Establishing a Sustainable COVID-19 Behavioral Health Care Unit

New York City saw its first coronavirus case on March 1, 2020. By March 5, more than 8,000 coronavirus cases were identified, and at least 107 coronavirus deaths had been reported. Within weeks the coronavirus had hit like a tsunami, and New York City was declared an “epicenter.”

Case counts in New York City increased rapidly from a weekly mean of 274 diagnosed cases per day during the week of March 8 to a peak weekly mean of 5,132 cases per day by the week of March 29. The rising infection rates led to increases in hospitalizations. Several of the psychiatric units in the NewYork-Presbyterian Hospital system were converted to medical units or ICUs to treat those patients.

During the early days of the pandemic, it was clear that the healthcare industry needed to deal quickly with the crisis to avoid a potential crash of the healthcare system. Experiences around the world indicated that the most common problems hospitals faced in the early phases of the healthcare crisis were confusion, chaos, and lack of resources, all of which added to the rapidly increasing mortality rates.

The coronavirus pandemic was a “chaos” that demanded a transformational change. Creating healthy organizational cultures is an ongoing task, and the COVID-19 crisis provided a prime opportunity to build resilient teams to provide the best possible patient care. Richard Hackman, a pioneer in organizational behavior, asserted that it is the “enabling conditions” that help teams thrive.

Gracie Square Hospital, a part of NewYork-Presbyterian’s healthcare system, is a free-standing psychiatric hospital in New York City with 125 inpatient psychiatric beds. Due to the increased number of hospitalizations linked to COVID-19 infections, three of NewYork-Presbyterian’s inpatient psychiatric units were converted into ICU units.

Because many psychiatric patients required both medical and psychiatric care, leadership at Gracie Square teamed up with NewYork-Presbyterian enterprise to dedicate their units to COVID-19 psychiatric patients. Gracie Square Hospital was the first behavioral health care unit in an acute care setting to manage the crisis.

A Sustainable Behavioral Health Care Unit

Gracie Square leaders knew that with effective management, a team approach, and precise planning, they could minimize the healthcare crisis’s adverse effects. They undertook the following steps to create an effective and sustainable COVID-19 behavioral health care unit.

1. Articulate the vision.

Any project’s success requires articulating a vision, which entails defining reality and allocating efforts and resources accordingly. Due to rapidly increasing infection rates, Gracie Square Hospital leaders were forced to ramp up their efforts even as they researched, understood, and assimilated information about the disease. With the uncertainties about COVID-19, a short timeframe was essential. The senior leadership at Gracie Square had several meetings with frontline and support staff to give employees a clear vision of the next eight weeks.

On March 17, 2020, plans were made to open the first COVID-19 suite of 12 beds; a second COVID-19 suite of 12 beds would open within a week, and plans to transform the entire unit were laid out. Additional suites of 12 beds, each on other floors, were identified as potential “back up” units.

On March 27, 2020, the first COVID-19 psychiatric unit was opened. Creating such a unit entailed working out the logistics of bed capacity across the hospital while effectively managing behavioral health issues. Considering the challenges ahead, teams needed to be energized, oriented, and engaged in carrying out the vision.

2. Implement the vision.

A groundbreaking strategy or a brilliant idea cannot be successful without solid execution. Gracie Square Hospital faced a dual task of continuing its admissions to non-COVID-19 units while creating a specially designed behavioral care unit for COVID-19 patients. Leadership had the complex task of managing in-house conversions of COVID-19 cases in addition to accepting COVID-19 patients from all of the NewYork-Presbyterian emergency rooms.

Information about monitored patients along with symptomatic and asymptomatic COVID-positive cases was available 24 hours a day. Nursing and frontline staff were included in decisions and actions concerning patients for whom they were responsible. Prompt identification of symptomatic cases on the unit and rapid testing and isolation were ensured. Medicine and infectious disease support from the NewYork-Presbyterian enterprise was available all day, every day.

With the creation of COVID-19 suites, Gracie Square Hospital cared for existing non-COVID patients, thereby avoiding transfers within the hospital and decreasing the risk of infection; however, increasing infection and isolation rates posed a challenge to managing a census of about 90 inpatient beds.

With dwindling outpatient behavioral health care programs and increasing infection rates, maintaining the balance between admissions and discharges became difficult. Although census for each unit was defined, the director of nursing, director of admitting, patient care directors, and environment staff scheduled daily meetings. Also, the NewYork-Presbyterian enterprise conducted service line calls three times a week to collaborate with emergency room directors and directors of other inpatient behavioral health units to review the census and conditions on each campus.

In general, teams were composed of a manageable number and mix of members with optimally designed tasks and processes. Leadership at Gracie Square Hospital focused on defining the role and performance expectations of team members — medicine, psychiatry, nursing, social work, lab technicians, and environmental staff — while promoting a positive dynamic and giving teams autonomy in managing their work.

It was also imperative that teams receive feedback about their performance. Daily and weekly meeting schedules and protocols to manage psychiatric and medical management were established and followed on the unit, organizational, and enterprise levels. Emphasis was on adopting a team mentality where active collaboration, critical thinking, and a zero-tolerance policy were at the forefront. An outgrowth of the meetings showed an increasing need for a collaborative approach and situational flexibility.

During the implementation phase, leaders identified and categorized some of the problems they would face, such as delay or lack of accurate and timely information, staff shortages, psychological reactions, and equipment shortage, all of which could lead to a failed project and increased mortality. Leadership acknowledged the importance of high-performing teams with a balance of technical and social skills.

3. Manage protocols.

Clinical protocols allow healthcare providers to offer appropriate diagnostic, treatment, and care services to patients and quality training to clinical staff. By March 2020, COVID-19 had proven to be the most virulent of the SARs viruses of the 21st century, and its rapid spread allowed little time to establish standard protocols.

At the outset of the pandemic, the CDC (Centers for Disease Control and Prevention) recommended wearing masks, isolating, and maintaining a six-foot distance from others. A protocol for mask-wearing by all patients and staff was quickly established; however, several behavioral health care units faced a severe shortage of PPE because the medical units and ICU were given preference. In addition, forcing patients in an inpatient psychiatric unit to wear a mask presented an ethical challenge.

In April 2020, New York’s governor imposed a mask mandate for all individuals where social distancing could not be maintained. The mandate established the protocol of mask-wearing for inpatient units; the availability of masks and PPE translated into staff feeling safe and empowered to care for their patients.

Gracie Square Hospital’s first COVID-19 patient was an in-house conversion with infection spread during a family member’s visit. A command center was quickly established to disseminate information and allocate available resources under strict protocols to ensure the success of the operation.

COVID-19 behavioral health care units faced unique challenges in that stress from isolation can compound the already existing fears of infection, stigma, and boredom from quarantine. This can all translate into worsening of the current mental health crisis. Repeated announcements on the intercom emphasizing the need for safety and wearing masks and hospital leaders addressing their frustration and despair over the difficulty in implementing this protocol indicated the level of concern.

Other protocols were directed at the mechanics of the operation. Specific equipment to monitor vital signs, EKG machines, medication carts, and emergency crash carts were designated for COVID-19 patients. Medicine, psychiatry, nursing, and environmental staff were brought together to establish protocols around testing, cleaning, and emergencies.

Testing was a priority task during the initial two weeks of the COVID-19 crisis. NewYork-Presbyterian enterprise’s link with medical schools made labs available for rapid testing. Protocols for PUIs (persons under investigation) and COVID-19 positive patients were quickly established. The decision to test every inpatient admit in emergency rooms ensured the separation of COVID-positive patients early on with subsequent admission to a COVID-19 unit.

Managing medical and psychiatric emergencies concurrently was difficult; system-wide meetings of Gracie Square senior leaders and other psychiatric facilities of NewYork-Presbyterian Hospital three times a week meant a constant change of COVID-19 protocols for identifying high-risk patients and setting guidelines for how often vitals and pulse oximetry were measured. Based on medical protocol, an internist saw all COVID-19 patients at least once a day.

Behavioral health units posed their own challenges. In behavioral health management, seclusion, restraints, and intramuscular injections are often used to manage agitation and violence. Implementing a psychiatric emergency protocol meant swift management from administering medication to initiating restraints and seclusions; guidelines with step-by-step instructions of such an emergency resulted in zero incidents of violence or staff injury during eight weeks of the COVID-19 crisis.

Specific attention was focused on instructions to all disciplines for managing a COVID-19 psychiatric patient from their arrival via EMS to the emergency rooms to their transportation to inpatient units. On a behavioral health care unit, patients’ medical decision-making capacity is often based on their psychiatric condition; therefore, if a patient refused medications or COVID-19 testing, the psychiatrist applied for a court order, and a telecourt hearing could be held on the unit, thereby mitigating the risk of infection spread during management.

4. Use a digital technology platform.

The COVID-19 public health crisis led to a revolution in digital technology in inpatient psychiatric units. For example, reduced restrictions at federal and state levels allowed video conferencing to be used for evaluations, attorney visits, court proceedings, recovery support, and group therapy.

Regulatory barriers were loosened in New York to allow access to healthcare via telemedicine. Telehealth reduced the rate of infection spread by person-to-person contact; access to consults, clinical psychiatric care, and psychosocial rehabilitation were continued during inpatient admission. Digital technology was also employed in the psychiatric COVID-19 unit.

The use of telehealth in a psychiatric unit is challenging. Because patients with depression, mood disorder, psychosis, delirium, and other conditions find isolation difficult to manage, they are at increased risk of suicide. In the COVID-19 suites and the COVID-19 inpatient unit where all in-person groups were suspended to minimize physical contact, each patient in isolation was provided with an iPad through which they could access group therapy, alleviating some feelings of isolation.

Although New York state suspended all visitations to inpatient units to minimize the risk of transmission, patients remained connected with families through FaceTime and other methods of audio-video interactions.

Patients admitted to inpatient psychiatric units were medically cleared, yet some patients required varied forms of consultation and follow up. While a digital platform may not provide the same benefit as an in-person appointment, it ensured the continuation of medical and psychiatric management, minimized aggression and agitation, and improved patient satisfaction.

5. Ensure the wellbeing of staff.

Early research on the effects of the COVID-19 crises in Wuhan, China, indicated increased anxiety, stress, depression, PTSD, and even risk of suicide among healthcare workers. Similarly, during the COVID-19 crisis, many New York City healthcare workers have described stress as comparable to being in a war zone or on a battlefield.

Regular training built resilience among staff. Resilience meant the staff’s having the tools and education to adapt to variable workflows daily. The online Saba e-learning platform was used to provide PPE and other educational training to the entire staff. Robust educational programs can only succeed if staff members believe their organizations are supportive and their voice matters. Active listening at daily rounding and huddles provided opportunities for staff to communicate.

The burden of caring for their own families, in addition to the relentless stress at work, often precipitated staff shortages that required leadership at Gracie Square Hospital to modify staff models. The employee assistance program of the NewYork-Presbyterian enterprise offered support with free meals, free childcare, and free transportation among many other services. Spirituality staff members across the hospital were available to provide emotional support to staff and patients.

Addressing the interrelationship of healthcare worker wellbeing and patient care had become a long-term goal. Senior leaders conducted daily rounding on all units to get a pulse check of the staff. To help staff deal with burnout and encourage them to seek counseling, Gracie Square Hospital and NewYork-Presbyterian websites offered information through videos, documentaries, and written materials. Video conferencing with the NewYork-Presbyterian enterprise leaders encouraged staff to be confident and committed to their roles. Open communication among all disciplines ensured that staff members believed they were heard and that their opinions mattered.

Conclusion

Team building is crucial to any organization’s approach to implementing a successful operation. Effective communication, lean structure, emotional wellbeing, and synergy all contributed to the success of the New York operation. With the creation of COVID-19 psychiatric units at Gracie Square Hospital, NewYork-Presbyterian Hospital transformed its three other psychiatric units into ICU units, thus increasing the vital bed capacity during such a crisis.

Institutions across the country must invest in developing similar flexible models for future disaster situations. Having a plan in place can significantly reduce financial and physical losses and lead to a quicker and more robust emergency response.