Special Report: C-L Psychiatrists Provide Overview of Response to COVID-19 Pandemic and Patient Management

iStock/South_agency

In a pandemic outbreak, consultation-liaison (C-L) psychiatrists suddenly find themselves at the front lines in the fight against the infection, which is a challenging situation that requires immediate and decisive adjustments to meet the transformed demand for psychiatrists practicing in general hospital settings. Before they can begin to treat SARS-CoV-2 (COVID-19) patients, C-L service leadership needs to review its operations, make necessary changes, and develop contingency plans.

Organizational Considerations

Infectious outbreaks, like the COVID-19 pandemic, have several unique features among disasters, the most important one being a presence of considerable health risk and emotional burden on health care workers who are taking care of the affected patients and families.

Another unique feature is having the necessary time for readiness that allows communities and health care systems to prepare for the surge of critically ill patients. To do that, hospitals may decide to discharge or transfer all noncritical medical inpatients and cancel elective procedures (such as surgeries or endoscopic procedures) in an attempt to make more hospital beds available for COVID-19-affected patients. This temporary reduction in census usually translates into a slight reduction in the number of psychiatry consults requested, and this “calm before the storm” allows C-L services to prepare the following:

• Contingency plans, including staffing adjustments and backup psychiatry staffing plans in case of disruption. Alternate modalities for communicating with patients (developing telepsychiatry approaches and other approaches for communication).

• Communication with other consulting services on defining a unified approach to COVID-19-positive or suspected patients and when and how to use each modality.

• Liaison work with frontline health care workers (physicians, nurses, respiratory therapists, advanced practice professionals) and processes to address staff’s emotional needs, which can be expected to arise from the stress of the outbreak. Advocacy work with hospital administrators to underscore the need for logistical support, to promote a clear set of expectations and guidelines for staff, and to establish appropriate two-way communication channels as the best way to minimize the development of emotional trauma and burnout among caregivers.

Contingency plans are very service specific and should address basic questions including the following: What happens if one or more members of the psychiatry service becomes incapacitated? What changes to our psychiatry workflow can be implemented to reduce exposure to SARS-CoV-2 and thus minimize risk of transmission? What will happen with medical students? Residents? Administrative staff? Who needs to be on site and who can work off site? How do we still provide the same level of care as a service to our hospital with so many constraints? How do we utilize COVID-19–recovered health care workers when they are ready to return to service?

Developing alternate modalities for communicating with patients is a critical step in minimizing exposure risk while still being able to communicate with, evaluate, and care for COVID-19 patients. Although some medical centers have already developed in-house communication systems, as a specialty, psychiatry services have been less ready to implement programmatic on-site telepsychiatry so psychiatrists in general hospital settings need to improvise and develop strategies to safely perform consultations and follow-up care with COVID-19 patients. There is a plethora of HIPAA-compliant platforms that can be used. With regulatory requirements currently loosened, psychiatrists can use FaceTime, Skype, or Zoom in good faith to provide immediate and adequate assessment and care to COVID-19 patients.

In some instances, COVID-19 patients are unable to participate in telemedicine, and other approaches need to be considered, including observation from outside of the room using a window to engage the patient and observe behavior. Both curbside and indirect consultation are other methods to perform consult work during the pandemic with focus on chart review and information from family, physicians, nurses, and other staff who have direct patient contact. When psychiatrists are at the bedside, familiarity with the use of personal protective equipment (PPE) is essential.

With regard to telepsychiatry communication, success will mostly be determined by two factors:

• Patients’ attitude and aptitude: Patients must be capable and willing and able to use any technology to engage with psychiatric consultants.

• Last-yard carrier: This staff person retrieves the piece of communication equipment from the patient’s room; there may be a need for staff to activate the communication device and to inform the patient about the upcoming tele-consultation. An identified system needs to be in place to disinfect the device after each use and store it in a safe environment for continued use.

Working with primary medical services to ensure optimal collaboration around communication presents itself as yet another challenge. Asking a medical team member to notify the consultant the next time he or she is about to enter the room of a COVID-19 patient and then virtually “take you in” with a communication device such as an iPad may be a good approach, though there may be a delay given staff work demands. The use of technology for psychiatric consultation work may lead to frustrations given the numerous challenges involved with its use and occasional failures to function and because no technology can replace face-to-face bedside consultation.

When developing alternate modes of communicating with patients, reach out to other consulting services to see whether they have thought through how to minimize exposure and protect their staff. Other medical consultants may be aware of existing communication modalities that the psychiatric consultant may adopt. Importantly, consulting services can work together to make an effective request from hospital administration to both unify and simplify the consulting process throughout a hospital system (for example, by placing a “consultation booth” with video equipment outside a unit for all consultants to use).

Studies from prior infectious outbreaks indicate that more than 10% of health care professionals providing direct patient care develop symptoms of traumatic stress (acute stress disorder, posttraumatic stress disorder), a percentage that is amplified by experiencing quarantine and/or isolation. Severe stressors for frontline staff include knowing that they are at risk of contracting COVID-19 infection, as well as the emotional demands of caring for colleagues who are critically ill with this infection. Frontline workers are quarantined if they become ill; some may choose to self-isolate outside of work hours to minimize risk of transmission to family members. And there have been reports of health care workers being ostracized outside of the work environment from COVID-transmission anxiety. These findings provide consultation-liaison services with both a challenge as well as an opportunity to reconfigure and advance liaison work with hospital staff and to develop processes to address the emotional needs of hospital staff arising from this unfolding outbreak.

There are no firm guidelines on how to provide staff support; it may take the form of supportive engagement with house staff and nurses during daily rounding on medical wards and critical care units. Another approach is to create a more formal, structured, and scheduled support or process group for staff, such as Balint groups. In their new iteration during the COVID-19 pandemic in which there is risk of transmission without social distancing, these staff support groups should be implemented virtually, relying on software that allows multiple video streams (such as Zoom, Microsoft Teams, and Skype). Some psychiatry services have implemented an as-needed model to support staff in which psychiatrists are on call for telemedicine shifts for distressed frontline health care workers. The focus of these virtual individual sessions is a debriefing model to help the frontline workers develop effective short-term coping skills. Health care systems may already have staff support interventions in place that can be leveraged to minimize redundancy.

Finally, partnering with hospital administration may prove crucial in preventing traumatic stress symptoms among health care workers. Limited research indicates that administrative factors can play a significant preventative role by implementing appropriate processes and providing material and logistical support to staff (examples within this pandemic include access to appropriate PPE, staff meals during work shifts, appropriate instruction on how to don and doff PPE, and on-site housing for staff who choose to self-isolate or whose commute is proving onerous given the work schedule).

Some of the factors that can be emphasized as critically important to reduce risk of staff psychological trauma when talking with administrators or service chiefs include the following:

• Clear guidelines and expectations: Factual preparedness ranks high among factors in most surveys, indicating that the existence of a clear plan, policies, and procedures and occasional drills may have a significant positive psychological impact on staff as well. Knowing what one’s role is and what is expected of each staff member clearly helps health care workers focus on the provision of patient care and also reduces anxiety-provoking uncertainty. Frequent policy changes, unclear criteria of case management, and other ambiguities during the crisis (for example, which PPE to use for specific clinical scenarios) can create substantial frustration, stress, and anxiety within staff.

• Communication: Fostering communication between the frontline providers and their supervisors is another important factor to promote resilience. It is essential that this communication be bidirectional. Health care workers appreciate being able to give feedback to supervisors as this process automatically heightens the sense of appreciation and support that they expect from supervisors.

• Logistical support: This important segment includes both elements of logistics—clinical on-site and general off-site. Adequate and accessible PPE and fail-safe, easy-to-use communication equipment are basic elements of logistical support and relevant factors in lowering the risk of posttraumatic stress symptoms in staff.

Clinical Considerations

A bushfire-like spread of COVID-19 has not given psychiatrists who are also on the front lines much time to conduct research on the neuropsychiatric aspects of this disease, though clinicians are beginning to see the outline of the challenges for C-L psychiatrists helping to manage COVID-19 patients.

One of the preliminary inferences to date is that this virus does not appear to frequently show significant direct CNS involvement and marked neuropsychiatric sequelae. There have been case reports of viral encephalitis and other neurologic complications from SARS-CoV-2, but, so far, the former cases seem to be sporadic. Neurologic complications include headache, seizures, ageusia, hyposmia, and loss of consciousness. In Italy the response to the COVID-19 pandemic has included a dedicated neuro-COVID-19 inpatient unit to better understand the pathogenesis of neuro-COVID disease.

Common Disorders

Delirium, agitation, and anxiety are common complications encountered in critically ill COVID-19 patients. This is thought to be secondary to the overall severity of this illness, particularly among ICU patients, as IL-6 (interleukin-6) plays an important role in both the cytokine release syndrome associated with severe COVID-19 and in the delirium cascade. Metabolic abnormalities including hyponatremia have been noted, which can contribute to delirium, and COVID-19 patients’ course may be complicated by acute renal failure and in some cases the development of uremic encephalopathy (or delirium). Many COVID-19 patients are receiving hemodialysis, and limited resources can strain how well a hospital system can care for its patient population in this regard.

Pharmacological Treatments

A significant number of patients on ventilators are on an alpha-2-adrenergic receptor (α2-AR) agonist dexmedotomidine (Precedex), which has anti-agitation properties and may reduce the need for additional psychopharmacological intervention for agitation. However, once weaning from intravenous dexmedotomidine is initiated, agitation and hyperactive delirium often surface for which urgent psychiatric intervention is often requested.

After recommending melatonin as a routine agent in delirium management with little risk, C-L psychiatrists may elect to continue the management of delirium via the α2-adrenergic agonism route by utilizing agents such as clonidine or guanfacine, orally or transdermally. These agents are often effective at combating agitation; hypotension can limit their utility in this setting. Both second-generation and first-generation neuroleptics, such as olanzapine, aripiprazole, quetiapine, or haloperidol continue to have an important role in the acute management of the hyperactive delirious COVID-19 patient who may be removing oxygen support or pulling out intravenous lines. Haloperidol can be given intravenously when other routes of administration are not an option; it also has additional in vitro disruptive properties toward SARS-CoV-2 proteins binding to σ1 and σ2 receptors. These in vitro properties have not been confirmed in clinical situations.

Neuroleptics are associated with QTc prolongation, and this feature becomes clinically problematic in patients on hydroxychloroquine (HCQ), which is now used to treat many patients with COVID-19 despite limited data of its efficacy. To further complicate matters, HCQ itself can cause or contribute to neurobehavioral side effects, such as irritability or delirium. Close monitoring of EKG and comprehensive and assiduous monitoring of electrolyte imbalances become imperative if delirous COVID-19 patients are managed with neuroleptics given the potential risk of arrhythmia.

An alternative approach to treating delirium in patients with prolonged QTc is the use of valproate, which does not prolong the QTc interval and is also available for intravenous use. Additionally, valproate was found to block HDAC2 in vitro, an enzyme implicated in replication of SARS-CoV-2. This property has not yet been established as meaningful in clinical use. The use of valproate may burden the liver, and caution should be exercised if valproate is considered for delirium in patients who are on remdesivir (RDV). RDV is a nucleotide analogue also used to treat COVID-19 patients, and it is known to have the potential to cause liver damage. Valproate may be contraindicated in COVID-19 patients with significant thrombocytopenia, and when valproate is prescribed for patients with agitated delirium, the platelet count should be monitored.

Complications From Respiratory Distress

Another psychiatric symptom complex that C-L psychiatrists are encountering in COVID-19 patients is anxiety/distress stemming from respiratory compromise, as well as anxiety associated with ongoing, prolonged intubation and ventilatory support. COVID-19 patients also report anxiety and distress related to the uncertainty associated with prognosis. Anxiety is further amplified by patients being in isolation, away from family and without visitors for prolonged periods. Anxiety from isolation is also observed in COVID-19 outpatients who are home and quarantined.

Benzodiazepines have immediate anxiolytic benefits but can both worsen confusion and contribute to respiratory suppression, so these medicines are not typically used to manage ongoing anxiety. A better approach to anxious COVID-19 patients may be to utilize agents with 5-HT2 antagonist properties. For patients with primarily anxiety, hydroxyzine can be an appropriate choice. If anxiety is coupled with insomnia, trazodone becomes a consideration. If a patient has depression along with poor sleep and poor appetite, mirtazapine can be a helpful treatment. Anxious patients with considerable risk for delirium or with both mild delirium and anxiety may respond favorably to low doses of second-generation neuroleptics such as quetiapine. A risk-benefit analysis is appropriate given potential EKG changes from a second-generation antipsychotic drug before initiating treatment with a second-generation neuroleptic.

Addressing Problems Related to Isolation

Outside the realm of psychopharmacological treatment, perhaps the biggest psychological challenge COVID-19 patients face is pervasive isolation. They spend most of their hospital days alone, separated from their families with very little meaningful human interaction. Hospital staff are minimizing direct contact with patients given potential transmission risks, and this also adds to the cumulative isolation that COVID-19 patients report. These patients experience palpable uncertainty as they anxiously await getting better or taking a turn for the worse. An essential role for psychiatrists working with a COVID-19 patient is being an effective advocate. Breaking the physical and emotional isolation by facilitating communication and interaction between patients and their medical teams and also between patients and their loved ones therefore becomes a central theme and role of a C-L psychiatrist’s work during this pandemic, which includes this advocacy, as well as conducting supportive psychotherapy.

Once basic logistical and resource challenges to enabling COVID-19 patients to use communication devices are addressed, supportive psychotherapy then becomes an important component of our psychiatric treatment plan with COVID-19 patients.

Other Areas of Involvement

Other areas where C-L psychiatrists’ input may be sought include end-of-life care, communication with families around goals of care when patients are unable to participate in these discussions, and bereavement support. In some centers, consultation-liaison services have closely partnered with palliative care services to provide the necessary workforce to engage COVID-19 patients and families in a discussion about the goals of care. This critically important work may begin in the emergency department as decisions may need to be made regarding whether to proceed with life-sustaining approaches such as intubation. Critically ill COVID-19 patients who are at especially high risk for poor medical outcomes include the elderly, African Americans, and those with chronic medical conditions including heart disease and lung disease. During this pandemic, psychiatrists may also participate in hospital ethics committees, which may deliberate the dispensation and allocation of limited resources such as ventilators or dialysis availability in exigent circumstances.

Psychiatrists responding to the COVID-19 pandemic will benefit from a healthy, balanced focus on self-care as they work with critically ill COVID-19 patients. Supporting frontline distressed health care workers can be both emotionally taxing as well as extremely rewarding work. While support interventions that psychiatrists lead are needed for frontline workers, there is also an indication and need for psychiatrists to have their own outlet for support and debriefing to promote resilience. Ideally, there should be both team and individual options for psychiatric consultants. C-L psychiatry service leadership may also promote further team building opportunities with scheduled social gatherings through a remote modality of communication and interaction given the continued risk of transmission.

The authors wish to acknowledge the contributions of the recently formed list serve by the Academy of Consultation-Liaison Psychiatry to share information and resources on COVID-19.