Sunday, April 5, 2020

Acute-Care Psychiatry During the Pandemic




in the early days of this century, I spent a lot of time in Avian Influenza Task Force meetings. I was on two separate task forces and at the same time working on an acute care inpatient psychiatric unit. One of the meetings took up four hours in the afternoon and I would have to go back to my unit and make up those four hours. I made the mistake of that not saving all the documentation from those meetings. There were hundreds of pages. The main focus of one task force was on “surge suppression” or helping with crowd control to prevent emergency departments from being overwhelmed by people who did not really have the viral infection. The other meeting was more about the actual response to the viral infection. I was always skeptical of what I heard. We kept hearing that if there was an epicenter of infection, large pallets of Tamiflu would be on the way. We saw presentations with pictures of those pallets under plastic wrap. At the same time there was discussion about morgues and refrigerated trucks that have become part of the current crisis.

I was more concerned about what would happen to inpatient psychiatry units. I kept hearing that the medical and surgical beds would be overwhelmed. When I suggested that we increase the capacity of negative airflow rooms and rooms vented directly to outside air, I was told that was impossible. One expert gave the opinion that if there is an airborne virus in the hospital: “The minute you walk into the hospital you should be wearing an N95 mask”.

That was about 2005 and I had never heard of an N95 mask before that. I had certainly worn masks for painting, dust protection, and various chemical and biological experiments that I did in the course of education and research. I went out and bought a small package of N95 masks. I fitted them per the instructions and noticed a couple of things. The fit was extremely snug due to upper and lower elastic bands (that have a much smaller circumference than a human head or neck), the circular contour of the mask providing a suction fit to some extent, and a flexible metal band that bends over the bridge of the nose to effectively seal that area. When you are wearing an N95 mask your voice is muted and you are breathing against resistance. If you wear it long enough, it becomes soaked with exhaled droplets. I rapidly concluded that it would be nearly impossible to conduct a psychiatric interview wearing this mask.

I never really learned at the time whether there was a plan to shut down inpatient psychiatry and use all the beds for avian influenza patients. Thankfully it never got to that point. Flashing forward 15 years a real pandemic is upon us and the problems remain unsolved. Inpatient psychiatric units and residential drug and alcohol treatment units are considered necessary services in most states and they remain open. Very recent information from the authorities now suggest that SARS-CoV-2, the virus causing COVID-19 is airborne and that there are a significant number of asymptomatic carriers.

I have been using telepsychiatry at this point for two weeks and it seems to be going well. There are definite constraints compared with face-to-face interviews. I have noticed more constraints since my original post on this topic. I put a couple of questions out there on social media today to see how my colleagues who are still actively engaged in acute care are adapting to the changing parameters of this pandemic. Before putting those questions out, I had the thought that telepsychiatry could be used over the short distances in inpatient settings. As a resident I had the experience of observing psychotherapy firsthand and being observed from adjacent rooms that also had microphones for communication between those rooms. I was interested in seeing whether or not anyone had implemented those solutions.  I was pleased with the feedback that I have so far.

One of the first responses was that psychiatric staff were using surgical facemasks and face shields in some settings. In other settings, adjacent rooms and telepsychiatry both on-site and off-site were being used for acute-care units. The most unique solution I heard of was a consultation liaison team using iPads to interview medical and surgical patients remotely where possible. That reminded me that some people have joined my telepsychiatry sessions using smart phone apps. It was generally very suboptimal if the phone was not completely stabilized.  I also had the experience this week of getting a link sent to me from a colleague who worked for a large healthcare system. It was an invitation to open up a video session with him even though I am not registered in his clinic.  It was very similar to a Zoom session that I did for a podcast. All this information shows that there are technologies available right now that are effective and actively being used. They have also been very rapidly deployed or are in the process of being deployed. There is some potential that this sudden change in the delivery of psychiatric services may be a more permanent one.

I asked the question about whether or not the services were saving personal protective equipment (PPE). The response to that question was somewhat mixed. I am not clear on what it means but speculate that some of the staff still need to have direct patient contact at some point during the day. Most acute-care staff at this point have been assigned PPE. The PPE specifics seem to vary from place to place but it is clearly rationed. If I was designing a survey of acute-care psychiatric facilities I would like to see the specifics of how many people had N95 masks and other kinds of protective gear.

Preadmission screening remains a question mark.  There is general agreement that there is an asymptomatic carrier state for SARS-CoV-2 (1,2).  Carriers may have a lower viral load and be partially symptomatic. Most people admitted to inpatient psychiatric units these days require intensive nursing care for their own safety. If there were environments where patients with COVID-19 could be safely segregated and treated that would be ideal, but I doubt those kinds of environments exist on inpatient psychiatric units. Even then the asymptomatic carriers would require the same psychosocial interventions as non-carriers.  The general screening done is to ask about contact with known cases and daily temperatures. I am not aware of any screening procedures that involve trying to identify the virus and carrier state.

My overriding concern is that medical and psychiatric staff everywhere have adequate protection. We have known since my days on the avian influenza task forces that airborne viruses are difficult to contain. They can infect through surface contamination, droplet contamination, and traveling on air currents. Working to cancel all those routes of infection is a tall order especially on an inpatient psychiatric unit.

The only practical way to maintain the level of communication necessary and minimize risk of infection is through some type of electronic communication. Some of the early methods have been listed in this post. Having worked in these settings for a large part of my adult life I am very concerned about the staff with daily direct patient contact including nursing, nursing assistants, and occupational therapy.  Housekeeping staff also have a vital role and are directly exposed to most contaminated surfaces. I have seen large numbers of inpatient staff come down with seasonal respiratory viruses and I know that vulnerability is there. They all need PPE. We need additional innovation in these settings to protect all staff and patients.  

And we have needed that innovation for a long time.


George Dawson, MD, DFAPA




References:


1: Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, Yen MY, Ko WC, Hsueh PR. Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths. J Microbiol Immunol Infect. 2020 Mar 4. pii: S1684-1182(20)30040-2. doi: 10.1016/j.jmii.2020.02.012. [Epub ahead of print] Review. PubMed PMID: 32173241.

2: 1: Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, Ma H, Chen W, Lin Y, Zheng Y, Wang J,Hu Z, Yi Y, Shen H. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020 Mar 4. doi: 10.1007/s11427-020-1661-4. [Epub ahead of print] PubMed PMID: 32146694.

Supplementary 1:

I am very interested in what you are doing at your facility to contain this virus while continuing to go to work every day and treat patients.  I am also very interested in whether you have enough PPE.  I am interested in hearing from everybody staff psychiatrists, residents, social workers, occupational therapists, nurses, nursing assistants, and housekeeping staff.  Please post in the comments section below and feel free to remain anonymous. 


Graphic Credit:

Shutterstock per their standard agreement.






5 comments:

  1. Hi there! Re: OT, we currently get face masks each morning, 1/day. We continue to meet with patients on a 1:1 basis, trying to meet with everyone at some point during the day. We try to maintain 6 ft, however it's difficult. We wash hands and sanitize constantly. I'm guessing in the upcoming weeks, we will continue to have changes and restrictions. I'm glad to hear that you are able to work from home!

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    1. Kris, give it up and go to telehealth. Asymmetric risk. The benefits of meeting face to face are a small fraction of the downside risk. What happens if someone gets it through the clinic and gives it to an elderly relative? You don't have weeks to decide, do it tomorrow. Also read up on the six feet rule, that's being disputed as way too low.

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  2. The WHO and CDC blew it on the mask situation and the epidemic from the beginning. It's evident to me that even epidemiologists don't understand asymmetric risk/fat tails and why you need to overreact early. Nassim Taleb/Yaneer Bar-Yam have been astonishingly correct about COVID since January 26. As far as the WHO they are completely corrupt and controlled by the CCP who lied for six weeks. The WHO played politics and ignored Taiwan who sent the early warning.

    Glad I DID NOT choose Zoom HIPPA. Zoom has been having many security breaches. The free version is a sucker's game even for casual chat. The HIPPA version isn't cheap but now tainted by the brand.

    Lesson from Facebook: if it's free you're NOT the customer, you're the product being sold. I don't know how many times we are going to have to relearn that lesson.

    Which platform did you end up choosing?

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    1. My employer chose Mend. The person I was contacted by that I mentioned in the post was on doxy.me. So those are the choices by big local organizations that I am aware of so far.

      I think the mask issue has been politicized due to the obvious lack of PPE and preparation. It is frustrating to think that I was in the planning stages for this over 15 years ago and even then - I was the only guy interested in what would happen on inpatient psych units. Probably part of the general neglect and rationing of psychiatric services.

      The other factor is the lack of knowledge about airborne viruses. In the absence of that knowledge it is easy to take a political position on - airborne or not. Most of the literature is done by engineers and in journals that physicians don't typically read. Time to get up to speed on that literature instead of speculating.

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    2. I got into heated arguments with physicians including internists in January about this as I was an early alarmist. I even wrote an editorial explaining why Dr. Drew was wrong. One reason is that I follow Nassim Taleb and the NE Complex Systems Instituted on Twitter. Another was the R0 of 2.4 and the early death rate numbers looking like 1-3 percent vs. .1 percent for flu. I knew the comparisons to the flu were stupid because you cannot compare fat tailed new pathogens to established diseases. I also knew the Chinese government were lying and was very suspicious when Li Wienlang was made to disappear. It's not really political as much as it is based on understanding that with new global risks, being right most of the time doesn't matter but being right when it matters is the crux of the issue. Michael Fumento had a good record on contagion up until now and destroyed it being dismissive on this one.

      In layman's terms, it's better to overreact than to be the mayor from Jaws. When you fasten your seatbelt, you're basically wrong 9999/10000 times but that's not the point, and you're not predicting a crash. The same with mask...the downside of wearing one pales to the upside and you're not predicting exposure when you wear it.

      One thing about the precautionary principle is you hope you were wrong. I'm not gloating about being right. If this were less than the seasonal flu, one of these days a lax response is going to be Spanish Flu 2.

      Kris, I'd shut that down and go to telehealth tomorrow. You don't have a couple of weeks. The next couple of weeks are going to be bad.

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