The coronavirus disease (COVID-19) pandemic has posed unprecedented challenges for the field of psychiatry, subjecting the general public—and healthcare workers in particular—to elevated levels of stress and trauma while disrupting established modalities for therapeutic intervention. NYU Langone’s successful response offers lessons for other institutions in responding to this crisis, and to similarly complex emergencies that may arise in future.
A Multipronged Approach
At the peak of the pandemic in New York City, between March 1 and April 8, 2020, 11,544 people were tested for SARS-CoV-2 at NYU Langone; 5,566 patients received positive test results, and 2,780 patients were admitted to the hospital. This massive influx of patients required the redeployment of hundreds of physicians to the “COVID Army.” The risk of exposure also necessitated a sharp reduction in the face-to-face interactions that typically characterize mental healthcare.
Yet the need for such care was surging, both in the community at large and among frontline healthcare workers. Along with all the other pressures of the pandemic—from concerns over contagion to the impact of lockdowns—care providers on COVID-19 floors faced grueling shifts treating critically ill patients, many of whom died despite heroic efforts to save them. In such cases, informing family members added to the psychological burden.
NYU Langone’s Department of Psychiatry, led by chair Charles R. Marmar, MD, the Lucius N. Littauer Professor of Psychiatry, developed a multipronged approach to these challenges, guided in part by the department’s previous experience with disasters such as Superstorm Sandy and the 9/11 attacks. In July, members of the department published a package of continuing medical education (CME) articles in the journal Psychiatric Annals, providing a preliminary road map for navigating this difficult terrain.
“Responding to a pandemic is a demanding task, and there are many opportunities for us to learn from each other,” observes Dr. Marmar. “We feel an obligation to share insights we’ve gained as one of the first major medical centers in the United States to weather the onslaught of COVID-19.”
Creating a Virtual Consultation–Liaison Psychiatry Service
The Psychiatric Annals articles highlighted four aspects of NYU Langone’s response. The first was the development of a virtual Consultation–Liaison (CL) Psychiatry Service for Tisch Hospital and NYU Langone Orthopedic Hospital. “The CL team aimed to provide the hospital system with comprehensive psychiatric consultation for all patients, regardless of isolation status, while preserving personal protective equipment and avoiding unnecessary exposure for team members,” explains Rachel A. Caravella, MD, interim director of the Consultation–Liaison Psychiatry Service and clinical associate professor of psychiatry.
Before the pandemic, few models of telehealth existed for psychiatric consultation to hospitalized medical and surgical patients. Nonetheless, the Consultation–Liaison Psychiatry Service completed the transition within two weeks.
Telepsychiatry best practices, including administrative, technical, and clinical considerations, were key to creating the virtual CL service. In collaboration with NYU Langone’s Medical Center Information Technology (MCIT) team, site-specific workflows were designed to address the needs of each clinical setting because technological infrastructure differed from site to site. For example, the recently constructed Kimmel Pavilion features single patient rooms equipped with bedside tablets for remote assessments, though this technology had rarely been used before COVID-19. At other locations, the CL psychiatry team quickly procured Apple iPads, along with rolling stands and cases capable of withstanding repeated disinfections.
The new workflows relied on a clinical team member to bring the tablet to the patient’s bedside and facilitate the encounter. For the adult CL service, psychiatric nurses were redeployed to serve in a role referred to as the tele-CL nurse. These tele-CL nurses proved vital to clinical encounters regardless of whether the patient’s room had dedicated telemedicine equipment. In between patients, they also performed psychological first aid for frontline clinical staff throughout the hospital. Members of the pediatric CL service, whose teams did not include a dedicated registered nurse, communicated by phone with pediatric primary teams or bedside nurses, who obtained clinical information about the patient and then initiated the video encounter.
At all sites, a crucial issue was the need to develop an approved system for obtaining consent for voluntary psychiatric hospitalization. The final procedure necessitated collaboration among legal, medical, and nursing teams and was approved by the New York State Office of Mental Health for use during the pandemic.
By the time the Psychiatric Annals report was published, all of these changes were firmly in place. With the conversion to a virtual service, more than 70 percent of consultations were performed via telepsychiatry. Only 13 percent of encounters required in-person assessments, and these typically involved patients with severe agitation, profound intellectual impairment, or refusal of consent.
Addressing the Pandemic’s Mental Health Impacts
Other articles in the NYU Langone–authored CME package offer recommendations for preventing and treating stress-related disorders associated with the COVID-19 crisis, guidelines for redeploying psychiatrists to inpatient medical floors during a pandemic, and guidance on the development of additional mental health services and wellness programs for frontline healthcare workers.
The latter task, the authors reported, required coordination across NYU Langone’s system to decrease duplication of services and increase centralization of information. This included enhancing pathways for faculty, staff, and trainees to obtain individual and group treatment and to access high-quality self-help resources. A broad range of virtual and in-person resources were developed to address pandemic-related mental health impacts including difficulties with sleep, anxiety, and the pressures of juggling work and family responsibilities.
“The rapid pace of program development was fueled by an urgency to support and care for our frontline colleagues,” says lead author Amanda M. Spray, PhD, clinical associate professor of psychiatry and director of the Steven A. Cohen Military Family Center. “Strong leadership, timely communication, and investments in infrastructure predating the pandemic all contributed to the success of the evolving effort.” These efforts were co-led by Marra G. Ackerman, MD, clinical associate professor of psychiatry and director of consultation–liaison psychiatry.
Embracing Telemental Health for Outpatient Care
As noted in the journal articles, one of the Department of Psychiatry’s most significant responses to the pandemic involved switching outpatient care primarily to virtual delivery. Although studies have long shown that telemental healthcare can be as effective as in-person treatment, regulatory and reimbursement issues have severely limited its application in the United States. The COVID-19 crisis has prompted rule changes at the federal and state levels to lower these hurdles, at least temporarily.
NYU Langone Psychiatry Associates, the outpatient practice, was well prepared for this transition. In 2016, the medical center’s Military Family Center launched an innovative Telemental Health Program, funded by a grant from the Home Depot Foundation, offering a full array of psychiatric and psychotherapeutic services, free of charge, to veterans and their families. The founding director of that program was Paraskevi Noulas, PsyD, clinical assistant professor of psychiatry. In collaboration with MCIT, Dr. Noulas began an ambitious campaign to build telehealth capacity and training there.
“When COVID-19 hit, we were in an excellent position to switch over completely,” Dr. Noulas says. By mid-March, nearly 100 percent of patient visits were being conducted via video link, enabling patients and providers alike to avoid the risk of contagion and to connect even if the pandemic had prompted them to leave the city. Meanwhile, virtual team meetings allowed providers to coordinate care and discuss complex cases on a daily basis.
Though the pandemic passed its peak in New York in late summer, telehealth has remained the dominant modality at the outpatient practice. “The feedback we’re receiving is extremely positive,” Dr. Noulas reports. “When all of this is over, I’m sure many people will be happy to return to office visits. But the convenience of tele makes it a compelling option. If the rules allow, I expect that a high proportion of patients will stay with it going forward.”