Infection Prevention in Behavioral Health: Critical Strategies for a Safer Care Environment

Workshop at Medical Institution with Participants

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When providing infection prevention consultation to specialty care environments such as behavioral health, it is vital to understand the aspects that differ from what one would consider a typical patient care environment. Within behavioral health, special considerations must be made to ensure patient and staff safety and prevent potential risks.

Infectious organisms pose a unique set of challenges for a behavioral health setting. Special considerations when a patient has an infectious organism include patient placement, personal protection equipment (PPE), hand hygiene, and textiles.^1-3 Patient placement for an infectious organism must be planned and discussed with behavioral health leadership.

First, you must consider what the organism is. For example, a colonized or infected patient with a multidrug-resistant organism, such as an extended-spectrum β-lactamase, should remain on the unit in a private room. For respiratory illnesses, such as influenza, respiratory syncytial virus, and COVID-19, mask adherence must be considered.²

However, for units that do not have an airborne infection isolation room, all patients with suspected or confirmed infection requiring airborne transmission precautions should be transferred to a medical unit with a constant observer. A constant observer, often referred to as a one-to-one observer or a sitter, is an employee who monitors the patient to ensure zero harm. Patient exposure is common in a behavioral health inpatient setting due to an open care environment that supports patient cohabitation.

In certain circumstances, including but not limited to specific organisms, the institution may require exposed patients to be monitored for the development of signs and symptoms and may be directed to remain in a private room during the incubation period. In the event of an outbreak, one of the units may be converted to mitigate further spread within the patient population. This scenario requires a designated PPE station for donning and doffing. Best practice recommends placing PPE outside the secure unit to ensure patient and staff safety. For safety reasons, PPE should not be readily accessible in these units, as it may be used unintentionally. The PPE should be maintained securely, such as in a locked nurse’s station. Similarly to PPE, hand hygiene dispensers should be thoughtfully placed, and patient access should be controlled.

The primary driver for this is ligature risk. It is essential to recognize that this could lead to a decrease in hand hygiene adherence among staff and result in increased pathogen transmission due to limited access.³ A risk assessment should be conducted to determine the optimal locations for hand hygiene dispensers and to determine whether alcohol-based or alcohol-free hand sanitizers best support the patient population and institution.

When completing the assessment, using a multidisciplinary approach and considering any prior patient incidents concerning hand sanitizers is essential. Additionally, ligature-resistant hand hygiene dispensers may be installed to eliminate the risk of patient self-harm.

Patients have the right and privilege to launder their clothing, which is encouraged, while admitted to an inpatient unit. The washing machine, clothes dryer, and laundry detergent should be stored securely on the unit that requires staff supervision before use. Patients’ clothing should not be mixed in the washer and dryer.² Other special textile considerations include when a patient has an infectious organism. For these cases, bleach is recommended for wash cycles, and high-temperature drying cycles are required.³ It is important to remember that each facility is unique and may have its own processes based on its patient population and risk assessment.

Like other patient care environments, behavioral health settings must consider environmental conditions. Two important factors are ensuring that the unit remains ligature-resistant and establishing and maintaining a process for construction, renovation, and maintenance activities (CRMA).

Ligature resistance is defined as limiting the environmental risk for patient harm.³ This includes hand hygiene dispensers as well as door hardware, furniture, and bathroom fixtures. According to the American Society for Health Care Engineering, a patient safety risk assessment should be conducted to ensure all areas are accounted for.⁴ There should be no plastic used in the unit. For example, a hospital-approved waste receptacle with a brown bag insert may be used for trash. These bins can also be used as receptacles for soiled linen until environmental services can collect and transport linens and trash from the unit.

Some requirements must be implemented when completing an infection control risk assessment for CRMA within a behavioral health setting. As the use of plastic is prohibited, construction activities that require containment must utilize alternative materials, such as lighter, fire-retardant plastics, plywood, or hard plastic containment.⁴

Additionally, site accessibility should be limited to essential contractors and employees. A 2-person job is required when working above the ceiling within a high-efficiency particulate air (HEPA) cart. One worker will remain outside the HEPA cart while the other works above the ceiling to support contractor safety. Additionally, before workers enter a workspace, a tool checklist must be completed. This ensures all tools are accounted for, eliminating the potential for tool loss and/or patient self-harm. For construction worksites requiring a dust collection mat, the mat should always remain secured inside the active construction site, reducing the risk of access to other plastic materials.

The infection prevention plan and risk assessment should be reviewed and updated at least annually to determine whether there are any significant changes needed to account for population, preparation, associated risks, and impact. It is recommended that institutional programs and services, including factors for on-site and off-site locations, be highlighted to include behavioral health. Additionally, factors concerning infection prevention process measures should be included, such as hand hygiene, environmental cleaning and disinfection, transmission, and standard precautions.

Also, special considerations should be made to mitigate and remediate exposures, outbreaks, and emergency management within behavioral health care spaces. Furthermore, environmental control factors should be evaluated and included as noted previously. CRMA, including air handling units and controls, should be highlighted when conducting and reviewing annual risk assessments and plans.

Behavioral health care plans may involve wellness activities requiring review and thoughtful consideration for safety and infection prevention practices. Such activities may include group therapy, crafting, and physical exercise. A best practice solidified during the COVID-19 pandemic, included outpatient meals and snack delivery processes.

This involved adherence to single-packaged food items, strict adherence to hand hygiene, and staff handing out food items requested by patients. This process mitigates the risk of cross-contamination of products and reduces product waste. Staff can further manage appropriate periodic automatic replacement levels for perishable and nonperishable inventory control.⁵ Another practice example is when single-serving snacks are placed on a designated meal tray and the patient may make selections from the tray once hand hygiene has been completed.

Similarly, infection prevention practices can be applied to medication management. In inpatient settings, the nurse dispenses the medication from a secured area to deliver it to the patient. Single-use disposable medication cups and water cups are utilized for medication passes. Hand hygiene is performed as indicated throughout the medication delivery. A similar process may be utilized for outpatient settings.

General infection prevention and control principles for mitigating cross-contamination and maintaining a clean environment can also be thoughtfully applied to arts and crafts activities. Designating single patient-use items, routine cleaning and disinfection of high-touch items, encouraging and providing hand hygiene supplies, and designating cleanable, wipeable storage receptacles can be supportive.

Some practice examples include handing out single pages from a coloring book directly to the patient for them to keep. For coloring utensils, such as crayons, the patients are encouraged to perform hand hygiene before and after use, and crayons should be discarded when visibly soiled.

When approaching writing policy and procedure, the general rule of thumb is to ensure that you have all key stakeholders at the proverbial table. Having a robust multidisciplinary team involved in the development and implementation will ensure the completeness of the documentation and will be more supportive of clarity and adherence with frontline staff. Considerations for policy and procedure development, reevaluation, and implementation should consider all the above, including but not limited to the care environment and transmission of infectious organisms.

Additionally, special attention should be paid to keeping policies lean and providing staff with clear and concise direction and resources. In contrast, procedures can be more detailed and supportive. As a cautionary reminder for accreditation purposes, an institution will be held to its policy and procedures, and it is essential to be mindful of what laws, regulations, guidelines, and best practices apply. It may pose an unnecessary consequence if policy or procedures are overly specific, such that staff are not able to maintain them, whereby, if surveyed, the opportunity for improvement is identified by staff not following institutional policy and/or procedure.

REFERENCES

1. Behavioral health. Infection Prevention and You. Accessed February 12, 2025. https:// infectionpreventionandyou.org/settings-of-care/ behavioral-health/.

2. Schweon SJ. Preventing infection in behavioral health settings. Nursing. 2019;49(7):15-17. doi:10.1097/01.nurse.0000559930.04760.4e

3. Moss MK, Camins B. Behavioral health. In: Dean R, Popescu S, eds. APIC Text. Association for Professionals in Infection Control and Epidemiology; 2024.

4. Reyes S, Turner K. Performing a psychiatric inpatient bathroom evaluation. HFM Magazine. October 31, 2021. Accessed February 12, 2025. https://www. hfmmagazine.com/articles/4328-performing-a-psychiatric-inpatient-bathroom-evaluation

5. Bland A. PAR levels in inventory management (with formula & examples). Unleashed. August 3, 2022. Accessed February 12, 2025. https://www. unleashedsoftware.com/blog/par-levels-in-inventory-management-with-formula-examples/