The COVID-19 pandemic has brought unprecedented upheaval to the traditional practice
of healthcare worldwide [1]. Social distancing and hospital isolation protocols pose
a unique challenge for inpatient psychiatric settings, where the standard of care
includes social interactions through group and milieu therapy [2]. During the height
of the COVID-19 pandemic in New York, our hospital created an inpatient unit dedicated
to the care of COVID-19 positive psychiatric patients. We designed and implemented
an inpatient telehealth delivered mental health care (Telemental Health) [3] protocol
to:1) maintain multidisciplinary treatment delivery despite isolation protocols; and
2) promote patient support by family and friends during a time of in-person visitor
restrictions, and reduce the risk of COVID-19 cross-contamination during in-person
contact. Here we describe in brief the benefits and challenges of our inpatient Telemental
Health conversion (see Appendix 1 for detailed information).
The COVID-19 pandemic has brought unprecedented upheaval to the traditional practice
of healthcare worldwide [1]. Social distancing and hospital isolation protocols pose
a unique challenge for inpatient psychiatric settings, where the standard of care
includes social interactions through group and milieu therapy [2]. During the height
of the COVID-19 pandemic in New York, our hospital created an inpatient unit dedicated
to the care of COVID-19 positive psychiatric patients. We designed and implemented
an inpatient telehealth delivered mental health care (Telemental Health) [3] protocol
to:1) maintain multidisciplinary treatment delivery despite isolation protocols; and
2) promote patient support by family and friends during a time of in-person visitor
restrictions, and reduce the risk of COVID-19 cross-contamination during in-person
contact. Here we describe in brief the benefits and challenges of our inpatient Telemental
Health conversion (see Appendix 1 for detailed information).
Prior to admitting only COVID-19 positive patients, our unit had a capacity of 17
beds, with most rooms housing one patient per room. Patients received daily assessment
by a psychiatrist, individual psychotherapy, several group therapy and activity sessions,
and met with nursing staff and non-psychiatric physicians, physical therapists, pharmacists,
chaplains, as needed throughout the day. After the COVID-19 conversion, the census
was limited to 15 patients, so that each patient had an individual room; two rooms
were used for donning and doffing personal protective equipment (PPEs). To mitigate
viral spread, patients had to remain in their room with the door closed and only had
in-person interactions with the treatment staff for medication dispensing, vital signs,
blood drawing, and room checks. [4]
Initially, patients communicated with staff and family via portable landline telephones,
therapy groups were suspended, and PPE including masks, gowns, and face shields made
in-person interactions difficult. We quickly realized, while these procedures limited
the risk of contamination, they led to patient isolation with the potential to interfere
with treatment progress.
Within two weeks, we planned implemented our protocol for inpatient Telemental Health
delivered mainly though tablets provided by our hospital. We selected a core team
consisting of a clinical psychologist and a clinical social worker to design and lead
our Telemental Health conversion program and manage program logistics including training
hospital staff on-site. All program documentation was stored in a secured server-based
folder accessible to clinical staff. Each patient received a tablet to use for meetings
with the treatment team, virtual family visits and to access therapeutic applications
and content. Password secured meetings via teleconferencing software replaced in-person
clinical team rounds.
While rapidly designed out of necessity, the implementation of Telemental Health followed
an iterative process of improvement [5]. Our paramount concern was patient safety.
In response, we implemented daily risk and safety screenings before patients were
given a tablet (Appendix 2: Tablet risk screening). Another concern had been the patients'
ability to navigate technology. Psychopathology, cognitive impairment, and limited
prior familiarity with technology were potential barriers to use. To address these
issues patients received verbal and written instructions to orient them to tablet
functions.
While rapidly designed out of necessity, the implementation of Telemental Health followed
an iterative process of improvement [5]. Our paramount concern was patient safety.
In response, we implemented daily risk and safety screenings before patients were
given a tablet (Appendix 2: Tablet risk screening). Another concern had been the patients'
ability to navigate technology. Psychopathology, cognitive impairment, and limited
prior familiarity with technology were potential barriers to use. To address these
issues patients received verbal and written instructions to orient them to tablet
functions.
We were particularly sensitive to protecting patient privacy. Initially, we created
“dummy” email addresses that anonymous use by patients. However, we were forced to
abandon this approach because the high volume of COVID-19 positive admissions places
a heavy demand on staff time. The hospital's Information Technology Department purchased
several hundred temporary email addresses from a large corporation for patient use.
These email addresses were used to access telecommunications software and were kept
in a “directory” on our secured server so that staff could contact patients directly.
At discharge, patient temporary email addresses were retired, and the tablet was reset
to factory settings, deleting all personal user information. A new temporary email
address was assigned to the next admitted inpatient. Disinfection and charging of
tablets were also challenging. Each night, we collected all tablets from the patients,
disinfected, charged and returned them to the patients on the next morning.
The Telemental Health conversion of our inpatient psychiatric COVID-19 positive unit
was supported by funding from our hospital system. Although investing in technology
to support inpatient psychiatric treatment is costly, containing the spread of COVID-19
while offering high-quality psychiatric care to address psychiatric symptoms is imperative
and could prevent larger long-term healthcare costs. Our inpatient Telemental Health
protocol can be modified and used with a variety of different hardware and software
to fit the needs of smaller institutions during these challenging times.
The following are the supplementary data related to this article.
Appendix 1
: Components of protocol for Telemental Health inpatient unit conversion.
Appendix 1
Appendix 2
: Daily Risk Assessment Questionaire for patient use of tablets on an inpatient psychiatric
unit.
Appendix 2
Supplementary data to this article can be found online at https://doi.org/10.1016/j.genhosppsych.2020.08.011.
Funding sources
10.13039/100000025
NIMH
ALACRITY P50 MH113838.
Declaration of competing interest
Dr. Alexopoulos serves on the Eisai Advisory Board and Otsuka Speakers Bureau. He
also served on the Speakers Bureaus of Allergan and Takeda-Lundbeck and Janssen Advisory
Board. All other authors do not have financial conflicts of interest to report.