Andy Angelino, director of psychiatry at Howard County General Hospital, assists a nurse with donning and doffing personal protective equipment.
Last March, as the COVID-19 pandemic intensified in Maryland, several patients with psychiatric issues arrived at Howard County General Hospital’s emergency department and tested positive for the virus. Others in the same predicament had already been admitted to inpatient medical units.
The spike in psychiatric admissions was hardly surprising, says Andrew “Andy” Angelino, director of psychiatry at Howard County General — a member hospital of Johns Hopkins Medicine. “After all,” he says, “patients with mental illness often live in group homes, shelters and correctional facilities, where close contact and inadequate infection control are common.”
Yet the idea of closing or significantly changing inpatient psychiatry services, or treating such inpatients in medical units, “was unacceptable to us,” recalls Angelino. “Instead, we sought to preserve our established methods of teaching patients to practice new thoughts and skills, while finding a way to monitor symptoms and reduce the threat of contagion.”
“We were faced with a major challenge,” he said. “Our psychiatry leadership team was meeting daily and trying to find a place to care for these very vulnerable people.”
Fortuitously for Angelino and the department, a vacated former 20-bed psychiatric unit presented an opportunity. He and his staff fast-tracked a plan to renovate the area and make it available for up to six patients, following infection control regulations. Still, Angelino recognized the challenges these patients presented. He knew he needed to act swiftly to contain the spread of disease while supporting patients emotionally.
Unable to find a precedent for such a unit in U.S. hospitals, Angelino and his colleagues sought guidance from psychiatrist Mark Weiser, head of psychiatry of Sheba Medical Center, at Tel HaShomer, in Tel Aviv, Israel, who had recently set up a unit for SARS-CoV-2-infected patients with mental illness.
Drawing from Weiser’s experience, Angelino mobilized his team, which includes four psychiatrists, two nurses and a psychiatric nurse practitioner. By April 21, 2020, the Howard County General inpatient psychiatric unit for asymptomatic COVID-19 patients was up and running. The unit also accepted patients from across the health system’s four other regional hospitals, and then began receiving referrals from hospitals across Maryland.
In a recent article published in Psychosomatics, Angelino and his colleagues describe what it took to set up and run the unit. The unit was made into a complete negative pressure space, allowing patients to freely roam the halls and spend time in common areas, behaviors that psychiatry recognizes as “normalizing,” says Angelino. “We emphasize rehabilitation toward normal daily behaviors, like eating in a common area, group activity and such.”
Typically, “We see one to five patients a day,” says Angelino. “Most have very mild COVID-19 symptoms. Zoom group sessions are incorporated into the day. And we have activities and snacks.” Some patients stay until their COVID quarantine is over — about two weeks. Others go home to quarantine, or are discharged to quarantine facilities, such as the Baltimore Convention Center, once psychiatrically stable.
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Challenges remain. For many people with psychiatric illnesses, such as depression, group therapy is a given. But personal isolation forbids it. In addition, patients with severe psychosis and mania are vulnerable to inappropriate behaviors and disregard for rules, such as those related to wearing a mask or hand-washing.
But perhaps the greatest hurdle in caring for these patients, says Angelino, is trying to help them understand why they were admitted to this unit in the first place. Most don’t have COVID-19 symptoms, or they’re mild. They simply tested positive for the virus. “Patients aren’t shy about complaining: ‘We don’t have anything wrong with us! Why are we here?’”
Despite the new unit’s success, Angelino expresses concern about scores of other people with mental health problems contracting COVID-19. “Psychiatric patients are vulnerable,” he says. “Unfortunately, many are in jail or shelters — the worst-case scenario is such crowded conditions. You just have to breathe to get COVID-19.”