The COVID-19 pandemic has raised an important issue regarding how to treat COVID-19-positive patients requiring inpatient psychiatric care (Augenstein et al., 2020). To avoid the risk posed to patients on ambulatory psychiatric units, different strategies have been used by hospitals, including COVID-19-positive psychiatric units, “surge units” to be used in times of high patient numbers, and admission of infected patients to COVID-19 medical floors with the consultation-liaison (C-L) service managing their psychiatric condition. At our institution, we adopted the latter protocol. We will present a challenging case which highlights the specific issues faced, review related literature, and offer insights moving forward.
Mr. X is a 29-year-old male with past psychiatric history of major depressive disorder who presented to the emergency department for a suicide attempt via low potential lethality overdose. Disposition to inpatient psychiatry was planned, however the patient tested positive for an asymptomatic COVID-19 infection in the pre-admission order set. He was admitted to the medical floor and the C-L service was consulted. Given the unique circumstances surrounding the patient’s admission, the roles of the medical team as compared to the C-L team were unclear. Originally, the C-L team was asked to take full responsibility of the patient, but that changed during admission because of disagreements in management. Our evaluation revealed significant borderline and antisocial personality traits, and after three days of stabilization on an anti-depressant, thorough safety planning, and establishment of intensive outpatient follow-up, we recommended discharge. However, the medical team objected to our evaluation and disposition plan and opted to continue hospitalization. Ultimately, the discord was due to contrasting thresholds for de-escalating safety measures in a patient with chronically elevated suicide risk and significant maladaptive personality traits. Another contributor was likely burnout in an already overwhelmed medical team, likely heightened by caring for an asymptomatic patient who otherwise did not require medical admission.
From our review, there are no standardized guidelines on managing COVID-19 patients in the medical hospital given how quickly healthcare systems had to develop protocols to address caring for this patient population. We will review various hospital protocols and highlight pros and cons of each.
Without universal access to COVID-19-positive psychiatric units, it is imperative that C-L psychiatrists be aware of the challenges involved in co-managing COVID-positive psychiatric patients on medical floors. We recommend enhanced communication with medical providers and hospital leadership along with more research into the development of standardized guidelines.
References
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Augenstein, T.M., et al. (2020). Creating a Novel Inpatient Psychiatric Unit with Integrated Medical Support for Patients with Covid-19. NEJM Catalyst 2020.
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Reports and Protocols. (2020, December 01). Retrieved March 20, 2021, from https://www.clpsychiatry.org/covid-19/member-submitted-resources/