When COVID-19 began to spread within Ontario, the inpatient mental health team at Baycrest knew they had to act quickly to protect their high-risk patients.

Located in Toronto, Ont., in a neighbourhood considered to be a COVID-19 hotspot, Baycrest is a leader in geriatric care and residential living, placing a special focus on brain health and aging.

Maria Nelson, Advanced Practice Nurse for Inpatient Mental Health and Behavioural Neurology, noted that the team realized they needed to establish a process to safely screen patients for COVID-19 on a regular basis to prevent and control infection. She said that “in a matter of minutes” an effective process was put in place, which has since become a recognized Health Standards Organization (HSO) Leading Practice and one of the first related to COVID-19.

Baycrest’s Leading Practice, COVID-19 Surveillance Testing for Patients with Acute Responsive Behaviours, offers a surveillance testing protocol that helps in managing acute responsive behaviours and mental health-related behaviours during a pandemic, such as COVID-19.

Baycrest team members PPE

Baycrest team members preparing for COVID-19 surveillance testing.

Nelson noted that Canada’s long-term care sector was hit hard by COVID-19 due to its high-risk demographic of residents who are often suffering from conditions such as Alzheimer’s dementia or other mental health-related illnesses. “There are a lot of residents living with various types of dementia or mental health diagnoses that pose a significant risk in the spread of COVID-19 due to the presence of responsive behaviours and an inability to isolate patients,” she said. “Not only are behaviours such as disinhibition, agitation, aggression, restlessness – specifically for people who are ambulatory – difficult to contain, the infrastructure in hospital settings or long-term care settings do not readily support it. It is challenging when working with patients and residents who may not have the cognitive capacity to understand the need for isolation or rationale for a COVID-19 test.”

Nelson added that “it would not have been in line with our ethical practice” to rely on medication to sedate and restrain patients or residents solely for the purpose of preventing and/or controlling the spread of COVID-19. “The care team at Baycrest had to find a safe and ethical way to proceed,” she said.

Nelson explained that the surveillance testing protocol follows four key elements: 1. Selection of swab and test method based on the patient’s behavioural profile; 2. Use of bite blocks to prevent injury to patients; 3. Mild pre-sedation and early timing of tests; and 4. Engagement of interdisciplinary team members to inform the testing approach.

“With this process, we’re choosing the right swab that presents the least amount of risk for the patient and the team members. We know the behaviours of our patients as well as effective interventions both pharmacological and non-pharmacological. With all of these considerations, we managed to roll out surveillance testing for our whole unit,” she said.

Nelson noted that many patients suffering from dementia for example, have behaviours or conditions that make a nasal or throat swab particularly difficult to administer. “They could act out physically. Also, for a lot of patients with dementia, depending on the stage, they may have swallowing difficulties or reflex issues. We have some patients with oral fixation, who could potentially swallow or bite the swab,” she said. “These issues really required us to figure out what we could do and utilize to increase safety.”

Nelson added that if a patient or resident’s behaviour improved during their inpatient stay, each factor of their behavioural profile would be re-evaluated and the process would be adjusted accordingly. Through this protocol, Baycrest was able to achieve a 100% COVID-19 testing rate for patients in its inpatient psychiatry and behavioural neurology units.

To date, Baycrest’s inpatient mental health units have only seen one confirmed patient COVID case, which was managed with great success and no spread of the virus. “In addition, 95% of our patients were vaccinated when vaccines rolled out. As the inpatient population continues to turn over, we make the maintenance of surveillance testing and vaccination a priority,” she said.

Nelson noted that prior to the pandemic, Baycrest already had some practices in place to prepare higher risk patients for blood work, dental appointments or other required care. She said however that COVID-19 pushed Baycrest to refine these practices into a more effective process.

“Mental health in general has been a high-risk area of COVID-19,” Nelson said. “The fact that we were able to achieve this level of success with our surveillance testing is something that many have not for a variety of reasons, with the complexity of this population being one of them.”

Maya Hohmann, Quality and Process Improvement Consultant at Baycrest, attributed some of Baycrest’s success during COVID-19 to quality improvement (QI) methodologies the organization already had in place. “We applied those same methodologies around gathering data, learning from that data and testing different things in terms of how to screen people,” she said. “The application of QI methods to our pandemic response is something that allowed us to rapidly evolve in this situation.”

Nelson adds that whether in a pandemic or not, working with this particular demographic of patients and residents is challenging. “We are faced with challenges every day, especially when managing a high-risk population with acute behaviours,” she said. “The fact that we were able to come up with this process demonstrates the ability of our team to be agile and pivot to meet the needs of our patients as well as their families.”

Hohmann added that the now HSO Leading Practice came from clinicians – from Nelson and her team. “They didn’t wait to be told what to do,” Hohmann said. “It really came from Maria Nelson’s knowledge of the population and her team’s willingness to try something new to solve a problem.”

At the time this article was published on April 22nd, Baycrest’s inpatient psychiatry and behavioural neurology units remained COVID-free, with no new positive cases.

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