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 Table of Contents  
INVITED PERSPECTIVE
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 154-161

Organizing inpatient services in a general hospital in times of COVID-19


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Submission01-Aug-2020
Date of Acceptance01-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Prof. Mamta Sood
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_247_20

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  Abstract 


COVID-19 is an unprecedented event and has affected patients with psychiatric disorders in multiple ways. Patients in inpatient settings are at high risk of exposure of getting COVID-19 infection. We reviewed the literature on the inpatient psychiatric facilities and measures regarding how to address COVID-19 in these settings. We then provide an experiential narrative of the strategies and improvisations to meet the challenges of COVID-19 so as to continue the inpatient services at a large public funded medical school and hospital in North India. Literature suggested that it is important to restrict hospitalization, expedite discharges, prohibit visit of the attendants, minimize group activities, provide psychological assistance, multidisciplinary teams to provide care, to tackle issue of stigma, have adequate means for practicing preventive measures, creating facility for isolation and have clear guidelines for diagnostic testing. The psychiatry ward in our hospital was designated non-COVID ward and substantial beds were reserved for surgical trauma patients. For organizing inpatient services, we created a multidisciplinary team. Some of the measures were institute-mandated, while others were intra-departmental measures to protect staff as well as patients in the psychiatry ward. It can be concluded that COVID-19 pandemic is still an evolving situation. The measures to prevent exposure to COVID-19 infection in the inpatient facilities continues to evolve as and when fresh challenges emerge.

Keywords: COVID-19, India, inpatient services, psychiatry


How to cite this article:
Sood M, Patra BN, Deep R, Kalyansundaram L, Dua S, Vijay S. Organizing inpatient services in a general hospital in times of COVID-19. Indian J Soc Psychiatry 2020;36, Suppl S1:154-61

How to cite this URL:
Sood M, Patra BN, Deep R, Kalyansundaram L, Dua S, Vijay S. Organizing inpatient services in a general hospital in times of COVID-19. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 26];36, Suppl S1:154-61. Available from: https://www.indjsp.org/text.asp?2020/36/5/154/297146




  Introduction Top


”I have no idea what's awaiting me, or what will happen when this all ends. For the moment, I know this: There are sick people and they need curing.”

-Albert Camus, the Plague.

A new coronavirus originated in Wuhan China in December 2019 that caused coronavirus disease, also known as COVID-19. The World Health Organization (WHO) declared the COVID-19 outbreak a pandemic on March 11, 2020.[1] It is an unprecedented event that caught the world unaware and was described as an event that the last three generations had not witnessed since the Spanish Flu of 1918. A high contagion capacity that has resulted in its widespread, high R0, limited clarity on clinical features, pathophysiology and therapeutic measures, lack of vaccine, and large number of asymptomatic carriers in the community make this pandemic a force to reckon with. It has resulted in a large number of deaths across nations and continents. Availability of high-speed internet services though smart phones and other devices, widespread use of platforms such as Facebook, WhatsApp, and Instagram and intense media coverage has resulted in rapid spread of information. As the number of cases increase in a region or a country, health-care systems start to get overwhelmed. This is compounded by risk of high rates of infection in front line health-care workers due to its highly contagious nature. Health-care workers and the population at large have many psychological symptoms such as depression, anxiety, and stress;[2],[3] these are increased by the stigma attached to the diagnosis. Due to lack of definitive treatment, preventive measures such as regular hand washing, respiratory etiquettes, social distancing, wearing of mask, and self-isolation are important for controlling its spread. On June 6, 2020, as per the World Health Organization website, the number of confirmed cases were 6, 644, 011 with 391, 839 deaths [1] and in India, the total number of cases were 236, 657 with 6642 deaths.[4] Nationwide lockdown was started on March 24, 2020, which has been extended in phases at different regions in the country.

COVID-19 may affect persons with psychiatric illness in multiple ways. Psychological problems such as anxiety, depression, and stress caused by the pandemic may result in worsening or relapse of their psychiatric condition. Many patients and their caregivers travel long distances for follow-up care and medicines. Due to travel restrictions and non-availability of transport due to various degrees of lockdown, their follow-up care may get disrupted and they may not be able to get free medications available at certain public hospitals. Due to nonrenewal of prescription slips, they may not be able to replenish their medication stock even if they can afford to buy them. A high prevalence of physical comorbidities in these patients may complicate the management and prognosis of the infection.[5] Due to lack of insight and lack of awareness about risk of infection, poor personal care and functioning, negative and cognitive symptoms, the persons with psychiatric illness may not be able to adhere to preventive actions. The patients admitted to psychiatric facilities are at high risk of exposure due to multiple reasons. They may not be able to give an accurate account and chronology of symptoms. They may not be able to carry out preventive measures. In some of the psychiatric inpatient facilities, patients and staff may stay at close quarters due to limited space and resources. Usually, many group activities are also carried out in these facilities. There may be frequent turnover of the patients.

In India, the persons with psychiatric illnesses may seek treatment from psychiatric services in general hospitals, stand-alone psychiatric hospitals, psychiatric nursing homes, polyclinics, and office-based practices. Psychiatric services in general hospitals are major source of treatment seeking behavior. In addition, all medical schools have a psychiatry department and an inpatient facility. The patients requiring admission are admitted along with a family member to the inpatient services and are provided with comprehensive care, food, essential medicines, beds, bed linens, and basic recreation facilities.[6] There are many advantages of availing psychiatric services from general hospitals such as less stigma and involvement of family members. In the times of COVID-19 pandemic, availability of other specialists for care of physical ailments in the same premises and integration of emergency psychiatric services with hospital emergency services is of great help. However, amidst the pandemic situation, some of the aspects enhance the vulnerabilities for getting infection like space and manpower constraints, physical proximity to medical wards and casualty, frequent rotations of support staff and doctors across the various zones of hospital.

As per the National Mental Health Survey (2016),[7] the life time prevalence of any mental disorder in India is 13.7%, with a huge treatment gap of 70%–92%. Those were non-COVID times. Now in the time of COVID-19 when most of the health resources have been diverted to dealing with its management, meager resources available for marginalized populations such as persons with mental illness should be used judiciously.

This paper has been divided into two parts. In the first part, the literature is reviewed on the inpatient psychiatric facilities and the measures as to how to address the risk of COVID-19 in these settings. The second part is an experiential narrative of the authors in organizing and updating inpatient services in a large public funded medical institution and tertiary care hospital in North India.


  Review of Literature Top


Methodology

We searched for published literature in English available in PubMed, Elsevier resource link on novel corona virus and Google scholar. We looked for articles in English, irrespective of the type of the article (included reviews, mini reviews, research article, correspondence, commentary, and short communication). We searched with the key words: COVID-19 OR CORONA VIRUS OR 2019 nCOV or SARS Cov2 AND Psychiatric hospital OR Psychiatric inpatient OR mental hospital OR psychiatric units OR Psychological OR psychosocial OR India OR low- and middle-income countries (LAMICs), in different combinations. Cross references of the articles on corona virus in psychiatric inpatients were also searched. We selected articles published till the 3rd week of May 2020. We also searched Google for any information on psychiatric illness and COVID-19. Two authors (M. S., B. P.) independently searched, short listed, and extracted data. When newer data become available, information shared in this review will need to be updated.

COVID-19 and psychiatric inpatients

COVID-19 is significantly more infectious and pathogenic than seasonal flu, with an estimated case fatality rate of 0.5%–3% and approximately 5% of diagnosed patients requiring critical care. Disease severity is associated with advanced age and comorbidities.[8] With such a huge number of cases and deaths, the corona virus pandemic is expected to exert a high amount of pressure to the already strained health-care systems across the world and more severely in LAMIC like India.

Patients with serious mental illness, due to their unhealthy lifestyle and underlying medical illnesses, are more vulnerable to develop severe COVID-19 infection. Lack of proper living arrangement can raise the risk of infection and make it difficult to identify, follow-up, and treat those who are infected. Poor social support may limit opportunities to obtain help from friends and family members if individuals with serious mental illness catch the infection. Patients who are having impaired judgment will not be able to practice the appropriate preventive measures, for example, wearing a mask, practicing hand hygiene, and maintaining social distance which are of utmost important to avoid the corona virus infection, especially in the absence of any vaccine and treatment for this infection. Taken together, these factors may lead to elevated infection rates and worse prognoses in the patients with mental illness.[9] In a general hospital, patients with medical illnesses, including patients with COVID-19 are also treated, which could potentially enhance the risk of exposure in these general hospital based psychiatric inpatient units.

During the pandemics, the major focus of the authorities remains around reporting on the disease related mortality rather than focusing on the mental health aspects. Furthermore, in some cases due to scarcity of hospital beds for COVID-19, the psychiatric beds are likely to be used for COVID-19 patients. For example, in Madrid, the number of psychiatric beds has been reduced by over 60%. The most large university hospitals do not have inpatient psychiatric units anymore, as almost all beds have been freed up for COVID-19 patients. Day hospitals, rehabilitation units, and vocational units for psychiatric patients have all been closed.[10] Due to increased number of patients with COVID-19, staff from psychiatric units are likely to work for the medicine/infectious diseases (IDs) department. In addition, a greater number of mental health professionals are engaged in providing psychosocial support to the frontline workers which can cause a shortage of workforce. Hence, an increased risk of infection to psychiatric patients coupled with reduced workforce can further complicate the situation. Some psychiatric hospitals also tend to refuse receiving new inpatients because of their poor medical conditions, which possibly can deteriorate their co-existing psychotic symptoms.[10]

Reports of corona virus infection of psychiatric patients started coming in February 2020. At the end of 1st week of February 2020, the China News Weekly reported that at least 50 inpatients with psychiatric disorders and 30 mental health professionals in a major psychiatric hospital in Wuhan, China, were diagnosed with the COVID-19.[2] The National Health Commission of China on February 18, 2020, reported that 323 patients with severe psychiatric disorders were diagnosed with COVID-19. The lack of clear information about COVID-19 outbreak in January 2020 and insufficient supplies of protective gear were the possible reasons. Moreover, patients in psychiatric hospitals often live in crowded conditions. They also participate in group activities which may increase patient-to-patient contact. Further, unhealthy lifestyle, side effects of psychotropic medications and poor physical health make them susceptible to COVID-19 and its complications. The lack of adequate training of the psychiatrists in the prevention and treatment of IDs could also have contributed to infection.[2] A COVID-19 outbreak in a South Korean inpatient psychiatric unit also infected 100 of its 102 patients and resulted in seven deaths; at the time accounting for nearly half the COVID-19-related deaths in the country. Factors identified as having contributed to this outbreak were the lack of ventilation due to windows having been sealed shut to prevent suicides, and restrictions on the use of hand sanitizer due to fears that some patients would drink it.[11]

Review of measures to address COVID-19 in psychiatric inpatient settings

To address the above-mentioned issues, some proactive measures have been suggested:

It is important to restrict hospitalization, expedite discharges, prohibit visits of the attendants, and provide psychological assistance. It has been suggested that an observation room outside the routine ward should be set up for isolation and observation for 14 days before formal hospitalization. Some even suggested to test all individuals for COVID-19 before entry into treatment facilities. Due to higher risk of transmission of infection, complete isolation of mental health centers has been recommended during the COVID-19 epidemic. Before admission, the symptoms suggestive of COVID-19 infection, travel history to (and from) high risk area must be enquired. Medical, nursing, logistics support, and canteen staff should limit their approaches to the hospital and have their temperature taken before entering and leaving the ward on a regular basis.[12]

The current policy and regulation issued by the government should highlight the needs of psychiatric patients and their families to provide mental health services. The provision for communication between psychiatric inpatients and their families should be considered by hospitals. The teams responsible for patient's psychological support and treatment should include not only psychiatrists and psychologists but also psychiatric nurses, social workers (psychiatric and medical), volunteers, and family members.[13]

The patients with mental illness should be supported by providing them accurate information about measures to reduce corona virus infection and when to seek medical help for the same. The educational material developed for general population should be tailored so that it is understandable and acceptable by the patients with mental illness. The risk of having dual stigma associated with infections and their mental health conditions should be kept in mind. Empowerment of mental health professionals and strengthening the mental health-care system are important. Mental health clinicians need to be trained to recognize the signs and symptoms of corona virus infection and develop knowledge about basic strategies to reduce the spread of disease. They also need support to maintain their own safety and well-being. In view of a smaller number of psychiatric facilities in LAMIC, plans should be developed for continuing operations particularly at the time of staff illness. Standard operating procedures should be developed to identify and refer high risk patients and self-quarantine strategies for clinicians who develop symptoms of the illness. Adequate environmental protection including well-ventilated spaces, easy access to hand washing, and personal protective equipment (PPE) should be available. The mental health policies in the coming days should also be geared toward the welfare of the psychiatric patients.[9]

Other important measures like advocacy, mobilizing fund for research in this area, supporting own colleagues and the system have also been highlighted.[8] Strategies implemented at the Centre for Addiction and Mental Health in Toronto, Canada, modeled after a system developed during the 2003 SARS outbreak, involve designating different units to segregate patients with suspected infection, diagnosed infection, or absence of infection, and assignment to every inpatient psychiatrist of backup outpatient psychiatrists prepared to seamlessly assume care in the event that an inpatient psychiatrist becomes unable to work.[11]

A hospital from Italy reported that they had divided the hospital into COVID and non-COVID areas. The psychiatry ward is allocated to the non-COVID area and if any patient comes positive, he/she would be transferred to the COVID area and the patient would be managed by the consultation liaison psychiatry team. One seclusion room was designated in the COVID area and in the non-COVID psychiatric units for the violent patients.[14] Because some patients with COVID-19 can be contagious yet asymptomatic, especially in the initial days after infection, knowing who is infected requires timely diagnostic testing as well as when and how a patient was exposed and when symptoms began. This could be challenging in individuals with psychiatric disorders as some are unable to recall or are unaware of potential exposures and symptom onset.[15]

The group therapy sessions in the psychiatric unit should be changed. As the group therapy requires close contact, decisions to facilitate changes in group treatment may be needed, including limiting the number of individuals participating in a group and ensuring that physical distancing among individuals occurs. In addition, older patients with multiple medical comorbidities may be a “at risk” in group settings and need to discontinue and minimize group therapy during a pandemic [16]. A core leadership task force can be developed to address immediate operational concerns. This Task Force should include representation by clinical leaders in psychiatry, social work, clinical psychologists, and nursing, at minimum. The aim of a small core group would be to initiate and coordinate ongoing response efforts and to minimize sharing of misinformation. Furthermore, additional smaller workgroups can be created to work on staffing, COVID-19 precautions, operational issues, and other important contingency planning efforts.[16]

To restrict inpatient hospitalization, mental health home hospitalization care has been proposed as a substitute of inpatient hospitalization. This novel home-based approach has two main modalities: Home intensive community teams for mild to moderately ill patients and home hospitalization teams for moderate to severely mental illness cases. Both seem promising and of clinical relevance during the COVID-19 pandemic. This approach has demonstrated their usefulness in reducing hospital psychiatric admissions for adult patients with moderate and severe mental illnesses, as well as in decreasing the risk for conventional psychiatric hospitalization of adolescents experiencing a psychiatric crisis.[17] The home care is also important for people with intellectual disabilities and/or autism and patients with severe mental disorders and poor functionality who live with older caregivers.[18]


  Narrative Experience of Updating Inpatient Services at Our Hospital Top


At All India Institute of Medical Sciences, New Delhi, psychiatry department is one of 42 departments. We have a 30 bedded inpatient ward facility with two beds for child psychiatric patients. This is located in the main building on first floor with dermatology ward as our neighbor. Immediately above is medicine ward and on the ground floor, is the main emergency of the hospital. The psychiatry ward is an open ward with a day care facility. The beds are laid out in “rig pattern,” with bedside trolley and a small bed for the family member which slides under the patient's bed in daytime. There are two cubicles with bed capacity of 6 each and two isolation rooms with attached bathrooms. One of the isolation rooms was not available as it was under repair that was halted because of lockdown. There is gender-wise separation of wash rooms; three for each sex. In the middle of the ward is the nursing counter and the room. As per the Mental Health Care Act 2017, most of the admissions in the ward are independent admissions. Although every year, more than 80-85 thousand patients are seen in the outpatient services, only about 300 patients are admitted to the psychiatry ward for either management difficulties or sometimes for diagnostic clarification. Admission is usually done with a family member as a hospital policy. In the ward, there are faculty, resident doctors, nursing staff, an occupational therapist, orderlies, cleaning personnel, and guards. For the management of physical comorbidities, referrals are made to the specialists in the concerned department who examine, advise investigations, and management. The management is usually carried out in the psychiatry ward itself. If there is any need, the patients are temporarily shifted to the relevant ward and managed there. The planning to prepare the psychiatric in-patient unit in the face of COVID-19 pandemic began in March itself. Some of the measures were institute-mandated, while others were intradepartmental measures to protect staff as well as patients in the psychiatry ward. A team was built within the department, inclusive of a nodal officer, with an aim to brainstorm for specific measures for the ward and implement these and to modify them, if necessary, for use in psychiatry ward. All authors in this write-up also serve as members of this COVID-19 preparedness team, and represent various cadres of health care professionals (psychiatrists, senior nursing personnel, and occupational therapist). Two senior residents (post-MD) were also included for the ward-related activities, with a scope to add new members kept open, as and when required. The team contributed regularly to awareness generation among ward staff, provision of informative display material in ward, ensuring indent and supplies for personal protection equipment and setting up various processes and procedures for the safety of patients and staff. The group met in-person, as required and also maintained a WhatsApp group for coordination and periodic updates.

Following is the narrative account of the various aspects, along with the trials and tribulations, of COVID-19 preparedness in the psychiatry ward. At the outset, it is acknowledged that in view of COVID-19 pandemic being an unprecedented and still an evolving situation, the learning curve also continues to evolve and may not have peaked yet.

Initial actions

Although in February and half of March, the news was pouring in the media about COVID-19 from some of the countries and sporadic cases in India, this had no impact on our services. However, in the second half of March, preparations to deal with the pandemic at our Institute started and in sync with nationwide complete lockdown on March 24, 2020, the outpatient services were stopped. At the Institute level, one of the large 260 bedded centers was designated as COVID hospital and a number of task forces and committees were constituted to handle the impending crisis.

  • Psychiatry ward was designated as non-COVID ward
  • As early as March 17, 2020, the first two beds of each general ward, including psychiatry, were earmarked for use by the hospital in preparation toward the pandemic. On March 31, 2020, 22 beds of psychiatry ward were reserved for surgical trauma patients, since trauma center was being prepared as COVID-19 facility
  • Twenty-five percent of the faculty and the residents of the psychiatry department were posted for duty in COVID areas
  • The group activities conducted in the day care were suspended immediately as there was not enough space to ensure safe distance between patients
  • Discharges of in-patients who were stable and could be managed at home, were expedited. It also facilitated their timely travel back to their homes and native places especially for the outstation patients
  • The routine admissions to psychiatric unit were temporarily stopped
  • The telepsychiatry services were started by the department and any patient requiring emergency help was asked to visit hospital casualty for further evaluation.


Psychiatric emergencies

These were attended to in the hospital casualty services and if required, admissions to psychiatry ward were also through it. There were many inherent challenges.

  • The patients in casualty spend several hours to a day amidst other medically ill patients, often in a crowded environment. There was danger of exposure to our on-call residents. For consultation in emergency services, the hospital directives were that first telephonic consultations with the help of emergency doctor could be done. If at all, the patient needed in person examination, it was to be done in full PPE kit provided in emergency with donning and doffing to be done there only
  • Patients with certain psychiatric emergencies (e.g., those with acute-onset psychosis or manic episode) are often potentially vulnerable to acquire infection and may not adhere to basic preventive measures such as hand hygiene, mask or distancing in the days prior to consultation due to impaired personal judgment and absence of insight. Some may even be overactive or over familiar to others in community, dismissing any risk to self. The patient may not be able to give reliable information pertaining to COVID-19 symptoms
  • Some patients were brought to emergency by distant acquaintances or police personnel with their family or caregivers living in another state, with no travel possible during the lockdown. This led to clinical, psychosocial, and medicolegal issues in emergency situations
  • Getting a reception order for unattended patients with psychiatric illnesses/homeless mentally ill persons who are brought to emergency can be a task in itself, since the majority of police workforce was diverted to COVID-19 duties. These problems were handled in liaison with the duty officer, usually a senior resident of hospital administration department who coordinated the conversations between various departments
  • In addition, the residents on call were apprised of the reported association of new onset psychiatric symptoms, altered sensorium or deranged higher mental functions and COVID-19.[19],[20] In these cases, consultation from ID team and if need be, neurologist was to be sought in the casualty itself.


Psychiatry ward

In the first week itself, a patient presented to emergency who needed to be admitted to the ward. Being an open ward with no separate cubicles and shared washrooms and spaces, it was difficult to isolate the patient and his/her attendant. Chances of his/her being asymptomatic carrier could also not be ruled out. However, routine testing for all new admissions was not advised at the institute level.

This admission started a chain of a few actions:

  • A symptom checklist of COVID-19 was made. It was applied at the time of admission and on a daily basis by the resident in charge for both patients and attendants. This was documented in the clinical file and nursing notes
  • There was a need to devise some kind of “isolation” for new admissions from casualty in anticipation of an incidentally detected COVID-19 suspect patient/symptomatic patient. It was decided to reserve one isolation room with attached bathroom and one cubicle of general ward for new admissions for the first 5 days, to observe and monitor them
  • All potential emergency admissions would be mandatorily discussed with consultant/faculty member to decide on the critical need of admission
  • Admissions of follow-up patients must be facilitated by psychiatrist-on-call in a manner which circumvents waiting time in casualty
  • It was advised to clean all ward surfaces, which could serve as potential sources of infection, frequently using 1% sodium hypochlorite, every 4–6 hourly depending on whether surface is high-touch (e.g., door knobs) or low-touch surface (e.g., walls). A register was also maintained as a record for cleaning at regular intervals
  • Family members/attendants of patients were advised to keep their visits outside the ward to minimum and were encouraged not to go outside repeatedly without a justifiable reason.


At institute level, the policies were modified with incoming of information as well as the need on ground. In the psychiatry ward, we also incorporated these suggestions:

  • Prior to every new admission, place of residence was checked for its current status of containment zone. These zones were based on the risk profiling of the areas. Green zones were those where there were zero confirmed cases in the past 21 days. Red zone (hotspots) was defined by total number of active cases, doubling rate of confirmed cases, extent of testing and surveillance feedback. The areas which were neither in the red nor in the green zone were classified as orange zones.[21] If the patient/attendant was from red zone, the hospital ID team was consulted and need for testing addressed as per clinical discretion/policies was decided. Usually, such cases were carefully observed/monitored and not tested if asymptomatic, as per prevailing policy
  • If any admitted patient was found to be symptomatic at any given time, referral to ID team for sampling and further action was done. The isolation was ensured
  • Separate space was needed for donning and doffing of the PPE. To begin with, no suitable, non-clinical space could be found for use as doffing room. The nursing sister-in-charge of the ward had the much-needed idea to have a pantry under repair cleaned out, washed and prepared to be used as doffing room
  • All the persons in the ward, doctors, nurses, support staff, admitted patients, and their family members and visitors were instructed to wear a mask at all times in the ward and were instructed to practice social distancing and hand hygiene
  • All staff reporting on duty was also asked for new onset symptoms from symptom checklist, and was advised to refrain from coming to ward in case they experience any symptoms.


In the last few weeks, further actions have been taken:

  • A list of all staff and personnel working at ward, including their names/telephones/residence was made available with nodal officer for coordination and contact tracing, in the event any staff at psychiatry ward is confirmed to be COVID-positive
  • Staff on relieving/rotating duty across various wards of the hospital were screened for any symptoms at the time of reporting on duty
  • The staff was educated to sanitize hands after coming in contact with clinical files or administrative papers delivered to ward or any potential fomites
  • Staff was advised not to have lunch or tea together, since eating/drinking requires taking off the mask, which could increase vulnerability. Therefore, lunch breaks should be taken in a sequential manner by all staff cadres in the ward. Collective lunches were prohibited
  • Before discharge of patients, the treating team must check that the residence/locality where patient shall go back to after discharge from ward. For example, a patient planned for discharge from our ward could not go home when he found that his residence had been designated as containment zone. His ward stay was extended as a result for several days, with an option to move out to a suitable alternate place of his choice.


Personal protection equipment

The set of guidelines on the use of PPE for health-care personnel (HCP) and others evolved over weeks in the Institute, based on several national and international recommendations:

  • Initially, the use of fluid resistant, three-ply/triple-layer mask was advised for HCP in non-COVID wards. Subsequently, the revised Institute guidelines recommended the use of N95 masks for health-care workers. Sanitation staff were additionally advised to wear heavy duty gloves for disinfection and health attendants were advised to wear gloves during the patient shifting. This was later upgraded to level I PPE (N95 mask, gown, gloves, and eye goggles) for all HCPs in non-COVID wards
  • For patients and their attendants, to begin with, the use of medical masks was not recommended, which later got revised to mandatory use of triple-layer mask for all patients and their attendants visiting hospital premises. If they did not wear any mask, the nursing personnel (or any designated person) would provide them with triple-layer surgical mask every day
  • The stocks of PPE are being maintained by periodic indents on a weekly basis, with revision of estimates every week as per change in demands
  • Staff was advised to adhere to standard operating procedures for bio-waste management, especially with regard to disposal of PPE.


Information display, sensitization, and training

These activities were started in the beginning and were reinforced at periodic intervals.

  • All categories of health-care personnel underwent training sessions. For example, nursing officers were asked to take an online course for infection control offered by the institute which generated certificate after completion
  • Sanitation staff was sensitized about the method of dilution of sodium hypochlorite and duration of contact (e.g., 20–30 min for eye goggles/face shield), in addition to training by sanitation supervisors/officers
  • The staff at the entrance of the ward interacts with a variety of personnel visiting the ward (e.g., health attendants sent from other departments). They were sensitized about preventive measures such as not allowing anyone inside without a mask. Further, the need for carrying out these preventive measures was emphasized to them for both on-duty and off-duty hours, as many of them were staying in shared accommodations or crowded personal spaces
  • Information was displayed in the form of posters educating about the preventive measures for COVID-19. The posters were in simple and easy to understand language
  • Specific informative material on donning and doffing was made available in the respective spaces, in a visual format.



  Conclusion Top


COVID-19 pandemic is an extraordinary event that has challenged mental health care systems worldwide. Inpatients in psychiatric facilities are at high risk of exposure due to multiple reasons. Literature suggested that it is important to restrict hospitalization, expedite discharges, prohibit visits of the attendants, minimize group activities, provide psychological assistance, multidisciplinary teams to provide care, to tackle issue of stigma, have adequate means for practicing preventive measures, creating a facility for isolation and have clear guidelines for diagnostic testing. We were able to implement institute-mandated and intradepartmental measures to protect staff as well as patients in psychiatry ward in a constantly evolving scenario. This could serve as a model for continued functioning of a tertiary care teaching medical facility in a pandemic situation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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