this patient population has been recognized and treated on an outpatient basis, the example described in this article may be the first known case to be treated in an acute inpatient psychiatric hospital setting. A variety of steps had to be taken to ensure the highest standards of care, as well as an optimal outcome for this patient. In addition to the individualized plan of care for depression, a more medically oriented and technologically advanced plan of care was also instituted. The inpatient psychiatric setting provides the necessary care and treatment to help the patient move beyond severe depression to engage in activities essential for health and the proper care and function of the LVAD. This article highlights an unusual psychiatric-mental health nursing situation to help others who may face this challenge in the future.

Adaptations are frequently made by hospital administrators, clinicians, and other staff to accommodate for the changing populations of state psychiatric hospitals in the United States. For example, many mental health treatments, including evidence-based treatments, have been adapted for use with forensic patients and in forensic settings. Specialized ethical guidance has also been developed for working with forensic patients. However, there is a gap in the literature regarding the logistics of safely conducting therapeutic interventions and assessments in environments that were not designed for forensic populations, or individuals with intellectual and developmental disabilities as primary diagnoses. Further, most training programs for mental health clinicians do not include specialized training for working in inpatient psychiatric settings, including state psychiatric hospitals, and so it often falls to training sites to provide that foundational knowledge. The current manuscript describes the context and practical challenges mental health clinicians across disciplines may face in providing services to clients in inpatient settings. Recommendations for maximizing safety of all persons, while simultaneously attempting to protect the privacy of the patient in the course of clinical interventions, and maintain the integrity of clinical interventions administered in inpatient settings, are also discussed. Recommendations are based on a review of the literature and the professional experiences of the interdisciplinary research team in several state hospitals across the United States. The target audience of this manuscript includes clinicians and trainees who are new to working in inpatient psychiatric settings, and seasoned clinicians adjusting to the changing demographics of state psychiatric hospitals.

Undocumented Patients and Rehabilitation Services

Acute myocardial infarction (AMI) is a catastrophic manifestation of coronary artery disease that strikes more than 900 000 Americans each year. One fourth of afflicted patients die, and many survivors develop impaired functional status, anginal symptoms, and diminished quality of life. Fortunately, an explosion in scientific discovery and clinical research has created great potential for treating patients, and concurrent with these advances, there has been a marked decrease in AMI mortality.1 Yet the full benefit of scientific progress is often unrealized by patients because of the gap between knowledge and its application to clinical care. To address this gap, the AMI Working Group of the first American Heart Association (AHA)/American College of Cardiology (ACC) Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke brought together national leaders and committed practitioners to share knowledge and insights on measuring and improving the quality of AMI care (see Acknowledgments for Working Group members). This group sought to create a comprehensive framework for quantifying the components of AMI care and to summarize current methodological considerations in quality assessment/improvement while formulating a research agenda to address unmet needs in the field. The present report supplements the overall insights gained from the conference2 with data specifically relevant to the quantification of care for AMI patients. Although new evidence may alter the relevance of specific measures, it is hoped that the principles described in this report will assist local and national organizations in their efforts to improve the quality of care for patients with AMI. As a means of conceptualizing the components of quality assessment, the Working Group on AMI embraced the approach of Donabedian,3 which considers 3 domains of quality: structure, process, and outcome. Structure refers to those aspects of care that exist independently of the patient. Examples …

Background: The Health of the Nation Outcome Scales (HoNOS) were developed to assess the severity of a mental illness. They are used as outcome measures in different countries, and are meanwhile translated from the original English version into many languages, among others into German (HoNOS-D). We conducted a study in order to estimate the concurrent validity and sensitivity to change using clinical parameters as ICD-10 diagnoses, as well as the Clinical Global Impression Scale (CGI), and the Association for Methodology and Documentation in Psychiatry (AMDP) psychopathology scale, a frequently used psychopathological rating system, in a representative clinical sample. Sampling and Methods: Data on the three instruments (CGI, AMDP, HoNOS-D) were collected at admission and discharge of 100 psychiatric inpatients using a representative clinical sample. Experienced clinicians completed the CGI, AMDP and HoNOS-D. Descriptive and comparative data analyses were performed. We estimated the concurrent validity by calculating correlations between the HoNOS and other scales. Secondly, we examined the differences between HoNOS scores related to diagnoses and demographic parameters. Thirdly we calculated change criteria and outcome effect size for the HoNOS. Results: Even in a small clinical sample (n = 100), the HoNOS-D items are highly correlated with the corresponding AMDP syndromes (p < 0.003). The HoNOS-D score is associated with the CGI score (p < 0.01). Correlations of HoNOS symptoms, behavior and impairment items with AMDP syndromes as well as differences in diagnoses were appropriate and comprehensible as regards clinical content, and change on the HoNOS total score is statistically significant (t = 6.57, d.f. = 89, p < 0.0001). Conclusion: This study is the first to investigate the concurrent validity of HoNOS-D concerning psychopathology using the AMDP rating system in a clinical sample of patients with mental disorders in an inpatient setting. HoNOS-D can be recommended for routinely screening outcomes in inpatient psychiatric settings. Our analysis showed that HoNOS-D covers psychopathology corresponding to the AMDP rating system. A limitation of the study is that the study sample comprised only an inpatient population; there may well be differences compared to an outpatient sample.

The prevalence of diabetes mellitus and abnormal glucose metabolism in the inpatient psychiatric setting: A systematic review and meta-analysis.

BackgroundTobacco-related diseases are a leading cause of death among individuals with severe mental illness (SMI), yet interventions to address tobacco cessation are rare in inpatient settings where persons with SMI are hospitalized. While cigarette smoking rates have declined in the general population, they remain high in persons with SMI. Inpatient settings would be a prime location to intervene on tobacco consumption among persons with SMI. The objective of this review was to examine evidence of smoking cessation interventions in psychiatric inpatient facilities. MethodUsing narrative overview guidelines, we searched PubMed, PsycINFO, and CINAHL for smoking cessation RCT studies published between 1950 and 2018. Studies included had to have at least started in inpatient psychiatry settings. Examples of search terms included: smoking cessation in inpatient psychiatry, smoking cessation in inpatient mental health treatment facilities, and smoking cessation and mental health. ResultsFollowing the inclusion criteria, eight RCT studies were reviewed. One study was among adolescent psychiatric inpatient smokers ages 13–17, and 7 were among adult psychiatric inpatients with mean age 41 years. Treatment periods lasting 8 to 12 weeks started in inpatient settings and continued post discharge. A combination of behavioral and pharmacological interventions were used. Pharmacological interventions were nicotine replacement therapies, and at least one study used varenicline. At baseline, participants smoked an average of 18.1 cigarettes per day. ConclusionSmoking cessation in inpatient psychiatry settings is rare or delayed. There is a need for more tailored treatments among this population to help them quit smoking.

INTRODUCTION: Access to culturally sensitive care is critical for addressing known mental health disparities among trans-and gender-non-conforming (TGNC) individuals. Although there has been a proliferation of TGNC healthcare guidelines from accrediting bodies, policies have failed to address the needs of TGNC patients in inpatient psychiatric settings. To identify unaddressed needs in policies and policy recommendations for the care of TGNC patients to inform recommendations for change. A scoping review protocol was developed following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 850 articles were reduced to seven relevant articles with six themes identified via thematic analysis. Six themes were identified: lack of consistency in preferred and pronoun use, lack of communication among providers, lack of training in TGNC healthcare, personal bias, lack of formal policies, and housing segregation by sex rather than gender. The creation of new guidelines or bolstering of existing guidelines to specifically address identified themes and gaps may improve the well-being and treatment outcomes of TGNC individuals in inpatient psychiatric settings. To provide a foundation for future studies to integrate these identified gaps and inform the future development of comprehensive formal policies that generalize TGNC care in inpatient settings.