risks and mitigation strategies for acute mental health ... · 4/28/2020 · admission to a mental...

DEPARTMENT OF PSYCHIATRY

Risks and Mitigation Strategies for Acute Mental Health Admissions During the COVID-19

Pandemic

Joss Reimer MD, John Embil MD, Diana Aikens RN, BN, Joanne Warkentin, Jitender Sareen MD, Lisa Karvelas MD,

Josh Nepon MD, Sherief El-Gaaly MD, Nina Kuzenko MD

Learning Objectives

• To describe the public health and acute care infection prevention and control policies related to COVID-19.• To describe the evolving provincial planning for

COVID positive and suspect admissions.• To describe the assessment process required by

mental health staff prior to admission in Winnipeg• To describe inpatient management & discharge

process of COVID positive/suspect patients.

Dr. Joss Reimer MD, FRCPC, MPHPublic Health Physician

Medical Director of Population and Public Health, WRHAwith contributions from Dr. Lerly Luo

COVID-19Psychiatry Grand Rounds | April 28, 2020

Public Health UpdateDischarge Management

Today’s Talk1. Current situation summary2. Expanded testing criteria3. COVID-19 testing strategy + locations4. Special populations + topics5. Discharge management6. Public health roles7. What to expect: coming months and

year

1. Current Manitoba Summary

22,598tests completed active casestotal cases

267 62 199recovered

7 2currently in ICU

6deaths

As of April 25, 1pm

COVID-19 Dashboard

www.gov.mb.ca/covid19/updates

29currently

hospitalized

13total hospitalized total ICU

admissions

2ventilated patients

10.9%hospitalization rate

4.9%ICU rate


Frequency of new cases among household contacts of known cases.

2° Attack Rate14.4%

95% CI (10.0-18.8%)Based on 99 households in Winnipeg

Manitoba data as of April 25

Case counts remain highest in females aged 20-29


1. Current Manitoba SummaryIncidence per 100,000 people

WRHA 25.4

SH-SS 14.9

PMH 7.0

NRHA 3.9

IERHA 13.6

Manitoba 19.0

Canada 111.1As of April 25, 1pm

COVID-19 Dashboard; www.gov.mb.ca/covid19/updates


As of April 25, 1pm

www.gov.mb.ca/covid19/updates


As of April 24

COVID-19 Dashboard

Updated April 23

2. COVID-19 expanded testing criteria in MB

Providers may test based upon clinical judgement• “Constellation of symptoms suggestive of COVID-19”• Respiratory / MSK / loss of taste or smell / GI Sx

Testing asymptomatic patients is generally not supported

• Unique situations where it may be useful• Low yield for positive results• Negative results may be falsely reassuring

All symptomatic healthcare workers and first responders (police, fire-fighter, paramedic) may self-refer to a testing site.

Patients not assessed by a HCP must meet criteria by Health Links

Criteria for testing will continue to change as Manitoba’s response to COVID-19 evolves

3. COVID-19 Testing Locations

Urgent Care sites Emergency Departments

• Concordia Hospital• Seven Oaks General Hospital• Victoria General Hospital

• Health Sciences Center• St. Boniface Hospital• Grace Hospital• Children’s Hospital

Other Emergent/Urgent Services

• Crisis Response Center (CRC)• St. Boniface Obstetrics Triage• Women’s Hospital Obstetrics Triage• Misericordia Emergency Eye Intake

Drive Through Testing

• Bison (15 Barnes St.)• Main Street Drive (1284 Main St.)

Testing & Assessment Clinics

• St. James Assiniboia Centennial Pool + Fitness Centre (644 Parkdale St.)

• Sergeant Tommy Prince Place (90 Sinclair St.)

3. COVID-19 Testing Results

Negative• Notified via Call Center

• Work underway to provide a secure online option and a phone option.

• Notified by Public Health officials

• Notified by Occupational Health if a health care worker

Positive

3. COVID-19 Testing Strategy

• Currently 1.18% of all tests in Manitoba have been positive

• Test as many individuals as we can given our current available resources in swabs and testing reagents.

• Prioritize vulnerable and high risk groups

• Prioritize service providers

• Plans in place to expand testing capacity and accessibility

3. COVID-19 Testing Strategy

• Nasopharyngeal Swabs via Reverse Transcriptase PCR• Sensitivity: ~75% (Cadham)• Specificity: >99% (Cadham)

4. Special Populations and TopicsPopulations at risk:

• Remote and Indigenous communities• Overcrowded housing, limited resources, community awareness1

• Individuals with no fixed address• Overcrowding in shelters, lack of access to soap and water for

handwashing, access to phones for virtual care, high chronic disease rate1

• Mental health patients • Caution with difficult history, poor compliance, limited insight and

judgement

1 University of Manitoba COVID-19 report, 5th edition

Proportion of medical co-morbidities among COVID-19 cases in Manitoba, March 12 - April 22

4. Special Populations and Topics

Co-morbidities associated with ↑risk of severe disease

• Cardiovascular disease• Underlying respiratory disease• Hypertension• Diabetes• Older age• Renal disease• Immunocompromise• Malignancy

University of Manitoba COVID-19 report, 5th edition

6. Public Health roles

Case follow up Contact tracing

Public health measures Healthcare capacity & safety Special populations

Public education Surveillance & testing Resources: public, HCP Working with government, sectors, communities

7. The coming months and year

Anticipate restarting and likely future closures Second wave Influenza season

Combined virtual-in person models of care? Educating patients on changing public health recommendations

Questions

Questions for Dr. John Embil and Diana Aikens

• If a COVID Test is negative, why is it necessary for some patients to be isolated and not others?• What is the probability of a COVID Suspect patient

being COVID+?• Why do COVID Suspect patients need their own

bathroom?• Why can COVID Positive patients can share

bathrooms with other COVID positive patients?


Jitender Sareen MD

To describe the evolving provincial planning for COVID positive and suspect

admissions.

Provincial Planning for COVID-suspect and positive mental health units

• Review the literature• Interjurisdictional scan in Canada• Provincial Mental Health and Incident Command• Engage key stakeholders with other disciplines (ID,

Public Health)

International Literature

• Wuhan China – Lancet Psychiatry 2020• One psychiatric hospital with 50 cases & 30 staff

• In South Korea, Psychiatric hospital was locked down - 101 patients developed COVID-19; 7 of those patients died• Mental Health patients have high rates of comorbid

physical health risk which puts them at risk for poor outcome

Risk factors of Novel Coronavirus Pneumonia (NCP) Infections among Inpatients in Psychiatric Hospitals -(Zhu March 2020) China

Key Risk Factors - Psychiatric hospital wards are not designed to the

standards of isolation against infectious respiratory diseases

- It is difficult for psychiatric patients to accept and cooperate with self-isolation measures

Prevention- Recommendations that have been incorporated in our planning in Manitoba

How many COVID-19 mental health beds do we need in MB?

• Currently there are NO guiding principles wrt to how many COVID positive or COVID suspect patients will require mental health admissions

• Dr. Antonio Paletta & Faculty from UM and University of Alberta are leading a national survey• How many COVID cases in Province or city?• How many beds designated and occupied?• What are their processes?

Provincial planning for beds as of April 282020• The planning will evolve based on the number of cases in

MB & level of community spread• Child & Adolescent Mental Health – COVID+ and Suspect

mental health admissions will go to Child Health• Rural Manitoba• COVID suspect adult patients will either managed by in

their own region or transferred to Selkirk Mental Health Centre • Selkirk Mental health Centre – COVID+ unit

• 10 beds


Lisa Karvelas MDWRHA and Shared Health (HSC) MH Bed Manager

To describe the assessment process required by mental health staff prior to

admission in Winnipeg

Assessing COVID suspect status:Most recent Algorithm:

https://sharedhealthmb.ca/files/COVID-19-update.pdf

There has been a change in the recommendations around determining a person being considered COVID suspect. This change may be due to a low incidence of community spread of COVID.

Patients who are not the most reliable historians or are homeless or from shelters and are asymptomatic (ie. no ILI : influenza-like illness symptoms) are no longer considered COVID suspect, unless, based on clinical judgment they should be considered suspect.

COVID swabs of asymptomatic patients are very low yield, but may be requested if in the physician’s clinical judgment, there is merit to do so.

https://sharedhealthmb.ca/files/COVID-19-update.pdf

In the uncooperative patient or the patient who is unable to answer the screening questions, observation for ILI and monitoring of vital signs may be adequate to determine whether a patient should be considered COVID suspect or not and whether a swab should be performed.

Speaking with reliable collateral sources to go through the screening questions is also acceptable.

If in doubt, the assessor is free to ask IP&C or ID for an opinion around risk.

If admitting such a patient, it is recommended that temperature be checked BID and that the patient is asked about ILI symptoms daily.

As a general reminder, any patient who is placed on isolation at IPC or ID’s direction may only be removed from isolation at IPC or ID’s direction.

Please refer to the COVID-19 – Updated Information on Referral Process for COVID-19 Testing in the memo issued by Dr. Brent Roussin and Lanette Siragusa, dated April 23/2020.

April 24/2020


Joshua Nepon MD

Medical Director of COVID+ Units at HSC and SBH

COVID Positive medically stable patient that requires mental health admission

• The inpatient unit has the following infrastructure & staffing:• Small number of beds• Appropriate isolation procedures

• All are COVID positive – do not require individual bathrooms because they all have COVID• Capacity to seclude patients• Psychiatry and staff are appropriately trained in PPE

procedures• Medicine & infection and Prevention Control support to

ensure early identification and treatment of infections

COVID+ Adult Mental Health units• HSC PY1 South (8 beds+ seclusion room)• Reassessment Observation Unit (ROU) space

does not have a seclusion room.• PY1 South has a seclusion room• Child and adolescent mental health beds from

PY1 south temporarily transferred to ROU space• ROU closed temporarily àVirtual ROU

COVID+ units- Planning

• As of April 28, no COVID+ patients have required admission to a mental health unit in Manitoba• To minimize loss of beds in the province, we plan to

open one COVID+ unit at a time.• HSC 8 beds first and then if required open the other

units.• Saint Boniface Hospital (SBH)• Mcewen First Floor (M1)- 5 beds• Temporarily stopped construction at Mcewen

Psychiatrists on call for COVID+ patients• Mental Health inpatient units (PY1South + M1)• Consult Liaison to HSC, SBH and GH COVID+

Medicine/ICU unitsNina KuzenkoAmir ShamlouMaaz UsmaniJosh Nepon

*7 day call starting Monday morning* Reachable through HSC paging -204-787-2071*Available for phone questions to rural areas

COVID Database – Dorothy Yu MDCOVID Isolation Initiationa) COVID Suspect/Positive on

Admissionb) Admitted as COVID Negative

but became Suspect/Positive

- Demographics- COVID Factors

- Symptoms- Swabbed? When/where?- Medical comorbidities

- Psychiatric Factors- Reason for admission,

voluntary/involuntary, diagnosis

- Disposition Issues- IP&C consulted? ID? Internal med?- Where were they admitted

Off Isolation/Transfer/Discharge

- Demographics

- COVID Factors- # days on isolation- When was the pt asymptomatic- Swabbed? When/where?

- Psychiatric Factors- Code whites? Seclusion?- Discharge diagnosis- Overnight pass before discharge?

- Disposition Issues- IP&C/MOH consulted?- Follow up plan


Nina Kuzenko MDSherief El-Gaaly MD

To describe inpatient management & discharge process of COVID suspect

patients

COVID Suspect Inpatients

Dr. Nina Kuzenko?

Adult COVID Suspect units• HSC – PY3 South 2 beds• PY3 North- 9 beds (temporary decrease by 5 beds)• If PY1South not used yet for COVID positive patients

– up to 2 COVID Suspect beds• SBH• If M1 not used yet for COVID positive patients – up to 2

COVID Suspect beds

• VGH• 8 COVID suspect beds

Protected Code White

For COVID positive or suspect patients

Always try to avoid a Code White

Code White while wearing PPE

Staff training for PCW

Only as many staff as you need

COVID Suspect patient

Cooperative?(will they stay in their room while on isolation?)

PY3-South (psychiatric ICU) - seclusion

No

Assess ILI symptoms qShift, VS BIDAwait swab results

Assess daily: Asymptomatic and Swab negative?

PY3-North (no seclusion rooms)VGH

Yes

Call IP&C, discontinue isolation?

Yes No

Transfer List

Non-COVID patient can now go to another unit or another hospital

Yes No

?COVID Negative patient

Challenges

25 16

Protected Code White

For COVID positive or suspect patients

Always try to avoid a Code White

Code White while wearing PPE

Staff training for PCW

Only as many staff as you need

VGHCOVID Suspect

PatientsDr. Sherief EL-Gaaly

VGH COVID Suspect Beds

• 8 COVID Suspect rooms.

• Adult units: Unit 3 – 5 beds and Unit 6 – 3 beds.

• Not on a separate unit.

• None on our Geriatric unit.


• Separate Bathroom and shower in each room.

• Rooms are clustered beside one another.

• Health Care Aid (full PPE, code white alarm), 2 to 3 rooms.

• Average of 3 – 5 Patients at any given time over past 5 weeks.

Examples of COVID suspect patients being admitted - VGH

• Travel History.

• Tracing identified Contact with a COVID positive patient.

• Majority: Poor Historians – Asymptomatic.


• Daily update to IP and C.

• Decision to take off of isolation, Consulting Dr. Embiland/or IP and C.

• 48 h to 14 days, test results, temperature and other ILI symptoms.


• Patients Comfort.

• Nurses and Psychiatrist meet daily to review medications.

• HCA, support.

• iPad’s and Snacks donated by Foundation.


• Challenges, Manageable.

• To test or not to test, evolving situation.

• Unsettled patients, Code White, PPE, Mixed ward.

• Significant staffing costs, with heavy care.

Dr. Joss Reimer MD, FRCPC, MPH

Public Health PhysicianMedical Director of Population and Public Health, WRHA

COVID-19 Psychiatry Grand Rounds | April 28, 2020

Discharge Management

Joanne WarkentinRegional Director, Mental Health Program, WRHA

with contributions from Dr. Lerly Luo

Today’s Talk

1. Discharge Planning Priorities2. WRHA3. Southern Health4. Prairie Mountain

Processes

COVID-19 Discharge Planning Priorities

WRHA sites

Key stakeholders

• IP&C• Public Health• Patients & Caregivers• Community Service Providers

• Unit Discharge Package• Notification & Resources

Ensure:• Supports are available prior

to discharge• Education on isolation

• Asymptomatic

• Not a contact

• Clear history of low risk

• Patients unable to give clear histories• consider ↑ virtual follow ups for

ongoing assessment of symptoms

Discharges who require isolation1. Confirmed COVID positive

2. Contact to COVID

3. Symptomatic Influenza-Like-Illness and awaiting swab results*

Discharges require isolation

• Engage caregivers in D/C plan• Provide COVID education• F/U care & community resources available

• Assess home to determine isolation safety (single bedroom & washroom)

• Complete Unit Discharge Form Fax 204-940-2690 to notify public health *except those awaiting results

• Provide isolation guidelines + education• Engage community service provider F/U and

notify of isolation

COVID-19 cases or contacts

Quick Summary

↓

Need public health consultation?

↓

• You’ll be directed to the appropriate person• After hours: HSC paging Medical Officer of

Health on call

• To notify public health of the discharge• Public health daily F/U in the community

Fax 204-940-2690 Call 204-788-8666

Patients who cannot isolate at home or have no fixed address

Those who have no fixed address and require substantial services and support to isolate

Those who require minimal or no services and supports to isolate

Refer to Main Street ProjectCall 204-306-7857

↓

Refer to Shared Health for alternative isolation accommodations

Fill form

↓

Transport

When discharging a presumptive or confirmed COVID-19 back home

• Call Interfacility Transport 204-986-8410 to arrange transportation upon discharge

• Provide the patient’s COVID-19 status Questions:Milton GoodDirector Patient Transport, Shared Health Office: 204-787-8741 Cell: 204-479-3482

Patients who cannot isolate at home and cannot go to alternative accommodation would need to

remain in hospital (psyc or medical) until their test result is back

Southern Health

Isolate for 14 days and 72 hours asymptomatic

Positive Negative

Isolate until asymptomatic for 24 hours*

*If they have travelled or been exposed to a case, then isolate for 14 days and asymptomatic for 24 hours.

Patients who can safely isolate at home:

Notify public health of the discharge of COVID-19 cases or contacts by fax 204-428-2734

Discharge Management

Discharge ManagementPrairie Mountain

Patients who can safely isolate at home:

Notify public health of the discharge of COVID-19 cases or contacts by fax 204-759-4033

Those who have no fixed address and require substantial services and support to isolate

Those who cannot isolate at home and require minimal services and supports to isolate

No service synonymous to Main Street Projectcase-by-case consideration

↓

May refer to Shared Health for alternative isolation accommodations. However,

patients would need to go to Winnipeg

↓

Questions

risks and mitigation strategies for acute mental health ... · 4/28/2020 · admission to a mental...

Documents