Psychiatric Wards Need More Rigorous Infection Prevention Measures

Doctor and nurse with clipboards
This study determines which psychiatry specific factors contributed to a nosocomial outbreak taking place in a psychiatric department.

Few COVID-19 outbreaks have occurred in psychiatric wards. However, the psychiatric department of an acute care hospital in the Netherlands was one exception. Because so few outbreaks occur in psychiatric departments, researchers from the hospital investigated the cause. Results were published in the Antimicrobial Resistance & Infection Control journal. The investigators found health care worker-to-health care worker transmission and patient-health care worker-patient transmissions to be the primary culprit.

The Canisius-Wilhelmina Hospital, a 480-bed acute care hospital in Nijmegen, The Netherlands, followed standard precautionary measures to limit COVID-19 spread beginning March 1. The outbreak studied involved 43% of the total staff and 19% of patients in the ward.

The first person identified as spreading the disease, a patient, developed symptoms on March 9, 2020. The patient tested negative 48 hours after reporting symptoms. A health care worker reported symptoms on the same day. That worker was not tested and did not wear PPE. Another worker was suspected of having COVID-19 on March 6, 2020.

Health care workers did not follow social distancing measures, PPE guidelines, or infection prevention policies, which resulted in 2 clusters of transmission.

The researchers presume reasons for not following protocols include “lack of urgency, unfamiliarity with infection control measures and aspects typically associated with the mental health care system, such as frequent interdisciplinary meetings, group therapy and prolonged interactions with psychiatric patients, often taking place in close proximity. Another contributing factor might be that [health care workers] often continue to work with mild symptoms, and may potentially infect others while doing so, thereby facilitating and maintaining a nosocomial outbreak.”

The hospital’s infection control unit did not identify the psychiatric ward as a high-risk unit. Therefore, the unit was not reconstructed adequate to accommodate COVID-19 distancing and other protocols. For example, 5 out of 13 patient rooms are 2-person rooms with a shared shower. Insufficient ventilation and high exit and entry may also be to blame.

Limitations include the fact that identification of cases relied on self-reporting. Asymptomatic patients and workers were not tested.

“Infection control measures designed for general hospital departments are not directly applicable to psychiatric departments,” the researchers concluded. “Psychiatric patients should be considered a high-risk group for infectious disease, particularly during a pandemic. Therefore, general infection prevention and outbreak management policies should be adjusted to fit the specific needs of the mental health care system.”


Rovers JJE, van de Linde LS, Kenters N, et al. Why psychiatry is different – challenges and difficulties in managing a nosocomial outbreak of coronavirus disease (COVID-19) in hospital care. Antimicrob Resist Infect Control. 2020 Dec 1;9(1):190. doi:10.1186/s13756-020-00853-z