Psychiatry and SARS-CoV-2: what happened in Codogno

Evidence based Psychiatric Care – SIP, 2020

Giancarlo Cerveri – Department of Mental Health and Addiction, ASST Lodi

On February 20, 2020 the first case of SARS-CoV-2 pneumonia was diagnosed in Italy. This happened in the Codogno Hospital (Lodi). From the beginning, the hospital set-up began to change, the emergency room was closed, the health workers who came into contact with the patient were placed in solitary confine-ment for long interminable days.So what would be called the “red zone” was outlined, the inhabitants were forbidden to move and the army set up checkpoints to allow transit for health workers and in case of limited emergencies. The Mental Health Department of Lodi (230,000 inhabitants) found itself sep-arated into two areas, “Red Zone” and the yellow one. The structure of the various hospital units began to change and consequently also the structure and organization of the clinical activities of the Department of Mental Health changed.The Psychiatric ward is located in Codogno, the epicenter of what would soon become a world pandemic; always in the red area there is one outpatient ser-vice (Community Mental Health Service CMHS), meanwhile two outpatient services (CMHSs) and the community rehabilitation structure are located in the yellow area.In the emergency situation, the Mental Health Department was confronted with the need to guarantee essential services relating to the areas of Psychiatry, Neuropsychiatry and Addiction.As regards the psychiatric area, activities relating to hospitalization, community hospitalization, territorial management of outpatients, consultancy activities in the Emergency Department and in the various hospital wards were guaran-teed.The operators of the community structure worked to carry out health education interventions, guaranteeing safety behaviors for the patients and for the opera-tors themselves.Outpatients services have guaranteed the management of first visits and emer-gencies, the administration of oral and long acting drug therapies, the assis-tance and treatment of patients with severe mental illness by means of home visits and interventions in the context of semi-residential activities. The Mental Health Department faced various health, administrative and per-sonnel management difficulties. Health difficulties:

• It was not possible to discharge patients (who were detained for 3 weeks and more) and, even they had tested negative for SARS-CoV-2, it was difficult to be able to discharge patients at home or send them to the relevant commu-nity structures because they were hospitalized in red zone and resident in the yellow one. The operators worked to ensure an adequate level of tolerance among the patients, confronting the increase in intolerance to hospitalization, the fear of contagion and the frustration of waiting for the results of nasal swabs performed, the worsening of dysfunctional aspects and aggression.
Transport difficulties caused the delay or impossibility to carry out instrumental diagnostic tests or counselling for patients with organic comorbidities.
• The emergency room of the Codogno hospital has been closed, therefore the procedures for patient admission and the procedure of mandatory health checks and treatments have been partially changed. At the same time the layout of the Lodi Hospital emergency room was modified and a “clean” area was created, where the triage of psychiatric patients is carried out in order to be evaluated by the psychiatrist.
• It was also necessary to change the logistical and organizational structure of the psychiatric ward.
– The psychiatric ward has been divided into two areas: a green area where the asymptomatic patients with negative swabs are located and an orange one in which we hospitalize patients suspected or confirmed positive for
SARS-CoV-2 infection, new hospitalizations awaiting nasal swab and deemed potentially positive.
– In the absence of certain medical and clinical information, each new hospitalized patient is treated as possible infected. Therefore the operators present during the hospitalization procedures and until the end of the incubation period must wear the appropriate PPE = personal protective equipment (disposable gown, mask, shoes, gloves, visor).
– The patient must be placed in the hospitalization area defined as orange and in isolation in the room with respect to the other patients even if asymptomatic (alarm symptoms are considered: hyperpyrexia and
respiratory symptoms).
– SARS-CoV-2 nasal swab should be requested immediately.
– Operators carefully check the sudden onset of at least 1 of the following signs and symptoms of acute respiratory infection: fever > 37.5°C, cough and difficulty breathing. Therefore body temperature, saturation, heart and respiratory rate, blood pressure are constantly monitored.
• Travel difficulties have arisen, with consequent difficulty of the psychiatric services to implement a correct territorial management of psychiatric outpatients and social services to intervene in cases of need; furthermore there was the impossibility of relatives to came to psychiatric
ward to provide patients with emotive support and kinds of comfort.
Administrative difficulties:
• The staff were asked to suspend their children attending school and all activities in which they were engaged, with the onset of problems related to management of work and family needs.

Psychological and personnel management difficulties:
• Staff placed themselves in isolation, who could eve from their family members, and found themselves living every day with the fear of a possible infection.
• Staff were unable to reach their family members residing in other regions, some of whom died from SARSCoV- 2 infection.
• There was an increase in work activity, due to the absence of ill colleagues and to the hospital reorganization for the ongoing emergency, with a consequent increase in emotional stress.
• The staff had to face daily the fear of the infection, the possible onset of flu symptoms and the exposure to positive cases for SARS-CoV-2 (contacts with relatives /friends affected, as inhabitants of the common red zone, or with SARS-CoV-2 positive emergency medicine operators).
After the first phase of the emergency, the demand for psychological and psychiatric support is emerging both from many citizens (some of them burdened by recent family mourning) and from health service operators who have been exposed to exceptional job requests and to a heavy emotional stress, with the risk of developing posttraumatic and reactive psychiatric symptoms or of exacerbating pre-existing psychiatric diseases.
Regarding to psychological and personnel management, the Mental Health Department has also provided a valid contribution in the management of the staff of the other departments, especially emergency medicine, providing a dedicated service with the presence of a psychiatrist and a psychologist.
In this emergency situation, the health figures have drawn on their professional, ethical and communication skills to deal with the various requests. For management figures, it was not only important to provide coherent answers in terms of clinical and professional risk management, but also to manage the leadership role to provide operators with answers and indications in a phase of uncertainty, to encourage collaboration and ensure the best safety within the workplace.
The question that resonates everywhere is: can we save ourselves? Health workers, patients, ordinary people must collaborate with the institutions, scrupulously comply with the directives issued by the Italian Ministry of Health, and all this is possible if we all rediscover empathy and focuson individual resilience, to respect ourselves and others.

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