Timeline of the publication of the principal guidelines about the epidemic in France
In France, on 20 February 2020, the health ministry published the first volume of a methodological guide about the organisation to be set up to deal with the first epidemic wave of COVID-19, entitled "Preparation for the COVID-19 epidemic risk: Healthcare facilities, physicians in private practice, and medicosocial facilities" [26]. The emergency plan ("plan blanc") was activated in the hospitals of the regions most strongly affected on 6 March and enlarged to all hospitals in France on 13 March. This plan is intended to enable a healthcare facility to prepare immediately all of the resources it has available for the possible influx of patients or victims and thus cope with an exceptional health situation. On 16 March, the French government published the second volume of the methodological guide, entitled "Preparation for the COVID-19 epidemic phase" directed at the same groups [27]. The nationwide lockdown began on 17 March and continued until 11 May. The French government did not publish the first specific guidelines for licensed inpatient psychiatry establishments until 23 March [28].
The principal recommendations for specific management for infection control and hospital hygiene came from the high council on public health (HCSP) and the French society of hospital hygiene (SFHH). Accordingly, the SFHH published the first recommendations about the barrier measures (additional hospital hygiene precautions) to implement for the management of patients infected by COVID-19 on 28 January 2020; they were completed by the HCSP recommendation on 27 February [29, 30]. These guidelines were modified several times during the first wave. On 15 March, the HCSP published a document about issues related to screening patients at risk of severe COVID-19 and organising dedicated channels of care for them [31]. Finally, the HCSP published recommendations for the management of the body of deceased patients infected by SARS-CoV-2 virus on 27 February and modifications to them on 24 March [32, 33].
Organisation of psychiatric care in France
The organization of psychiatric care in France is divided among three main types of providers:
- Public institutions (general or specialised hospitals offering inpatient care and medical-psychological consultations for outpatients),
- Private establishments participating in public service, administered by an association or mutual insurance company (healthcare facilities referred to as private of collective interest or private non-profit), and
- Private for-profit establishments (doctors' offices and psychiatric clinics).
The French hospital sector comprises 1,364 public establishments, divided into four subtypes:
- 178 regional hospital centres that provide the most specialised care to their region's population, as well as routine care for the local population including psychiatric services;
- 947 intermediate-category hospital centres, managing most short hospitalisations (medicine, surgery, psychiatry, obstetrics, and odontology), as well as care for the elderly;
- 95 hospital centres specialised in psychiatry;
- and 144 other public establishments, most of them providing long-term care.
Among the private hospital structures, there are 1,002 private for-profit clinics and 680 private non-profit facilities. Some of them are specialised in psychiatry.
In comparison with other medical disciplines, psychiatry has several specific characteristics:
- Few technical procedures
- Many outpatient facilities
- Management of recurrent and diversified patients.
Psychiatric care is essentially provided by public establishments, especially for outpatient psychiatric hospitalisation. Psychiatric care as a public service is provided in France by the public and private non-profit facilities. Each French district (département, France's basic administrative division) has been divided into geographic zones, referred to as "psychiatric sectors". The psychiatric sector simultaneously designates the geographic area but also the mental health care services available within its boundaries. A sector covers a territory of around 67,000 inhabitants [34, 35].
As a general rule, this psychiatric care is voluntary. The patients concerned enjoy the same rights as all other people receiving health care. Nonetheless, a system of care without consent makes it possible to provide the necessary care to patients who are not conscious of their mental disorders or of their imperative need for care. This care without patients' consent is regulated by French law, which requires that only facilities participating in public service are licensed to provide it. The law sets conditions to guarantee the protection of the individual's rights and liberties [36].
Three types of care are available in psychiatric healthcare facilities:
- Outpatient management, which designates reception and care performed essentially in medicopsychological centres (CMPs), as well as consultations at other sites, especially those related to liaison psychiatry in health and social establishments;
- Part-time management, more than that provided for outpatients, but without continuous day- and night-time management: centres for part-time therapy (CATTP), therapeutic workshops, day hospitals, and night hospitals;
- Full-time inpatient care in premises enabling care and monitoring 24/7;
- Other types of services can be set up, such as home care, provided essentially as a public service in France.
There are 56,000 beds available for full-time management (but also in family therapy placements, residential aftercare, therapeutic apartments, home hospitalisation, and crisis centres) and 29,000 places for day- or night-hospital care. Outpatient management, mostly in CMPs, is the most frequent form of care [37].
Constitution of a structured audit grid
The audit grid was elaborated specifically for the study. To identify the different organisational measures taken and changes made in psychiatric facilities, a working group of seven professionals with diverse jobs and expertise (psychiatrists, psychiatric nurses, physician-hygienist, nurse-hygienist, pharmacists, a quality/risk management supervisor, and administrative staff) was set up to identify the recommendations published in their fields of expertise.
We conducted a review of the international literature for this purpose.
It enabled us to compile references for the principal publications related to opinions, recommendations and guidelines, operational feedback, and scientific studies of the organisational changes adopted by psychiatric hospitals during this period.
The literature review was performed on PubMed, by querying the following key words: "COVID-19", "psychiatry", "mental health", and "organisation".
Other bibliographic sources were also consulted to identify pertinent information, including but not limited to the World Health Organization (WHO), the French national authority for health (HAS), the HCSP, and various professional societies (SFHH, the French microbiology society, and French-speaking society of clinical nutrition and metabolism). For each recommendation, we recorded its topic, its title, publication date, and recommended implementation date of the measure, if different; the organisational items judged important by the experts were extracted.
The working group identified 48 important items grouped in 4 major themes identified at the end of this work: general planning and coordination of the crisis management (10 items), specific measures associated with patient management and with their families in psychiatry departments (13 items), hospital hygiene and epidemic control measures (13 items), and management of human resources (5 items). In addition, 7 items were added to identify the profile of the persons audited (3 items) and the impact of COVID-19 on the facilities: number of patients with COVID-19, number of hospital staff infected by it, and number of deaths — all during the first wave (4 items). When it was considered relevant for a particular item, we included the date that this measure or action was added.
The project team, with support from the working group, selected and finalised the 48 items included for the survey questionnaire and the elaboration of an interview guide for the investigators. Table 1 synthesises the items considered in the audit grid and the type of response expected.
Table 1
Synthesis of items covered in the audit grid and expected type of response
Items
|
Type of response
|
Profile of the individuals audited
|
Function of the person interviewed
|
Open
|
Membership in the crisis management group
|
Closed yes/no
|
Function in the crisis management group
|
Open
|
Impact of the first wave of COVID-19
|
Number of patients with COVID-19 at or after admission during the first wave (March to early May 2020)
|
Categorical (0; [0–20[; [20–50[; 50 or more)
|
Number of staff members with COVID-19 during the first wave (March to early May 2020)
|
Continuous
|
Number of deaths due to COVID-19
|
Continuous
|
Planning and coordination of crisis management
|
Activation of the crisis plan ("plan blanc") and of the crisis management group
|
Date
|
A territorial partnership in mental health set up with a for-profit private, public, or private non-profit establishment
|
Closed yes/no
|
Bed management system set up
|
Closed yes/no
|
Availability of medical equipment at the start of the epidemic: blood pressure monitors, pulse oximeters, thermometers, semiautomatic defibrillator, suction aspirators, oxygen bottles, special steps taken to increase the stock of this equipment
|
Closed yes/no
|
Real-time inventory management system for personal protective equipment set up
|
Closed yes/no
|
Presence of occupational physician in the crisis management group
|
Categorical (Never/Rarely/Often/Very often/ Always)
|
Presence of staff representatives in the crisis management group
|
Closed yes/no
|
Frequency of information to staff representatives
|
Categorical (Never/Rarely/Often/Very often/ Always)
|
Frequency of information to user/patient representative
|
Categorical (in real time/daily/twice a week/ once a week/every two weeks/less often)
|
In a research study about COVID-19
|
Closed yes/no
|
Specific measures related to the management of patients in psychiatry departments and their families
|
Reduction/adaptation of activity during lockdown period: full-time hospitalisation, day hospitalisation, outpatient consultations, CATTP activities, activity therapy, psychosocial rehabilitation activity, home care/visits
|
Categorical (Completely maintained/ Partially maintained/Closed/ Not concerned)
|
Specific activities initiated in-person consultations with adherence to barrier measures, telepsychiatry (video conferencing), telephone consultation, home visits with barrier measures
|
Closed yes/no
|
Maintenance of some activities that are part of psychiatric support: psychological follow-up, social support
|
Closed yes/no
|
Update of provisions to ensure the rights of patients, freedom of movement, protection of the dignity of hospitalised persons, organisation of hearings in front of the judge deciding on the liberty or detention of patients hospitalized without their consent, continuity of follow-up of patients obliged or mandated to attend psychiatric care
|
Closed yes/no
Categorical (in person/videoconference/ judge decides alone, based on their own file, /other (specify)/not concerned)
|
Staff assigned for in-person or telephone availability for patient follow-up
|
Closed yes/no
|
Formalisation of a list of drugs at special risk with COVID-19
|
Closed yes/no
|
specific procedures for – food services, – laundry, – mail, – patient transport,
|
Closed yes/no
|
Establishment officially listed as admitting COVID-19/ opening of units exclusively for COVID-19
|
Closed yes/no
|
Formal official protocol for operation of COVID-19 units opened
|
Closed yes/no
|
Distribution of written instructions to patients to explain the barrier measures
|
Closed yes/no
|
"Listening services" for patients and their families
|
Closed yes/no
|
Maintenance of in-person family/friend visits and establishment of alternative means of communication
|
Closed yes/no
|
Remote follow-up for carers
|
Closed yes/no
|
Innovative arrangements
|
Closed yes/no, details
|
Hospital hygiene and epidemic control measurement
|
Designation of an expert responsible for infection vigilance
|
Categorical (designated before the epidemic/ designated during the epidemic/not designated)
|
Advice sought from the EOH
|
Closed yes/no
|
Shortages of medical equipment
|
Categorical (surgical mask, FFP2 masks, gloves, smocks, detergents, disinfectant, disinfectant wipes, other) then closed yes/no
|
Systematic screening for signs suggestive of COVID-19 by a somatic physician at patient admission
|
Closed yes/no
|
Systematic testing for COVID-19 at admission
|
Closed yes/no
|
Established a specific procedure for patients with confirmed or suspected COVID
|
Closed yes/no
|
Screening at admission and specific follow-up of patients with risk factors for severe COVID-19
|
Closed yes/no // open (frequency)
|
Dedicated channel of care for the persons at risk
|
Closed yes/no
|
Specific programme to educate patients about barrier measures and social distancing
|
Closed yes/no // Categorical (< 10; [10–50[; [50–100[; [100–250[; [250–500[; > 500)
|
Specific training for professionals about additional precautions beyond hospital hygiene in the management of patients with COVID-19
|
Closed yes/no // Categorical (< 10; [10–50[; [50–100[; [100–250[; [250–500[; > 500)
|
Training some staff members to take nasopharyngeal samples for RT-PCR testing
|
Closed yes/no
|
Procedure for specific follow-up of risk of infection among staff (monitoring symptoms, seeing the occupational physician, nasopharyngeal tests, etc.)
|
Closed yes/no
|
Procedure for the management of persons who died with COVID-19
|
Closed yes/no
|
Human resource management
|
Staff attendance chart, and chart of persons who can be called on if needed
|
Closed yes/no
|
human resources management enabling psychological care for staff (QoL at work plan), – telephone listening services for care providers
|
Closed yes/no // open
|
Organisational models to support and protect the health care staff and enable flexibility in staffing
|
Closed yes/no
|
Work at home (telecommuting) for some occupational categories
|
Open (type of category), Categorical ([0–25%[; [25%-50%[; [50%-75%[; [75%-100%]
|
Study of the potential financial impact
|
Closed yes/no
|
Study scope
The study covered all facilities in metropolitan France with a capacity for full-time, that is, inpatient psychiatric hospitalisation of adults (16 years and older) that exceeded the 3rd decile according to the annual establishment statistical survey (SAE) conducted in 2018.
This administrative survey is mandatory and exhaustive; the ministry of health's department of research studies, evaluation and statistics conducts it annually among all health-care facilities, public and private, in France [38].
The study base thus comprises all 331 establishments in metropolitan France with a capacity of 56.6 beds for full-time inpatient adult psychiatric hospitalisation, that is, 70% of the facilities in metropolitan France that provide this type of hospitalisation, according to the 2018 SAE survey.
This bed threshold was chosen because it enabled us to exclude excessively specific organisational models, while covering 70% of all facilities providing full-time inpatient psychiatric care to adults, including a large number of medium-sized public and private non-profit institutions.
The sampling plan was designed to optimise the representativeness of the situations experienced by the facilities while taking into account the survey resources available for the study.
Our methodology aimed to obtain an empirical sample of responses, representative according to the quota method, based on the status of the facility (public, private non-profit, private for-profit).
Audit
The initial survey questionnaire was pilot-tested in the planned survey conditions: the investigator entered responses during a telephone conversation with a qualified staff member working on the respondent facility's crisis management, after this interlocutor had received an interview guide to enable him/her to know what the questions would be and thus prepare responses.
Three establishments, included in the sampling base and known to the investigators (1 public, 1 private non-profit, 1 private for-profit), participated in the test.
By administering the pilot-test under the planned conditions, we were able to assess its feasibility to be done in a fixed amount of time and the usability of the responses.
A survey team composed of one coordinator and 6 investigators, trained specifically for this survey, was recruited to conduct the initial contact and appointment scheduling. To ensure the rigour and reliability of this survey campaign and the responses obtained, the investigators underwent an initial 2-hour training about the survey context and received standardised survey instructions, supporting documents, and each question in the interview guide. The project team also accompanied each investigator for their first interview. In addition, all investigators received a consolidated listing of information about contacts for all establishments in the sampling base, as well as a set of information relative to the survey, including the emails, telephone discourse for approaches and reminders, and the interview guide for the questionnaire, with an introduction explaining the survey objectives and procedures.
By the end of June 2020, all 331 establishments in the sampling base had been contacted by one of the 6 investigators, by email and telephone, and telephone appointments had been scheduled. At the appointment, the investigator entered the responses in the data collection tool, which was based on Qualtrics software (Qualtrics 2020©, Provo, UT, USA) and preset according to preparatory data collection work conducted in advance by the respondent facility with the interview guide.
Each establishment received regular email and telephone interviews until we obtained at least the number of appointments planned, by substrata. All appointments made took place, even after the objective of the relevant substrata had been attained. The responses above the objective were recorded to strengthen the reliability of the survey results for these substrata.
All methods were carried out in accordance with STOBE checklist.
Statistics
The descriptive data about the questionnaire items are presented as numbers and percentages. Facilities were compared for each item by status. The comparisons used a Chi-2 test or Fisher's exact test, when necessary because of the small numbers. All of the analyses were performed with SAS software (SAS v9.4, SAS Institute, Inc., Cary, NC, USA). The results concerning the measures taken were categorised to facilitate their analysis. Results ranging from 80–100% were judged very satisfactory, from less than 80–70% satisfactory, from less than 70–60% inadequate, and results less than 60% very inadequate.