Operational Changes on Child and Adolescent Acute Psychiatric Treatment Programs During COVID-19

Abstract

This Letter to the Editor examines the operational changes on two child and adolescent acute psychiatric treatment programs during the COVID-19 pandemic. On an inpatient unit with roughly two-thirds of its beds in double-occupancy rooms, we found that average daily census and total admissions were lower in the early pandemic period compared to the pre-pandemic period, whereas length of stay was significantly longer. In contrast, a community-based acute treatment program with only single-occupancy rooms showed an increase in average daily census, and no significant change in admissions or length of stay during the early pandemic period compared to the pre-pandemic period. Recommendations include considering preparedness for infection-related public health emergencies in unit design.

To the Editor:

This Letter to the Editor examines the operational changes on two child and adolescent acute psychiatric treatment programs during the COVID-19 pandemic. On an inpatient unit with roughly two-thirds of its beds in double-occupancy rooms, we found that average daily census and total admissions were lower in the early pandemic period compared to the pre-pandemic period, whereas length of stay was significantly longer. In contrast, a community-based acute treatment program with only single-occupancy rooms showed an increase in average daily census, and no significant change in admissions or length of stay during the early pandemic period compared to the pre-pandemic period. Recommendations include considering preparedness for infection-related public health emergencies in unit design.

The COVID-19 pandemic had a major impact on healthcare delivery and operations in inpatient settings, due to both the highly contagious nature of the virus and the need for rigid infection control protocols to minimize healthcare-associated infections.^{1 , 2} Despite the known impacts of COVID-19 on inpatient care, there is a lack of literature explicitly highlighting the operational effects of the pandemic on inpatient psychiatry services. In Massachusetts, access to acute psychiatric treatment programs was severely limited during the pandemic, with hundreds of patients boarding in emergency departments or medical/surgical units, waiting for admission to an acute inpatient psychiatric unit.^{3 , 4} For pediatric patients, the length of wait time more than doubled during the first year of the pandemic.⁴

We evaluated the operations of two acute 24-hour psychiatric treatment programs within one pediatric hospital system in an academic medical center in Massachusetts to assess changes in unit operations before and after the pandemic onset. At the beginning of the pandemic, our pediatric general hospital had a 16-bed inpatient psychiatry unit with 5 double-occupancy rooms and 6 single-occupancy rooms, and a 12-bed community-based acute treatment (CBAT) program with only single-occupancy rooms. CBAT is a type of treatment program in Massachusetts for children/adolescents who require a 24-hours-a-day, 7-days-a-week staff-secure (unlocked) acute treatment setting where patients are typically less symptomatically severe than on inpatient services. Both units serve patients 8 to 17 years of age. We studied unit operations during the 16-month period preceding the declaration of a state of emergency by Governor Baker of Massachusetts (November 2018-February 2020) and the 16-month period during which the state of emergency was in effect (March 2020-June 2021). Specifically, we reviewed 3 important markers of operational functionality and access: total admissions, average daily census (ADC), and length of stay (LOS). Results are shown in Table 1 . Both units screened all new patients for COVID-19 prior to their admission, with only negative-screening patients admitted onto the units.

Table 1.

Comparison of Inpatient Unit With Mixed-Occupancy Rooms and Community-Based Acute Treatment (CBAT) Unit With Single-Occupancy Rooms Before and After the Start of the COVID-19 State of Emergency in Massachusetts

Variable	Site	Pre-Pandemic Period (Nov. 2018-Feb. 2020)		Pandemic Period (Mar. 2020-Jun. 2021)		Significance (p)
		Mean	Median (IQR)	Mean	Median (IQR)
Monthly admissions	Inpatient	26	26 (7)	16	16 (6)	.000∗
	CBAT	18	18 (4)	21	22 (8)	.108
Average daily census	Inpatient	15	15 (1)	13	13 (3)	.000∗
	CBAT	9	9 (1)	10	10 (3)	.020∗
Average length of stay (days)	Inpatient	19	13 (9)	25	18 (17)	.001∗
	CBAT	15	14 (7)	15	14 (5)	.738

Note: Data are based on t tests. IQR = interquartile range.

^∗p < .05.

During the 16-month pandemic state of emergency, the inpatient unit with mixed single- and double-occupancy rooms had a significant decrease in total admissions and ADC compared to the pre-pandemic period. In contrast, the CBAT unit with only single-occupancy rooms had a significantly increased ADC, accommodating one more patient on average per day than pre-pandemic. Furthermore, the CBAT showed no significant change in total admissions during the pandemic period compared to the pre-pandemic period. We did not assess referral patterns; however, studies^{4 , 5} conducted during the pandemic reflect an increase in youth boarding for inpatient care in Massachusetts and across the country, suggesting that a decrease in patients requiring inpatient care was likely not the reason for the decrease in total admissions and ADC to the inpatient psychiatry unit.

Also notable is the difference in LOS; whereas the CBAT unit was unchanged in the pandemic, the inpatient unit LOS significantly increased. Although we did not assess patient illness severity as part of this study, previous studies describe an increased volume of pediatric patients presenting with suicide attempts during the first 12 months of the pandemic compared to the prior year.⁴ Therefore, an increase in more severely ill patients may have contributed to increased LOS. One other difficult-to-quantify variable with a potential impact on LOS is the closure or decreased treatment capacity, after the pandemic onset, of settings in Massachusetts to which the inpatient service typically discharges patients (eg, residential, state hospital, partial hospitalization programs, etc). Without these programs, some patients required longer inpatient stays in order to be safely discharged.

The data illustrate operational changes on pediatric acute psychiatric treatment programs during the COVID-19 pandemic. During the pandemic state of emergency, the inpatient unit had to convert several of its double-occupancy rooms to single-occupancy in order to facilitate social distancing. The unit was also more vulnerable to COVID-19 infections among patients, whereas the CBAT had no patient test positive for COVID-19 during the 16-month state of emergency. Although multiple factors likely contributed to the changes in operations in the inpatient unit compared to the CBAT, the reduction of double-occupancy rooms to single-occupancy due to heightened concern for nosocomial infection is a significant operational impact of the pandemic. There are currently no standards requiring single-occupancy rooms when designing inpatient psychiatric treatment programs.⁶ Double-occupancy rooms increase bed availability in non-emergency circumstances, but their risk during infection-related public health emergencies may make them liabilities. Moreover, studies show substantial cost savings for single-occupancy rooms in similar medical settings⁷; more study is needed on the costs and benefits with respect to inpatient psychiatry services. Several studies^{8 , 9} highlight clinical benefits of single-occupancy rooms, including increased privacy, reduced noise, better sleep, reduced crowding, reduced risk of aggression, lower stress, and improved patient satisfaction. Further benefits of single-occupancy rooms include addressing the needs of gender and sexual minority patients, avoiding the possible effects of distressing behaviors on roommates, and minimizing the risk of inappropriate interpersonal relations between patients.

Given the benefits of single-occupancy rooms on patient care, even during non-pandemic periods, we are advocating for this to be the standard of care when designing pediatric inpatient psychiatric units. The primary benefit of double-occupancy rooms is to create more access, which can be achieved via alternative design methods. Specifically, reducing the square footage of each room in order to accommodate smaller single rooms in lieu of double rooms means that the overall unit does not need to be twice the size in order to accommodate the same number of beds in single-occupancy vs double-occupancy rooms. Moreover, single-occupancy rooms have been shown in other studies⁸ to be associated with decreased operational costs, increased occupancy, and decreased LOS, all of which could mitigate access concerns.

As the COVID-19 pandemic stretches into its third year, with ongoing mutations and new potential pandemics on the horizon, inpatient psychiatry services ought to make every effort to ensure that their operational ability remains intact in order to maintain safety and access to care, especially during the co-occurring pediatric mental health crisis. One further aspect for acute psychiatric treatment programs to consider is the importance of milieu programming and management. Previously published articles describe steps that inpatient psychiatry services may take to reduce risk during emergencies like the COVID-19 pandemic.¹ This includes screening patients before and throughout admission, implementing universal masking, and reducing the density of patients in common spaces (eg, lowering the number of patients participating in in-person groups at a given time, decreasing the number of family members allowed to visit at a time, and using telehealth strategies for group programming and family visits). Units with double-occupancy rooms may additionally consider creative use of flex spaces to alter room occupancy; however, safety design requirements, including ligature risks, may make this a less feasible option unless mitigated by additional staffing to monitor safety concerns. For hospitals where youth are boarding awaiting psychiatric admission, proactively providing active treatment while boarding to divert from higher levels care should be considered. Finally, transitional care teams and other outpatient crisis teams may be established to facilitate discharges when other typical placements are unavailable.

The environment of care is an important part of the therapeutic treatment on an inpatient psychiatric unit. This letter provides data on the challenges in maintaining operational functionality that can occur in public health crises, and we have highlighted some basic efforts that may alleviate their effects. Although we recognize the challenges inherent in creating programmatic changes, we believe that systemic preparation will strengthen inpatient psychiatry services for public health crises and—for inpatient services able to accommodate single-occupancy rooms—potentially improve patient care, regardless of prevailing circumstances.