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.

The Pandemic Report From Beam Avenue

It was my day off yesterday but I have been looking at a “need maintenance” light for the past four days. I had to leave the house for car maintenance. Given the pandemic status this would be a whole new trip. Even though Minnesota does not have a lot of cases at this time, they are increasing and there is an identified COVID-19 case in a town 5 miles away and a neighbor four houses away with direct exposure to coronavirus in the workplace. My secondary goal during this trip was to take a look at social distancing and the other practical suggestions to contain the spread of this virus.

Beam Avenue is a busy thoroughfare that connects Highway 61 on the west and White Bear Avenue on the east. My Toyota dealer is on the west end of Beam Avenue and 1.5 miles away a popular shopping mall sits on the corner of Beam Avenue and White Bear Avenue. St. Johns Hospital is about half way down and the photo was shot from the sidewalk. Average vehicle traffic in this area is about 17 to 18,000 vehicles per day.

I don’t generally set up appointments for vehicle maintenance. I wait until the light goes off and then I typically drive in and wait. Even though the wait takes 1 to 2 hours, the accommodations for customers at this dealership are excellent. A comfortable waiting area, free cookies, and free coffee. This waiting area is generally very congested due to the high levels of work done at this dealership. It was going to be a challenge to see if social distancing was possible or not.

I pulled into the service area and was greeted by one of the service managers. He took me over to his desk and we started going through all the details. I told him I needed a new battery in my starter fob. He took it from me, pried open, installed the new battery, blew the dust out of both halves of the fob with his own breath, snapped it together, and handed it back to me. We talked about the purpose of this visit specifically oil change and tire rotation. He offered to sell me a new service plan but I told him I was thinking of trading in my current RAV4 for a new one. He asked me what my timeframe was and I told him:

“I want to see this coronavirus thing pans out.”  He smiled at that.

After deciding the course of action he told me it might take one to two hours and I headed into the customer waiting area. I have probably seen more customers there at other times but it was packed, everyone was eating cookies and drinking coffee, and there were few open seats. There are study carrels along one wall. That is where I typically sit and do computer work while I wait. I decided it was a bad idea because there is no expectation that these surfaces would be sanitized. The same would be true of the padded and more comfortable seating in the middle of the waiting area. Appropriate social distancing was not evident and in fact I counted 16 people in the service area that were probably within a 10 foot radius of me. I decided it was a good time for a walk.

Beam Avenue is not the ultimate walking course. There are numerous pedestrian crossings just to get to the main sidewalk on the north side. Several large businesses have entrances across that sidewalk. It was an opportunity to see how many motorists never stop or even slow down when making a right-hand turn at a red light or stop sign. Costco motorists seemed more prone to that maneuver. The problem with the walkway is the intensity of traffic and the associated noise and exhaust fumes. That might explain why during the entire 3 mile walk I did not encounter a single fellow pedestrian. The traffic at 3 o’clock on Friday afternoon was as intense as I have ever seen it.

I got to the mall and walked through the main entrance. All the entrances and exits to the mall had pneumatic sliding doors and that is clearly a plus in terms of virus transmission. As I walked further into the mall those benefits seem to diminish. I came across children who were swarming all over free plastic playground equipment. I also saw kids jammed into moving seats wearing some kind of virtual reality goggles that appeared to be simulating a Star Wars battle. I did not inspect all of this equipment but hand sanitizers were not apparent. The kids all looked like they were having fun - it is probably hard to think about social distancing when you are a parent of young children.

When I got to the food court I was surprised that the tables had been thinned out. It looked like there was about a 60% reduction in the total number. As a result there was roughly 10 to 12 feet between most of the tables-the suggested social distancing interval. The other notable change was that even with fewer tables, there was hardly anybody eating at the food court. There was one long line of what appeared to be high school students who had not been seated. There is also visible housekeeping staff with sanitation equipment and they appear to be interested primarily in the food court area.

The men’s room was disappointing. With all the emphasis on handwashing there should be an expectation that any facility will be adequate for that task. In the men’s room, 40% of the soap dispensers and 60% of the faucets were not working. One of the faucets was totally gone. There was a paper towel dispenser that was empty and two air hand dryers. I had time to discover that I needed to go from sink to sink but if there was any crowding - I am sure it would affect the number of people adequately washing their hands. I headed out the door and back to the Toyota dealer.

When I got back - social distancing remained a problem. The service manager met me in the cashier line and reviewed all of the billing. There are two cashiers with six people in two lines and we were all about 1 foot apart. Nobody was coughing or sneezing. I was able to pay and leave in about five minutes.

On the way home I had to pick up some milk and bread and stopped at one of the major grocery store chains in the Twin Cities. The parking lot was packed. I decided to shop without a cart and avoid any cart contamination. There were hundreds of people in the store many of them very old. The store was well-stocked and the only thing that was missing was the toilet paper and paper toweling. A woman in front of me laughed very loudly when she turned the corner and saw that there was about a 50-foot section of shelving completely empty where these paper items had been. I grabbed the milk and bread and headed to the self-checkout line. Six people in line again to get to the touchscreen checkout computer. I checked out got in my car and used a liberal amount of hand sanitizer. I had also used outdoor gloves to negotiate doorways at the car dealership.

On the final drive home, I was thinking about how social distancing was absent in most of the scenarios I encountered. Vehicle and foot traffic were heavy and there was plenty of congestion.  What will it take to get people to stay home and out of public spaces? Some commentators have said that inconsistent messaging is a big part of it. Declaring a pandemic a political hoax one day an actual public health emergency the next day doesn’t work. Today I read three different conspiracy theories on COVID-19 as a bio weapon that was either deliberately used by the United States or China or inadvertently escaped the Chinese bioweapons lab. None of those theories appears to be consistent with what really happened. I was watching a celebrity news program and saw a caller say that the only time he took the pandemic seriously was when he learned that Tom Hanks and Rita Wilson had contracted the virus.

I started to think about why I take it seriously. I worked on two different Avian Influenza Task Forces about 15 years ago. It was a significant effort. One of the main concerns was surge suppression or preventing emergency departments and other resources from being overwhelmed by people who thought they had the disease. There is actually a program called Psychological First Aid where mental health professionals train volunteers to counsel these people and direct them away from emergency departments. I was a trainer for this course. In our meetings there was always a vague discussion of what would actually happen in hospitals if they were overwhelmed by patients with avian influenza.  In some of those discussions we would see a PowerPoint slide of a pallet loaded with Tamiflu at some Air Force Base. We were reassured that in the event of a local epidemic- that medication would be made available. The specifics about negative pressure rooms, ventilators, workflow, and manpower requirements were never really discussed. The current strategy for coronavirus of slowing the infection rate by social distancing and quarantine was also not discussed. At some point it was apparent to me that if avian influenza pandemic occurred, we would be making it up as we went along. I had studied several of these epidemics and had concerns about surge suppression especially in a highly infectious situation.

There appear to be some common errors that are made along the way when considering that pandemics are not only possible but likely. The first one is analyzing the situation according to a particular political bias. This is a very common mistake these days even though it clearly doesn’t work. Contradictory information in addition to those political biases amplifies the problem. Independent of political bias, it takes the ability to imagine that a pandemic is possible. That approach can be historical, biological, medical or mathematical. Any one of those disciplines can provide the necessary knowledge base. There are concerns today that in the era of social media dynamics – every one is an expert at the rhetorical level. The signal of real expertise is lost in the noise of grabbing for celebrity and the associated benefits. Self-selection leads to all of the adherents of a common belief isolating themselves in one little area on the Internet. That leads to the expected cognitive biases but also the illusion that life can go on as a member of an isolated group with no role in greater society.  Pandemics directly confront that denial.

I did see some bright spots on Beam Avenue today, but not many.  Vehicle and foot traffic is heavy and social isolation is a problem in high congestion areas. If people are expected to wash their hands frequently – washrooms need frequent attention and repair. The focus on cancellation of mass sporting and entertainment events is useful, but day to day sources of possible contamination need attention – especially when there are clearly identified cases and exposures in the area.

People need to stay home unless travelling to congested areas is absolutely necessary.  It is the best way to prevent the severe measures being taken in some countries right now and get through this.

George Dawson, MD, DFAPA