Although the development and implementation of the CRU was generally quite successful, the program faced a number of challenges.
Staffing: Staff were recruited from various settings and did not work full time on the unit. Many did not have experience working with PEH or managing mental illness and substance use. This made it difficult to create a consistent culture of harm-reduction free of stigma in the CRU.
Determining appropriate discharge criteria: Criteria for clearance from isolation precautions changed frequently due to evolving CDC recommendations and shortage of COVID tests. Swab-based discharge criteria turned out to be impractical, and inconsistent with the approach taken by partner organizations, since many patients’ swabs remained positive for weeks; and so discharge criteria were revised to align with the CDC’s 10-day symptom-based discharge 12.
Predicting demand for beds: Demand was driven by the curve of the epidemic, but also by two other factors. First, COVID-19 testing was intermittent in PEH. When testing occurred, large groups of patients were suddenly identified who needed admission for isolation and quarantine4. A second challenge was the tremendous variability in the prevalence of COVID-19 infection that was found during testing, ranging from 37% to 0% over the course of 8 weeks. This variability meant that daily admissions ranged from 0 to 17, making it difficult to predict staffing needs.
Patient use of drugs/harm reduction: The Commonwealth of Massachusetts operated isolation and recovery units, typically set up at hotels, in other parts of the state to provide housing for COVID-infected PEH. Guidance documents for staff promoted a harm reduction approach. These units collaborated with harm reduction agencies which provided harm reduction materials, including sterile syringes and naloxone rescue kits. People who used drugs or alcohol were not discharged for substance use. Staff worked with guests to stay safe (personal communication, Dr. Alex Walley, Medical Director for Overdose Prevention Program, MA Dept. of Public Health). Within the CRU, it was challenging to fully implement a harm-reduction approach. There was disagreement over the appropriate approach, with many medical staff advocating for harm-reduction, while security personnel as well as some staff and administration officials expressed concerns regarding safety on hospital grounds and public perception regarding laws that prohibit supervised injection sites. A compromise included distribution of sterile syringes at the time of discharge (rather than admission), and a policy of having clinicians, rather than security personnel, address use of substances.
Caring for patients with serious mental illness: Serious mental illness was common, and initially staff were uncomfortable caring for patients who were paranoid, actively hallucinating, or delusional. Later, counselors and social workers became available to assist on the unit, which lessened staff concerns. The CRU filled an important need in the community by providing care for COVID-infected patients with serious mental illness13.
BMC expanded its role as a safety-net hospital to provide care for COVID-infected PEH, and utilized the opportunity to initiate treatment for SUDs for many patients, as well as caring for patients with severe psychiatric disorders. Rapid deployment of services in this emergency was achieved through hospital and Commonwealth coordination, and relaxation of regulations to allow speed and efficiency. Community partnerships were key factors in our success.
The CRU helped BMC avoid exceeding hospital bed capacity during the epidemic surge11. Lower-acuity bed capacity in the CRU provided a vitally-important release mechanism to allow BMC to reserve inpatient beds for patients with critical needs. Other cities that are currently being affected by the COVID-19 surge should consider similar programs that increase lower-acuity bed capacity for vulnerable populations.
Finally, the experience of creating the CRU has shown us that we can provide safe and effective medical respite for PEH and has inspired us to explore the implementation of similar services beyond the COVID-19 pandemic.