Case Study

Maintaining inpatient psychiatric services: Malaysia

Maintaining the provision of services for service users with little access to unsubsidised or private healthcare.

27 January 2022


To support individuals from the lowest income group requiring Electroconvulsive Therapy (ECT) during this time, a range of service delivery methods were employed by the Psychiatry Department at the National University of Malaysia Medical Centre, to maintain the provision of services for service users with little access to unsubsidised or private healthcare.

Key benefits and outcomes

  • Maintenance of ECT treatment for the most vulnerable service-users during periods of lockdown
  • Maintained capacity despite requirements for social distancing
  • No recorded instances nosocomial infection among inpatients post-service innovations.

The challenge

Malaysia is a highly urbanised upper-middle income nation, with a health system comprising a mixture of government-funded and private sector care. For the South-East Asian country, ECT is a crucial treatment for individuals suffering from life-threatening depression with an imminent risk of suicide, refractory mania, psychosis or catatonia. It is considered a non-invasive brain stimulation technique.

However, it is also an aerosol-generating procedure that requires high numbers of specialist staff to administer. This presented a risk of spreading of COVID-19 infection among staff and service-users.

As service-users in the lowest socio-economic bracket had significant barriers to access private or non-subsidised psychiatric services, it was not possible to stratify demand across centres. Government centres therefore had to meet these demands despite the human and physical infrastructure challenges presented by the pandemic.

The solution

Physical capacity

Despite the need for social distancing reducing the standard capacity of the inpatient wards used for ECT, by working with the hospital engineering team the psychiatry department staff were able to use a range of low-cost solutions to maintain pre-pandemic capacity. These included:

  • Air pressure in the ECT suite was tested to be more negative compared to the adjacent recovery bay.
  • An isolated buffer zone was created with floor to ceiling plastic sheeting with in-house engineering support to reduce the risk of COVID-19 transmission due to potentially aerosol generating procedure
  • Repurposing the inpatient common dining area adjacent to the female ward into a day-care area for pre-ECT check-in and post-ECT recovery clinical review before discharge

Professional capacity

  • Given the high-risk nature to staff and service-users from the generation of aerosols throughout the delivery of ECT the psychiatry department established an in-house COVID-19 testing swab centre.
  • A Train the trainer model was also established whereby Psychiatry residents were trained by infectious disease physicians to perform nasopharyngeal (NP) swab for COVID testing of service users pre-ECT. Subsequently, a dedicated team of psychiatry residents lead further training supervised by a psychiatrist in liaison with the hospital-wide infection control committee

Results and benefits

  • Delivery of indicated ECT to new clients experiencing a mental health crisis was uninterrupted
  • Overall, a total number of 634 ECT procedures were delivered in 2021 and 766 in 2020; which was 76.7 per cent and 92.6 per cent respectively of pre-pandemic baseline capacity of 827 in 2019.
  • No reported cases of nosocomial COVID-19 infections involving inpatients after implementation of service innovations

Overcoming obstacles

Due to the dynamic and unpredictable nature of the ongoing pandemic, they face considerable challenges in terms of establishing an ideal mechanism for maintaining clear, real-time communication amongst all stakeholders (service-users, caregivers, clinicians, administrators, policymakers) regarding stakeholder needs and priorities, and evolving protocols in service provision, delivery and accessibility.

The additional burden of pandemic-era protocols on an increasingly stretched workforce is a reality to contend with. The risk of burn-out and moral injury amongst health-care workers need to be addressed pro-actively at multiple levels i.e. individual resilience and whole health wellbeing; as well as systemically at the institutional and societal level.

Takeaway tips

Key approaches for successful development and implementation of service innovations during the pandemic:

  • Proactive
  • Adaptive
  • Flexible
  • Multi-disciplinary
  • Service user centred

Contact details

Lai Fong Chan, Eu Choon Leng, Hajar Mohamad Salleh Sahimi, Nuur Asyikin Mohd Syukor, Nurul Ain Mohamad Kamal, Luke Woon Sy-Cherng, Liu Chian Yong, Petrick @ Ramesh K. Periyasamy, Najma Kori, Tan Toh Leong, Clarence Ko Ching Huat, Nor Hasnani Zahari & Azlin Baharudin.

National University of Malaysia

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