COVID-19 outbreak management in a mental healthcare setting

In 2020, COVID-19, an infection caused by a novel coronavirus, transmitted significantly on NHS wards, exposing patients to a viral infection that could be fatal and which produced significant implications for patients and healthcare workers (HCWs). Outbreaks placed an additional burden on already stretched resources (Taylor et al, 2020). By early 2020, infection rates had soared in UK hospitals with data published by the Office for National Statistics (ONS) showing a significant increase in mentions of COVID-19 on death certificates in England and Wales (ONS, 2020). The UK had registered 73 621 coronavirus-related deaths before 2021 (Worldometer, 2021). Mental health settings were also severely affected by the fallout of the pandemic, with HCWs trying to control the transmission and suddenly dealing with challenging outbreaks of infections that had not been experienced before and having to treat patients suffering the effects of the virus in a confined environment that was ill-designed for treating patients with such a virus (Rodgers et al, 2021).

In many mental health settings, COVID-19 resulted in patients suffering a loss of their liberties by being refused home leave, visiting from friends and family being stopped and ultimately losing therapeutic services or relationships that had greatly assisted in their recovery. Patients with mental illness often have several risk factors that make them highly vulnerable to the infection, and this can further increase the morbidity and mortality of COVID-19. These risks include there being a high rate of smoking, lung disease, cardiovascular disease, diabetes and obesity in this population (Xiang et al, 2020). Thus, many patients in this vulnerable group who do contract COVID-19 are at an elevated risk of a severe prognosis. De Hert et al (2011) argued that patients with severe mental illness are often unaware of their physical symptoms due to cognitive deficits, so symptoms of COVID-19, such as having a cough or a high temperature, may go unreported, allowing the virus to spread.

People experiencing mental health issues on inpatient wards are often ambulatory, eat meals together, undergo group therapy and interact with one another in close proximity, potentially facilitating the rapid spread of infection (Rovers et al, 2020). They may find the advice to socially distance from others difficult and innocently make contact by shaking hands, hugging and unknowingly touching other staff and patients. This close contact exposes the HCWs to a higher risk of COVID-19 as they are more involved in close personal exposure to patients, through tasks such as communicating with patients, doing their observations and dispensing medication. This close exposure of frontline HCWs puts them at high risk of infection, contributing to further spread (Black et al, 2020).

Psychiatric inpatients show poor adherence to infection control measures (Williams et al, 2021). Mental illnesses and psychiatric medications tend to negatively influence patients' capabilities of comprehending and following instructions (De Hert et al, 2011). Following instructions in a COVID-19 outbreak is crucial for adequate reporting of symptoms and for adhering to preventive measures (Gaspard et al, 2014). Infection prevention and control (IPC) measures would include patients adhering to hand-hygiene measures, staying in their rooms and covering their nose and mouth when coughing. The use of home leave, overnight leave and patients being allowed to leave the ward increases the risk of contracting the virus. Not adhering to these aspects of preventive IPC practices and the risks involved with ward leave lead to a higher risk of infection acquisition, risks its transmission, and makes managing an outbreak more challenging (Brown et al, 2020).

Managing an outbreak of COVID-19 infection

An outbreak has been defined as two or more confirmed cases of COVID-19, or clinically suspected cases of COVID-19, among individuals associated with a specific setting with onset dates within 14 days (Public Health England (PHE), 2020). When an outbreak of COVID-19 is declared, the IPC team should take action to prevent further spread and notify immediate stakeholders, senior leadership teams and external agencies (NHS England/NHS Improvement, 2020a) (Box 1). HCWs must follow established outbreak control methodology for managing an outbreak as per their trust's outbreak policy (PHE, 2014).

Box 1.Hospital onset COVID-19 outbreaks: actions to be taken by trusts
Source: NHS England/NHS Improvement, 2020a

Source: NHS England/NHS Improvement, 2020a

Key: CCG=clinical commissioning group; ICC=integrated care communities; ICS=Integrated care systems; IIMARCH=information, intent, method, administration, risk assessment, communications and humanitarian issues; IPC= infection prevention and control; PCR=polymerase chain reaction; SitRep=situation report; STP=sustainability and transformation plan

Outbreak management will require particular attention from the IPC team, which must be sufficiently staffed and resourced to cover this unprecedented demand on their services (Royal College of Nursing, 2021). It will incur a lot of strict IPC procedures and fundamentally put restrictions on patients' movements.

Hierarchy of controls for controlling COVID-19

Under health and safety legislation, employers have a duty to ensure that risk assessments are carried out and control measures put in place to reduce the risk of harm to staff and patients (Health and Safety Executive (HSE), 2021a). The ‘Hierarchy of Controls’ (Figure 1) should be prioritised and used to guide safe practice in the workplace and could be used to contain an outbreak of COVID-19 (Centers for Disease Control and Prevention (CDC) and National Institute for Occupational Safety and Health (NIOSH), 2015). In the Hierarchy of Controls for COVID-19, the control methods at the top of the graphic are potentially more effective and protective than those at the bottom.

This hierarchy contains a number of risk controls to assess and manage prior to the use of personal protective equipment (PPE). The initial control element is to eliminate the hazard; however, as COVID-19 cannot be eliminated, measures must be put in place to mitigate the risk, such as stopping routine appointments for symptomatic patients, and testing and isolating patients as necessary. ‘Substitution’ (Figure 1) indicates replacing the hazard; however, as COVID-19 cannot be replaced the workplace must be changed or substituted with different work practices to remain safe. These arrangements could be adopting practices such as maintaining 2-metre distancing and contacting patients in the community remotely, instead of face to face.

The ‘engineering controls’ involve the isolation of people from the hazard. This could be measures such as installing partitions, improving ventilation and providing adequate bed spacing and single room facilities for patients (Sehulster and Chinn, 2003). The administrative controls assist in changing how staff work, such as enabling staff to work from home, if they can, reducing the number of deliveries to the wards, reducing the number of staff in break areas, changing rooms and offices, and displaying maximum occupancy on entry to and within rooms. The provision of additional hand hygiene and face mask stations, increased cleaning and improved ventilation are also examples of mitigating the risks in this element of control (NHS England/NHS Improvement, 2021a). Finally, PPE must be provided for the safety of staff in a COVID-19 outbreak and this will involve providing training, displaying guidance and monitoring its usage.

Infection prevention and control measures

The primary objective in outbreak management is to protect the patient and HCWs by identifying the source and implementing control measures to prevent further spread or recurrence of the infection (PHE, 2021a). Outbreak measures must specifically target practices that will prevent further respiratory transmission, such as following the ‘catch it-bin-it-kill it’ rule when sneezing or coughing (Loveday et al, 2014). The outbreak measures required to curtail further transmission of infection will be influenced by the IPC teams and will predominantly affect the patient, the practices and the environment.

The patient

During an outbreak of COVID-19, all patients within the affected setting should be tested and isolated until the tests results return and HCWs should continue their daily lateral flow testing as directed by the IPC outbreak lead (PHE, 2021a). The IPC team will advise the ward or affected area is closed to admissions and transfers, if patients are not able to safely cohort (be grouped together). Patients ready for discharge can be risk assessed if asymptomatic to be discharged home. Discharge advice must always be given to patients. Staff will be advised to keep doors to single-occupancy rooms and bays closed and to place signage on the doors informing HCWs of the closed status and restricting access to essential staff only. A risk assessment will ascertain if the door is required to remain open for observations of the patient.

COVID-19 careplans and checklists should be instigated to ensure all patients are given safe care according to national guidance, checking vaccination status, offering face masks and recommending COVID-19 vaccinations (PHE, 2021a). The affected area must maintain an up-to-date record of all patients and staff with symptoms and continuously monitor their vital signs on an early warning score system to help to identify patients at risk of deterioration. The use of the national early warning score (NEWS2) can help to identify sepsis or COVID-19-related respiratory symptoms to provide patients with appropriate treatment as promptly as possible (Royal College of Physicians, 2017).

If a patient does not have relevant mental capacity, for example, to make necessary decisions (including care and treatment), staff will need to consider the legal decision-making framework offered by the Mental Capacity Act 2005. Guidance has been issued on the use of the Act and of Deprivation of Liberty measures during this emergency period (NHS England/NHS Improvement, 2021b). If a patient lacks capacity to provide consent to be tested for COVID-19, the decision maker should, where necessary, make a ‘best interests decision’ under the Act. When doing so, they must consider all the relevant circumstances and must make a record of their decision. This must be undertaken in relation to the individual and must never be determined in relation to groups of people. Additional time may be required to make a ‘best interests’ decision in these situations.

When the COVID-19 test results return, a healthcare-associated infection post-infection review (HCAI-PIR) will be instigated if the patient has acquired the infection after a certain time frame since their admission. Although there are technically three categories for determining potential HCAIs, for the purposes of defining an outbreak NHS England/NHS Improvement (2020b) advises that only probable and definite cases of healthcare-onset COVID-19 infection (HOCI) will be considered, as below:

• Healthcare-onset probable healthcare-associated (HO-pHA): first positive specimen date 8 to 14 days after admission to trust
• Healthcare-onset definite healthcare-associated (HO-dHA): first positive specimen date 15 or more days after admission to the trust.

Each case falling within these categories will undergo a rapid root cause analysis (RCA) to establish how the transmission occurred and to establish any shared learning (NHS England/NHS Improvement, 2020b). Identifying the primary cause—how the patient acquired COVID-19—is essential to show if practices or improvements can be made. If patients on mental health wards are leaving the wards and visiting other departments and not wearing a face mask, this could be an unintentional action and may have led to the person acquiring the infection. Identifying this can establish procedures where all service users leaving the ward must wear a mask.

The practices

Positive COVID-19 patients should be given information on the reason for their isolation period and offered a face mask to wear if transferring to other departments is necessary (UKHSA, 2021a). Isolation can negatively impact patients in a mental health setting and can result in feelings of anxiety, depression and despair (Purssell et al, 2020). Patients who are isolated in a room can experience a low mood and cognitive or functional decline (Evans et al, 2003). A study on hospitalised patients in isolation showed a negative impact on their mental wellbeing and behaviour, including higher scores for depression, anxiety and anger, with doctors contacting such patients least on the wards (Saint et al, 2003). It can also increase the risk of falls (Gould et al, 2018). HCWs should be aware of the negative impact that asking patients to stay alone in their rooms can have on patients and find ways to keep in contact with them to alleviate any concerns.

Ways to improve the patient's isolation experience could be by aiming to prevent boredom by offering the use of a television, radio or newspapers and magazines (Abad et al, 2010). Staff taking the time to say ‘hello’ and giving patients daily updates can give them the welcome contact and support they need. Patient information leaflets can help to support explanations, but must be presented in a user-friendly format that patients can understand. Enlisting the help of patients may be beneficial to help adopt IPC measures. This could involve showing them how to wash their hands correctly, giving them posters explaining why they should stay in their rooms and also providing them with training on wearing face masks. These may all assist in containing the virus. However, this involves creating an accepting environment and is a change from the paternalistic culture that sometimes exists on NHS wards (Fernandes Agreli et al, 2019). Giving patients clear tasks and supporting with relevant information can enable mental health patients to contribute to IPC measures if they choose.

During an outbreak, PPE such as gloves, plastic disposable aprons and face masks should be located close to the point of use (where this does not compromise patient safety, for example, plastic aprons and ties on the face masks may be considered as ligature risks and must be risk assessed). On inpatient wards PPE must be transported in a clean receptacle and stored safely and in a clean, dry area to prevent contamination (PHE, 2021a). The PPE should be within the expiry date and be single use unless specified by the manufacturer or as agreed for extended/sessional use, including surgical face masks. Staff should be trained in the wearing of PPE, especially around donning and doffing in the correct way, and an FFP3 mask must be fit tested for use in aerosol-generating procedures (AGPs) (PHE, 2021b). AGPs are procedures that stimulate coughing and promote the generation of aerosols. Extra respiratory protection is required here and HCWs must wear an FFP3 respirator mask, additional PPE and IPC precautions are required for some AGPs where an increased risk of infection has been identified (PHE, 2020).

Hand hygiene is now regarded as one of the most important elements of IPC activities, and is required even if gloves are worn. The COVID-19 pandemic has heightened the importance of IPC practices as more people are involved in containing the spread of the virus (Alzyood et al, 2020). During an outbreak, all patients and staff must be informed of the importance of regular hand hygiene and the monitoring of hand hygiene compliance via audits or staff observation must be pursued. The World Health Organization (WHO) (2022) has produced a model showing five moments for hand hygiene at the point of care that explains when hands should be decontaminated (Box 2). Hands must be decontaminated immediately before each and every episode of direct patient contact or care and after any activity or contact that could potentially result in hands being contaminated.

Box 2.The five moments of hand hygiene
Source: World Health Organization, 2022

Source: World Health Organization, 2022

Patient-shared equipment, such as commodes, vital signs machines and glucometers, is necessary to administer care, but if it is not effectively and routinely cleaned, it can become contaminated by bodily fluids and infectious agents. Patient-shared equipment can become a key vector for the spread of dangerous micro-organisms including COVID-19 (National Services Scotland, 2021). For vulnerable and immunocompromised patients in particular, exposure to these pathogens can have devastating effects. Quick and effective decontamination of shared patient equipment is therefore essential to limit the spread of harmful diseases between vulnerable patients. All equipment must be cleaned at least daily and in-between patients with a solution of detergent and 1000 ppm chlorine, during an outbreak. Manufacturer instructions must be heeded for the correct reconstitution processes.

Patient-shared equipment must be decontaminated daily or after use, applying tape stating ‘I am Clean’ to items such as commodes, walking frames or empty bed areas and the time and date of decontamination recorded on the weekly cleaning schedules. The five principles of cleaning should be adhered to when using wipes to clean patient shared equipment (NHS England/NHS Improvement, 2021c) (Box 3).

Box 3.The five principles of cleaning
Source: NHS England/NHS Improvement, 2021c

Source: NHS England/NHS Improvement, 2021c

The first step in the process is to wipe in an S-shaped pattern, taking care not to go over the same area twice. It is important to clean from top to bottom because the top surfaces are usually the most touched and contaminated, and to wipe from clean areas to dirty areas, so that when cleaning a toilet seat or commode the seating area would be the last place to be cleaned (Edgar et al, 2019). A disinfectant must be in contact with a surface for a specified time and the surface needs to remain wet for that time. Staff should know the contact times for the disinfectants in use locally. Products with realistic contact times for use in a busy healthcare environment should be selected (PHE, 2021a). The ‘one wipe one surface’ rule should be followed, so regular changing of wipes is required. All patient-shared equipment must be included in a weekly cleaning schedule and reviewed by HCWs to ensure it is being implemented and recorded.

The environment

The increased frequency of decontamination/cleaning should be incorporated into the environmental decontamination schedules for all areas experiencing outbreaks of COVID-19, including ‘frequently touched items’, such as:

• Medical equipment
• Door/toilet handles
• Locker tops
• Patient call bells
• Over-bed tables
• Bed rails
• Communication devices (landline phones, mobile phones, tablets, desktops and keyboards).

Records of this cleaning should be maintained for inspection purposes (NHS England/NHS Improvement, 2021c). Many mental health settings have been designed with small dining rooms, enclosed activity rooms and often cramped sitting rooms where chairs are positioned very close together. If there is a lack of single rooms, patients can be cohorted (grouped together). If single rooms do not have en suites then a bathroom must be allocated to the affected patients only. These environments are where the virus appears to spread by respiratory droplets or aerosols more efficiently, and can easily contribute to prolonging outbreaks of infection, so taking precautions in these areas is even more important (de Man et al, 2021). IPC teams can give advice about practices and maintaining social distancing within wards but require evidence-based guidance on what is needed in a ‘COVID-19 secure’ built environment. This will ensure future patient safety in light of the recent pandemic recommendations. The current guidance on Infection Control in the Built Environment provides information on specifications for patient care facilities (Department of Health, 2013).

The risk of contracting COVID-19 is higher in crowded and inadequately ventilated spaces where infected people spend long periods of time together in close proximity (WHO, 2021). The fresher the air that is brought inside during an outbreak of COVID-19, the quicker any airborne virus will be removed from the room. Opening windows for fresh air in a mental health setting may be more problematic than a general hospital ward due to the risk it may pose (HSE, 2021b). Risk assessment and collaboration with the estates department would enable ways to access fresh air in this setting. Access to an outside space such as a garden or patio not only assists in blowing COVID-19 particles away, but being outside can also have a positive effect on the patient too, as it reduces mental distress, anxiety and depression, promotes greater wellbeing and healthier cortisol profiles (Barton and Rogerson, 2017).

Guidance to ensure good ventilation in healthcare settings recommends enabling cross ventilation rather than single-sided ventilation (WHO, 2021). If the ventilation guidance does not meet the WHO (2021) minimum requirements, then certain natural ventilation strategies should be deployed, such as considering potential new openings (such as adding or modifying window or door dimensions). The airflow must move from clean to less clean areas.

The use of a pedestal fan placed close to an open window could enable better ventilation. A pedestal fan facing towards the window (facing outside) serves to pull the room's exhausted air to the outside; a fan facing towards the interior of the room (facing inside) serves to pull in the outdoor air and push it inside the room. The orientation of the pedestal fan should be chosen according to the desired airflow direction. The use of fans should be risk assessed, used in a room with the door closed and be regularly cleaned and serviced (PHE, 2021c).

In rooms where an AGP is performed (such as the use of a continuous positive airway pressure (CPAP) machine for sleep apnoea) a ‘stack effect’ or use of anterooms to improve the airflow would enable strict control of the airflow direction The double doors in an anteroom should not be open at the same time in order to clearly separate the air between patient room and corridor (clean area). If the air flow does not move from clean to less clean air then HCWs should consider the use of an air conditioning system to increase the ventilation rate according to system capabilities (WHO, 2021).

Ventilation using natural or mechanical techniques and access to fresh air for patients can reduce the transmission of COVID-19 (PHE, 2021c). This should be discussed as part of the outbreak meeting by the estates department. Outbreak meetings must be convened at regular intervals during the outbreak and include key stakeholders involved in the decision-making relating to patient care and to discuss the rationale for IPC precautions. Accurate records should be kept of all meetings and be shared with outbreak meeting attendees. The decision to declare when an outbreak is over is made here and relevant staff informed. The end of an outbreak is 28 days after the last positive COVID-19 test (PHE, 2020). At this point, time can be taken to evaluate the outbreak, write a report and make recommendations for the prevention of future outbreaks.

Conclusion

Mental healthcare settings are complex environments that offer a range of challenges for HCWs. These challenges have been intensified by the COVID-19 pandemic and further exacerbated when outbreaks of infection are declared.

Specific challenges can be experienced by HCWs in mental health settings, such as caring for patients with poor literacy skills, poor physical health and lack of capacity who are non-compliant with IPC measures. There are also challenging environmental factors. IPC outbreak management policies need to be adjusted to fit the specific needs of a mental healthcare setting, with further consideration to staff working in this field as they are less familiar with the outbreak strategies required than those in an acute general hospital. COVID-19 outbreaks can be managed more effectively with an improved infrastructure, increased IPC staff resources and compliance with IPC measures. This will ensure safer care and reduce the harm to this vulnerable group of patients.

KEY POINTS

• Nurses and other health professionals working in mental health settings during the COVID-19 pandemic experienced the particular challenges of caring for patients in a confined environment that is ill-designed for treating patients with a contagious virus
• Psychiatric patients are often ambulatory and eat meals together and undergo group therapy and interact with each other and staff in ways that potentially facilitate the spread of infection
• Psychiatric patients may show poor adherence with infection control measures and may not be able to follow instructions
• Measures to curtain transmission will affect patients, practices and the environment and include talking to patients about wearing face masks and handwashing, following strict decontamination procedures for all equipment and ensuring all areas are adequately ventilated

CPD reflective questions

• The transmission of COVID-19 can occur on hospital wards, how can this infection spread between patients and what practices can be instigated to reduce its transmission?
• How can the ‘Hierarchy of Controls’ be adopted in your workplace to protect staff from being exposed to infections?
• When patients are requested to remain in their rooms due to infection how can their isolation period be improved or made more tolerable, by staff on the ward?
• In an outbreak on a ward staff are advised to particularly clean ‘frequently touched items’. Name these items and think about how they should be cleaned