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      Implementation of telehealth services for inpatient psychiatric Covid-19 positive patients: A blueprint for adapting the milieu

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          Abstract

          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.

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          Most cited references4

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          Rapid Response to COVID-19: Health Informatics Support for Outbreak Management in an Academic Health System

          ABSTRACT Objective To describe the implementation of technological support important for optimizing clinical management of the COVID-19 pandemic. Materials and Methods Our health system has confirmed prior and current cases of COVID-19. An Incident Command Center was established early in the crisis and helped identify electronic health record (EHR) based tools to support clinical care. Results We outline the design and implementation of EHR based rapid screening processes, laboratory testing, clinical decision support, reporting tools, and patient-facing technology related to COVID-19. Discussion The EHR is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication and adoption, and coordinating the needs of multiple stakeholders while maintaining high-quality, pre-pandemic medical care. Conclusion The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic.
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            A COVID-19 testing and triage algorithm for psychiatric units: One hospital's response to the New York region's pandemic

            Highlights • Patients with mental illness may be at higher risk for contracting COVID-19, and environmental factors place inpatient psychiatric facilities at substantial risk for local outbreaks. • Here, we described an operational algorithm for testing and triage for COVID-19 designed to reduce the risk of intra-institutional outbreaks in inpatient psychiatric facilities. • We developed this algorithm while treating 47 COVID-19-positive and 158 Covid-19-negative psychiatric inpatients in a large freestanding psychiatric hosptial near new york city between march and april 2020.
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              Practice guidelines for videoconferencing based Telemental Health. American Telemedicine Association

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                Author and article information

                Journal
                Gen Hosp Psychiatry
                Gen Hosp Psychiatry
                General Hospital Psychiatry
                Published by Elsevier Inc.
                0163-8343
                1873-7714
                10 September 2020
                10 September 2020
                Affiliations
                Department of Psychiatry, Weill Cornell Medicine, New York-Presbyterian Hospital, Westchester Behavioral Health Center, 21 Bloomingdale Road, White Plains, NY 10605, United States of America
                Author notes
                [* ]Corresponding author at: Weill Cornell Medicine, New York Presbyterian Westchester Behavioral Health Center, 21 Bloomingdale Road, White Plains, NY 10605, United States of America.
                Article
                S0163-8343(20)30130-4
                10.1016/j.genhosppsych.2020.08.011
                7481799
                32972728
                497fbe35-b6a2-4b3e-a7b8-c400e6761b23
                © 2020 Published by Elsevier Inc.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 31 July 2020
                : 27 August 2020
                : 31 August 2020
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