COVID-19: Secondary and specialist mental health settings

Explore below our guidance for psychiatrists and their colleagues working in secondary and specialist mental health settings. 

This includes Supporting patients of all ages who are unwell with coronavirus (COVID-19) in mental health, learning disability, autism, dementia and specialist inpatient facilities  a compilation of guidance, produced by the Royal College of Psychiatrists, NHS England and Improvement, the Royal College of Nursing’s Mental Health Programme and Unite in Health.

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Much of what exists in the NHS worker guidance on COVID-19  and on assessment and diagnosis and management of suspected and confirmed cases applies ton mental health settings.

Specific guidance on “Supporting patients of all ages who are unwell with coronavirus (COVID-19) in mental health, learning disability, autism, dementia and specialist inpatient facilities” has now been developed by RCPsych in collaboration with NHS England and Improvement, the Royal College of Nursing’s Mental Health Programme, the Royal College of Psychiatrists and Unite in Health (30 April):

People with mental health needs, a learning disability, autism or dementia should receive the same protection and support with managing COVID-19 as other members of the population. This will mean providing additional support, including by making reasonable adjustments to care systems and clinical practice.

Infection control prevention considerations

  • Testing should be expanded to all individuals admitted to inpatient settings. This includes preparing to cohort patients as possible COVID-19 cases who need to be admitted while they await a test result.
  • Standard infection control precautions (SICPs) and transmission-based precautions (TBPs) must be used when managing patients with suspected or confirmed COVID-19. Further guidance can be found in COVID-19 Guidance for infection prevention and control in healthcare settings  
  • Staff should use the PPE provided by their service for activities that bring them into close personal contact, such as washing, bathing, taking blood and administering medication
  • Case-by-case reviews will be required where any patient is unable to follow advice on containment, isolation and testing. Providers should decide the appropriate use of the relevant legal framework for each case, with support from medicolegal colleagues as required. Non-concordance with isolation represents a clear and obvious risk to other people. This should, in the first instance, be conveyed to the patient, helping them to understand the clinical reasons for self-isolation and testing. For further detail, see Legal guidance

Cohorting

  • Inpatient settings should reorganise wards/bays/en-suite facilities and staffing arrangements to separate these cohorts of patients, to maximise protection for the maximum number of patients. Specific local arrangements will need to be kept under regular review as the size and gender mix of these cohorts are likely to change over time; see Managing capacity and demand guidance.
  • Individuals with confirmed COVID-19 should be isolated as far as possible. If they do not have their own en-suite room, they should be moved to a side ward/bay at the earliest opportunity to reduce the risk of transmission. Where en-suite rooms already exist, providers should move people so that all COVID-19 cases are cohorted in one area. All rooms and individuals should be risk assessed before any individual patient is transferred. For further detail see Managing capacity and demand guidance.

Monitoring

  • Regular observations and key symptom monitoring should be completed and documented. The National Early Warning Score (NEWS 2) may be used to monitor the rate of physiological deterioration in individuals with suspected or confirmed COVID-19 cases (not appropriate for use in under 16s). Providers are encouraged to use appropriate, validated tools in specific populations, such as children and adolescents and pregnant women. Additional local tools such as Stop and Watch and Restore 2 may also be valuable in conjunction with NEWS2
  • When an individual’s needs escalate, they may need to be transferred in a timely way to an acute medical setting. Providers and CCGs should work within existing protocols for transfer to an acute setting. These protocols should support joint decision-making and ensure timely transfer and equity of access.
  • Individuals should be assessed for pre-existing conditions which would make them high risk if they contract COVID-19 (vulnerable groups  and those advised to shield), as well as their current general physical health, including COVID-19 signs and symptoms. Advice from physical health specialists should be sought where required. Additional consideration should be given to the known specific contra-indications of medications and their side effects in patients with COVID-19 and other infections.
  • Patients with a learning disability, autism or dementia and a co-morbid physical health condition may present with additional, softer signs or early indicators of deterioration, eg mood or behaviour changes, becoming unsteady when walking, increasingly tired, sleeping more, restlessness and agitation. It would be advisable to speak (where possible) to carers and those most familiar with the individual to assess and note in the patient record for future reference how the person usually presents when well.

Clinical management

  • In many cases, patients can be safely cared for in their existing mental health, learning disability and autism, dementia and specialist ward, depending on the availability and safety of local facilities and the competence of the staff team in each setting to assess, monitor and intervene in physical healthcare.
  • In some circumstances, transfer to a local acute facility may be necessary. Where required, an individual should be transferred at the earliest opportunity. All care and support provided should be in the individual’s best interests, with the aim of promoting positive patient experience and outcomes
  • Some providers will be able to deliver more advanced physical healthcare, depending on their configuration and available resources, including workforce and equipment. Where possible, community and district nursing teams should provide advice, guidance and support virtually
  • Overly restrictive practice, must continue to be guarded against. See corresponding legal guidance
  • Individuals and their families and carers as appropriate should be involved in key decisions about the patient’s care and should be provided with all relevant information in an accessible format.
  • Providers are advised to provide refresher physical health training (eg monitoring vital signs and the management of a physically deteriorating patient, or rapid upskilling from neighbouring physical health teams) to all relevant clinical staff so that they can provide some level of physical healthcare for people with COVID-19.

Palliative care

  • Where possible, providers should follow existing processes for patient transfer to an acute facility.
  • In some cases, transfer to an acute facility may not be possible, e.g. where an individual has deteriorated significantly and transfer would not be clinically appropriate. Any decision not to transfer an individual to a local acute facility for further treatment should be discussed with the individual, their family and carers, and possibly with the local ethics committee.
  • ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) forms should only be completed in appropriate circumstances where it is in the patient’s best interests and when the patient and their family and carers agree. If the person does not have capacity, then a due process of decision-making under the requirements of the Mental Capacity Act 2005 (MCA) should be completed. Advance care planning guidance is available here.
  • No ‘blanket’ treatment plans across a group of individuals, based on their diagnosis, age or care setting, should be in place. The legal frameworks of the MCA and GMC guidance on decision-making should continue to be followed. It is crucial that decisions are made on an individual basis even if the predicted outcomes are similar across patient groups. These decisions can be approached in a sensitive and timely way given the current situation.
  • A ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) order is purely clinical guidance for a decision in the circumstances of a cardiac arrest, and not for a decision regarding any other clinical interventions. A DNACPR order does not cover decisions about escalation in the context of COVID-19 or an individual’s end-of-life care needs.
  • Regular observation measurement should continue, including NEWS2 testing and food and fluid monitoring. Comfort and pain issues should be regularly reviewed. Palliative care support and advice should also be sought from specialists via telephone. Providers may wish to consider developing a shared protocol with local services around obtaining advice, guidance and support for the individual concerned. Friends, family and relatives should be consulted on a regular basis. Where appropriate, please refer to the Clinical guide for the management of palliative care in hospital during the coronavirus pandemic.
  • In line with government guidance on social distancing, conversations with friends and family members should take place remotely, which can be extremely difficult for the patient and their family. Digital technology solutions should be considered as far as possible, eg using video calls to keep people in touch, although for some older people, including older carers, voice calls may be more accessible.
  • Some mental health and learning disability nurses may not have provided end-of-life care before and may need additional training and support through this.
  • Guidance for infection prevention and control in healthcare settings should be followed for the deceased. All steps should be taken to clear the area and carry out the required infection prevention and control measures

This section of the guidance is in line with NHS England's guidance for managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages (published on 25 March).

Maximising capacity

NHS England have stated it will be necessary to consider the following when developing capacity plans:

  • Ongoing risk stratification and dynamic risk registers
  • Flexible approaches to deployment of workforce across different settings, e.g. mental health practitioners from community services moving into crisis teams, ensuring liaison psychiatry teams have capacity to support discharge, working with voluntary sector providers and using technology to provide remote professional access
  • Refresher training and upskilling staff on key aspects of physical healthcare
  • Standing down activity not directly related to care provision after risk assessment of the impact on safety, business continuity and the wider system, such as: non-essential education and training; audit activities; quality improvement initiatives; and reporting on targets where clinical input is required
  • Waiting times for routine and non-urgent care may be impacted. Patient and clinical safety should be prioritised.

NHS England have suggested that services consider using the CREST appointment/bed modelling tool to support capacity planning: http://dev.cypmh-model.nhs.uk/.

To both maximise the use of community insight and to draw on the insight and expertise of partners, response plans will need to be developed alongside patients, families, carers, voluntary community sector (VCS) organisations as well as neighbouring mental health, learning disability and autism providers. This will include planning within an NHS-led provider collaborative, with social care partners, criminal justice system, commissioners and education providers for children and young people.

Inpatient service planning

Discharge planning

  • All current inpatients should be reviewed to support safe discharge where feasible. This should be a case by case assessment of patients' needs and risks, in partnership with them, their family, carers and onward care provider where relevant. Discharge plans should reflect individual COVID-19 risks
  • Close partnerships with adult and children's social care services are essential to determine funding arrangements and care packages. Suggested approaches include: temporary budget pooling; enhanced capacity in intensive home treatment teams; and more frequent section 117 panels. 
  • Key transforming care activity for learning disability and autism inpatients should be maintained including community care (education) and treatment reviews (C(E)TRs).

Referral assessment

  • Providers should also review processes for assessment of referrals for admission. Referrals can be assessed using the care programme approach or C(E)TR multi-agency framework prior to admission with a robust review of community alternatives. C(E)TRs can be done remotely with digital technology.
  • Dynamic risk registers should be established in each locality for people with a learning disability and autism.
  • Providers will want to screen admissions for COVID-19 symptoms to ensure appropriate bed allocation.

Specialised service considerations

Across all specialised services, NHS England highlight that the following should be considered:

Demand and capacity

  • Understanding and oversight of regional and national capacity of specialised services is crucial
  • Systems for CAMHS inpatients and mother and baby units must be accurately maintained, with similar systems for other services in development
  • Closure of specialised commissioned inpatient services on precautionary grounds alone is not supported by NHSE
  • Temporary closures or moves to restrict admissions should be planned and agreed jointly with the relevant regional commissioning team. This will facilitate regional management and communication of capacity.

Access to services

  • Robust access assessment arrangements are important to ensure the most acutely unwell patients receive the care they require in a timely way. Specialised services should consider alternative approaches such as digital consultations and ensure access to appropriate technology is available
  • It is important to discharge as many patients as possible where it is safe and clinically appropriate, with an enhanced focus on delayed discharges.

Working together across the system

  • NHS provider collaboratives and other networks and partnerships should produce plans across relevant geographical footprints. Where partnerships with local independent sector providers can be further developed, this should happen as soon as possible to ensure best use of available capacity
  • Specialised inpatient services should consider redeployment of specialist community staff who have the skills to work in these inpatient settings and consider redeployment of other staff who may need a bespoke/rapid induction package
  • Estate and capacity should be considered flexibly when taking into account the requirements of specific provision
  • Existing relationships with stakeholders involved in delivery of care pathways should be further enhanced.

Cohorting patients

  • Cohorting should consider the specialist nature of services and needs of each patient group. Certain groups are particularly physically vulnerable, e.g. pregnant women, those with low body weight or underlying conditions, older people
  • Adult secure services, as an example, will need to produce detailed plans, evaluating how best to cohort patients while maintaining security and safety of patients, staff and public.

Patients receiving ECT are usually amongst the most psychiatrically unwell and are likely to be severely affected by a halt in treatment.

Given the potentially life-saving nature of the treatment, Trusts faced with difficult decisions should try not to withdraw anaesthetic staff from ECT lists without prior clinical consultation with psychiatric colleagues about the urgency of the scheduled patients.

As usual, psychiatrists should consider all other options before ECT.

NHSE/I have provided further information on continuing to provide ECT during the COVID-19 pandemic.

For further details on ECT during the COVID-19 pandemic, please refer to the ECT Accreditation Service.

For guidance on clinical practice relating to COVID-19 in Psychiatric Intensive Care Units, please refer to the following resources:

Patients with suspected or actual infection who go to hospital for treatment in an intensive care environment may experience their situation as traumatic. These experiences may have profound, and at times lasting, psychological and emotional repercussions even after the patient’s recovery from the physical illness.

  • Providers should adopt a trauma-informed approach, with particular consideration of the effects of staff in personal protective equipment (PPE) providing care and support to individuals, recognising the overall aim of reducing trauma.
  • Consider what can be done to make the environment less threatening and more familiar for the patient and provide them with as much reassurance as is feasible given the situation.It is also noteworthy that having a loved one in intensive care, is likely to be extremely anxiety-provoking or distressing for patients and their relatives. Where a patient dies, family members may suffer traumatic stress symptoms related to what happened to their loved one or indeed what they imagined happened to them.
  • For both patients, and their families, it is appropriate to make sure that they are actively monitored, in accordance with NICE guidelines, for a month or so after the patient recovers to ensure that their mental health is stable. Where someone is suspected of having a trauma-related mental health problem, they should undergo a thorough assessment and where necessary provided with evidence based care in accordance with NICE.
  • Trusts should be mindful that healthcare staff, family and carers may experience traumatic stress and/or grief due to deaths that occur. Active monitoring of these individuals should also occur and where such difficulties are severe and/or persistent, a full assessment and where necessary evidence based treatment should be provided.

Relevant papers on coping with traumatic stress in health settings can be found below:

This is in line with the NHS England guidance on managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages (published on 25 March).

Cohorting physically vulnerable patients

  • Providers should consider the feasibility of reconfiguring inpatient estate to create 'cohorted' wards to reduce the contagion risk among vulnerable groups. These include older adults with frailty, patients with a BMI of 40 or more, pregnant women, patients with an eating disorder and patients with physical co-morbidities
  • Providers are urged to consider enhanced physical monitoring and infection control measures on these cohorted wards
  • Flexibility in management of acuity and ward type restrictions (e.g. patients grouped by sex, age or diagnosis) should be evaluated, with records of decisions and ethical considerations maintained.
  • Providers will also want to consider whether enhanced mental healthcare may be needed to mitigate the impacts of isolation and the use of digital technology.

Flexible use of estate and independent sector collaboration

  • Patients with COVID-19 require single-room accommodation and access to their own bathroom, in line with PHE self-isolation guidance.
  • This estates reconfiguration may potentially span a group of providers, including independent sector, in a provider collaborative or local footprint.
  • Providers are asked to consider the following: how further single room accommodation for those with COVID-19 could be provided through independent sector partnerships; and whether modification of adult secure estate capacity is feasible to accommodate voluntary patients.
  • NHS England expects providers to: analyse and map current inpatient estate; identify gaps, risks and pressures; and develop contingency plans in partnership with other local inpatient providers.

Creating additional inpatient capacity

  • Providers are also being asked to evaluate whether any beds previously scheduled for closure could be retained or whether there are opportunities to reactivate mothballed wards.
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