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Inside the Terrifying World of Psychiatric Emergency Rooms During COVID-19

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Megan*, a nursing assistant in Minnesota, ordinarily loves her job. Most days you can find her leading patient groups, doing one-on-one check-ins or sitting with a patient in crisis.

But that was before COVID-19, the new-to-humans coronavirus currently decimating hospital resources. As mental health symptoms worsen due to pandemic-related fears, Megan said she feels trapped in a “COVID echo chamber where there is no escape.”

She’s not alone. Across the country, another crisis brews, largely unseen, in inpatient psychiatric units.

“I feel like next to no one is talking about mental health in the context of COVID,” said Megan*, who wished to remain anonymous. “I think it completely went out the window. And I personally believe unless something radically changes, we will feel its effects for years to come.”

From unprotected mental health workers to a lack of basic hygiene for psychiatric patients and threats of retaliation for speaking up, we need to take a hard look at emergency mental health care now.

Here’s what your frontline mental health professionals told us about their experiences.

Hidden Dangers in Psych Wards

While efforts are in place to contain COVID-19 at hospitals, mental health workers say their units have been largely disregarded. Angela Allen, BSN, RN-BC, a psychiatric nurse in North Carolina, works in the psychiatric arm of an emergency department. After learning about COVID-19, Allen asked her manager about N95 respirators, a critical piece of personal protective equipment (PPE) along with gowns or gloves for her and her colleagues.

Allen was informed that professionals in the psych unit would not be allowed to use N95 respirators — these would stay locked up — because the psychiatric “population was deemed low probability of getting this disease.”

“We went round and round,” Allen told The Mighty. “I was like, ‘Do you feel good about that as a human being?’ And [my manager] said, ‘Yes, I trust our leaders not to let us die.’ So what do you say to that?”

In order to preserve PPE that’s in short supply, the Centers for Disease Control and Prevention (CDC) relaxed its guidelines on face masks. Prior to March 10, the CDC required at minimum an N95 respirator. Now its guidance allows for both face masks and respirators. The CDC released guidelines for decontaminating and reusing N95 respirators in health care settings, while the Food and Drug Administration (FDA) approved decontamination methods for face masks.

Considering how much we still don’t know about SARS-CoV-2, N95 respirators should be the minimum protection for all health care workers to reduce infection risk. A N95 respirator fits tightly around the nose and mouth and blocks at least 95% of airborne particles. Surgical masks don’t offer enough protection. These masks can keep out (or in) infectious respiratory droplets, but not potential airborne particles.

All of the typical guidelines, Allen said, have now been thrown out the window, leaving professionals and patients in the psych unit vulnerable to COVID-19. While every hospital is different, to get to Allen’s unit, mental health patients are admitted to the regular ER with everybody else. Here, patients wait to be seen and must be cleared medically before they are sent to the psych unit. In the meantime, they’ve been occupying the same space as those entering the emergency room with possible COVID-19 infections.

“Where I work, psychiatric patients have to go through the medical department first to be cleared medically to come to us,” Allen said. “So everything’s coming from where the COVID or suspected COVID patients are going anyway.”

Megan, the nursing assistant from Minnesota, explained that in her unit, nobody was wearing PPE. There was no signage letting workers and patients know extra precautions were necessary. The staff didn’t want to make the patients feel uncomfortable. As a result, Megan said she has likely been exposed to COVID-19. However, she cannot be certain since her hospital won’t test many people.

“If [a] patient was violent or aggressive and I had to do hands-on care (which I normally do to keep a patient safe for themselves and myself) I don’t have gloves or a mask,” Megan said. “I just gotta do what I gotta do to get the job done, and so I know for a fact that I have been exposed at the hospital.”

Inpatient psychiatric units are often unique because many typical items are banned to keep patients in crisis safe. Things like shoelaces or shaving razors may come to mind, but in Allen’s psych safe unit, prohibited items include soap dispensers. Allen said they have bottles of baby shampoo in the bathroom and newly added hand sanitizer at the nurse’s station. Hospitals are trying to follow the CDC’s guidance to maximize resources. But it’s not enough.

“[The CDC] relaxed the rules,” Allen said. “It’s laughable. It’s criminal.”

Concerns about infection risk aren’t unfounded. In South Korea, a psychiatric ward was locked down after all but two of its 100 patients became infected with COVID-19. Seven of those patients died. In Washington state in the U.S., 12 staff members and four patients at Western State Hospital, a psychiatric hospital, got COVID-19. According to Medscape, Western State Hospital staff blamed the administration’s poor infection control protocols for the outbreak.

Lack of Transparency and Support

Another frustration the mental health care workers we spoke with expressed was a lack of transparency from their institutions. Megan only became aware her hospital had its first COVID-19 case after reading about it in a news report. The daily updates she gets from her hospital system includes COVID-19 case counts, but not specifics. The hospital system spans four states.

“In all honesty, I would not put it past my hospital to not tell me if I had been directly exposed to COVID, either by mistake or just by plain laziness,” Megan said.

Allen also learned about changes to her unit’s PPE policy thanks to a news report. Initially, Allen heard from colleagues that PPE brought from home was not allowed. Community advocacy with the local media likely led to a change in hospital policy, but none of this information was ever communicated directly to employees. Staff read about it in the news along with everybody else.

Megan, who is also having a harder time managing her mental health, said she feels trapped by COVID-19 between her personal and professional lives. Meanwhile, the health system is doing little to provide meaningful support for its staff. Megan was given a crisis phone number and access to an “online class on stress.”

“When things started intensifying with COVID, we got an email from HR with a video saying that everything was fine and to self-care, but nothing beyond that,” Megan said. “In talking to my co-workers, this is the number one thing we all wish we had. Even just the waiting and the anticipation is causing a lot of frustration and panic.”

Challenges Delivering Mental Health Care

COVID-19, and the unique issues facing psychiatric units, presents a major challenge for delivering care to those with mental illnesses. This starts with decisions about hospital admission.

“When we do have a patient in crisis we always weigh the risks versus benefits of an admission,” Michelle Zaydlin, M.D., a psychiatry resident in Miami, told The Mighty. “The problem is right now the risks are very different from anything we have experienced before.”

Staff is limited on the inpatient unit, which means patients have fewer resources, Zaydlin said. Physical distancing requirements make delivering treatment activities like group therapy nearly impossible, while many health systems are prohibiting visitors for patients. Other programs designed to support people with acute mental health needs like residential, intensive outpatient and partial hospitalization programs are limiting admission and can’t easily transition to telehealth.

Both Megan and Zaydlin expressed concern that those who need emergency care don’t realize psychiatric units are still up and running. So much attention has been diverted to COVID-19 cases, those who need inpatient mental health services may be scared to reach out for help.

“I think a lot of people are afraid to seek hospital-based care, even in crisis situations, and people are left suffering alone at home,” Zaydlin said. “Mental illness can also be life-threatening so it’s important to remember that the resources are still there and available.”

What Went Wrong?

The lapse in ensuring mental health workers are protected during the COVID-19 crisis, like basic infection control measures, reflects larger issues with acute mental health care. Conditions also vary between hospitals. Zaydlin said she’s seen colleagues trying to navigate a lot of unknowns as best they can and trying to take proper precautions.

“I know our hospital, like a lot of other facilities, is promoting social distancing, hand washing and appropriate hygiene on the unit along with monitoring patients closely for fevers, cough and other flu-like symptoms,” Zaydlin shared. “It’s definitely a huge change for inpatient psych units.”

But in other psychiatric units, like where Allen works, relaxed infection control measures put staff and patients at risk. COVID-19’s high probability of asymptomatic virus transmission requires more stringent protective measures, not less. Dinah Miller, M.D., wrote in Clinical Psychiatry News that inpatient units aren’t typically equipped for infection control yet “the treatment of psychiatric illnesses involves more — not less — social interaction.”

Scott Zeller, M.D., vice president of acute psychiatry at Vituity in California, said that inpatient psychiatric care isn’t adequate in the first place. In the last 20 years, the number of psych patients going to the emergency room has increased significantly, while the number of available inpatient beds has decreased. Emergency rooms are not good places for people experiencing a mental health emergency — the ER can be disorienting and overstimulating. And, they’re not necessarily equipped to care for mental health patients.

“Historically, a lot of times … the psychiatric patients get the short end of the stick and ended up being the last to be seen,” Zeller told The Mighty, adding:

We think of psychiatric emergencies as equivalent in concern and severity as medical emergencies, and they deserve the same level of attention and efforts to stabilize. And not only is that a good idea, but it’s federal law.

Zeller and his team developed a model for crisis mental health care called the EmPATH unit. People experiencing a mental health crisis are diverted to an EmPATH unit designed to be soothing and more in line with what patients need. This includes a non-restrictive environment with comfortable chairs and faster access to providers. Zeller said he is working with one hospital to build out an EmPATH unit in just a few weeks to better serve psychiatric patients and increase capacity for COVID-19 patients at the same time.

As hospitals try to ramp up capacity and make do with scant resources in response to COVID-19, the issues with emergency mental health care are exacerbated. Prior to COVID-19, even psychiatric nurses would likely be disciplined or fired for not following proper PPE guidelines. Now, professionals are fired for speaking out about PPE shortages. Allen said it doesn’t matter who’s to blame for the state of inpatient mental health care right now.

“I’m not an administrator or a CEO. I don’t know. I don’t care. There’s no excuse for it,” said Allen, adding:

You’re asking health care workers to go fight a war with no armor, no weapons and the enemy is invisible. And it’s unacceptable. We signed up to take care of people. Most of us do it because we were called to do it, but we didn’t sign up to die doing it or to hurt someone else doing it.

Repercussions for Taking a Stand

In an effort to control the narrative, mental health workers along with their medical colleagues who criticize their institutions are now at risk of being fired. Allen founded a website, The Unmasked RN, to help other nurses like her anonymously share the conditions at their hospitals and know they’re not alone.

But outrage led Allen to take a powerful step and put her name to what she was seeing and hearing, regardless of the consequences. Her duty as a nurse, she said, is to protect patients. She wrote (and you can read her full letter below):

I am scared of losing a job that I love. I am scared of losing my income. I am scared that the corporate giant that employs me will find ways to make my life hell. I am scared that I won’t be able to practice nursing again.

And then, I decided to do it scared. I decided to do it because it is the right thing to do. I decided to do it because I am a nurse and it is my duty to protect my patients from poor or misguided health care from any source, even if, especially if, that source is a system of which I am a part.

Statement from Angela Allen: “Participating in this interview was a no-brainer… Choosing to do so publicly, rather than anonymously, was not as easy. I am scared of losing a job that I love. I am scared of losing my income. I am scared that the corporate giant that employs me will find ways to make my life hell. I am scared that I won’t be able to practice nursing again. And then, I decided to do it scared. I decided to do it because it is the right thing to do. I decided to do it because I am a nurse and it is my duty to protect my patients from poor or misguided health care from any source, even if, especially if, that source is a system of which I am a part. I have a duty to stand up to “the system” that is causing harm to my patients, to my peers, to my loved ones, to the community at large, and to me. I see this pandemic, this unprecedented challenge, as an extraordinary opportunity to change our broken health care system. To cut out the profiteering cancer that has invaded it at every level and for too long. To restore it back to health so that it can do what it should have been doing all along- healing people. This won’t happen if we remain silent. It won’t happen if, as a collective, nurses continue to allow hospital CEOs, answering to corporate shareholders, to dictate policy that disregards safety, science and best practice. As nurses, we are the checks and balances in health care. We are the tip of the spear. This moment in history is one that will leave this world forever changed. The way that it is changed will rely on our collective response to it.” — Angela Allen, BSN, RN-BC

The Takeaway

The lack of basic infection control measures and transparency in emergency mental health settings during COVID-19 provides powerful evidence that the current system isn’t working. Allen wants to make sure this crisis becomes an opportunity for much-needed change.

“There’s a very real chance that when this is over, everyone’s going to be so exhausted, and the economy, just everything that’s going to happen, that this gets swept under the rug,” Allen said.

“That’s not acceptable. We can never have this happen again.”

Header image via Juan Ignacio Rodríguez Moronta/Getty Images

Originally published: April 18, 2020
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