Risk-mitigation measures in a tertiary care psychiatric hospital during COVID-19 pandemic : Indian Journal of Psychiatry

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Risk-mitigation measures in a tertiary care psychiatric hospital during COVID-19 pandemic

Gowda, Guru S1; Ganjekar, Sundarnag1; Dinakaran, Damodharan1; Philip, Sharad1; Chithra, Nellai K1; Purushothaman, Deepa1; Shankarappa, Vishukumar Hallikere1; Jaisoorya, T S1; Sivakumar, Palanimuthu T1; Nagabhusana, Shashidhara Harihara1,2; Singh, Veena Kumari3,4; Kesavan, Muralidharan1,5; Bhadrinarayan, V6,7; Murthy, Pratima8; Gangadhar, Bangalore N9

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Indian Journal of Psychiatry 63(4):p 406-408, Jul–Aug 2021. | DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_20_21
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The long-stay psychiatric facilities such as asylums, old-age homes, and shelter homes have common dining and bathroom spaces and are often overcrowded. Individuals in these settings often have cognitive deficits and poor self-care due to chronic mental disorders. This results in a higher risk for COVID-19 infection since it is difficult to adhere to rules and standard preventive measures.[12] In addition, poor nutrition, low level of immunity, substance use, and comorbid physical conditions may lead to poor outcomes in infected patients.[3] In this letter, we provide an experiential account of the steps of preparation, changes in routine practices, and risk-mitigation strategies adopted during the COVID-19 pandemic in a tertiary care psychiatry facility in India. National Institute of Mental Health and Neurosciences is a tertiary neuropsychiatric care institute located in South India. The psychiatric division of the hospital has a bed strength of 545 of which 120 beds (about 20%) are earmarked for difficult to manage patients as well as those with social/medicolegal issues (homeless persons with mental illness, persons without adequate family/social support or admitted with forensic issues). The 120 beds are distributed across two “closed” wards (male/female). Prior to pandemic, 47 PMIs (25 males, 22 females) were long-stay patients who had been under the care of the institution for a mean period of 15.1 years (range 2–55 years). The mean age of these patients was 48.2 (24–79) years, all of them had severe mental illness (psychosis/mood disorders). Additionally, they had cardiometabolic disorders (40.4%) and neuroendocrine disorders (23.4%). It was deemed that the closed wards of the psychiatric units represented a high-risk area for COVID-19 incidence and spread. The higher risk stemmed from the possibility of a single infection rapidly turning into a cluster outbreak within the closed wards. The Department of Psychiatry, in liaison with the Hospital Infection Control Committee of the Institute, developed preparedness and contingency plans and adhered to the standard protocol provided by the Ministry of Health and Family Welfare, Government of India, and Government of Karnataka.[456]

  1. COVID-19 general preparedness plan:
    • To ensure minimal overlap of patients with COVID-19, the hospital facilities were categorized into:
      • Green Zone (inpatients setting with COVID-19-negative patients)
      • Orange Zone (inpatients holding area, with patients deemed at high risk of exposure and who awaited COVID-19 test results)
      • Red Zone (inpatients setting with COVID-19-positive patients).
      • The following additional measures were adopted in the closed wards;
    1. Staff: A single psychiatry consultant was put in charge of administrative issues of the ward (single point of contact [SPOC]). The SPOC was required to liaise regularly with the dedicated team of nursing and support staff. This ensured reduced staff footfalls within the wards. In addition, all the workers were permitted to enter only after temperature checks, sanitizing hands, and wearing masks. All the staff were advised to self-monitor using Aarogya Setu App as per the government guidelines[7]
    2. Protocol for visitors: Routine visitors were not encouraged. However, if required, visitors could speak across a physical barrier with adequate physical distancing.
    3. Patient care:
      1. All existing patients were made aware of the COVID-19 outbreak to the extent possible through awareness classes that specifically focused on safety and COVID-19 prevention practices, including wearing masks and ensuring social distancing.
      2. All new admissions to the closed ward were made only after mandatory testing for COVID-19 with reverse transcription–polymerase chain reaction. Further, for 1 week, newly admitted patients were isolated in a designated room, restricting interaction with existing patients in the ward.[8]
      3. Self-reporting of COVID-19 symptoms was emphasized and ascertained on a day-to-day basis.
      4. Group activities such as prayer, exercises, and games were conducted in smaller groups to ensure social distancing.
      5. Dining/bathing times were staggered.
      6. Older patients, with more comorbidities, were separated from the younger group (reverse quarantining).
  2. COVID-19 outbreak contingency plan:
  3. The COVID-19 outbreak contingency plans in the event any patient testing positive were prepared:
    1. Risk stratification for all the health-care workers, male and female patients of the ward.
    2. The closed ward area to be classified as a containment zone and all movements into the ward and external contacts to be restricted.
    3. Intensive and immediate cleaning of the ward in case of an outbreak.
    4. All patients to be informed of the outbreak, the potential risks, symptoms of COVID-19, and precautionary measures to be followed.
    5. All patients to be encouraged to wear masks at all times and social distancing to be encouraged.
    6. Monitoring of all existing patients for common COVID-19 symptoms like fever, cough, cold, and shortness of breath (with mandatory saturation screening) twice daily.
    7. No new admissions into these wards during the mandatory quarantine period.
    8. Information regarding the COVID-19 outbreak in the ward to be conveyed to the patient's family wherever feasible.
    9. Family members to be given the option to transfer care to any other hospital.
    10. Family to be instructed not to visit the hospital and patients and to be advised to continue contacts facilitated over the telephone.

The focus of creating a preparation and contingency plan is to suit and manage according to the dynamic situations during pandemic. A standard operating procedure that focuses on upgradation and customization of the existing protocols helps to reduce the morbidity and spread. COVID-19 preparedness and mitigation plans adopted in the institute include categorization of hospital facilities into different infection-risk zones, redefining the work patterns of hospital staff, and training hospital staff and patients in risk mitigation. Containment measures such as isolation, quarantine, universal screening, source control, and early risk stratification can help to prevent the spread of COVID-19 within psychiatric institutions. These measures are practically feasible and may be implemented worldwide in such facilities.

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Conflicts of interest

There are no conflicts of interest.


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4. Health & Family Welfare.Last accessed on 2020 Sep 05 Available from: https://karunadu.karnataka.gov.in/hfw/Pages/home.aspx
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