Research Article, Int J Ment Health Psychiatry Vol: 9 Issue: 4

Adaptation Protocol of a Portuguese Psychiatry Department in the Pandemic Context Caused by COVID-19

Pedro Felgueiras^*, Odete Nombora, Andreia Guimaraes Certo, Raquel Ribeiro Silva and Georgina Lapa

Department of Psychiatry, Vila Nova de Gaia Hospital Center, Vila Nova de Gaia, Portugal

*Corresponding Author: Pedro Felgueiras
Department of Psychiatry, Vila Nova de Gaia Hospital Center, Vila Nova de Gaia, Portugal
E-mail: pedro.felgueiras@live.com.pt

Received date: 15 September, 2023, Manuscript No. IJMHP-23-113834;

Editor assigned date: 18 September, 2023, PreQC No. IJMHP-23-113834 (PQ);

Reviewed date: 03 October, 2023, QC No. IJMHP-23-113834;

Revised date: 11 October, 2023, Manuscript No. IJMHP-23-113834 (R);

Published date: 19 October, 2023, DOI: 10.4172/2471-4372.1000234

Citation: Felgueiras P, Nombora O, Certo AG, Silva RR, Lapa G (2023) Adaptation Protocol of a Portuguese Psychiatry Department in the Pandemic Context Caused by COVID-19. Int J Ment Health Psychiatry 9:4.

Abstract

Keywords: Pandemics; Inpatients; Outpatients; Community psychiatry; COVID-19

Introduction

The limitations imposed by the new coronavirus implicated great modifications and adaptations in health services. Several strategies were delineated, politically and institutionally, by the entire world to overcome these difficulties [1]. Services that provide hospital psychiatric care have also had to respond to the challenges imposed by the COVID-19 pandemic, to maintain consistent treatment patterns and simultaneously guarantee patients and professionals’ safety. To achieve this, it was necessary to promote a culture that rewards initiative and capacitates teams to implement and upkeep changes that everyone understands and benefits from [2].

However, this represents a challenge considering the patient profile and the operationtal structure of psychiatry departments. The inpatient units for example, are particularly vulnerable to the dissemination of infectious diseases, considering the treatment depends on interpersonal relationships, group therapy and community interactions. Simultaneously, patients wander around, being incentivized to leave their beds and interact between them as part of treatment [3].

According to experiences of most hospitals, adaptive strategies must include good communication, a healthy work environment, flexible rules, dynamic infection control and the adoption of new technologies for the clinical service and multidisciplinary work. Additionally, proactive leadership, transparency and shared responsibility ethics are described as the main tools to build effective teams [2]. It was in this context that our psychiatry department decided to create a group of strategies and interventions to overcome the challenges imposed by the COVID-19 pandemic, considering the main objective of guaranteeing quality care to patients and safety for their professionals. Such strategies included organizational, logistic, clinical and even formative aspects, which are described in the present protocol.

Materials and Methods

In our hospital center, a comprehensive plan was devised to address these unprecedented circumstances. This plan was meticulously communicated to all staff members through informative bulletins distributed via institutional email addresses. Throughout the pandemic, these informative bulletins have been invaluable in relaying essential information, such as the latest guidelines from health authorities, safety protocols, and changes in hospital procedures. It served as a primary means of communication, offering guidance, updates, and instructions as the pandemic unfolded.

In addition to the informative bulletins, another key element of our pandemic response was the development of a contingency plan by the department of psychiatry. This plan consisted of a set of strategies that involved changes in the organization of the service, its activities, the care provided to users and the training of its professionals, and it was divided into care units of the department. It outlined strategies for supporting patients with pre-existing mental health conditions, as well as those experiencing new or exacerbated symptoms due to the pandemic-related stressors. Furthermore, it emphasized the importance of caring for the mental health of healthcare professionals.

We consulted all of these bulletins messages sent during the pandemic, as also as this contingency plan developed by the direction of psychiatry department.

Results

Contingency plan

Hospital contingency plan: The general plan for the adaptation to the pandemic context in the hospital center included measures at the level of healthcare practice and clinical service, and of the hospital functioning dynamics. Through informative bulletins, sent to the institutional email addresses of all professionals, recommendations were progressively divulged. These bulletins were also used to transmit messages of courage and appreciation to all professionals.

The hospital adopted some of the global measures and recommendations imposed during the pandemic, such as:

• Mandatory continuous use of surgical mask, with the exception of mealtimes, and the reinforcement of immediate use after these periods.

• Reinforcement of the systematic need to self-monitor temperature and alert signs and symptoms.

• Increased regularity of cleaning/disinfection of common use places and surfaces.

• During the critical period of the pandemic, there was a recommendation for services to reorganize – the working teams were reduced to an indispensable minimum, thus creating “mirror” teams.

• Non presential appointment preference in clinically adjustable and applicable situations.

• The need to maintain patients with masks on and reduce wandering inside the inpatient unit.

• The admission of “non-COVID-19” patients was able to be conducted in every available bed in the hospital considering that, at this period, the barriers between services was lessened.

• Reinforcement of the importance of responsible and judicious attitudes in the usage of Individual Protection Equipment (IPE), making available videos and explanatory protocols.

Contingency plan of the psychiatry department

The contingency plan developed by the direction of the Psychiatry Department was divided according to units. It encompasses a group of strategies that implicated changes at the service organization level, its activities of patient care and professional training.

Inpatient unit

This unit kept the totality of its 28 beds functioning. To do so, hygiene and safety measures were reinforced, the use of masks was mandatory to all professionals, as well as patients; professionals also had to use hospital uniform with daily renovation; the meals were conducted in shifts, with a reduced number of patients in each period in order to maintain predetermined physical distancing; a substantial reduction of participants in each period of group therapeutic activities, and when possible, in open spaces; restricting the number of visitors per patient.

The procedure of admitting patients directly from the emergency department, other hospitals or other units of the same hospital, included the need for a negative SARS-CoV2 screening. If there was a positive result, the patient would be immediately transferred to a COVID area inside the hospital center, where it would maintain the needed medical care and regular observation by the inpatient unit medical team. At the 5^th day of admission, all patients hospitalized with a negative SARS-CoV2 screening at admission, must repeat testing; on the other hand, the patients with history of COVID-19 with cure criteria for the disease that were hospitalized in the 90 days after the laboratory diagnosis of SARS-CoV2 infection, did not have criteria to undergo a new SARS-CoV2 test.

Concerning the care practice, the needed restructuring of the department included the inpatient unit in the way that teams started to work in a “mirror” system. Each team was divided in order to function in alternate wee ks, defined by a sche dule articulated between psychiatrists and residents. Concerning the evaluation of the clinical evolution of patients, there was a joined effort to immediately discuss any intercurrence or change in clinical or therapeutic course of patients, with a weekly conveyance of the clinical state of patients by telephone, between the resident of each respective team.

The limitations in patient evaluation, particularly in the inpatient unit, with the need for masks and distancing during the interviews, made it so that residents had to develop alternative ways to assure the therapeutic relationship (for example, reinforcing interventions by verbal language) and that conditioned the acquisition of additional competences.

With the evolution of the pandemic situation, the Electro- Convulsive Therapy (ECT) sessions were conducted only with admitted patients, maintaining the need for previous SARS-CoV2 testing, the outpatient activity was conditioned, with the patients having to initially undergo SARS-CoV2 screening at least 48 hours before sessions.

Day hospital

At the beginning of the pandemic period, in person sessions of the perfusion program (with diazepam or clomipramine) and therapeutic groups were canceled and the follow up of patients already integrated was conducted through daily telephone contact by a member of the multidisciplinary team. Simultaneously, an institutional email account was created, through which patients were able to share their doubts, symptoms or even occupational activities proposed by the Program of Intervention for the Integration in the Community (PIIC).

About a month and a half after the beginning of the pandemic, specific measures were adopted to receive patients once again. The maximum number of patients in the perfusion program and therapeutic groups was progressively reduced to assure the needed physical distancing. The timetable of the activities developed in the therapeutic groups was changed, being restricted to the morning period, avoiding the risk of contagion at lunch time. In May of 2021, with the improvement of the epidemiological situation, the schedule was extended to the afternoon period.

Every patient proposed to integrate the partial hospitalization regime had to present a negative SARS-CoV2 test to actualize their referencing. Additionally, patients integrated in therapeutic groups were tested weekly. Multidisciplinary meetings kept their normal functioning, but were conducted in spaces with larger dimensions, assuring the recommended social distancing.

In terms of training, all internships of professionals not related to the Psychiatry Department were disregarded, only allowing the continuity of internships already started, in order to maintain training quality patterns.

Concerning activities organized by the occupational therapy service, the main adaptation to the pandemic reality consisted of the need for each patient to frequent only one activity group, without the overlap of activities. Ateliers were reorganized in a way to maintain those that did not involve close physical proximity, or the sharing of didactical materials.

It is worth referencing that during the first phase of the lockdown these activities were suspended, with the follow-up of patients assured via telephone. An attempt to maintain the promotion of healthy lifestyles was made, with the challenge of continuing projects and activities that were divulged to the therapists via email or video sharing.

Projects made during the year 2020 were posteriorly used in a virtual exposition, one of the commemorational activities of the World Mental Health Day.

Outpatient unit

During the pandemic phase there was the need to also reorganize the Outpatient Unit. Priority was given to telemedicine, reserving the in-person appointments only for patients with more serious illnesses or in need of physical revaluation, and posteriorly to every first appointment.

However, after the more acute phase of the pandemic, subsequent appointments were once again preferentially in-person, with the possibility of maintaining the telepsychiatry modality, considering the clinical evolution of the patient, their preference and epidemiological curve of the pandemic. Hygiene measures of spaces of patient care, waiting and treatment rooms and appointment offices were reinforced, with a process of disinfection after each appointment. The number of people in the waiting room was reduced and the presence of escorts was forbidden, unless strictly necessary.

Additionally, the signaling of spaces and circulation rules were reinforced, favoring the close adherence to schedule times to decrease the time patients spent waiting in the department.

Specialized programs

Early Intervention in Psychosis Program (EIPP): The contingency plan that was applied to the EIPP, a program that assures the follow-up of patients after a first psychotic episode, encompassed the initial suspension of psychoeducation and family support groups, important activities in the therapeutic approach to this special population of patients. However, articulation with families was always maintained, especially in patients with more serious illnesses or increased risk of decompensation, by telephone.

The psychoeducation group restarted their activities with some adjustments. The number of participants was reorganized so that one element of the program team received in each meeting, four patient family members, one family member for each household.

Additionally, there was also the adaptation of the meeting space, with the determination of a more ample sized space, with a more adequate ventilation system.

The follow-up of patients in this program in the context of medical appointments was divided into in-person care in first appointments and telemedicine in subsequent appointments.

The scheduling of nursing appointments for the administration of injectable antipsychotics was made to coincide with the dates of medical appointments, to decrease the contact time of patients with the hospital space and consequently minimize their exposure to transmission risk.

Specialized Refractory Psychosis Program (SRPP): Despite the challenges, SRPP maintained the monitoring and follow-up of patients medicated with clozapine according to the “consensus statement on the use of clozapine during the COVID-19 pandemic” [4]. Appointments were mostly conducted through telemedicine and inperson only in cases with some degree of decompensation or in need of better supervision. The main objective was to maintain the hematological monitoring of the neutrophile count, guaranteeing regular clinical evaluations of patient mental state and excluding possible adverse reactions to the medication. Even with its limitations SRPP continued to admit new patients, always with the adherence to the safety norms imposed by the National Health Direction.

Liaison psychiatry: Liaison psychiatry adapted its functioning, prioritizing a hybrid model of appointments and support to different hospital services. Response to evaluation and observation requests by other clinical departments was given preferentially by telephone [5]. However, when there was the need to evaluate patients physically, the team would go to the units, always following the individual protection and infection prevention norms.

Community psychiatry: The Community Psychiatry unit adopted a consultation model of telemedicine with Primary Healthcare of the area, initially by telephone and posteriorly by videoconference. Then, a mobile phone was allocated for this purpose, which was kept operational even after the acute phase of the pandemic. Family medicine doctors contacted, and still contact, the community psychiatry team to discuss clinical orientations, in a concise and objective manner. The outpatient appointment in community institutions, another service offered by the unit, was also conducted through the articulation by telephone and webmail. Additionally, two training protocols with the local health center groups were developed. These consist of formations directed towards Family Medicine doctors. This activity, besides supporting clinical practice and reinforcing the training program of this group of physicians, contributed to the promotion of a greater connection between primary health care and the mental health service, which is incentivized by the National Mental Health Plan. It also allowed to enrich the training and curricular activity of the department’s psychiatry residents, considering that they were the responsible for the elaboration of protocols and conducting the formation sessions through videoconference.

Still considering the scope of this unit, in the context of the pandemic, psychoeducational pamphlets were made, directed towards patients and their families, with strategies to deal with emotional and behavioral challenges imposed by the pandemic and serve as an orientation guide.

Forensic psychiatry: Despite the limitations imposed by the pandemic, response to every diligence inherent to the fulfillment of the Portuguese Mental Health Law and information requests was was assured, giving priority to the most urgent cases and always following the safety norms imposed by the General Health Direction [6].

Emergency Department (ED): The teams in ED maintained its functioning, with attendings and residents. To reduce the number of professionals simultaneously present in the physical space of the ED, there was a temporary end of participation of other specialties’ residents, currently in internships on the department, in the evaluation of these patients.

Innovative projects

World mental health day: The commemorational theme for 2020 was “Mental Health for All, Greater Investment, More Access”. It is with particular relevance that we highlight the organization of the commemorations of the World Mental Health Day of our department, which adopted a digital format, somewhat innovative in our services, with the creation of a website where work made by patients was displayded. There was also the participation of a mixed coral group (patients and professionals) and also psychoeducational information [7].

Psychiatry department patient support line: To overcome difficulties of access to health care during this period, a Direct Support Line for Patients was created [1]. The Direct Support Line for Patients was available every working day from 9 hrs to 12:30 hrs, from the 22^nd April of 2020 until the end of the period of in-person activities suspension. It was maintained by 4^th and 5^th year Psychiatry residents, in connection with and supervision by attending from the department. Its dissemination was made through text messages to patients that had appointments scheduled in the period of in-person activities suspension. This resource allowed fulfillment of patients’ needs that presented with minor symptoms, identifying those that benefited from in-personal evaluation and reducing the difficulties in the management of the imposed social isolation and restriction to health care access [8]. It also allowed adequate triage of situations, avoiding unnecessary referencing to the emergency department.

Mental health support appointment: The appointment of support to professionals was kept active, with two attending from the department allocated to it. In the acute phases of the pandemic, this line was available daily from Monday to Friday, in a 9 hrs to 10 hrs schedule. Afterwards, the circuit for requesting a psychiatry appointment by a health professional consisted of sending an email to the electronic address designated for this purpose, with the scheduling of the appointment made according to the availability.

Training and scientific meetings: Despite the suspension of every clinical or formative meeting in the psychiatry department in the initial phase of the fight against the pandemic, in the beginning of the year 2021, an internal training program was created, directed to the residents of the department [9]. According to national (and international ) directives, regarding the reunification of elements in a physical space, this formative activity was conducted alternately, and frequently complementarily, via online or in-person. It also had the participation of residents from other medical specialties that were in internships in the department. This initiative was originated from the additional necessity identified by residents and attending concerning an internal formative moment, in addition to formation provided by the reference hospital of the geographical region, which was suspended at this period.

Department meetings were initially suspended, being reinitiated with limitation of participants and under a hybrid model, resorting to online transmission through the Teams platform for the participation of the medical residents on some occasions.

Discussion and Conclusion

Dealing with the pandemic brought opportunities for innovation and incentivized creativity, team spirit, multidisciplinary work, which certainly will become part of our new routines. It left us with the will to reinvent ourselves, implement new projects and amplify our field of reach, for the benefit of our patients.

It is worth praising the efforts of the professionals, particularly those of the inpatient unit, the most vulnerable place, which was able to maintain stability and commodity that acute psychiatry treatment demands. Still worth mentioning is that our inpatient unit was the only one in our hospital that did not have any positive case of COVID-19 in the 2020-2021 period, which would not be expected considering the profile of our patients and the difficulties they might had in adhering to the safety and prevention norms.

Undoubtedly, more than any norm, working with team spirit is the simplest way to manage and overcome challenges. More than ever, it was essential to have teamwork in controlling this pandemic, and it was a teaching moment that surely will remain as a positive experience that will prevail for the rest of our lives.

Acknowledgements

No acknowledgements to report.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

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