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There was no hand sanitizer on the hospital's psychiatric ward for fear patients would drink it; they slept together on futons in communal rooms and the windows were sealed shut to prevent suicide attempts — all conditions that created the perfect environment for the rapid spread of a potentially deadly virus.
This scenario may sound like a something out of a horror film, but as reported last month by the UK newspaper The Independent, it was the reality in the psychiatric ward of South Korea's Daenam Hospital after COVID-19 struck. Eventually health officials put the ward on lockdown, but it wasn't long before all but two of the unit's 103 patients were positive for the virus.
To avoid a similar catastrophe, staff at an Israeli hospital have created what they describe as the "world's first" dedicated COVID-19 unit for psychiatric inpatients.
Clinicians at Israel's national hospital, Sheba Medical Center Tel HaShomer in Tel Aviv, believe the 16-bed unit, which officially opened on March 26, will stop psychiatric inpatients with the virus — who may have trouble with social distancing — from spreading it to others on the ward.
"Psychiatric patients are going to get sick from coronavirus just like anybody else,"
Mark Weiser, MD, head of the psychiatric division at the institution told Medscape Medical News. "But we're concerned that on a psychiatric ward, a patient who is COVID-19 positive can also be psychotic, manic, cognitively impaired, or have poor judgment…making it difficult for that patient to keep social distancing, and very quickly you'll have an entire ward of patients infected.
"So the basic public health issue is how to prevent a single psychiatric patient who is hospitalized and COVID-19-positive from making everybody else sick," he added.
Unique Challenges, Rapid Response
Adapting an existing psychiatric ward to one exclusively used by inpatients with COVID-19 required significant planning, coordination, and modifications to ensure the well-being of patients and staff.
First, the ward's air conditioning system was re-engineered to separate it from the hospital's main system. A dedicated entrance for the exclusive use of infected psychiatric inpatients was also created.
In addition, two-way television cameras in patients' rooms were installed to facilitate a constant flow of communication and enable therapeutic sessions and family visits. All of these modifications were completed in under a week.
"Under normal circumstances, we have cameras in the public areas of our wards, but in order to respect people's privacy, we do not have cameras in their rooms.
"In this specific ward, on the other hand, we did put cameras in the rooms, so if a patient needs to be watched more closely, it could be done remotely without exposing staff to the virus. We have a person who's watching the screens at all times, just to see what's going on and see what patients are doing," said Weiser.
Protective personal equipment (PPE) and clothing for staff was tailored to the unique challenges posed by the ward's patient population.
"Of course, you need to wear clothes that are protective against the virus," said Weiser. "But sometimes our patients can get agitated or even violent, so you've got protect against that as well."
With this in mind, all personnel working on the ward must put on an extra layer of PPE as well as a tear-proof robe. The institution has also implemented a strict protocol that dictates the order in which PPE is donned and doffed.
"It's got to be done in a very careful and very specific way," said Weiser. "We have all of it organized with a poster that explains what should be taken off or put on, and in what order."
For institutions considering setting up a similar unit, Weiser said close proximity to an active care hospital with the capacity to provide urgent care is key.
"We're psychiatrists; we're not great at treating acute respiratory problems. So patients with significant respiratory problems need a place to get appropriate care quickly," he said.
In setting up the unit, there were still a few obstacles, Weiser noted. For instance, despite the many protective and safety measures undertaken by the institution, some of the hospital staff were concerned about their risk of contracting the virus.
To address these concerns, the hospital's leadership brought in infectious disease experts to educate hospital personnel about the virus and transmission risk.
"They told our staff that given all the precautions we had taken, there was very little risk anyone else could become infected," Weiser said.
Despite the many challenges, Weiser said he and his colleagues are thrilled with the dedicated ward and the positive reception it has received.
"My colleagues and the directors of psychiatric hospitals all around the country are very happy with this because now they're not hospitalizing infected patients. They're very happy for us to take care of this," he said.
"No Easy Solutions"
Commenting on the initiative for Medscape Medical News, John M. Oldham, MD, chief of staff at Baylor College of Medicine's Menninger Clinic in Houston, Texas, raised some questions.
"Is it really going to be the treatment unit or a quarantine unit? Because if you don't have a comparable level of established, effective treatment for these patients, then you're simply herding them off to a different place where they're going to suffer both illnesses," he cautioned.
Nevertheless, Oldham recognized that the issue of how to treat psychiatric patients who test positive for COVID-19 is complex.
"We're still wrestling with that question here at Menninger. We have created an enclosed section of the inpatient area reserved for this possibility.
"If we have a patient who tests positive, we will immediately put that patient in one of these rooms in the quarantine section. Then we will use protective equipment for our staff to go and provide care for the patient," he said.
However, he acknowledged that a psychiatric hospital is in no position to treat patients who develop severe illness from COVID-19.
"We're certainly worried about it," he said, "because how many inpatient general medical units are going to want to take a significantly symptomatic COVID-19 patient who was in the hospital for being acutely suicidal? There are no easy solutions."
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Cite this: Cautionary Tale Spurs 'World's First' COVID-19 Psychiatric Ward - Medscape - Apr 17, 2020.