Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and Health Systems Expert for SMI Advisor. I'm pleased that you are joining us for today's event, SMI and COVID, Successful Models and Protocols. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Although this training is not designated for any continuing education credit, you'll be able to claim a certificate of participation at the end of the training. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 15 to 20 minutes at the end of the presentation for Q&A. Now I'm really pleased to introduce you to the faculty for today's event, Dr. Jeffrey Feder and Dr. James Ashworth. Dr. Jeffrey Feder is the Chief Medical Officer of New Hampshire Hospital at Dartmouth-Hitchcock Health. He's board certified in internal medicine and psychiatry with expertise in public psychiatry, inpatient psychiatry, correctional medicine and psychiatry, community mental health and utilization management. Dr. Feder was instrumental in leading COVID-19 mitigation measures at New Hampshire Hospital, including patient vaccinations. Dr. James Ashworth is the Vice Chair of Clinical Services and Medical Director of Psychiatric Services at Huntsman Mental Health Institute. He is board certified in both psychiatry and child and adolescent psychiatry. Dr. Ashworth led the efforts within the Huntsman Health System to develop new protocols for their inpatients during the COVID-19 pandemic. Today's presentation will begin with Dr. Feder speaking on best practices for handling COVID-19 in state hospitals. We will then hear from Dr. Ashworth on the pandemic and inpatient psychiatry. We'll leave 15 to 20 minutes to answer questions from the audience. Dr. Feder and Dr. Ashworth, thank you so much for sharing your insights with us today. Good afternoon. Thank you for having me here. I'm Jeffrey Feder, Chief Medical Officer at New Hampshire Hospital. Maybe you remember at the beginning of the pandemic, how new and unfamiliar this whole situation seemed. I remember that I was the Medical Director at the Community Mental Health Center in March of 2020. And the question I kept getting was, when are we going to close? When is the clinic going to shut down? The answer was always never. Because if mental health care is medically necessary, and I believe it is, then our patients' needs don't go away when a pandemic comes. And we need to find ways to fulfill our mission as a mental health center. In those early days, we attempted to understand COVID by trying to draw analogies to the flu and to other coronaviruses. And the Swiss cheese model was a well-understood part of that model, that every precaution you take against an infectious disease has flaws. It has holes in it. But like a deck of Swiss cheese, eventually, if you put enough slices in the way, you block the virus from getting through to where you're trying to protect. And so in the state hospital, after I moved there in later 2020, we felt like the use of multiple layers of imperfect protections would be the only strategy available to us to be able to continue to fulfill our mission and to support the general medical system of which we were a part. So you can see on this slide a list of some of the best practices I'm going to go over in the next couple of slides. But the broader strategy is understanding that none of them are perfect, and all of them have to be combined with other measures. So from the Cochrane review, looking at preventing infection in long-term care facilities, this model is presented that shows that as the infection starts in the community, a facility like a state hospital must have some entry regulations. We screen our employees at the front door. We require COVID PCR testing and sending facilities before patients come here. But if there is a contamination, if there is a patient who comes here and develops COVID, we isolate them. We've got good isolation and quarantine procedures, including the use of a COVID care unit for when we have large numbers of isolation. In the meantime, surveillance, both of the community by watching various measures of transmission and surveillance of our hospital, allow us to decrease risk and avoid an actual outbreak. And if there is an outbreak, we maximize social distancing and avoid transmission to the extent that it causes widespread morbidity and mortality. So this is the model. At the beginning of the pandemic, our state hospital used a modification of the Bureau of Prisons model for flu containment, which you can look up. And then I was familiar with my prior correctional work that looks at increasing layers of precautions as community transmission increases. And then when the healthcare system gets overwhelmed, then increasing measures as it penetrates into your facility. Problem over time was that as the science changed, every time we moved from one level to another, it was like a new code white. It took a lot of planning and it was necessary because the science was changing. Over the course of the last two months, we have moved to a more agility-based model, where we have green, yellow, and red. The definitions are there, as you can see. And what we look at is being able to have such good surveillance that we can move levels one to the other rapidly with minimal warning or planning, and that we're able to move levels to green as much of the time as possible, so that we have minimal social distancing and maximum psychosocial programming, access to visitors, et cetera. You can see our level green guidance is here. And it lays out in some detail. These posters are all over the hospital, various video screens right now. What's that surveillance look like? Well, part of it is you can wastewater test. You may have heard of COVID wastewater testing at a community level. We're lucky enough that University of New Hampshire is a leader in this field and has been using wastewater testing to keep its in-person undergraduate college open. And so we tapped them. You can see them tapping our main sewer line, both using a long wire with a big, well, with a sampling cup, what we like to call the Seldinger technique here. Or on the upper left, you can see the swabs, cotton swabs that don't just take a moment of time, but dwell for 24 to 72 hours. And those get a little bit better reading. You can see the readouts on the bottom right. On the far right column is a human DNA control. And then there's two COVID readout columns of different imaging targets. And what we find is that in our facility, as long as it's below about two or 3,000, we probably don't have an outbreak. Those levels will probably be different from facility to facility. And we're doing analysis too to see whether it makes sense to give it as a ratio to the human DNA and that kind of thing. UNH is on the coming edge on this. But that's a big part of our surveillance strategy. Staff communication is critical. They say that a pandemic is a medical emergency or a public health emergency. But really, as I think we've all learned over time, it's a communication emergency. And you can't over communicate. We've had frequent Zoom sessions with our executive team, posters and message boards, like I said. For a while, we're doing office hours. Anyone can come in and meet with an executive team member during office hours and dedicated email channels. I carry a COVID pager right now. I have it, as you can see. If you are an employee or you have a patient who is wondering whether they should get vaccinated for COVID, you can call this pager. And either I or one of my partners who carries it will drop anything we are doing short of chest compressions and talk to that patient about why COVID vaccination might be a good idea for staff. And it's mostly been staff that I can communicate with, actually. So let's see. Another concept that's important, I think, for state hospitals is to be able to utilize the contingency standard of care. This is a concept that's mostly been applied to medical hospitals in mass casualty situations, but also has been applied in more recent situations with the pandemic. It is true that a statewide emergency declaration is necessary for the liability protection, but you can declare this on your own as a state hospital or as any hospital in order to help justify necessary measures to keep functions going. It's important to know that different domains can be in contingency. You could be perfectly fine with PPE, for example, and there you're in standard, conventional standard of care. But you may be out of staff beds as we were at one point. And we would then say, you know, our discharge threshold needs to be in contingency. And what that meant as a state hospital is that some patients that we would normally want to hold on to a bit longer, or would not be comfortable discharging to a shelter with ACT team coverage, for example, we would discharge to a shelter and not wait for another housing situation. Or we would discharge with a little bit more residual symptoms that we would normally do. We would have systems in place to make sure there was some oversight over this, but it was necessary at times to get our patients out of emergency rooms. So mitigation strategies for staffing when you're in contingency. One concept is team-based care. That's a concept that we borrowed from ICUs. So as you may know, they had, you know, people working essentially, you know, family docs working as internists overseen by ICU docs, that kind of thing. Well, we were prepared. We never actually had to do this, but we had prepared to have medical APRNs work as nurses, psychiatry working as internal medicine, and the internists would oversee the psychiatrists doing primary care, that sort of thing. We had finance staff working as mental health workers. I worked as a mental health worker, or psych tech, as they might call it in some systems, just to give people a break in our COVID care unit so they could go have lunch. It's really helpful for morale, for senior management to do that kind of thing. We consolidated units. We learned some things about the use of telehealth for providers. I'm talking particularly that when we have providers who have worked in the hospital for a while, understood the geography of the unit, understood the culture of the unit, that worked pretty well. When we called in locum folks who had never physically been on site, that culture mismatch was really hard to bridge. Another thing that we learned was that the use of social work or nursing as telepresenters, while that might work in some situations, in a contingency staffing problem situation, that causes resentment on the part of those disciplines, both because they may also have their own staffing problems, but because the implication is that they're throwing their bodies in front of a virus to save a provider, and that doesn't feel real good. It makes sense to think about your resilience to sudden staff absences. At the Community Mental Health Center, we did caseload risk stratification, by which I mean that every case manager looked at their caseload and highlighted red, yellow, or green, the name of every one of their patients, and that was kept on their desk. If it was highlighted red, that meant this patient should be seen within two weeks or else they're going to end up in a hospital. If it's yellow, it means they should probably be seen in four to six weeks, and everybody else was green. That way, if that case manager was out unexpectedly, or they had to quickly decide how they're going to spend a limited amount of time, it was easy. In our state hospital, we developed sign-out procedures where every provider had a sign-out sheet on their door at the end of each day during the peak of the Delta and Omicron waves, so that if they were out sick, another provider could easily pick up their caseload. Then cross-training in computer apps, like scheduling apps. I need to make sure that I understood how to use the latest version of our scheduling app in case my associate medical directors were out yesterday. This is a paper that we put out during the operation of our COVID care unit using repositioning to try to keep patients who are still on oxygen from being re-hospitalized after they came back to us. I put this in to emphasize that it's helpful to think ahead of time about what the guardrails of the medical care your hospital is willing to perform on. We had decided early on that if someone needs new oxygen, they go straight to the medical hospital, but if they come back on oxygen, we're going to be able to manage them. Some facilities may not feel like they have the ability to manage patients who are remaining on residual oxygen, or there may be other guardrails. It's helpful to have thought those out ahead of time, as it's harder to do patient by patient. We've developed some protocols to support our decisions. The last piece of Swiss cheese that has come into the mix that didn't exist at the beginning of the pandemic is therapeutics. It's a very different pandemic if you have an 88% effective therapeutic preventing death and hospitalization. We have the Pfizer product, Paxlovid, which is becoming more and more available. We stockpile a number of courses. I think we have 17 courses in our hospital right now. It has a problem with the psychiatric population, in that it interacts with many psych medications and has an absolute contraindication with Clozapine. That needs to be part of the planning. Monupiravir is much less effective. It doesn't have those interactions. It has some problems with fertility. Citrobamab is an IV medication. If you have infusion services in your facility, that is effective against Omicron. Evishelve is a shot, two shots that are given simultaneously that are, that's effective to prevent COVID in patients that you don't expect to respond to vaccination. Vaccination is a key piece of this. I didn't go into detail in this talk, but for those who can't have a reliable vaccination, Edmarshield should be considered because mental illness and congregate living are both considered significant risk factors for COVID. So I hope that I've painted the picture here that we have lots of tools to manage COVID in the state hospital now. So we can fulfill our mission for our patients and be a responsible part of the broader medical system. And with that, let me turn over the floor to Dr. Ashworth. All right, well, thank you, Dr. Fetter. That was great, and it was, if you like, we had similar experiences, though we were a country apart. Go ahead and go to the next slide. So I'm over a, we have roughly 160 bed freestanding psychiatric hospital. It's part of the University of Utah health system. And it has, we have inpatient, it's acute care, inpatient, child, adolescent, and adult. And early on, as I was talking to my colleagues, my medical colleagues, I had to remind them our space is designed to minimize isolation of our patients. Isolation in a psychiatric patient is often not a good thing. And so we have communal spaces, right? Groups, group spaces, eating spaces, beautiful cafeteria come in, there's beautiful group area to, they can sit and look out at the mountains, that kind of stuff. And of course, in a pandemic, this was not that helpful. I also reminded them we have carpeted floors, warm and inviting, carpeted floors, fabric on the wall. Sometimes we have these big, heavy furniture with wood and fabric and everything's warm, inviting, comfortable. But what that leads to is our rooms are much less like the medical or surgical rooms in our main hospital. And frankly, more like, next slide, a cruise ship. A cruise ship. And I actually presented this at, when I, early on in the pandemic, I had to do a presentation for all our providers in our system. And I did this obviously kind of joking a little bit, but at the same time to get the point across that we're different and we are built differently by design. It wasn't like we just haphazardly came up this way. So consequently, we have additional challenges when we're trying to deal with a pandemic. And I bring this up now because quite honestly, it surprised me a little bit that folks within our system, even though we've been here for like 30 plus years, still didn't understand kind of the differences. And it was helpful for me to be able to talk about it and then refer back to, remember, we're kind of like a cruise ship, so we're gonna have to do this a little different. And yeah, we really do need all those masks so we can mask all our patients all the time. Because at the beginning, they didn't really include us in some of their calculations of supplies and stuff like that. So it was just an interesting thing I wanna pass on. Next slide. Now, I just wanna talk about kind of different topics. First off, and Dr. Federer alluded to this too, there's a lot of fear and anxiety of staff and patients. This is a significant problem. And you've got, again, back at the beginning, we didn't know a lot. And people were really worried. And yet they still needed to come to work and take care of patients. And so we had to combat this. And one way was to communicate and develop regular, clear communication about coronavirus in general, and then specifically what we're gonna do about it and how we're gonna best manage our patients. So we developed, and our health system did a really nice job and they had these kind of twice a week, these live stream sessions where we talk about national level, down to our state level, and down to us, what was going on, what we do. And these were very useful sources of information. We did a, we had a similar approach. We developed a working group around COVID and we included leadership from all aspects of patient care here at our hospital. And so it included the clinical folks, included administration, included the leadership in facilities and engineering and housekeeping, and everybody would get together. And we call it the COVID working group because we're not that creative. But we would meet three times a week, a Zoom meeting, and just talk about the issues and how they relate, how we're gonna adapt, but also a great time to answer specific questions from people or concerns and kind of keep everybody moving forward in the right direction. The, let's see, the pressure not to admit psychiatric patients, that really, again, Dr. Federle did this, and I had the same experience. It wasn't our hospital system that said this. It was our people. I had seasoned providers and clinicians coming up going, hey, why don't we just not admit for a while when you're kind of scared and unknown and didn't know what was going on. And it was like, well, wait a minute. No, this is, in order to get into an acute inpatient facility, you have to be an imminent danger to yourself or someone else. This is serious, life-threatening kind of illness that we need to continue to treat. You can die from coronavirus, but you can also die from serious mental illness. And so it was interesting to me and a take home to me is like, okay, I've got to address that early on and upfront. It's like, no, we're gonna stay open. We're gonna support our people. We're gonna support the patients we know how to take care of. And I know it's hard, but we got to keep doing that. But again, it wasn't pressure from on high. It was actually from within. Early on COVID versus now, just, I don't know if you recall, I'm sure you do. There was just the patients then, they could get so sick so quickly. And so we had really good relationship with our internal medicine providers, our other medical providers. And we were able, they were able to see, and then once they understood what we were up against, we were able to transfer people to the medical floors. If they were positive and then had any kind of symptoms, we were able to move them to a medical floor. And then we helped, we gave some of our psych techs to help with behavioral supports to some of those patients. But that was very helpful for us early on because we still had to get our ducks in a row over here. And so I thought about those days versus contrasting with Omicron, very infectious. But by then, all of us were vaccinated, all of us were boosted. We had spaces within our hospitals where we could isolate COVID positive patients who also had psychiatric illness. And we actually hung on to a lot of our patients unless they were really ill medically. And in fact, our main system was very appreciative about that because we, so we sort of flipped over time from kind of transferring a lot of people who are positive to really holding on most patients who had both psychiatric illness and were COVID positive. Of course, the physical layout is an issue, right? We've got all this community space. So we had to make some changes very quickly. Our cafeteria, the way we fed people had to change very rapidly. So initially we just sort of shut down the cafeteria and just took trays up to everybody's room until we could get the cafeteria reworked to have shields, protective shields up around certain places and that kind of thing. It's still not back to normal. We also, the big communal eating space is got a few people now in it, but that isn't back to normal yet, but we're at least allowing people to come down and get their food and they can take it back up to the units, that sort of thing. But these are all just a lot of problems you didn't anticipate and then you start having to think through. The group rooms in our open space on the units, we would put Xs with masking tape on the floor to kind of help get a sense of people how to space out. Of course, we always wanted our patients to wear masks and there was constant encouragement for some patients. They just had real trouble with that. And then I'm including under this section also our infection control. And again, initially going back two years, our biggest problem was supplies. We just didn't have masks, we didn't have, and the system wasn't really thinking of us until later. So that was a problem. So it seems like we are constantly scrounging for stuff and it was just an ongoing process. And we got donations. We got cloth masks initially donated, which were great until we were able to get more traditional kind of disposable masks donated and then finally got them through the system. So, and then the next big step was training, like training, training, and training. Again, we were not, you know, training everybody, staff, faculty, patients, patients' families. How do you wear a mask? How do you, what's good hygiene? And then we're staff more like, what's the appropriate way to enter a room that's got droplet precautions and how do you put on the protective gowns and how do you use a PAPR, you know, the Power Air Purifying Respirator and finally got some of those. And, but how training everybody how to do this. We were sorely behind that curve, that learning curve. And so we paid for that. And I think as a, certainly something we're moving forward, we're going to make sure everybody has always does a N95 fit test every year. So they're up to date on that, that everybody does their training on how to use this stuff and that we have adequate supplies of these things. Certainly important take home messages there. And after training, training, training, we also did a lot of explaining and then explaining because it was really important. We recognize early on that we not only tell people what they needed to do, but tell them why. Have them understand so they could then help tell other of their colleagues and peers why and, you know, give good information. And that's why I think those, you know, good, clear communication pathways are so important because people feel better, that it helps support them emotionally. Plus it gets the right information out and you get people moving in the right direction more quickly. Testing, again, when we had, you know, we were able to get testing and we got it faster, I think, than other areas of the country. We have a A-RUPS, a big laboratory here as local. And so, but we did initially, we had a tent outside. It wasn't a big fancy tent like the main hospital, but it was a tent. And we would initially test people out there and then bring them in. But we would only test people where they thought they, we thought they might be admitted, you know? So if it was a crisis, but we felt like we didn't have to initially did that because, again, we had limited number of tests. As the testing capability improved and resources improved and our system improved, we were able, and people got vaccinated, we were able to move that testing inside into our hospital. We actually left the tent up a little bit longer than we needed to, just to kind of a signal, a visual signal to everybody, hey, it's different now. And so if you're, we used to, you know, take all these walk-ins and have all these visitors, and that was a little bit different. Another thing that was big for us was when we were able to do surveillance testing. So we test people, usually a rapid test and a PCR and admission. And then when we got the ability, we test every seven days just to check and see sometimes these asymptomatic or early on cases, we could get them and make sure they were isolated quickly to prevent spread. Then we were able to go to every four days. And that's where we've been through the, we stayed at every four days through the rest of the pandemic. And that's been really helpful in picking up cases. And we have had definitely more than one case where they got on admission, they got a, you know, a rapid test, a PCR, you know, comes back in a day and that was negative. Then four days later, they were positive. And, you know, was it a visitor? Sometimes it was, or was it we just missed it the first time because it was so early on, but that was helpful and helped, I think, prevent a lot of spread. Let's see, and then there's no way to put this. So I just put it in here, but you know, other stuff can happen. And that in the first year of the pandemic, we're adjusting to all this. And we actually had an earthquake here in Salt Lake. And fortunately it just damaged buildings, but it didn't kill anyone. But that added to everybody's stress because we are on a fault here and we're always preparing for and expecting the big one. And so then we also had this windstorm of literally a hundred mile an hour plus winds, which we never have here. And these hundred year old trees were toppled over and power was lost throughout huge parts of the city. And again, this is all during the pandemic. And then we had a wildfire that kind of got close to the hospital. So we were, you know, and you just have to, I'm sort of smiling because you just have to laugh about it. It's like, wow, that was a bad year. But so far we haven't had a volcano, so that's good. And, you know, but other stuff can happen as you're dealing with this and something to be aware of. You're going to may have to adapt to something in addition to a pandemic or a plan on to something else. One thing I thought was interesting, remember the temperature checks? Remember how that was such a big deal early on after your temperature everywhere. And, you know, in reality that probably didn't help a lot from a clinical sense of catching a lot of cases, but I do think psychologically it was helpful. But I also know it was a huge manpower resource. So I can see why we moved away from that fairly quickly once, you know, after a few months. Let's see, where am I doing on time? So facilities and engineerings, I want to make sure we talk about that. That this, you know, we recognize that we would have to be able to isolate these positive patients and kind of keep away from the rest of the group. Again, we're a freestanding psychiatric facility. I didn't mention, but we got, we about 11 years ago, we more than doubled in size. So we have this part that was built in 1985 to 87. And this other part that was built and finished in 2011. And that the newer part is three stories and it's beautiful, it's big, and it's a modern well-designed inpatient psychiatric hospital, just awesome. But things like air, the air handlers there, I have two air handlers for this newer part and everything is shared, right? It circulates, it just circulates from one room to another. And it's like, there's no way to separate out rooms. So actually having this older part of the building was helpful because some of those rooms on the older side of the building had separate air supplies and air, I forget what they call it, but you could, they didn't commute, their air wasn't shared with anybody else. So we actually were able to use the bathroom and fans that exhausted straight to the outside, change the inflow from these air supply systems. And when the doors were closed, it was effectively a negative pressure, flowing from the room to the outside. Wasn't my classic negative pressure, but it was better than nothing. And so we developed some spaces, both on our adult side and our adolescent side, to do that, to put, when we recognized we had COVID positive patients with psychiatric illness, we couldn't just discharge them. We had them in those rooms. The other thing we did was walled off certain areas to help make those spaces safer for the rest of the community. And there's temporary walls, there's a brand called EdgeGuard that our facilities people really like. In fact, we borrowed them from our main hospital and we haven't given them back yet, but they're very handy. And you can put up a wall in like a couple of guys can put up a wall in a couple hours and then take it down in like an hour. And so we did that over the course of the last two years, a couple of times, putting them up, taking them down, putting them up and we've kind of got it to where we're leaving the ones up now until we know for sure we're out of this, but it's been very handy to have some really kind of better isolated places from an infection control standpoint, but they're still kind of part of a unit and we can still work with it. And then at one point we had enough COVID positive psych patients to actually take over one of our units, one of our adult units, there's like we had nine. And so that was, so we just kind of, that was the next step. You know, if we couldn't do it in these little rooms, we expanded to the whole unit was COVID positive and everyone treated as such. Let's see, how am I doing? Okay, another thing just about facilities and cleaning. So when we discharge a COVID positive patient, we would first actually have to get help, a filter and just let it run in the room, doors closed for 30 minutes, just to try and scrub the air as best as possible and then do the terminal clean. We just, something our cleaning people thought would made sense and it made sense to us. And so we said, yeah, do it. And, you know, we didn't ever have any transmission. Oh, I didn't want to mention transmission. So far and away, the biggest source of transmission in our system, in our psychiatric hospital and also our main hospital was not patient to staff. It wasn't staff to patient. It was actually, you know, staff to staff. That was the highest rate of coronavirus transmission within our hospital. And it's what would happen is people would be on guard when they're around the patients, they'd be masked and make sure the patients are masked, but then, you know, they would take their break, they'd relax, they'd take off their mask, they want to talk to their friends, they want to eat and whatever. And that's when it would happen. That was an interesting fact. Very rare, incredibly rare incidents of transmission from a COVID-positive patient to a staff. Again, that's because of all the precautions that were put in place. The last few minutes, I just want to talk a little bit about day treatment. I think some people want to know, we have adolescent day treatment programs, we actually have two of those, and we call them Teen Scope, and then latency age day treatment programs, call that Kid Star, and we kept those running throughout the pandemic. We've had to adapt quickly. Some things we learned, first off, the latency age kids really couldn't do a virtual experience. I talked to the director about this, and she said, yeah, that was a disaster. What they did is they went with the adolescents, they did one day virtual, one day live, and then they developed programming for the virtual time, and that way they could spread out during the live portion, and they could be distanced, and of course, everybody was masked, everyone was closely monitored, things were cleaned, and HEPA filters were always going, and then with the younger kids, they just split the group into two pods, they called them. Once you're in that pod, you couldn't go to another pod, you're just in that pod, and we had enough space, we could spread out into other parts of the building, and run it that way, again, with very, very strict masking, very strict distancing, very strict cleaning, and again, didn't have any significant outbreaks. There was, in fact, in a two-year period, each of those programs only lost one week of time where they had enough positive people, they said, look, let's just close this, and give it a break, let these people stay in quarantine for a week, and then we'll get back. So in two years, one week lost, otherwise it was running the whole time, and so very proud of those guys. They did feel like they did a lot of things, jumped through a lot of hoops to make this work, and it was definitely better than nothing, but they're not thinking the future is that kind of thing, they're ready to get back to having everyone live again. You miss a lot of the ability to influence the behavior, and help train the parents on behavioral interventions, that kind of stuff, in a virtual world. Okay, I've gone over 20 minutes, and I really do wanna be able to answer any questions, and make this as useful as possible. Thanks for the opportunity to come and share a little bit about what we did. So I'll stop now. Thanks so much to both of you for such interesting, and really engaging presentations. So I want to invite attendees now, again, to feel free to submit your questions, by typing them into the question area, it's in the lower portion of your control panel. Before we shift into Q&A, I wanna take a moment, to let you know that you can access all of SMI Advisor's free resources, at smiadvisor.org. You can browse through dozens of live, and on-demand courses, in an education catalog, find hundreds of vetted resources, in an online knowledge base, and submit questions about SMI, via clinician to clinician consultation service. You can also download the SMI Advisor app, to access all these same services, plus a series of clinical rating scales, that you can use in real time, with individuals who have SMI. Before I go into the attendee questions, I just wanna say I was struck, and really impressed at the degree to which each of you, needed to become experts in infectious disease, and environmental health, and engineering. I'm just curious if you have any reflections, on what the experience was like for you, and in any ways perhaps, that it's changed how you think of your roles, as clinical leaders, you know, and moving forward. Well, I mean, certainly if you feel like an amateur, you know, engineer asking about MIRV 13 filters, and do we have them at like, I just know the word, I just looked it up. Like, that's the thing, like you ask the questions, without like all the background, but you know, in terms of like role as a leader, I mean, I feel like mostly the purpose is not, because I really need to understand the answer, that the engineer gives me in its entirety. I wanna make sure that the problem is being addressed, and that, you know, that other parts of leadership know, this is a clinical priority, and should be a leadership priority for, you know, the chief operating officer, and I'll let them figure it out. I'll just ask, you know, are we addressing that? And so, you know, from the standpoint of, you know, making sure that we're doing everything that we can to keep our patients safe, it really helps to engage, and as a new CMO at my hospital, having to get to know everybody. So that was helpful from a leadership perspective as well. Yeah, I agree, I mean, it's empowering your people. So this whole thing about the negative pressure, it's like, he was explaining to the engineering people, we don't want the air from that room to get out into the rest of the unit. Is there anything we could do, you know, with that kind of thing? And they say, well, oh, okay, let us look at it, you know, and they came up with that solution, and they helped us, they got these edge guard walls, which again, you know, has just been really handy. And so it's really listening, I think, you know, making sure people understand what the problem is, and then being wise enough to listen to the people that know what they're doing, and being wise enough to ensure you have good people, you know, and we've just got great people here, and that's been really awesome, but it's a team effort, there's no question, you know. Great, thank you. So a couple of questions about kind of where we're at now. So, I mean, what would you say is currently the biggest challenge at this point with COVID? It's obviously, you know, an ever-changing landscape, but what's the greatest challenge that your systems are currently facing? I mean, the greatest challenge always is communication on some level, or at least, you know, every challenge is filtered through communication, challenges that creates. Like Dr. Ashworth said, you know, you've got scared people, and in the worst moments, you've got both scared and angry people at various points that you're sitting face-to-face with, and making sure that you're balancing the needs to get the psychosocial needs met with the infection control, and as you move down levels of restriction, helping to reassure the people who are really worried about every change that might be made because of, you know, perhaps their own health conditions. Yeah, ours is, so some of our changes came at a cost of our capacity, and so we can, you know, like, we would get up in the 140s, occasionally 150, kind of on a 160 census. I mean, that's like hard to do with psychiatric patients, and, but we have a big demand, and that's now we're running, January was terrible, and it was because of the, 60% of our adult beds are dual occupancy, and of course, we've had to decrease how we use those, and then staffing has hit us, you know, the people, you know, part of it, really, it was, I think people retired early, and then, you know, people feeling like, look, this is too hard, I'm too scared, it's scary, it's hard, I'm just gonna go work for, you know, in a warehouse somewhere, and, you know, our psych techs, our entry level has been hard, and then we're in a university, you know, we're in a state system, if you will, and so not exactly the most nimble, you know, when you get HR involved, and trying to get salaries raised and stuff like that, so we've lost a chunk of our capacity to coronavirus, and then another chunk to staffing, and we're working hard to fix that, but that's our biggest problem right now, because there's people out there that need this service, and for the first time in my, I've been here over 20 years, I got here in 99, for the first time in my career, we have enough docks for the beds we have, like, it's always been, we haven't had enough scratchers, and now it's like, it's staffing, it's psych techs, it's nurses, it's therapists, and that's a challenge, and we're just doing everything we can to try and fix that. Great, I mean, you know, I think you were kind of both alluding to this a little bit, but along the way, when you had clinicians who were resistant to admitting COVID patients to inpatient psychiatry, what was that like, and kind of how did you work with them, or communicate with them? Well, I had one-on-ones with, I mean, they would usually come to me, and that was good, because they had good relationships and stuff, and it's like, well, wait, shouldn't we be closing? I just remember, shouldn't we be closing? Well, no, I mean, let's think through this, you know, where would these people go? And this is a population, as you know, the good news is I could use that against them, they've spent a lifetime working for, you know, with people with mental illness. They're gonna be, they can't advocate well for themselves, they're highly likely to get this, they're gonna be danger, they're in imminent danger themselves, we're gonna say no, I don't, that isn't how we're gonna do this. And I, you know, and they would kind of, you know, and it was out of their fear, you know, I did it nicely, because it's really out of their own fear, right, and anxiety, they were saying, well, shouldn't we, we gotta protect our people, and it's like, well, yeah, but this is what we do is to take care of these people, and this is like a bad time for them, we can't abandon them, so that's kind of how I responded. Yeah, similarly, I mean, I think that, you know, bringing the conversation back to the mission is that, you know, this is what we do, we don't abandon our people, but we're gonna manage the risks, and we're gonna be very transparent about the decisions we're making and why, and those personal relationships, like Dr. Ashworth said, are the foundation for helping to keep people on board. You've listed a number of people on board, you've laid the groundwork for that successful response in the time that you've built up good relationships with folks ahead of time. Thank you. And then as you look forward, I guess, or look backward and then take those experiences and look forward, do you see any positive changes that happened during COVID within your systems that you anticipate maintaining afterward, moving forward? Yeah, I mean, I think certainly the capacity, the ability to do tele-psychiatry, right? Well, I mean, we were always pushing that, but, you know, nobody wanted to pay for it, every, you know, and suddenly that's opened up, right? And that's been helpful. And I will say, and go on record here, Zoom meetings used correctly can be useful. But Jeffrey and I are in different parts of the country right now and we're participating. I mean, that's pretty slick, you know, and we didn't have to travel or anything like that. And we could pull the attendance at staff meetings, you know, department meetings, something like that has gone up significantly because we have places spread out in the Valley, but nobody has to drive and park and all that anymore. They can just Zoom in. So I do think that form of communication is useful. And then, and so I think it's just, but using it wisely, right? I think we've all been, we use Zoom. So I use Zoom a lot, but we've been Zoomed out, right? I mean, it's just like, it's like, oh, you know, we've got to get back to a little more normal sort of meeting kind of thing. But at the same time, there is, I think, power in that kind of communication and getting people. So everybody has the chance to hear and to communicate better because it's easy to get to the meeting they need to get to. I think that's been, you know, as horrible as it's been in many ways, it's been good for our hospital's cohesion. We went through this really rough thing together and medical help to have psych, psych swab patients for medical. You know, there's been a level of collaboration and sort of breaking down barriers that it takes something disruptive to do. And I think that there's been benefits to our hospital culture, particularly in that collaboration between the medical and psychiatric services. So I hope to preserve that. Great, thanks. And I'm curious, you know, given, you know, the new CDC guidelines, which are now relaxing, you know, masking requirements indoors, you know, how are you guys, how are the two of you and your systems kind of calibrating, adjusting so that you can, you can relax requirements as appropriate, but retain kind of the flexibility to dial them back up as might be needed in the future? Well, initially we were throwing in 95s at the problem. We were, you know, at one point, you know, a couple of weeks ago, the thought was, we want to get groups going again, we want to get visits going again. We're going to do as much as safely possible to get rid of social distancing and throw in 95s on everybody to make it possible because we haven't. And so, you know, at a certain point, everyone's like, okay, we've been doing this a while, everyone's like, okay, we've been doing this a while, we hate the N95s, they're so uncomfortable, I don't want to wear them all day anymore. So you saw our level green, we're really pretty maximally allowing visits and all this kind of thing. But what we've done is we've tied the N95 use to the new CDC website, giving community level risk. So if our community bumps up, our county bumps up to that red high level risk, we'll go back to the N95 masks in clinical areas. But at moderate where we are now, and if it hopefully goes below in the next couple of days, it'll be surgical masks or the lowest allowable mask by CMS, whatever, you know, however that evolves. But that's how we're looking at it. Yeah, we take our marching orders right now. We used to be kind of independent, now we're, a couple of years ago, we became part of the hospital, like we're another unit of the main hospital. So we sort of have to take our marching orders from what they're doing, and they're still using surgical masks for everyone. I'm okay with that, because quite honestly, the bigger fight is, not fight, but I really would like to get our spaces back. And so if everybody's wearing a mask, but that means we can get people down the cafeteria and eat down there and we can, and our visitor policy is not limited, it's limited still, it's not totally open. And so we can, if everybody's wearing a mask, we can expand that a little bit better. Those, I'd rather do that before we get rid of the mask. I'm tired of masks, I get it. And frankly, I don't know how useful they are on our units, because we're always telling people like, yeah, you got to put your mask on, you know? So, but for staff, I think it's protective. And so I see us, the masks, probably a couple, a few more months until we see, and, but when the main hospital starts thinking they can start backing off, then that's when we'll probably back off the masks. Yeah, for patient care areas, we emphasize the use of even non-fit-tested N95s. So whatever you're comfortable with, the most comfortable wearing, because there is evidence that a non-fit-tested N95 is significantly better for source control. So it's not for the staff, it's for the patients that they're wearing N95s. The similar here with a KN95s are better than, you know, we've got, we don't have that luxury of a ton of N95s, but we've encouraged, you know, so a staff can get their own KN95 and we'll say, oh, that's awesome, that's great, for that reason. Terrific, well, we're just at almost time and I don't see other questions coming in. So I just want to really thank you both again for sharing your experiences, your wisdom, lessons learned. And I guess we'll kind of move on to the final slide, which is that if anyone who's attending today has follow-up questions about this or any other topic related to evidence-based care for SMI, our clinical experts are available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. So thank you all for joining us and until next time, take care.

psychiatric hospitals

COVID-19

infection control measures

therapeutics

vaccination

communication

tele-psychiatry

virtual communication

flexibility