Screening for SARS-CoV-2 Infection Within a Psychiatric Hospital and Considerations for Limiting Transmission Within Residential Psychiatric Facilities — Wyoming, 2020

In the United States, approximately 180,000 patients receive mental health services each day at approximately 4,000 inpatient and residential psychiatric facilities (1). SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly within congregate residential settings (2–4), including psychiatric facilities. On April 13, 2020, two patients were transferred to Wyoming’s state psychiatric hospital from a private psychiatric hospital that had confirmed COVID-19 cases among its residents and staff members (5). Although both patients were asymptomatic at the time of transfer and one had a negative test result for SARS-CoV-2 at the originating facility, they were both isolated and received testing upon arrival at the state facility. On April 16, 2020, the test results indicated that both patients had SARS-CoV-2 infection. In response, the state hospital implemented expanded COVID-19 infection prevention and control (IPC) procedures (e.g., enhanced screening, testing, and management of new patient admissions) and adapted some standard IPC measures to facilitate implementation within the psychiatric patient population (e.g., use of modified face coverings). To assess the likely effectiveness of these procedures and determine SARS-CoV-2 infection prevalence among patients and health care personnel (HCP) (6) at the state hospital, a point prevalence survey was conducted. On May 1, 2020, 18 days after the patients’ arrival, 46 (61%) of 76 patients and 171 (61%) of 282 HCP had nasopharyngeal swabs collected and tested for SARS-CoV-2 RNA by reverse transcription–polymerase chain reaction. All patients and HCP who received testing had negative test results, suggesting that the hospital’s expanded IPC strategies might have been effective in preventing the introduction and spread of SARS-CoV-2 infection within the facility. In congregate residential settings, prompt identification of COVID-19 cases and application of strong IPC procedures are critical to ensuring the protection of other patients and staff members. Although standard guidance exists for other congregate facilities (7) and for HCP in general (8), modifications and nonstandard solutions might be needed to account for the specific needs of psychiatric facilities, their patients, and staff members.

Wyoming’s state psychiatric hospital is a complex residential facility comprising three very different units: Adult Psychiatric Services, Medical Geriatric Psychiatric Services, and Criminal Justice Services. Each unit presents its own multifaceted challenges in terms of patient populations, the level of care required, and the risks to HCP posed by patient behaviors, which are not typically encountered in other residential settings. Patients at the state hospital are all aged ≥19 years, and admissions come from other health care, group residential, and correctional facilities within the state. Approximately 300 staff members are employed at the hospital, mostly HCP who provide varying levels of patient care. The hospital currently has a 104-bed capacity, with approximately 65% of beds in double occupancy rooms.

The state hospital had no known COVID-19 cases among patients or staff members before the transfer of two patients from a private psychiatric hospital on April 13, 2020. In late March, the state hospital had started some testing of new admissions and patients with COVID-19–like symptoms, and staff members had been advised to seek testing through their primary care providers if they had symptoms suggestive of COVID-19, but no cases had been identified. In early April, the originating private hospital had performed SARS-CoV-2 testing for one of the transferred patients when planning for transfer to an alternative facility and received a negative result on April 3, 2020; no testing was performed for the second patient before transfer to the state hospital. Because of the reported COVID-19 outbreak at the private facility (5), both patients were tested at the time of admission to the state hospital. While awaiting test results, both patients were isolated in separate rooms as a precautionary measure, and any staff members with exposure to the two patients during transport or admission while not wearing all recommended personal protective equipment (PPE) (8) were asked to self-quarantine.

When both patients received positive laboratory test results, the state hospital immediately implemented enhanced measures to prevent further transmission, including 1) the screening and testing of all new patients by a dedicated admissions team, 2) immediate isolation of new patients in separate rooms until receipt of test results, and 3) isolation and management of new patients with positive SARS-CoV-2 test results in a separate ward (supported by eight dedicated nurses who provided clinical care and housekeeping services) for 2 weeks or until receipt of two negative SARS-CoV-2 results from nasopharyngeal swab specimens collected 24 hours apart.* These same procedures were also to be followed if symptoms were identified in any patients already at the state hospital. In addition, standard IPC procedures already in place were reinforced, based on long-term care facility guidelines (7), including 1) universal cloth face coverings for compliant patients and face masks for HCP at all times within the facility, 2) frequent disinfection of spaces accessed by patients with COVID-19 and all communal spaces, 3) cancellation of group dining or increase of space between patients at dining tables, 4) reduction in the number of persons participating in group therapy sessions, 5) limitation of all nonessential visitors and services, and 6) daily symptom screening and temperature checks of all patients and staff members (7). Some standard IPC measures were modified to facilitate implementation in the psychiatric patient population, such as adapting face coverings for patients to avoid elastic and metal components that could be used for self-harm or violent purposes (e.g., socks, a preapproved item, were modified for use as face coverings).

On May 1, 2020, the state hospital, with support from the Wyoming Department of Health and CDC, conducted a point prevalence survey to determine the prevalence of SARS-CoV-2 infection among patients and HCP and to assess the effectiveness of the newly implemented enhanced patient admission, isolation, and IPC procedures. All state psychiatric hospital patients and HCP (6) were invited to participate in the survey. Two-person survey teams were located in each of the hospital’s three units. Participants provided oral consent for survey participation; per hospital policy, hospital staff members obtained guardian consent before the survey for any patients with legal guardians. Survey team members administered a questionnaire to patients and HCP that elicited information about demographic characteristics, patient’s unit, symptoms, and HCP duties and work locations in the past 2 weeks. Survey team members also collected one nasopharyngeal swab specimen from each participant. Specimens were tested at the Wyoming State Public Health Laboratory using the CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase (RT)–PCR Diagnostic Panel (9). This survey was conducted by a public health authority to provide timely situational awareness and priority setting during the COVID-19 pandemic, and as such, was considered nonresearch public health surveillance as outlined in 45 CFR 46.102(l)(2).^†

Overall, 46 (61%) of 76 patients and 171 (61%) of 282 HCP participated in the survey and had nasopharyngeal swab specimens collected and tested (Table 1) (one clinical care staff member was excluded because their sample was received at the laboratory without a label). Included among the 76 patients were 21 (68%) of 31 in the Adult Psychiatric Services unit, 16 (76%) of 21 in the Medical Geriatric Psychiatric Services unit, and nine (38%) of 24 patients in the Criminal Justice Services unit. Included among the 171 HCP were 137 (58%) of 238 in clinical care, 14 (88%) of 16 in housekeeping, and 20 (74%) of 27 in transportation and security. Median length of patient stay was 150 days (interquartile range = 86–381 days). Among the 171 participating HCP, 151 (88%) reported providing direct care to the patients, eight (5%) reported working within another health care facility, and 98 (57%) reported working across multiple units at the state hospital within the previous 2 weeks. Responses to survey questions regarding COVID-19–like symptoms were inconsistent and incomplete because patients and staff members would often mention non-COVID-19–like symptoms or attribute symptoms to existing comorbidities; therefore, these responses were not included in the analysis. All patients and HCP had negative test results for SARS-CoV-2 infection.

Based on observations and discussions at the state psychiatric hospital and review of reports from other facilities in Wyoming, various unique concerns were identified related to preventing and managing SARS-CoV-2 transmission in psychiatric facilities (Table 2). In the rapidly evolving early days of the COVID-19 pandemic, the psychiatric facilities in Wyoming were faced with the task of adapting standard IPC procedures to their specific settings, given the needs of their patient population, the specific risks for their staff members, and the limitations of their physical facilities. These concerns were tabulated and organized in terms of provider group and processes, and possible solutions were proposed. The issues faced ranged from the ability to cohort infected patients when it was also necessary to segregate patients by age, gender, and treatment needs, to the ability to continue essential mental health services when physical distancing or isolation had to be maintained.

Acknowledgments

Patients and staff members at the Wyoming State Hospital; CDC Infection Prevention and Control Field Team.

Corresponding author: Anna W. Callaghan, ktv5@cdc.gov.

¹CDC Wyoming COVID-19 Response Field Team; ²Epidemic Intelligence Service, CDC; ³Wyoming State Hospital, Evanston, Wyoming; ⁴Wyoming Department of Health; ⁵CDC COVID-19 Response Team.

References

1. Substance Abuse and Mental Health Services Administration. National Mental Health Services survey (N-MHSS): 2018. Data on mental health treatment facilities. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NMHSS-2018.pdf
2. Kimball A, Hatfield KM, Arons M, et al.; Public Health – Seattle & King County; CDC COVID-19 Investigation Team. Asymptomatic and presymptomatic SARS-CoV-2 infections in residents of a long-term care skilled nursing facility—King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020;69:377–81. CrossRef PubMed
3. Mosites E, Parker EM, Clarke KEN, et al.; COVID-19 Homelessness Team. Assessment of SARS-CoV-2 infection prevalence in homeless shelters—four U.S. cities, March 27–April 15, 2020. MMWR Morb Mortal Wkly Rep 2020;69:521–2. CrossRef PubMed
4. Wallace M, Hagan L, Curran KG, et al. COVID-19 in correctional and detention facilities—United States, February–April 2020. MMWR Morb Mortal Wkly Rep 2020;69:587–90. CrossRef PubMed
5. Wyoming Department of Health. Two Wyoming State Hospital patients test positive for coronavirus. Cheyenne, WY: Wyoming Department of Health; 2020. https://health.wyo.gov/two-wyoming-state-hospital-patients-test-positive-for-coronavirus/
6. CDC. Infection control in healthcare personnel: infrastructure and routine practices for occupational infection prevention and control services. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/introduction.html
7. CDC. Coronavirus disease 2019 (COVID-19): preparing for COVID-19 in nursing homes. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html
8. CDC. Coronavirus disease 2019 (COVID-19): interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus diseases 2019 (COVID-19) in healthcare settings. Atlanta, GA: US Department of Health and Human Services, CDC, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
9. CDC. Coronavirus disease 2019 (COVID-19): how to get CDC’s COVID-19 diagnostic test and supplies. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/coronavirus/2019-ncov/lab/virus-requests.html
10. Lutterman T, Shaw R, Fisher W, Manderscheid R. Trend in psychiatric inpatient capacity, United States and each state, 1970 to 2014. Alexandria, VA: National Association of State Mental Health Program Directors; 2017. https://www.nasmhpd.org/sites/default/files/TACPaper.2.Psychiatric-Inpatient-Capacity_508C.pdf

Abbreviations: HCP = health care personnel; IQR = interquartile range.
*One HCP staff member was excluded because the nasopharyngeal sample arrived at the testing laboratory without a label.
^† As reported by HCP; at times housekeeping, transportation, and security staff members might provide nonclinical direct patient care, such as assisting the patients to move around the facility or intervening if a patient becomes violent.

Abbreviations: COVID-19 = coronavirus disease 2019; HCP = health care personnel; PPE = personal protective equipment.