You can find the latest national guidance from Welsh Government. This information will be updated.
*This guidance is consistent with UK-wide RCPsych COVID-19 Guidance for clinicians with several additions:
- Guidance for substance misuse and homelessness services from Welsh Government (27th March)
- How the NHS should manage hospital visitors during the coronavirus pandemic (22nd April)
- Hospital discharge services requirements (30th April)
- NICE guidelines to support the NHS and social care to respond quickly to the challenges of the coronavirus pandemic
- Guidance for medical practitioners on excess death provisions (8th April)
- Services under the Mental Health (Wales) Measure (21st April)
- Guidance for local health boards and independent hospitals on discharge powers under the Mental Health Act (21st April)
Mae'r wybodaeth hon hefyd ar gael yn Gymraeg, ar ochr dde'r sgrin.
Clinicians and other health professionals might need to work together to create clear and concise clinical decision tools to enable the allocation of care and treatment for community mental health patients/patients based on need. This framework might be useful when developing these.
Define patient groups by hierarchy of need
Identify those who are in high-need groups based on the following criteria:
mental health acuity
physical health acuity
accommodation/ home environment
support network (care package, carers, third sector services, community resources), and
other concerns/vulnerabilities (substance use, chaotic lifestyles).
Consider need by diagnosis:
psychotic illness, including puerperal psychosis (particularly those who may be adversely affected by incorporating the COVID-19 situation into their delusional beliefs)
intellectual disability and those lacking capacity
anorexia (who may also need enhanced support with physical health monitoring)
anxiety disorders and substance misuse disorders (who may suffer from withdrawal symptoms during periods of self-isolation), and
Consider the impact of medication: Patients on High Risk Medications, including:
High dose antipsychotic therapies (HDAT)
Consider the potential susceptibility to the virus for certain groups of patients:
Older adults particularly those over 70 years
People with severe and enduring mental illnesses who smoke, use alcohol and are in poorer physical health.
People with existing respiratory disease e.g. COPD and asthma, and people at risk of chest infestions
People who are also immunocompromised e.g. HIV positive/ undergoing chemotherapy
People who are malnourished for any reason (including anorexia nervosa and metabolic disorders) often have a reduced immune response and it may contribute to poor outcomes
People with substance use disorders
People with an underlying mental illness that means they do not adhere to self-isolation advice, such as delusional beliefs, chaotic lifestyles etc.
Complete RAG rating assessment/ zoning
Review caseload at least weekly for community mental health teams and daily for home treatment teams.
Consider whether there are local clinical or ethics advisory groups in place to provide advice on local policy and practice if helpful.
Vulnerable, high risk.
Frequent and preferably face to face contact [even if via window], or telephone/ online consultation if units are refusing visits
Include – Assertive Outreach Team, FACT, LAI and clozapine clinic
Moderate risks/ concerns.
Require regular monitoring and review – via telephone with option to step up to face to face if required
Generally stable presentation
Require telephone contact - need telephone review in place of face to face
Option to escalate
Managing care pathways with limited staffing resources
Consideration should be given to how to sustain continuity of treatment for different patients caused by unpredictability of staff absence and/or patient and staff self-isolation.
Local solutions are likely to be best for managing care pathways, because of the unpredictability of staff absence or patient and staff self-isolation.
Priority for delivery should be interventions that prevent crises as this is likely to have a significant impact upon demand for acute services.
Plans should be made to ensure medication treatment continues, which will require monitoring of mental and physical health, depot scheduling and supervised administration or oral medication.
Consideration should be given to whether a face to face interaction is needed or whether contact can be safely managed over the phone or via other visual technologies as per RAG rating. Services should progress the option for undertaking some assessments via indirect methods, such as tabletop reviews, review of video footage, telephone/telecon’s, skype etc to limit direct face to face contact/observations.
Local areas should agree and follow guidance for how best to assess mental state on the telephone. Consideration must be given to older people, or anyone who might be less likely to have access to technology or be able to hear well over the phone.
To sustain continuity of treatment for different patients and reduce demands on staff, clinicians should consider the resource implications when changing current treatment or care plans and take a calculated risk. Examples of decisions to delay, slowed or changes to reduce demands on staff include:
postponing new patient appointments for a memory assessment
patients requiring medication could stay on a lower dose and delay titration until staff can effectively monitor physical health to ensure it’s safe to change the dose provided this is clinically appropriate
patients deemed low risk in psychological therapy services could have treatment plans suspended or changed to telephone or skype if clinically appropriate.
Community mental health teams must determine how best to maintain contact in order to support ongoing assessment of these patient groups.
Keeping patients and families informed
Healthcare professionals should consider how best to update patients and families about what might be changing during the pandemic via regular contact.
Try to ensure provision of easy read/video/alternative media to convey information. Consider a central hub of easy read material themed into relevant areas.
Services/personnel should consider practical instructions on what to do in relation to COVID-19 i.e. people with dementia who may not know what a distance of 2mtrs is for social distancing, for example.
While specific guidance relating to COVID-19 is being developed, much of what has already been on the NHSE worker guidance on COVID-19 and Welsh Government will apply to working in mental health settings.
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, Health Boards 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.
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.
- How the NHS should manage in-patient visitors during the coronavirus pandemic. (Welsh Government)
- Guidance to assist critical care staff in surge response to coronavirus. (Welsh Government)
- How we will make additional critical care capacity available to meet demand as safely as possible. (Welsh Government)
Working with The Royal College of Nursing we have outlined some relevant advice for staff working on mental health inpatient wards.
How should we keep the ward community together?
Every ward is a community of people – staff and patients. As much as possible, this community should work together to best ensure the safety of everyone. But we cannot expect “business as usual” at this time. Each ward will have to find a way to focus on physical safety and infection control as the main priority. Key to managing this will be ward cohesion, communication and adapting as a community within local services.
- Inpatient wards treat people whose mental health needs cannot be met in less restrictive settings out of hospital. The present situation gives an added dimension to this decision and teams, patients and families will need to work together to best protect the ward from COVID-19 infection.
- Many of the familiar routines associated with ward care will need to be reviewed. All activities that bring people into close contact will need to stop altogether or be adjusted to meet national guidance. Ward groups, ward rounds, mealtimes and visiting times should all be reviewed to allow for as little contact as possible. It is anticipated that much of this routine will be postponed on wards for the foreseeable future.
- However, removing all ward activities is likely to be counterproductive. People who are restricted can become bored and agitated and require restraint or other restrictive practices. Wards should consider adapting communal activities to reduce duration, unnecessary attendance and increase personal space. Activities such as mindfulness/relaxation groups, dancing/exercise, karaoke and 1:1 meetings can all be done whilst maintaining the recommended two metre distance. Any such activity will have benefits in keeping up staff and patient morale and increase ward cohesion.
- Each ward community should work on keeping communication between staff and patients as good as possible through notice boards, written communication, smaller group or individual meetings and even text and digital messaging within the ward. As stated, meetings can still be carried out provided personal contact is avoided and adequate distancing is able to be maintained.
- Latest government and national guidance should be easily available to all and the whole ward encouraged to stay informed of the situation as it develops. Staff should be clear about rules that are being imposed from national advice and that must be followed by all. Staff should always also model this advice.
- Patients are active agents on wards and should be included as much as possible in assisting in the restructuring of activities and ward routines. Many can and should advise on what they need to stay informed and be included in decision making.
- It is anticipated that there will be high levels of anxiety in the present situation. Good mental healthcare staff are highly skilled in the management of anxiety, both their own and other peoples. It is important to remain confident in your ability and ensure that principles of mutual support and team cohesion remain a cornerstone of your care.
How should we deal with visiting and visitors?
Please follow the below visitor guidance as issued by NHS England (PDF).
We are asking the public to limit visiting and to consider other ways of keeping in touch, like phone calls.
Visitors must be immediate family members or carers.
They should not visit any health and care settings, and this applies to all inpatient, diagnostic and outpatient areas, if they are:
- unwell, especially if they have a high temperature or a new, persistent cough
- vulnerable as a result of their medication, a chronic illness or they are over 70 years of age.
Visitors should be limited to one per patient unless:
- the patient is receiving end-of-life care
- the visitor needs to be accompanied – accompanying visitors should not stay in patient, ward or communal areas, and this applies to inpatient and outpatient settings
- they are a partner and birthing partner accompanying a woman in labour.
No children under 12 should be visiting without the ward sister or charge nurse’s prior permission.
Hospitals and other health and care settings will restrict visiting to one hour per day at designated visiting times.
Slightly different rules apply to paediatrics and neonates – two visitors are allowed and this may include a child under 12. Paediatric trusts can use their own discretion on visiting hours.
We ask for the public’s help in respecting these rules.
What about infections on the ward?
Given the nature and spread of the infections, it is highly likely that every ward will have a member of the ward community display symptoms at some point.
At present the most common symptoms are fever and persistent dry cough. Most people will experience mild to moderate symptoms while a smaller number will have symptoms that have to be managed in a general healthcare setting. Managing infection on a ward should mirror the steps taken in the wider community both in trying to prevent spread and the management of any infections.
- Wards should exercise the principles of social distancing across the ward community. This means minimal contact and an advised distance of two meters. The need to limit contact between individuals should be clearly communicated to patients and staff.
- Careful and sensitive management of patients who experience symptoms of the virus while on the ward will be essential in the coming months. While it will not be possible to turn mental health wards into full isolation units, it will be necessary to take appropriate steps to isolate patients with mild symptoms on the ward.
- If symptoms do not resolve after 7 days, or the patient deteriorates, there will need to be a review of their safety on the ward. Each local area will need to develop a local agreement on the management of severe cases which will include transfer to a general healthcare environment. Teams should provide support and advice to general healthcare colleagues in these situations and continue to monitor the patient’s progress with a view to returning them to the ward should they improve.
- Wards that provide single rooms with en-suite facilities for patients should encourage patients to remain in their rooms as much as possible. We are aware that this is contrary to the normal running of a ward and staff and patients are encouraged to find creative ways to adjust to this. As with mobile phones, this may require rules and restrictions to be relaxed, such as allowing patients to eat, make phone calls or watch television in their rooms.
- Wards that have single rooms without toilet or showering facilities will need to proactively plan to manage personal hygiene. While this may require the use of commodes or planned bath and showers, these plans should consider the routine cleaning of the equipment that is needed and may require supervision. All such plans should be clearly communicated to patients.
- Wards that have dormitory accommodation should make specific plans for the management of infection control in these areas. If a patient in these areas were to display symptoms, they will need to be moved to a private area. Local services should identify provisional plans for this eventuality.
- When a patient does display symptoms, they should be managed in a private room under local infection control guidance. If this is not possible for any reason, this should be reported immediately to senior management and this should be treated as an emergency.
- Family and carers should be informed as soon as possible if any patient display symptoms and is placed in isolation on the ward. Any person who has visited the patient 7 days prior to the onset of symptoms should also be informed and advised to self-isolate in keeping with national guidance.
More detailed information can be found on the RCN website.
What about routine mental healthcare?
There is no doubt that providing even basic treatment for patient’s mental health needs is compromised in the present crisis. The provision of specialist services such as occupational therapy, psychology or pharmacology is secondary to maintaining their physical health in the present situation. However, given the nature of wards, patients will still require basic mental healthcare.
- The basic principles of care should be to provide at least minimum care to each patient according to their needs.
- For many patients this will mean being given the same information as the general public and assisted in following the advice given. Much of what has been discussed re communication and access to networks is to alleviate any deterioration in mental health. We cannot shield patients from the anxiety presently experienced in society, but we can make every effort to include them in planning and management of the situation.
- Patient ongoing mental healthcare will need to be reassessed. Again, wards should consider carrying out some care meetings via phone or video depending on the resources available. This should includer any ongoing 1:1 psychological therapy.
- Patient leave from the ward, either escorted or unescorted, will require additional risk assessment depending on patients’ exposure to symptoms. Where possible, leave and time off the ward should be maintained. If it is not possible this should be clearly communicated to the patient including the process for review. Escorted leave should be individual and follow the guidelines of social distancing i.e. staff are advised to only escort 1 patient at a time and to maintain a two metre distance.
- If a patient displays COVID-19 symptoms, their physical healthcare takes priority. This may require a postponement of any therapies and a revaluation of any medications in line with advice from Pharmacy departments. As far as possible therapy should be continued via phone when patients are in isolation.
- It is not possible to provide guidance for every complication in individual treatment, but ward staff should be assisted by the wider MDT in the management of issues as they arise. Each patient should have a minimum of a weekly MDT review. If they display symptoms there should be a daily review of their care.
- As mentioned above, wards should try and maintain some group activities with adjustments to maintain morale, communication and provide reassurance to patients.
- One area that staff and patients will need to be clear about is smoking. In the present situation staff and visitors will not be able to escort patients for smoking or so called “fresh air breaks”. This will need sensitive communication to patients and should be backed up with written information or posters. As COVID-19 attacks the lungs, patients who smoke should be encouraged to give up smoking as a priority at this time.
What can I expect from services around me?
- Ward staff, organisations and national bodies are facing unprecedented challenges. It will be important in the coming months for organizations to work to assist those staff and patients on the front line by anticipating and planning for issues and being responsive to issues as they arise.
- All organizations should create specialist clinical committees to assist wards to manage the current challenges. Those committees should be chaired by senior clinicians and should have a direct line of communication to and from all ward managers and frontline staff and patients.
- These committees should be available to problem solve issues that teams face as the pandemic progresses and should be the central point of communication for national guidance and contingency planning. The chair of these committees should be identified as the central point of communication for all national bodies providing guidance to ward.
- The committees should either have a subgroup to consider any ethical dilemmas individual patient care or have this as a standing item of business and follow national ethical guidance (due to be issued soon - this page will be updated as soon as possible) ward should be clear on how to seek advice about patient care through this route.
- Organisations should cancel all non-essential meetings or release front line staff from attendance at such meetings.
Liaison psychiatry services
RCPsych, RCN, NHS England and Unite’s Mental Health Nurses Association have worked to develop these guidelines which set out the key issues that liaison psychiatry staff teams should be conscious of at this time.
Guidance for liaison psychiatry services
Acute hospitals are rapidly responding to the challenge of COVID-19 with radical operational changes. Corresponding system-wide changes are underway in mental health and social care provision which aim to care for all except the most acutely physically unwell outside of the acute hospital.
Liaison psychiatry services are integral to adapted acute care pathways and will have a key role to play in contributing to system wide planning in their local areas.
Liaison psychiatry services remain essential to the functioning of the acute hospital with a key role in facilitating safe and timely discharges. However services need to be provided safely with teams minimising risk to patients, themselves and other with whom they have contact. Achieving this involves significant alterations to the way services are provided now and planning ahead will be vital to maintain service continuity in the coming months.
Areas will need to find solutions appropriate to their own circumstances, while following the guidance below which addresses four key areas:
- Clinical service prioritisation
- Alternatives to acute hospital Emergency Departments for patients presenting with primary mental health problems
- Service continuity planning
- Maintaining staff and patient safety
- Mental wellbeing of staff.
This guidance should be applied across the age and range of patient presentations, but specific responses will vary according to clinical need.
Clinical service prioritisation
- Prioritise activity which minimises patient exposure to infection risk and minimises delays of discharge. National guidance has been issued on hospital discharge service requirements while mental health needs are not explicitly covered, this liaison guidance document is consistent with this wider document on discharge.
- Prioritise moving patients with mental health presentations away from high-risk areas such as the emergency department or medical assessment areas to alternative, dedicated space where possible.
- If not possible then prioritise minimising risk to those patients whilst their mental health is assessed and managed.
- Service to inpatient wards should be maintained in order to minimise delays to safe discharge
- Services may consider developing their own local prioritisation processes consistent the principles within this guidance.
Alternatives to acute hospital Emergency Departments for patients presenting with primary mental health problems
- In seeking to moving patients away from EDs and high-risk areas consideration is needed of how to adapt appropriately according to local need and the local configuration of wider mental health services.
- Many acute services are rising to the challenge of maintaining patient safety at this time by setting up 24/7 urgent mental health telephone lines that are publicly accessible and these are being integrated with adapted acute care pathways.
- Where emergency assessments are undertaken off site, this will need to be planned with the wider mental health services including assessment teams, crisis and home treatment teams and others as relevant.
- Newly created off-site mental health emergency departments will require planning for:
- Location and facilities, including consideration of what degree of physical comorbidity can be managed
- Consideration of how a service can be delivered to both an offsite service and the general hospital, where there are still likely to be cases that require liaison psychiatry assessment and management
- Hours of work - 24/7 likely to be most effective where possible
- Staffing models – one model would be to have dedicated onsite mental health staffing, as for a ward, with more experienced staff from other services (e.g. CMHTs, Liaison Psychiatry, community assessment teams) undertaking assessments and possibly working across sites
- The degree of physical comorbidity and interventions that can be managed and what equipment would need to be available to support this
- Access to IT and administrative support
- Access to medication
- Access to pathology services
- Escalation protocol for patients with comorbid physical illness, including access to medical advice and when to transfer patients to an acute hospital
- Transport of patients between facility and acute and mental health sites (if not co- located)
- Access to assessments under mental health legislation
- Access to senior psychiatry advice
Service continuity planning
Liaison psychiatry services vary hugely in size, configuration, working hours, skill mix, and numerous other parameters, so no single document can provide all of the detail needed for every service. This section therefore sets out key overarching principles that services should follow:
- Protect and preserve senior liaison psychiatry expertise to the acute hospital in order to deliver the most effective support to hospital services
- Every service should design a continuity action plan which sets out how key activities will be safely maintained with reduced staffing numbers whilst preserving quality and skill mix
- Continuity action plans will vary depending on local contexts and may require collaboration between two or more acute hospital liaison services and across healthcare providers
Maintaining patient and staff safety
This section sets out principles to optimise ongoing staff capacity and reduce exposure to vulnerable patients and others
- Decision to undertake face to face assessment should be made on clinical need. Minimising face to face contact is especially important when patients are in a higher risk category for COVID-19 infection e.g. older patients, those with compromised immunity or significant physical comorbidity.
- Where face to face assessment is clinically indicated, liaison psychiatry staff should be supported by their organisation(s) to practice safely. They should be given the same access to relevant PPE as other services in the acute hospital and be supported to follow national and local guidance on safe working practices
- Whilst at work maintain social distancing. This will involve changes to working practice likely to include:
- Minimising face to face meetings
- Reviewing administration processes
- Reviewing use of office facilities and enabling remote working
- Exploring viability of telephone and video assessments
Mental wellbeing of staff
It is essential that it is recognised that liaison psychiatry staff and their colleagues in the general hospital are likely to be under significant pressure and to experience stress related to issues at both work and home and will require support.
- Within the limits of social distancing measures, liaison psychiatry team members should be encouraged to check how their colleagues are doing and to support each other. Specific team meetings, which may be held virtually, can be used to encourage reflection and provide mutual support.
- Senior staff should ensure that other team members are aware of where they can access support services.
- Senior staff should also be mindful that they are facing similar stresses to their staff and potentially additional pressures due to their roles and responsibilities. Such staff should role model self-care strategies to mitigate stress.
Liaison psychiatry services may be asked to contribute to the psychological support of hospital colleagues. However, services should be mindful of the stress that their own staff are experiencing and their own team resilience when considering what support they are able to provide for other colleagues.
- Essential patient care should take priority over the provision of hospital staff support.
- Where liaison psychiatry teams have the staffing and emotional resilience, they should consider using their expertise to either advise on or contribute to the provision of psychological support for other hospital staff, while remaining mindful of the need to also support staff within liaison psychiatry.
- Within a hospital, where possible seek to develop a coordinated approach to staff support using liaison psychiatry, staff counselling services, clinical health psychology and the hospital chaplaincy.
Welsh Government has published guidance within ‘COVID19: social or community care and residential settings guidance’.
All staff members to explain to the patient/carer the reasons for temporary change in protocol for carrying out telephone screening prior to home visits and that when staff do visit, they may be wearing PPE.
All staff to ensure they understand local arrangements for the supply of staff PPE equipment if required for particular community visits.
Prior to a home visit:
The staff member to make a telephone contact to the patient/carer to establish the physical health status of the patient/carer(s);
The staff member to ask the patient/carer
Do you have a high temperature/fever?
Do you have a new continuous cough?
Does anyone at your home address have these symptoms?
If the answer is yes to any of above this will be regarded as “symptomatic” for the purposes of this protocol.
Elicit when symptoms started/are they new symptoms? (Consider SU patients physical health history/baseline/Public Health Wales advice re have they recently returned from high risk countries, have they had any contact with someone with suspected or confirmed Covid-19).
Have they sought any medical attention/111/GP?
If SU patient/carer advises they are symptomatic carry out risk assessment as to whether the visit is essential for maintaining the SU patient mental and physical wellbeing i.e those patients in crisis/requiring medication;
If the SU patinet/carer is symptomatic, give advice (follow link for current stay at home guidance).
If in the case of a medical emergency where the patient is symptomatic for Covid 19 – call 999. Inform them that the patient is symptomatic for COVID19.
If visit is not essential – further to your risk assessment described above - do not visit.
Report to manager/RMO. Monitor with telephone contacts while care plan is established under COVID 19 advice. Update care plan confirming arrangements for maintaining contact and safe care.
If the SU patient/carer reports mild symptoms and a home visit is considered absolutely essential for safe delivery of care, arrangements to be made for staff to visit using PPE equipment. See section on the community below for advice on the use of PPE equipment in this setting.
If unable to make successful telephone contact prior to visit, try alternative methods of contact e.g. phone carer. If contact cannot be established and visit is not essential, do not visit, but continue to try to make contact. If home visit is absolutely essential, to carry out home visit as planned and complete doorstep assessment.
Role of Doorstep Assessment
If a doorstep assessment is deemed appropriate and after being undertaken there is a concern that the patient/carer has symptoms do not enter the home. Advice should be given to the patient. Carry out supportive contact remotely. E.g. telephone from car.
Older people are at increased risk of severe illness from COVID-19. Our current advice for psychiatrists and staff working in old age mental health services is:
For community services
Put systems in place to ensure the ability to respond rapidly to appropriate adjustments of care packages.
Ensure those at home with dementia whose care arrangements may be altered or who have to self-isolate are given understandable information which addresses their concerns and provides comfort. This is likely to take extra time. Consider using simple reminder notes or pictures for those with more severe dementia.
Be mindful of vulnerable older people who might be put at higher risk due to the social distancing (or reduced visits from hard-pressed social services). Consider what can be done to protect them by encouraging collaboration from local health, social care and third sector agencies.
Encourage them to seek support from friends and/or family members using regular phone calls and technologies if possible (such as WhatsApp and Skype).
Encourage them to undertake activities that will enrich them and their environment, such as learning something new. Encourage those with mild dementia to consider self-help activities such as relaxation and exercise.
Be mindful of older carers who may be particularly negatively impacted by the social isolation and are very likely to need increased support.
For acute hospital services
Older people with suspected or actual infection and their relatives may find being in an intensive care environment and/or being cared for by staff taking precautionary measures extremely anxiety-provoking or distressing. Consider what can be done to make the environment less threatening and more familiar and reduce the number of investigations, if possible.
Try to ensure that care staff are aware of non-pharmacological ways to address distressed behaviour.
Older people will often be at increased risk of delirium. Staff should be encouraged to consider risk reduction strategies early on (nutrition, hydration, constipation and pain etc).
The College has published a joint report, Coronavirus: managing delirium in confirmed and suspected cases, with the British Geriatric Society and European Delirium Association (available via the link under ‘Our reports and resources’).
For inpatient services
Review your procedures and plans for inpatient units.
Ensure that oxygen cylinders are available and that the physical knowledge and skills of staff are as updated as possible.
Check care plans reflect any updated lasting power of attorney documentation and advance directives.
The Old Age Psychiatry Faculty has also developed a list of specific, practical, suggestions for consideration by Old Age Psychiatry services, which we will add early next week.
This guidance seeks to supports teams in managing the particular challenges that the current pandemic of Covid-19 presents in the delivery of care to people with intellectual disabilities (ID). It provides advice on a range of areas that will be relevant to colleagues working in ID services and which they may find useful to share in clinical teams. A more detailed version of this guidance with references to other useful material will be available via our faculty page.
Guidance from NHS England on Managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages is available on the NHS England website (see pages 12-16).
Infection with Covid-19
People with intellectual disabilities are at greater risk of infection because of the higher prevalence of comorbid health problems and personal habits. It is important that families, carers and staff are aware of the risks to the person and reduce them as much as possible.
- Follow local and national guidance on reducing the risk of infection
- Follow national guidance on assessment and diagnosis,and management of suspected and confirmed cases.
- Encourage carers and family members to engage in regular hand washing
- Encourage families and carers to teach and support people with ID to wash their hands regularly
- Engage in social distancing while supporting the person
- Engage in telephone contact and use technology to maintain contact with people
- Have easy read information for people on preventing spread of infection, on self-isolation.
The practice of reducing social contact will have a direct effect on the delivery of clinical care by psychiatrists where clinical reviews often require the psychiatrist and patient to meet in person. To implement social distancing effectively, we need to consider what contacts are necessary to the tasks and to achieve specific clinical outcomes.
- Consider developing a register of people most at risk of COVID-19 infection and serious health complications as a result or consider creating a register of people at risk of placement breakdown.
- Follow Personal Protective Equipment (PPE) guidance for mental health staff.
- Use telephone contact and video conferencing technology with families, carers patients, and colleagues where possible.
- Be familiar with advice on using video conferencing safely and share in accessible formats with families and carers as far as possible.
- Use technology to review written records and prescription sheets.
- Reduce face-to-face contact with patients and carers.
- Maintain social distancing when meeting with patients, families, and carers.
- Co-operate with MDT colleagues on clinical and mental state reviews to reduce duplication of work and limit in-person contact .
- Reduce the number of professionals attending multi-disciplinary meetings by using other ways of sharing information, such as written feedback or teleconferencing.
- Support other carers/professionals who have direct contact to deliver the support skilling them up to do so where required and appropriate.
- Maintain good liaison with Social Care Services to support vulnerable people.
- Develop Covid-19 risk assessment as part of clinical care plans.
People with ID in in-patient care services are among the most vulnerable due to their intellectual disability. They are likely to have severe symptoms when infected with Covid-19. Controlling infection in congregated settings can be a challenge to staff..
Services will have to support patients and staff who develop the infection in order to reduce the risk of spread.
- Adhere national policies on managing cases of Covid-19 in in-patient services and develop and follow local policies
- Local areas should have dynamic support processes and ‘at risk of admission’ registers that help to identify those children, young people and adults with specific support needs.
- Local areas should review their processes and ensure they include everyone with intellectual disability autism or both.
- Local areas should identify children, young people and adults with ID who may be placed outside their local area in a residential special school or college, social care children placement or adult placement.
- Consider carefully if admission to an ATU is needed and the impact of admissions on services.
- Psychiatrists should support safe nursing environments when staffing is under strain.
- Support clinical staff in gaining relevant skills in managing people with infection.
- Maintain regular communication with ward managers and senior team members.
- Explore the use of technology when convening clinical meetings.
- Explore using telephone and video conferencing between patients and carers.
- Reduce the number of contacts at meetings and visits to wards.
- Be alert to a rise in the number of episodes of restraint and seclusion. Teams should continue to support safe care environments whilst services are under strain, including a minimum use of restraint and seclusion.
- Engage in active discharge planning to manage capacity in services.
Forensic Intellectual Disability Services
Covid-19 poses additional pressures to services for offenders with ID in supporting them in in-patient settings. The risk of infection is likely to be higher in congregated settings.
- Encourage use of technology to limit face to face contact, for example video-conferencing, to maintain family contact. Where such communication possibilities do not exist, units must prioritise setting up facilities for such communication as soon as basic safety precautions have been implemented.
- Manage contact with external professionals and solicitors by telephone or emails .
- Obtain Covid-19 status of service/prison from where the person is being admitted.
- Consider risk rating the Covid-19 status (for example using RAG rating) of the in-patient service, so that persons coming into the service are aware of the risk status.
- Consider increasing activities in hospital to replace discontinued activities.
- Adhere to local policies on escorted and unescorted leave from wards.
Mental health legislation
The Government has introduced emergency legislation to support the implementation of the Mental Health Act in England and Wales that will apply in Scotland and Northern Ireland through amendments to their relevant legislative frameworks. NB these changes are not yet in force. These pages will be updated as soon as changes are made.
- Be familiar with guidance on the temporary changes to the MHA in your jurisdiction.
- Where possible, apply current good practice for new assessments and reviews and renewals of current detentions.
- Document alternative processes in practice when assessing a person under the MHA.
- Changes to review tribunal operation in Wales can be found here.
We know that people with ID use psychotropic medication and the STOMP/STAMP initiatives seek to rationalise the use of medication. It is important that we adhere to these principles wherever practicable.
- Review and support non-pharmacological interventions as part of the person’s Positive Behaviour Support plan. Some primary preventative strategies may not be able to be supported due to staffing constraints and infection risks e.g. community outings, activities, shopping, visiting families, social groups, leisure, recreational, occupational, educational activities etc. This may mean that secondary and tertiary strategies will need to be used more.
- Support families and carers to maintain their current drug regimens.
- Liaise with family doctors and pharmacists to avoid disruption to medication supply.
- Use technology to monitor MARS sheets.
- Avoid overuse of medication where possible.
- Apply best interests framework where practicable.
- Consider how to safely administer depot injections and the frequency of dosing.
Further information on COVID-19 and psychotropic medication.
Community support services
Residential and Supported Living environments are likely to be under pressure on account of staff shortages due to illness or the need to self-isolate. Staffing levels will be stressed with the potential for whole group placements to break down at short notice.
- Maintain contact with families and carers by telephone.
- Support to community support staff by telephone or video calls to discuss clinical work and review patients.
- Use secure electronic communication for contact with GPs.
- Work with the clinical MDT to support paid and family carers.
- Liaise with Commissioners of services on people who are risk of placement breakdown and engage local mental health servicex to support community placements and avoid admission where possible.
Children and young people with ID are especially vulnerable to the impact of infection and
to changes in their care. Disruption to the routines of children and young people with intellectual disability and/or autism spectrum disorder can lead to significant increases in distressed behaviours.
- Consider creating a register of children and families most at risk.
- Maintain regular telephone contact with families.
- Be familiar with the schools that are operating.
- Support children and young people with information on Covid-19.
- Be aware of children who are returning to the parental home from residential schools.
- Make use of easy-read resources to help children and young people with adjusting to current changes in their environments.
Care (Education) and Treatment Reviews (C(E)TR) and safeguarding
The Care and Treatment Reviews framework operates in England to assist services in supporting people who are at risk of hospital admission and to review admissions that have taken place. NHS England expects CTRs to continue, advising services to consider creative ways to conduct the reviews.
- Engage with commissioners and care staff on implementing Care and Treatment Reviews .
- Commissioners should make use of technology to enable virtual C(E)TRs to take place with the input of usual participants, and to involve families, carers and patients in the process.
- COVID-19 guidance may mean that the way C(E)TRs are undertaken needs to be adapted but all local areas must continue to ensure that a process remains that fulfils this role. It is essential that a process remains for clear review and scrutiny before inpatient admission.
- As part of the C(E)TR , assess the person’s risk of infection from Covid-19 and support to protect them.
- The six to eight week commissioner oversight visits may need to be halted to prevent spread of COVID-19 but assurance to commissioners that people are safe remains the same.
- It may be difficulty to continue the Learning Disability Mortality Review (LeDeR) reviews at this time Local areas should consider how they communicate any pause in their LeDeR reviews with family members to reflect that this is due to unprecedented challenge in the system.
- For further information on specific guidance for community and inpatient C(E)TRs and safeguarding see pages 12-15 of NHS England guidance.
Mental health support
The impact of the pandemic on the mental health of people with ID and their families and carers is uncertain at present. Restriction in activities and the concerns of carers could impact upon the mental health of people leading to evidence of mental disorders and changes in behaviour.
- Offer direct support to patients and focused support to families and carers that will support the patient.
- Make use of all professional contacts as an opportunity to ensure patients, families and carers have accurate information on the risks of Covid-19 and how to minimise them.
- Enlist support from colleagues in the multi-disciplinary to work directly with patients and their carers.
- Work with MDT to develop innovative health and wellbeing resources for use at home by people with ID and by their families and carers.
Access to critical care for patients with ID
Where admission to a general hospital or critical care is required, support may be required for that person and their family to understand and manage the process.
NICE guidelines on critical care suggests frailty as a metric to guide access to treatment. It is important that a frailty scale developed for use in older adults does not result in disadvantage for people with intellectual disabilities who may have a greater stability in their presentation than is envisaged by the CFS.
- All patients should have a health action plan and hospital passport with details of underlying health issues that increase vulnerability to COVID-19 complications.
- Clinical staff in ID services to support the person and their carers during a hospital admission.
- Clinical staff to collaborate with Liaison ID nursing colleagues in acute hospitals.
- Advocate on behalf of people with ID for equal access to health interventions.
Working in the current environment with so many uncertainties and as a clinician with contact with families and patients at risk, can cause great pressure on your well-being.
- Maintain contact with colleagues especially where in-person contact is restricted.
- Be alert to the signs of stress in colleagues.
- Offer to assist colleagues when they are under pressure.
- Follow government guidelines on social-isolation.
The following information may change in line with national guidance. People who use drugs may be at greater risk from COVID-19 than the general population, for the following reasons:
Thus far, deaths and serious illness from COVID-19 seem concentrated among people who are older and who have underlying health issues, such as diabetes, cancer, and respiratory conditions. It is therefore reasonable to be concerned that compromised lung function or lung disease related to smoking history, such as chronic obstructive pulmonary disease (COPD), could put people at risk for serious complications of COVID-19. People with a history of problematic drug use have a significantly higher prevalence of chronic respiratory disease (asthma and COPD) than the general population.
Other risks for people include decreased access to health care, housing insecurity, and greater likelihood for imprisonment or detention in hospital. Limited access to healthcare places people with addiction at greater risk for many illnesses. If hospitals, clinics and ancillary health systems are pushed to their capacity, people with addiction - who are already stigmatized and underserved by the healthcare system - will experience even greater barriers to treatment for COVID-19.
Homelessness or imprisonment can expose people to environments where they are in close contact with others who might also be at higher risk for infections. Reduced stability due to unmanaged opioid dependence increases these risks.
Seperately, Welsh Government have also released guidance for substance misuse and homelessness services.
Other important considerations are:
Drug-related deaths and harm are at their highest on record.
Access to traditionally traded street opioids may be impacted by global restrictions on movement (as has already been seen in the street SCRAs/’Spice’ market) leading to a possible acceleration of the emerging synthetic potent opioids such as fentanyl and related analogues. If supply chains are disrupted, we may see more acute withdrawal from a variety of street drugs.
Services for the most vulnerable members of our community, such as homeless services may become more difficult to access or be completely unavailable. This may lead to an increased and unexpected demand on addiction services. Those with substance use disorders are also more likely to be immunosuppressed.
Therefore, we should consider people who use drugs as having the potential to be considered one of the high-risk groups with respect to COVID-19, and tailor our treatment delivery accordingly.
Our current advice for psychiatrists and staff working in addiction services is:
For individuals on Medication-Assisted Treatment (MAT)
The clinical priority currently is to safeguard delivery of life-saving clinical treatments such as opioid Medication-Assisted Treatment (MAT) such as methadone and buprenorphine.
Another priority area is access to harm reduction measures such as needle and syringe supplies for those who inject
Under normal circumstances these treatments are delivered in the community, require people to be able to move freely while feeling comfortable making frequent trips out of their home, and depend on other elements such as routine access to community pharmacies and reliable supply of essential medications.
As the external environment changes, it is likely that the disruption we are already noticing will increase and make it more challenging for individuals on MAT, particularly those on more restrictive MAT regimes, to continue receiving treatment as usual. We know that pharmacies have already started to restrict access for our service users due to reduced capacity and other reasons, even refusing to provide supervised consumption. This will probably become an even greater issue as the situation progresses.
People on MAT have raised concerns about frequent attendance at pharmacies, in some cases choosing to stop their treatment rather than increase risk of exposure and potentially put themselves or their loved ones at risk.
At this time, and wherever possible, it would be appropriate to consider relaxing the usual requirement for people to frequently attend community pharmacy, and to consider how treatment can be continued. Engagement with treatment in this population is challenging, so removing barriers to access and making treatment regimes acceptable to people will be a vital consideration.
It is almost always safer for opioid-dependent people to have MAT available to take-home, than to be off MAT and feel compelled to use street opioids with all the risks that entails. MAT does have the potential to cause harm if not taken as directed, but on balance is far more likely to benefit individuals. It is a lifesaving and harm-reducing intervention that is safer than using street opioids of unknown potency and purity. Safeguarding of children needs to remain a consideration.
Pharmacological considerations for people using drugs
Buprenorphine formulations are partial opioid agonists and have a better safety profile compared to full agonists such as methadone with respect to overdose. They are also less likely to cause harm to opioid-naive people should they be consumed inadvertently. This may be a more suitable option in situations where there are safeguarding concerns or other risks in the patient’s immediate environment.
The choice of MAT depends on individual circumstances, and choice is a key factor in adherence. Wherever possible continue the current MAT drug.
Consider providing individuals who already take-home medications with a longer duration of take-home medications. Two weeks supply could be considered and extended depending on external circumstances.
Robustly consider whether people on supervised consumption can move to unsupervised and be provided with take-home supply. In some places supervised consumption may cease to be an option, and its utility should be balanced against the risk of compelling people to make more trips out of the home than they would otherwise wish to do.
Take the opportunity to optimise dose as appropriate.
If only remote assessments are possible, and people are unable to have access to/provide a drug test – consider proceeding with buprenorphine titration based on an adequate assessment. This is unlikely to be possible for methadone but consider on a case by case basis.
Opioid detoxifications and dose reductions should be deferred, with people encouraged to maintain stability during this period of uncertainty. However, if individuals need to detox, then support accordingly.
If people are advised to self-isolate (but not treated in hospital) they could be asked to nominate an individual to collect the prescription on their behalf and could be provided with a longer supply of medication. If they cannot nominate an individual to do this, where possible, a member of staff could collect and deliver the medication.
The above should be supported with a) Provision of Take-home Naloxone b) Safe storage boxes c) Harm reduction advice d) Regular communication with first-line support.
Guidance for healthcare professionals on managing coronavirus (COVID-19) infection in pregnancy has been published by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives and Royal College of Paediatrics and Child Health, with input from the Royal College of Anaesthetists, Public Health England and Health Protection Scotland.
The guidance covers the most up-to-date advice on how coronavirus affects pregnant women and their unborn babies, how labour and birth should be managed in women with suspected or confirmed coronavirus, as well as information on neonatal care and infant feeding.
To supplement this, our current advice is:
For perinatal mental health services
There needs to be careful consideration of how pregnant women are assessed in community perinatal mental health teams following guidelines for community services. These services should continue to operate given perinatal morbidity.
A careful risk assessment should be undertaken on a case to case basis before planning a psychiatric assessment of a patient on a maternity ward prior to discharge, and only if women show symptoms of acute deterioration in mental state, or if there are significant safeguarding concerns that warrant a pre-discharge meeting requested by social care.
Women who are well and on a stable treatment plan should be discharged as soon as fit to leave hospital with their baby and be reviewed by their allocated perinatal care coordinator the following working day via phone or by virtual review preferably.
Perinatal services will continue to work closely with families to ensure that partners and families are aware of the importance of early detection and seeking advice.
Women who are under community perinatal services and who need a psychiatric review post-delivery should be seen as quickly as possible on the postnatal ward.
For mother and baby units (MBUs)
Psychiatric illnesses remain amongst the leading causes of maternal deaths. It is important that women continue to have access to inpatient mother and baby units. The benefits of joint admission with mother and baby, for physically well mothers, outweigh the risks. This can be reviewed on a case by case basis should the mother become physically unwell. The needs of co-parents need to be considered and this will be reflected in essential visiting.
Therefore, MBUs need to continue admitting mothers with babies with usual protocols for admission applying.
Pregnant women have received the advice to increase social isolation and so those admitted to the MBU should also follow this advice. This needs to be considered at the time of admission.
All professional contacts and meetings should be encouraged to happen virtually with exception of Mental Health Act assessments in line with guidance and the Coronavirus bill
Visitors to MBUs should be limited to partners, fathers or significant carers, with enquiry about possible symptoms and possible contact with those who may have COVID-19. Those who should be self-isolating will not be permitted onto the unit.
Discharge from MBUs must be planned safely, as it is less likely women will receive face to face home visits during this time of crisis.
If the mother has suspected Coronavirus:
She should be isolated in the MBU isolation area as arranged by local MBU infection control procedures.
A decision can be made about whether mother and baby remain on the unit based on the mother's wishes and case by case review.
Guidelines for contact with baby and breast feeding are as per latest RCOG guidelines
For women and children experiencing domestic abuse:
For women with domestic violence issues, please see the guidance published by Women’s Aid
Support services for women affected by:
Action on Postpartum Psychosis (APP) will continue their national peer support services throughout the outbreak. The APP forum is available for people affected by PP to talk to other women and partners.
They offer one to one peer support for anyone in the UK, where people are paired with an APP coordinator with lived experience, or a volunteer peer supporter. They offer one to one peer support via email, private messaging on the forum, or via video call. Their regional postpartum psychosis cafe groups will also continue via video call. People personally affected by PP (woman, partner, family members) who would like to access this support should email email@example.com.
Maternal OCD provides guidance and resources for coping with COVID-19 for people with perinatal OCD
Beat Eating Disorders provides resources for people with eating disorders during the COVID-19 pandemic.
Depression and other perinatal mental illnesses
The PANDAS Foundation provides support and advice for any parent and their networks who need support with perinatal mental illness.
Anxiety UK offers support, advice and information on a range of anxiety, stress and anxiety-based depression condition via email, text and live chat services.
Guidance for families
Guidance for parents and carers on supporting children and young people’s mental health and wellbeing during the coronavirus (COVID-19) outbreak.
The advice is to help adults with caring responsibilities look after the mental health and wellbeing of children or young people, including those with additional needs and disabilities, during the coronavirus (COVID-19) outbreak.
The Royal College of Paediatrics and Child Health (RCPCH) has released guidance for Children and Families on COVID-19.
It contains some links on helping children cope with stress or who are worried about coronavirus and highlights tthat if your child has a medical condition it is important that they continue to access treatment and attend medical appointments as recommended by their hospital, GP or healthcare professionals.
This is in line with the Welsh Government guidance for substance misuse and homelessness services, last updated on 27th April.
Further College guidance will follow in due course.
The best local solutions should be sought to enable the proper management of non-elective patients with alcohol dependence in need of care. It is acknowledged that societal factors arising from the current circumstances may result in an increased number and frequency of patients presenting in acute alcohol withdrawal. Patients with alcohol dependence are a vulnerable group due to the high prevalence of co-morbid physical and mental health problems.
Categories of people with alcohol dependence to consider
- Emergency department presentations - focus on minimising harm and reducing re-attendance, taking individual risk factors and clinical need into account
- Obligatory admissions and inpatients to acute trusts - patients with complications of alcohol withdrawal and underlying conditions continue to require admission and medical management. Early identification at triage is essential to optimise treatment and expedite discharge
- Obligatory admissions and inpatients to mental health trusts - patients with serious mental disorder and co-morbid alcohol dependence continue to require admission and management. Early identification on admission is essential to ensure appropriate management and expedite discharge.
- Secondary mental health community services - patients with co-morbid alcohol dependence presenting to and managed in community mental health services will require more integrated management to reduce crisis presentations
- Primary and community care - patients presenting to these services or NHS111 should be offered harm minimisation advice and signposted to community addiction services.
Three areas are identified for particular consideration when planning local responses. These are:
- Each acute and mental health trust should designate someone as COVID-19 alcohol lead with appropriate skills from within available workforce. They will be responsible for specialist support to staff in relation to protocols for the safest patient management and pathways to partner agencies.
- Alcohol leads must be competent to offer guidance on current best practice specifically relating to (not limited to) alcohol-dependent patients presenting with: COVID-19 and risks of respiratory depression during medically assisted alcohol withdrawal; complicated severe alcohol withdrawal; and co-morbid opioid use.
Emergency department presentations
- Referral for mental health assessment where appropriate
- Consistent harm minimisation and signposting to available resources if admission not required. Obligatory admissions and inpatients to acute and mental health trusts
- 5% of acute and 25% of mental health inpatient beds are occupied by someone with alcohol dependence. People with alcohol dependence often have multiple co-morbidities that put them at greater risk of severe manifestations of COVID-19 infection
- Alcohol lead to ensure: clear local/regional plans and policies for safe discharge into community; availability of clinical tools for alcohol withdrawal management; safeguarding of children and adults remains essential; integrated management of alcohol dependence, co-morbid conditions and coronavirus by non-specialist teams; and links with community addiction services to provide remote to those discharged if necessary.
Secondary mental health community services
- Co-morbid alcohol dependence is not a barrier to accessing mental health services
- Mental health services should maintain and optimise health of patients with co-morbid alcohol dependence throughout the pandemic
- Mental health staff should familiarise themselves with alcohol harm minimisation advice
- Many contacts can be performed remotely, which can also help to reduce crisis presentations
- Joint working with community addiction services should be established if not already in place
- Senior clinicians should support staff in risk management to prevent unproductive referrals to hospital attendance
- Seven-day services may need to be considered.
Welsh Government Guidance
Continued treatment with commonly prescribed psychotropic drugs (antidepressants, anxiolytics, antipsychotics)
Careful consideration should be given to whether now is the best the time to withdraw or change patients from antidepressant, anxiolytic or antipsychotic medication. In some circumstances this may be unavoidable due to clinical need but the clinical rationale should be carefully documented and arrangements for monitoring put in place.
For many patients it is likely that advice will be given to continue on regular medication until this can be reviewed in a face-to-face setting and the patient can be involved in shared decision making with their usual doctor or healthcare provider. This should take account of the fact that anxiety and depressive and psychotic symptoms are all likely to worsen during extreme stress and social disruption. Patients will be at increased risk of relapse or recurrence of affective and psychotic illness.
Advise patients to continue their current dosage until the changes in health care provision necessary during the COVID-19 outbreak have been reversed, and only then consider whether dosage reductions or withdrawal might be appropriate, in discussion with their usual doctors.
Benzodiazepines and/or rapid tranquilisation
Patients taking benzodiazepines and/or rapid tranquilisation should have increased physical health monitoring and this should be reflected in the patient’s individualised care plan.
Treatment with lithium in febrile patients
Febrile patients may become dehydrated and lithium levels may rise, putting patients at greater risk of toxicity. Look for signs of potential toxicity such as coarse tremor. If these are present obtain an urgent lithium level.
If there is any delay in obtaining a lithium level, pause treatment and obtain a lithium level as soon as possible.Ongoing treatment, and the dose used, should be governed by blood levels.Be aware that sudden discontinuation of lithium can be associated with a rapid relapse of symptoms, particularly mania.Use caution until the patient has regained physical health, with increased frequency of monitoring of lithium levels and renal function.
It is highly unlikely that during this period it will be possible to start patients on clozapine treatment safely unless normal haematological monitoring can be assured. There may be some rare clinical situations in inpatient settings where this is the right thing to do, supported by advice from the relevant clozapine patient monitoring service.
- Patients who are already established on clozapine should continue with regular blood monitoring whenever possible. Wear PPE and follow IPC procedures if a patient has symptoms suggestive of COVID-19 infection.
- If a patient describes symptoms suggestive of COVID-19, be aware that similar symptoms can arise from incidental (non-COVID-19) infections associated with neutropenia.
- Centralised monitoring of leucocyte and neutrophil counts for patients taking clozapine is mandatory. The frequency of blood testing and duration for which a blood test is ‘valid’, is based on the risk of clozapine-induced neutropenia and agranulocytosis. Dispensing or administering clozapine outside these durations (i.e. without a valid full blood count, FBC) is unlicensed.
- Normal monitoring of FBC for clozapine-treated patients may be unavoidably disrupted during the pandemic. Clinicians can request permission to extend blood test validity for individual patients in circumstances where clozapine might normally be withheld pending the results of a FBC. A local expert in clozapine use will review the request and respond with 48 hours. Local services must identify the local expert with responsibility for reviewing requests.
- The decision to supply clozapine outside the licensed duration of a valid blood test may be taken to meet the needs of a specific patient. The reasons for recommending and supplying clozapine so should be fully explained to the patient and documented in the patient notes.
- The three companies who supply clozapine have issued guidance about their brand of clozapine and Covid-19 virus. This information has been sent directly from each company to those pharmacies who supply their respective brand of clozapine. More details are available from firstname.lastname@example.org ( zaponex), Denzapine@britannia-pharm.com ( denzapine) and CPMS@mylan.co.uk Cloraril).
Key resources on clozapine:
- Clozapine and blood dyscrasias in patients with coronavirus (COVID-19)
- Clozapine - emergency protocol for patients on monthly monitoring
Patients with cognitive impairment
It is likely that people with underlying cognitive impairment will be at increased risk of delirium if suffering from COVID-19 related illness. It will be important when deciding on the best management plan (both non pharmacological and pharmacological) to consider all the relevant factors including risk to self and to others.
In this situation in the best interest of avoiding risk of further transmission of infection to others you may have to consider earlier pharmacological intervention if the situation warrants but be mindful of the need for physical health monitoring. Risk reduction strategies should be considered early on including careful review of any exacerbating factors such as anticholinergic side effects of psychotropic medication.
- If the patient describes COVID-19 symptoms, and is due to have their depot/LAI administered, consult the prescriber and consider an alternative short term treatment plan, such as deferring treatment for 2 weeks (if currently psychologically well and risk of rapid relapse is considered low) or switching to oral formulations (refer to guidance about dosage equivalence).
- If the decision is made to defer depot/LAI, ensure a clear plan/risk assessment is agreed and documented regards follow up with continued monitoring of mental and physical health, with the agreed date of when to review and next administer depot/LAI.
- If the patient describes COVID-19 symptoms but it is essential to administer depot/LAI, do so wearing PPE and follow IPC procedures.
- In all circumstances, ensure a clear plan is agreed and documented with patient/carer, care coordinator and the consultant responsible for the patient’s care (or their deputy) regarding follow up after depot administration and monitoring of physical and mental health symptoms. Ensure that colleagues in primary care are made aware of any changes to pharmacological treatment.
Other medication: Ibuprofen
While there is currently no strong evidence that ibuprofen can make COVID-19 worse, patients should be advised to take paracetamol to treat their symptoms, unless they have been advised paracetamol is not suitable for them.
If they are already taking ibuprofen or another non-steroidal anti-inflammatory (NSAID) on the advice of their doctor, they should not stop taking it without checking first.
Administration of medication to detained patients
For guidance on the administration of medication to detained patients, please refer to the section on Emergency legislation and the Mental Health Act.
For guidance on clinical practice relating to COVID-19 in psychiatric intensive care units (PICUs), please refer to the following resources:
This section of the guidance is in line with the interim national guidance already available for primary care services (NHSE), which offers four main principles:
identify potential cases as soon as possible
prevent potential transmission of infection to other patients and staff
avoid direct physical contact, including physical examination, and exposures to respiratory secretions
isolate the patient, obtain specialist advice and determine if the patient is at risk of COVID-19
Managing suspected COVID-19 cases during a consultation
If COVID-19 is considered possible when an IAPT session or outpatient consultation is already in progress, withdraw from the room, close the door and wash your hands thoroughly with soap and water. Avoid physical examination of a suspected case.
The patient, any accompanying family, belongings and any waste should remain in the room with the door closed. Advise others not to enter the room. If a clinical history still needs to be obtained or completed, do this by telephone. The patient should be asked to call NHS 111 from the room.
If entry to the room or contact with the patient is unavoidable in an emergency, wear personal protective equipment (PPE) in line with standard infection control precautions, such as gloves, apron and fluid resistant surgical mask (FRSM) and keep exposure to a minimum. All PPE in full should be disposed of as clinical waste.
When a telephone interview is being conducted with a patient located elsewhere (for example at home) and it is determined that COVID-19 is possible (based on the PHE criteria for a possible case), a face-to-face assessment in primary care (including out-of-hours centres and GP hubs) must be avoided.
Instead, call the local secondary care infection specialist to discuss safe assessment, if hospital care is being considered, if not refer to NHS 111.
This section of Welsh Government guidance includes registered residential care and nursing homes for people with learning disabilities, mental health and/or other disabilities. The equivalent guidance is available from Public Health England.
If a resident has symptoms of COVID-19 in a residential care home, key points include:
Implement isolation precautions in the same way they would if an individual had influenza. If isolation is needed, a resident’s own room can be used. Ideally the room should be a single bedroom with en-suite facilities.
Much of the care delivered in care homes will require close personal contact. Where a resident is showing symptoms of COVID-19, steps should be taken to minimise the risk of transmission through safe working procedures. Staff should use personal protective equipment (PPE) for activities that bring them into close personal contact, such as washing and bathing, personal hygiene and contact with bodily fluids. Aprons, gloves and fluid repellent surgical masks should be used in these situations. If there is a risk of splashing, then eye protection will minimise risk.
If neither the care worker nor the individual receiving care and support is symptomatic, then no PPE is required above and beyond normal good hygiene practices. General interventions may include increased cleaning activity to reduce the risk of the virus being present on hard surfaces, and keeping property properly ventilated by opening windows whenever safe and appropriate.
Other guidance for care homes on keeping people safe includes:
Use tools to report capacity for bed vacancies (such as Capacity Tracker or Care Pulse) to support system resilience.
Use tools for the secure information transfer, such as NHSMail where accessible.
Increase the use of Skype and other tools for secure virtual conference calls, to ensure advice from GPs, acute care staff, and community health staff can be given.
You are likely to be asked by your Health Board to consider which teams need to extend operational hours and explore options for alternative care models, including telecare and ‘hub and spoke’ models.
The guidance also sets out steps that the NHS and local authorities can take to support care homes. Clinicians will need to support this work.
Provided here is guidance for healthcare professionals working in low, medium and high secure hospital services, as well as those providing mental health in-reach services for prisoners and services to the courts or other agencies within the Criminal Justice System.
Secure hospital services in many areas will be able to draw upon general and mental health specific guidance, included those provided by the College, in terms of how it responds to COVID-19. However, secure hospitals (and especially so in high secure environments), there may need to be different approaches adopted in certain situations.
This section seeks to help services in responding appropriately.
It should be noted that safety advice and guidance in relation to COVID-19 is evolving all the time. Wherever decisions have to be taken that mean that significant extra restrictions have to be applied, every effort must be made to discuss these with at least one appropriately experienced colleague before continuing them beyond a few days, and the outcome of such discussion documented.
In prioritising services that must continue, the organisation must pay due regard to legal duties and also balance the impact of decisions on patient care against the risks associated with COVID-19. Please see further details in our COVID-19 ethical considerations page.
Staff must ensure that patients and their families have as much accurate, accessible information as possible about COVID-19 and are engaged as much as they can be with staff in providing the safest possible services.
Patients who test positive should be isolated. As far as possible this should be with the patient’s agreement and cooperation. If a patient lacks the capacity to understand the need for isolation, or declines to comply, then isolation may need to be enforced in the broader best interests of the patient as well as others. This is likely to be under the Common Law doctrine of necessity. The patient will require regular medical reviews whilst in isolation.
Every secure hospital setting should have a simple social distancing policy in place which is compliant with public health guidance and preferably drafted with the knowledge and acceptance of the patients and preferably co produced.
In secure forensic hospital settings the responsible clinician (or deputy) should ensure that there is a review of each patient’s pre-existing physical health vulnerability and consider any particular vulnerabilities for the circumstances as a result of their mental disorder. This will help to make patient level decisions when required. An example of the risk assessment is as follows:
- Refer to national guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.
- Does the patient have an underlying physical illness or anything causing them to be immunocompromised? If so, there should be a clear plan in place to provide extra protections and contingencies for that patient as far as possible.
- If the patient’s discharge were pending, is it still safe to send them home, taking account of the risks of covid-19 being in the secure hospital setting and risks of transmitting this at home/next placement and the potential risks of the next placement to the patient. If there is to be any deferral of discharge, this will have to be discussed sensitively with the patient and their family or significant others.
- If a patient’s discharge were not pending, is there any case for bringing this forward? This is unlikely, but should be formally considered in the interests of everyone’s physical health safety
- Should the patient require isolating, to what extent will s/he be able to cooperate voluntarily? What measures are in place to ensure cooperation for the few cases where there are difficulties in this respect?
- Is the patient on clozapine? What is the frequency of blood tests? When is the next one due? Which service can do clozapine blood tests in house?
- Can the patient have visits with family by Skype or by other interactive media? Can patients make free (or cheap) phone calls to family and friends? Where such communication possibilities do not exist, units must prioritise setting up facilities for such communication as soon as basic safety precautions have been implemented.
- It is really important that patients continue to have activities to occupy and divert them, and to stay fit or improve their physical fitness. It is unlikely that off-ward activities like OT can continue, but, as far as possible, occupational therapists should ensure an on-ward activity plan is available for each patient, which includes minimisation of any interpersonal interactions. Access to secure gardens must be planned to be compliant with public health guidance.
- All leave outside the secure perimeter must be reviewed with each patient who already has permissions for this in place, and a new plan formulated to ensure patient and unit safety. Any decisions about leave will need to be taken based on latest government advice at the time and analysis of benefits and risks for that individual patient’s recover. Please also refer to the guidance on this provided on the section on patient leave here.
Patient isolation because of COVID-19
Services should ensure they have made adequate arrangements in place to isolate patients where necessary because of covid-19 infection or suspected infection
All units should have access to covid-19 testing on demand (if tests are available) and there should be testing for patients who are presenting with symptoms now
- Patients who test positive should be isolated. As far as possible this should be with the patient’s agreement and cooperation. Those who do not comply with isolation should be secluded and the seclusion pathway be followed.
- Consideration should be given at that stage to what that means for the need for additional staffing on the relevant ward to reflect the need to care for both the isolated patient and those who remain on the ward.
- Any approach to staffing needs to be seen as a system wide prioritisation exercise. Secure services with need to be high priority and therefore in some situations be able to call on staff from outside their own services if there are significant workforce pressures. This will need to for part of organisation-wide contingency planning.
- Pretension and Management of Violence Physical Training, may need to be adapted to include social distancing where possible.
- Staff should ensure that they have access to and use appropriate PPE.
- Where patients in isolation show signs of deterioration, an urgent medical review should be undertaken to establish whether additional treatment support is needed
- If additional medical support is needed and it is deemed safe to transfer them to a general hospital setting, this should be done via the normal 999 arrangements in place for COVID-19 referrals.
- If additional medical support is required but the patient’s mental health condition means they are not deemed suitable for treatment within a general hospital setting, arrangements, including appropriate ventilation if needed, should be put in place. Where this happens, Aerosol Generating Procedure (AGP) is likely to be necessary
As of April 2019, the Ministry of Justice decided to provide all responsible clinicians at any hospital with general consent to exercise their power to grant leave for medical treatment. The terms of this consent differ, depending on the type of patient (whether the patient is a transferred prisoner or whether they have been diverted to hospital for treatment by way of a hospital order).
This does not apply to those restricted patients that the Mental Health Casework Section (MHCS) has classified as “high profile” cases.
Please note that this does not change the arrangements in relation for emergency medical leave, which responsible clinicians may continue to use at their discretion for any restricted patient, as necessary.
Managing behavioural crises
The nature of the secure hospital unit population is that, from time to time, a particularly distressed patient may threaten or enact violence towards themselves or others and staff must intervene. New protocols must be drawn up in each unit (or hospital) for the possibility that patients who are infected with covid-19 who may require physical restraint.
Plans must be in place to manage such eventualities as safely as possible.
Although all secure hospital units should be provided with personal protective equipment for this eventuality, it is already clear that supplies are slow reaching hospitals. Plans must therefore take account of this with guidance on interim protection and cleaning arrangements.
Staff will need to plan for how the practice of safe control and restraint will be affected when wearing protective clothing – interim or purpose designed. It is likely that such gear will restrict movement and could even create dangers in restraint situations. Staff should practice with each other to test out the changed situation. Plans should be agreed at the hospital, trust or the unit’s clinical reference group (or similar) as part of contingency planning.
General management responsibilities
Plans must be in place for the eventuality of staffing falling below safe levels. These may include:
- Movement of staff within and between units; when doing this, competencies of the staff coming in needs to be considered
- Role sharing between disciplines
- Confinement of patients in their rooms for periods of time when staffing is at its lowest
- Withdrawal of non-essential activities
- Consider medical or psychiatric emergency response teams
Ensure continuing supply of food, fluids and essentials during the pandemic period.
Staff should continue to offer re-assurance and engagement with to patients during any interaction (while working with social distancing).
Wherever more restrictive practices are introduced, it must be explicit that they are to cover only the period of crisis secondary to the pandemic and to ensure that the unit can comply with good public health principles, and must be reduced and abolished as soon as conditions allow.
Patients and their relatives must be kept informed of all restrictive practices and the reasons for them.
All patients in secure hospital units will be subject to detention under mental health legislation and most patients in other closed units or units with restricted egress will be under some kind of legislative containment.
It is important that such patients have their legal rights respected throughout the crisis.
It should be noted that the emergency Coronavirus legislation makes changes to UK mental health legislation, including that which covers secure care.
These changes have not yet been enacted, however information on the emergency changes is available here. These pages will be updated as soon as changes are made. All units should be aware of the changes which apply and help ensure that patients are aware of these too.
Services in prisons
Prisons are run by HM Prisons and Probation Service and, as such, not their management not the responsibility of healthcare staff. Healthcare staff do, however, have a responsibility to advise and to protect themselves and others as far as possible within such a framework.
COVID-19: prisons and other prescribed places of detention guidance states that any prisoner or detainee with a new, continuous cough or a high temperature should be placed in protective isolation for 7 days.
Prisoners or detainees who have a new, continuous cough or a high temperature but are clinically well enough to remain in prison or prescribed places of detention (PPDs) do not need to be transferred to hospital. Regular observations are not required unless indicated for other clinical reasons.
Suspected cases of coronavirus (COVID-19) should be notified by prison or immigration removal centre (IRC) healthcare teams as soon as possible to local Public Health England (PHE) Health Protection Teams (HPT)
People who are severely unwell must be transferred to appropriate healthcare facilities according to need, but it is the prison’s responsibility to organise escorts and follow advice on safe transfers
- Guidance on PPE for staff and managers, including a helpline number to request supplies and training resources, is here.
- All clinical mental health, learning disability and autism staff are to be bare below the elbow, with hair tied back, wearing no false nails, jewellery etc.
- For treating a patient with suspected or confirmed COVID-19 symptoms – a fluid resistant surgical mask (FRSM) and apron and gloves must be worn when working in close contact (within 2 metres) of a patient with COVID-19 symptoms
- In-reach mental health staff should encourage prisons to facilitate remote consultations with patients.
In-reach mental health staff should check with the prison governor that there is a plan in place for identifying an appropriate place to isolate patients with symptoms, preferably with input from an infection control specialist and to ensure that current infection prevention and control practices have been reviewed to ensure they follow national infection prevention and control guidance for PPDs.
HPTs will contact PHE’s National Health and Justice Team and Centre Health and Justice leads in response to cases in prisons and PPDs. The HPT and the National Health and Justice Team will decide whether to declare a formal incident and respond accordingly. This will support efforts across organisations to achieve infection prevention and control following the national contingency plan for outbreaks in PPD.
Court Liaison and Diversion Services
Almost all courts in the UK have access to mental health liaison and diversion services. These may become particularly important as courts strive to lower rates of new imprisonment. As most cases referred are likely to be unknown to the mental health services standard NHS guidance on personal protection of health workers as applied in A&E departments should apply.
Healthcare staff seeing people in this context should ensure that they and all relevant court staff have the most up-to-date accurate information on virus management in such circumstances.
People in this group include:
- Solid organ transplant recipients
- People with specific cancers:
- People with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer
- People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
- People having immunotherapy or other continuing antibody treatments for cancer
- People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
- People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
- People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe Chronic Obstructive Pulmonary Disease (COPD)
- People with severe single organ disease (e.g. Liver, Cardio, Renal, Neurological).
- People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe Combined Immunodeficiency (SCID), homozygous sickle cell).
- People on immunosuppression therapies sufficient to significantly increase risk of infection.
- People who are pregnant and children up to the age of 18 with significant heart disease, congenital or acquired.
Additionally, Welsh Government have outlined:
Supported living providers
As well as guidance for supported living (updated on 19 March 2020), there is further guidance from Welsh Government for individuals and families about how to maintain home care safely if they are advised to isolate at home.
Most of the care and support provided within supported living environments cannot be deferred to another day without putting individuals at risk of harm. It is therefore vital that these services are prioritised.
Providers are advised to do the following:
Review client list and level of informal support available to individuals.
Work with local authorities to identify those who fund their own care and help to determine informal support available.
Map all local authority-commissioned care and support plans.
Work with local authorities to establish mutual aid plans for sharing workforce across supported living, home care and health service providers.
Note the arrangements being put in place by NHS111, CCGs and local authorities to refer vulnerable people self-isolating at home to volunteers for practical and emotional support.
If someone in supported living has symptoms of COVID-19, risks to their health and wellbeing must be assessed and appropriate action taken. If neither the individual in supported living nor care worker is symptomatic, no personal protective equipment is required above and beyond normal good hygiene practices.
General interventions may include increased cleaning activity to reduce risk of virus retention on hard surfaces and keeping property properly ventilated by opening windows whenever safe and appropriate.
Hostel or day centre providers for people experiencing rough sleeping
Guidance for hostel or day centre providers of services for people experiencing rough sleeping:
hostels and day centres do not need to close at the current time, unless directed to do so by Public Health England or the government
frequently clean and disinfect regularly touched objects and surfaces using your standard cleaning products
if a member of staff becomes unwell on site with a new, continuous cough or a high temperature, they should be sent home
if a resident in a hostel becomes unwell, they should stay in their room
if someone becomes unwell in a day centre, and they do not have a home or room in which to self-isolate, they should be isolated temporarily in an area of the day centre and staff are advised to contact the local authority
staff, residents and visitors should be reminded to wash their hands for 20 seconds, more frequently and catch coughs and sneezes in tissues
local authority public health, housing and social care teams are encouraged to work closely together to identify appropriate local solutions for people who don’t have anywhere to self-isolate.
Members of staff need to consider contingency plans for situations such as:
reduced or interrupted supply of medicines, or access to them
reduced access to or interrupted supply of drugs or alcohol
greater vulnerability to the effects of viral infection because of reduced immunity from poor health, drug and alcohol use, or medication for other conditions
risk of exacerbation of breathing impairment from coronavirus (COVID-19) due to simultaneous substance misuse e.g. opioids
Responses should include ensuring that sufficient treatment capacity is available if people look for withdrawal support or substitute prescribing as an alternative to using illicit drugs, ie opioid substitution therapy.
This guidance on clinical management of drug misuse and dependence can be used when considering these contingency plans.
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.
- 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:
- A Systematic, Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak (PDF).
- Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace (PDF).
- The Support The Workers collective developed a rapid evidence-based training and support curriculum for staff providing psychosocial support to frontline workers.
- The COVID Trauma Response Working Group has been formed to help coordinate trauma-informed responses to the COVID-19 outbreak. It is being coordinated by staff at University College London and the Traumatic Stress Clinic at Camden and Islington NHS Trust. Their webpage includes a range of evidence-based resources for clinicians coordinating psychological responses to COVID-19.