A Virtual Inpatient Psychiatry Unit in a Multicampus Health Care System During the COVID-19 Pandemic

The COVID-19 pandemic has put a strain on hospital resources and disrupted effective delivery of health care services, including psychiatric care (1, 2). Most inpatient psychiatric units were not equipped to deal with COVID-19 patients; patients had to be COVID-19 free before they could be admitted. To address this requirement, one approach has been to create inpatient psychiatry units dedicated to COVID-19 treatment involving a multidisciplinary team with expertise in both general medicine and psychiatry (3). However, such an approach requires much effort, time, and resources. This challenge is further complicated by efforts to meet the care needs of patients who are admitted involuntarily because of a mental health emergency.

Each U.S. state has a psychiatric emergency hold law that allows for temporary involuntary hospitalization and examination of individuals experiencing acute mental illness (e.g., being a danger to oneself or others) (4). The Florida Mental Health Act, also known as the Baker Act (5), allows police, health professionals, or family members to have an individual admitted for a 72-hour involuntary mental health examination.

Before the pandemic, patients placed under the Baker Act were first stabilized medically and then transferred to an inpatient psychiatric facility. With the surge in COVID-19 cases, psychiatric patients started to face delays in care delivery because patients with an active COVID-19 infection needed to receive treatment and complete quarantine before being considered for care in an inpatient psychiatric unit. Patients who were asymptomatic but COVID-19 positive on the pretransfer screening needed to wait until they had completed quarantine or tested negative before they could be placed in an inpatient psychiatric facility.

Of note, despite these challenges, inpatient psychiatric care remained necessary for patients who had been placed under the Baker Act, requiring new approaches to meet this requirement. To this end, the implementation of telehealth services in the inpatient setting has gained momentum during the pandemic. Policy changes reduced barriers to telehealth access and promoted its use in acute, chronic, primary, and specialty care settings (6, 7). Telehealth modalities include synchronous, asynchronous, and remote patient monitoring (7). This column describes the development and operationalization of a virtual, telehealth-based inpatient psychiatric unit, which involved a multidisciplinary approach to care for patients who were involuntarily admitted for acute mental illness and tested positive for COVID-19.

Model Development and Operationalization

Approach

To improve care efficiency and patient access, the general medical and psychiatry teams in a multicampus health care system worked together to care for patients in this virtual inpatient psychiatric unit. COVID-19–positive patients under a psychiatric emergency hold across eight hospital campuses were admitted to the medical unit and the virtual inpatient psychiatry unit simultaneously. While receiving care from the general medical team, a patient was also receiving virtual psychiatric care provided remotely by a multidisciplinary team of psychiatrists, nursing staff, social workers, and case managers.

Setting

This unit was developed in a multicampus health care system headquartered in Central Florida. It was implemented across eight hospital campuses, which all have emergency room services and medical floors. The largest campus has an acute inpatient 44-bed psychiatric unit that is designated as a “Baker Act receiving facility.” During the COVID-19 surge in 2021, when patients placed under the Baker Act with COVID-19–positive status could not be admitted to a psychiatric facility, our team began using preexisting telepsychiatry services to develop this virtual unit for COVID-19 patients.

Development

Because of the scarcity of psychiatrists, the psychiatry teams could not be physically present at each campus. In 2016, the health care system’s psychiatry service was awarded an internal innovation grant to develop and provide telepsychiatry consultation services. Before the pandemic, these services were mainly provided to hospital campuses in outreach areas, with some use of this mode of delivery on the main hospital campus. At the onset of the COVID-19 pandemic, the system already had a fully functional telepsychiatry service in place, which the team used to care for COVID-19 patients placed under the Baker Act in order to ensure safety while continuing to provide psychiatric care.

Operationalization

The psychiatry team consisted of the attending psychiatrist, nursing staff, social workers, and case manager. Serving as a liaison between the general medical and psychiatry teams, psychiatric nursing staff closely coordinated with medical unit nursing staff to ensure delivery of the psychiatric aspects of care, including deescalation and monitoring of the procedural aspects of the Baker Act. Case managers and social workers found placement options for those who continued to require inpatient psychiatric hospitalization but could be taken out of COVID-19–imposed quarantine. The staff explored outpatient resources for substance use treatment, psychiatric care, therapy, and coordinating care with families of patients who were ready for discharge.

The unit followed a sequence of patient admission, 72-hour hold, and discharge. Admission occurred in one of two ways. Either a patient was admitted through emergency services and placed under the Baker Act (e.g., a patient with a primary psychiatric illness, such as severe depression or suicidal ideation) or a patient had already been admitted to the hospital and was then placed under the Baker Act (e.g., a patient presenting with a general medical condition, such as exacerbation of chronic obstructive pulmonary disease, was admitted to the medical floor and then reported severe depression or suicidal ideation). This unit ensured that COVID-19–positive patients placed under the Baker Act did not need to wait for placement and would get psychiatric care as quickly and efficiently as possible. These patients were included in a virtual inpatient patient list, which covered the eight hospital campuses and was regularly updated and shared among the members of the psychiatry team. Patients with COVID-19–positive status, including those who were asymptomatic, were admitted to medical floors that could adhere to infection control guidelines. The patients’ other general medical conditions were managed by the medical team consisting of a primary hospitalist, nursing staff, and case manager on the floor.

During the 72-hour hold, patients who tested positive for COVID-19 were admitted to the general medical unit. A patient received the initial visit by the multidisciplinary psychiatry team, followed by continued daily virtual visits by this team.

Standard Baker Act admission procedures for patient safety were followed. A one-to-one observation status was arranged for every patient. The patient’s room was modified to remove objects like sharps containers that would pose a potential safety hazard. The same safety precautions as in psychiatric units were followed for food trays. Patient belongings were stored in a secure location with the help of the unit charge nurse. During pre- and midshift briefings conducted by the charge nurse together with psychiatry nursing staff, nursing staff on the general medical unit were regularly updated on and reminded of personal safety precautions when caring for patients admitted under the Baker Act.

General Medical and Psychiatric Treatments

Patients were assessed and treated by the admitting general medical team in person and received treatment for COVID-19 and other general medical conditions as applicable. Moreover, a telepsychiatry device, consisting of a tablet connected to speakers and attached to a stand with wheels with an adjustable angle for optimal two-way video and audio communication, was utilized for virtual psychiatric visits and consultations. Microsoft Teams was used as a HIPAA-compliant and secure videoconferencing software. The multidisciplinary psychiatry team would meet virtually every morning to discuss each case and formulate a tentative treatment plan. The team would then meet with each patient virtually. For new patients, the attending psychiatrist would take a thorough history, do a mental status examination, obtain collateral information from family members, and engage in shared decision making by discussing the treatment plan with the patient. Psychotropic medications were started as applicable to stabilize psychiatric illness, and patients were closely monitored for adverse effects or drug interactions. For patients unable to participate meaningfully in rounds, information about their behaviors was obtained from nursing and observation staff. Follow-up evaluation for each patient was conducted daily, and medications were titrated as required to manage symptoms. The team would also discuss plans with patients for future care. Apart from psychiatric medication management, patients had access to chaplain visits.

Discharge Planning

After the 72-hour hold, patients were discharged in one of two ways. Patients were transferred to a traditional Baker Act receiving facility when COVID-19 management or isolation was no longer needed but psychiatric hospitalization was still required. Alternatively, patients were discharged by the psychiatric team when they had received adequate treatment for acute psychiatric illness during their hospitalization, leading to the Baker Act requirements being lifted. In this case, patients were connected with outpatient psychiatric resources. For a subset of patients, who continued to need both COVID-19 isolation and acute psychiatric care, Baker Act provisions were continued by asking the court to grant an extended period for inpatient psychiatric care.

Discussion

During the COVID-19 pandemic, telehealth care has been provided in diverse settings. The Centers for Disease Control and Prevention recommended use of telehealth services during the pandemic (7), and criteria and guidelines were relaxed so that physicians and patients could use telepsychiatry more extensively. To meet the compound needs of patients who had been placed under the Baker Act in Florida and subsequently tested positive for COVID-19, staff within a multicampus health care system developed a virtual inpatient psychiatric unit where these patients could begin receiving psychiatric care as quickly and efficiently as possible. This unit combined inpatient medical services with virtual psychiatric services delivered via telehealth.

This model of care blended aspects of consultation-liaison psychiatry and inpatient psychiatry in the following ways. First, patients were given aggressive treatment consisting of initiation and titration of psychotropic medications, even before they were cleared for psychiatric hospitalization by the general medical team. Second, the general medical and psychiatry teams coordinated their care. The psychiatry team was at the forefront for asymptomatic COVID-19 patients admitted to the medical floor for quarantine and waiting for psychiatric inpatient beds, while the general medical team was leading care efforts for patients with an active COVID-19 infection. Third, outpatient follow-up visits were scheduled, and treatment and aftercare plans were actively developed. Fourth, the care model involved family in care planning and court-ordered extension of inpatient stay as needed.

Health care facilities have taken extra consideration for psychiatric inpatients, and some have created a dedicated in-person psychiatric COVID-19 unit for patients who test positive (3, 8). Others have delivered care via telemedicine, such as tele–intensive care unit (ICU) services developed at Duke University. In this approach, severely ill ICU patients are treated by a team consisting of bedside facilitators and ICU physicians who could virtually assess patients and provide care, thereby decreasing exposure risk and preserving personal protective equipment (PPE) (9). Our approach was similar to this tele-ICU model but was used for psychiatric patients.

Although telepsychiatry has been used extensively for outpatient care, its use for inpatient care has been limited. We adopted the telepsychiatry model for the inpatient unit to meet the growing number of COVID-19 patients needing inpatient psychiatric care. This model of care has several advantages. It has the potential to expand or contract the virtual unit depending on needs, can provide psychiatric care in medical units across campuses rather than being limited to a Baker Act receiving facility, reduces COVID-19 exposure among staff, and enables judicious use of PPE.

Although one-to-one observation appeared to be expensive especially for asymptomatic COVID-19 patients, overall expenses were lower compared with those of a traditional in-person unit (data not shown). A single centralized COVID-19 unit would be more costly because of required infection prevention measures, such as negative-pressure rooms; hiring and retaining of staff, as well as contingency plans if staff members become sick; and transportation from various campuses with full isolation procedures. In the virtual model of care, patients started receiving simultaneous general medical and psychiatric care, leading to increased efficiency and cost savings due to overall fewer days in the hospital.

We note some challenges in the implementation of the virtual inpatient unit. Its operation placed additional demands on nurses’ time because they assisted with the devices and helped patients with hearing, visual, or cognitive impairments interact with the psychiatry team. Moreover, telehealth-delivered care requires a reliable Internet service. Not all patients initially felt comfortable talking on a virtual platform, and some patients needed interpreter services, which necessitated use of two devices.

Conclusions

The success of this virtual approach to caring for patients with COVID-19 who have been placed under the Baker Act highlights that a multidimensional approach has good potential for improving care efficiency. Future work may assess the efficiency of virtual inpatient psychiatric units and explore the development of additional virtual intervention modalities, such as synchronous telehealth for therapy and support groups (e.g., grief support) in inpatient psychiatry.