Value of an orthopaedic admission proforma.

BACKGROUND: Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery. PATIENTS AND METHODS: A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed. RESULTS: In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied. CONCLUSION: Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.

Intensive care unit guidelines for admission and discharge, 2023.

The Directorate General of Health Services (DGHS), India, has released guidelines for intensive care unit (ICU) admission and discharge [1] to guide intensivists and registered medical practitioners (RMPs) in an Expert Consensus Statement (ECS). This is based on the recommendations of 24 experts working in different ICU settings. This team deserves applause for their efforts in creating guidelines for clinicians working in ICU settings. The Delphi method [2], considered one of the most scientific methods for such statements, has been used for this ECS.

Effect of admission time of arrival on quality of in-hospital care in acute ischemic stroke patients in China.

OBJECTIVES: The quality of care for patients may be partly determined by the time they are admitted to the hospital. This study was conducted to explore the effect of admission time and describe the pattern and magnitude of weekly variation in the quality of patient care. STUDY DESIGN: A retrospective observational study. METHODS: Data were collected from the Medical Care Quality Management and Control System for Specific (Single) Diseases in China. A total of 238,122 patients treated for acute ischemic stroke between January 2015 and December 2017 were included. The primary outcomes were completion of the ten process indicators and in-hospital death. RESULTS: The quality of in-hospital care varied according to hospital arrival time. We identified several patterns of variation across the days of the week. In the first pattern, the quality of four indicators, such as stroke physicians within 15 min, was lowest for arrivals between 08:00 and 11:59, increased throughout the day, and peaked for arrivals between 20:00 and 23:59 or 00:00 and 03:59. In the second pattern, the quality of four indicators, such as the application of antiplatelet therapy within 48 h, was not significantly different between days and weeks. There was no difference in in-hospital mortality between the different admission times. CONCLUSIONS: The effect of admission time on the quality of in-hospital care of patients with acute ischemic stroke showed several diurnal patterns. Detecting the times when quality is relatively low may lead to quality improvements in health care. Quality improvement should also focus on reducing diurnal temporal variation.

The Brain Injury Guidelines (BIG) and emergency department observation and admission rates: A retrospective cohort study.

BACKGROUND: Emergency Department (ED) Observation Units (OU) can provide safe, effective care for low risk patients with intracranial hemorrhages. We compared current ED OU use for patients with subdural hematomas (SDH) to the validated Brain Injury Guidelines (BIG) to evaluate the potential impact of implementing this risk stratification tool. METHODS: Retrospective cohort of patients ≥18 years old with SDH of any cause from 2014 to 2020 to evaluate for potential missed OU cases. Missed OU cases were defined as patients with an initial Glasgow Coma Score (GCS) of 15 with hospital length of stays (LOS) <2 days, who did not meet the composite outcome and were not cared for in the OU or discharged from the ED. Composite outcome included in-hospital death or transition to hospice care, neurosurgical intervention, GCS decline, and worsening SDH size. Secondary outcomes were whether application of BIG would increase ED OU use or reduce CT use. RESULTS: 264 patients met inclusion criteria over 5.3 year study timeframe. Mean age was 61 years (range 19-93) and 61.4% were male. SDH were traumatic in 76.9% and 60.2% of the cohort had additional injuries. The admission rate was 81.4% (n = 215). Fourteen (6.5%) missed OU cases were identified (2.6/year). Retrospective application of BIG resulted in 82.6% (n = 217) at BIG 3, 10.2% (n = 27) at BIG 2 and 7.6% (n = 20) at BIG 1. Application of BIG would not have decreased admission rates (82.6% BIG 3) and BIG 1 and 2 admissions were often for medical co-morbidities. The composite outcome was met in 50% of BIG 3, 22% of BIG 2, and no BIG 1 patients. CONCLUSION: In a level 1 trauma center with an established observation unit, current clinical care processes missed very few patients who could be discharged or placed in ED OU for SDH. Hospital admissions in BIG 1/2 were driven by co-morbidities and/or injuries, limiting applicability of BIG to this population.

Evaluation of a Structured Review Process for Emergency Department Return Visits with Admission.

BACKGROUND: Review of emergency department (ED) revisits with admission allows the identification of improvement opportunities. Applying a health equity lens to revisits may highlight potential disparities in care transitions. Universal definitions or practicable frameworks for these assessments are lacking. The authors aimed to develop a structured methodology for this quality assurance (QA) process, with a layered equity analysis. METHODS: The authors developed a classification instrument to identify potentially preventable 72-hour returns with admission (PPRA-72), accounting for directed, unrelated, unanticipated, or disease progression returns. A second review team assessed the instrument reliability. A self-reported race/ethnicity (R/E) and language algorithm was developed to minimize uncategorizable data. Disposition distribution, return rates, and PPRA-72 classifications were analyzed for disparities using Pearson chi-square and Fisher's exact tests. RESULTS: The PPRA-72 rate was 4.8% for 2022 ED return visits requiring admission. Review teams achieved 93% agreement (κ = 0.51) for the binary determination of PPRA-72 vs. nonpreventable returns. There were significant differences between R/E and language in ED dispositions (p < 0.001), with more frequent admissions for the R/E White at the index visit and Other at the 72-hour return visit. Rates of return visits within 72 hours differed significantly by R/E (p < 0.001) but not by language (p = 0.156), with the R/E Black most frequent to have a 72-hour return. There were no differences between R/E (p = 0.446) or language (p = 0.248) in PPRA-72 rates. The initiative led to system improvements through informatics optimizations, triage protocols, provider feedback, and education. CONCLUSION: The authors developed a review methodology for identifying improvement opportunities across ED 72-hour returns. This QA process enabled the identification of areas of disparity, with the continuous aim to develop next steps in ensuring health equity in care transitions.

Interventions to improve patient admission and discharge practices in adult intensive care units: A systematic review.

OBJECTIVES: To identify and synthesise interventions and implementation strategies to optimise patient flow, addressing admission delays, discharge delays, and after-hours discharges in adult intensive care units. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Five electronic databases, including CINAHL, PubMed, Emcare, Scopus, and the Cochrane Library, were searched from 2007 to 2023 to identify articles describing interventions to enhance patient flow practices in adult intensive care units. The Critical Appraisal Skills Program (CASP) tool assessed the methodological quality of the included studies. All data was synthesised using a narrative approach. SETTING: Adult intensive care units. RESULTS: Eight studies met the inclusion criteria, mainly comprising quality improvement projects (n = 3) or before-and-after studies (n = 4). Intervention types included changing workflow processes, introducing decision support tools, publishing quality indicator data, utilising outreach nursing services, and promoting multidisciplinary communication. Various implementation strategies were used, including one-on-one training, in-person knowledge transfer, digital communication, and digital data synthesis and display. Most studies (n = 6) reported a significant improvement in at least one intensive care process-related outcome, although fewer studies specifically reported improvements in admission delays (0/0), discharge delays (1/2), and after-hours discharge (2/4). Two out of six studies reported significant improvements in patient-related outcomes after implementing the intervention. CONCLUSION: Organisational-level strategies, such as protocols and alert systems, were frequently employed to improve patient flow within ICUs, while healthcare professional-level strategies to enhance communication were less commonly used. While most studies improved ICU processes, only half succeeded in significantly reducing discharge delays and/or after-hours discharges, and only a third reported improved patient outcomes, highlighting the need for more effective interventions. IMPLICATIONS FOR CLINICAL PRACTICE: The findings of this review can guide the development of evidence-based, targeted, and tailored interventions aimed at improving patient and organisational outcomes.

Triage admission protocol with a centralized quarantine unit for patients after acute care surgery during the COVID-19 pandemic: A tertiary center experience in Taiwan.

BACKGROUND: During the COVID-19 surge in Taiwan, the Far East Memorial Hospital established a system including a centralized quarantine unit and triage admission protocol to facilitate acute care surgical inpatient services, prevent nosocomial COVID-19 infection and maintain the efficiency and quality of health care service during the pandemics. MATERIALS AND METHODS: This retrospective cohort study included patients undergoing acute care surgery. The triage admission protocol was based on rapid antigen tests, Liat® PCR and RT-PCT tests. Type of surgical procedure, patient characteristics, and efficacy indices of the centralized quarantine unit and emergency department (ED) were collected and analyzed before (Phase I: May 11 to July 2, 2021) and after (Phase II: July 3 to July 31, 2021) the system started. RESULTS: A total of 287 patients (105 in Phase I and 182 in Phase II) were enrolled. Nosocomial COVID-19 infection occur in 27 patients in phase I but zero in phase II. More patients received traumatological, orthopedic, and neurologic surgeries in phase II than in phase I. The patients' surgical risk classification, median total hospital stay, intensive care unit (ICU) stay, intraoperative blood loss, operation time, and the number of patients requiring postoperative ICU care were similar in both groups. The duration of ED stay and waiting time for acute care surgery were longer in Phase II (397 vs. 532 minutes, p < 0.0001). The duration of ED stay was positively correlated with the number of surgical patients visiting the ED (median = 66 patients, Spearman's ρ = 0.207) and the occupancy ratio in the centralized quarantine unit on that day (median = 90.63%, Spearman's ρ = 0.191). CONCLUSIONS: The triage admission protocol provided resilient quarantine needs and sustainable acute care surgical services during the COVID-19 pandemic. The efficiency was related to the number of medical staff dedicated to the centralized quarantine unit and number of surgical patients visited in ED.

Utilizing triage rates to improve ICU admission guidelines of elderly rib fracture patients.

BACKGROUND: Elderly rib fracture patients are generally admitted to an ICU which may result in overutilization of scarce resources. We hypothesized that this practice results in significant overtriage. METHODS: Retrospective study of patients over age 70 with acute rib fracture(s) as sole indication for ICU admission. Primary outcomes were adverse events (intubation, pneumonia, death), which we classified as meriting ICU admission. We utilized Cribari matrices to calculate triage rates. RESULTS: 101 patients met study criteria. 12% had adverse events occurring on average at day 5. Our undertriage rate was 6% and overtriage rate 87%. The 72 overtriaged patients utilized 295 total ICU days. Evaluating guideline modification, ≥3 fractures appears optimal. Changing to this would have liberated 50 ICU days with 3% undertriage. CONCLUSION: Elderly patients with small numbers of rib fractures are overtriaged to ICUs. Modifying guidelines to ≥3 rib fractures will improve resource utilization and save ICU beds.

The impact of emergency department crowding on admission decisions and patient outcomes.

OBJECTIVES: The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes. METHODS: A retrospective study was performed based on 2-year electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels. RESULTS: Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk [RR] = 1.006, 95% confidence interval [CI] = 1.005 to 1.007) and physician workload census (RR = 1.029, 95% CI = 1.027 to 1.032), but inversely correlated with boarder census (RR = 0.991, 95% CI = 0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR = 1.009, 95% CI = 1.004 to 1.014). CONCLUSIONS: Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3-5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.

The integration of mental health care act in primary care: an audit of the use of mental health care act forms for patients´ admission and the effect of continuing medical education on health professionals´ performance of usage, based on Letsholathebe II Memorial Hospital´s experience, in Maun, Botswana.

INTRODUCTION: despite the adoption of mental disorders act in 1972, the use of required mental health care act (MHCA) forms during admission of patients with mental illnesses remained below the legal expectation in the Maun District Hospital. This study audited Letsholathebe II Memorial Hospital (LIIMH) professionals´ usage of MHCA forms. METHODS: this was a quasi-experimental study that audited files of patients admitted with mental illnesses, before, three and six months after a continuing medical education (CME). Cochran Q, McNemar symmetry Chi-square were used for comparison of performance. RESULTS: of the 239 eligible files, we accessed 235 (98.3%). About two in ten (n=36/235, 15.3%) MHCA forms were not used in combination with required forms. The quasi-majority of MHCA forms set used, aligned with involuntary admission (n=134/137, 97.8%). Required admission MHCA forms significantly increased from nil before continuing medical education (CME-0), to 64.6% (n=51/79) at CME-3 and 77% (n=59/77) at CME-6 (p<0.001). However, there was no statistical difference between the last two periods (64.6% vs 77%, p=0.164). Voluntary admission remained below 13% (n=10/79). Only six types of MHCA forms were used during this study. CONCLUSION: there was no adequate use of required MHCA forms at LIIMH before CME. Thereafter, the proportion of adequate use increased from period CME-0 to the periods CME-3 and CME-6. However, there was no difference in proportion between the last two periods. We recommend an effective and regular CME twice a year for health professionals on selected MHCA forms.

A Tale of Two Cities: Applying the Boston Syncope Criteria to Jerusalem.

BACKGROUND: Syncope is a common reason for emergency department (ED) visits; however, the decision to admit or discharge patients after a syncopal episode remains challenging for emergency physicians. Decision rules such as the Boston Syncope Criteria have been developed in an attempt to aid clinicians in identifying high-risk patients as well as those who can be safely discharged, but applying these rules to different populations remains unclear. OBJECTIVES: To determine whether the Boston Syncope Criteria are valid for emergency department patients in Israel. METHODS: This retrospective cohort convenience sample included patients who visited a tertiary care hospital in Jerusalem from August 2018 to July 2019 with a primary diagnosis of syncope. Thirty-day follow-up was performed using a national health system database. The Boston Syncope Criteria were retrospectively applied to each patient to determine whether they were at high risk for an adverse outcome or critical intervention, versus low risk and could be discharged. RESULTS: A total of 198 patients fulfilled the inclusion criteria and completed follow-up. Of these, 21 patients had either an adverse outcome or critical intervention. The rule detected 20/21 with a sensitivity of 95%, a specificity of 66%, and a negative predictive value of 99. CONCLUSIONS: The Boston Syncope Criteria may be useful for physicians in other locations throughout the world to discharge low-risk syncope patients as well as identify those at risk of complications.

Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis.

BACKGROUND: Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. METHODS: A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. RESULTS: Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). CONCLUSIONS: This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.

The effect of the COVID-19 pandemic on non-elective otolaryngology admissions and a positive change in clinical practice.

As the COVID-19 pandemic progressed across the UK and Northern Ireland in March 2020, our otolaryngology department began to make preparations and changes in practice to accommodate for potentially large numbers of patients with COVID-19 related respiratory illness in the hospital. We retrospectively reviewed the number of non-elective admissions to our department between the months of January and May in 2019 and 2020. A significant reduction in admissions of up to 94% during the months of the pandemic was observed. Our practice shifted to manage patients with epistaxis and peritonsillar abscess on an outpatient basis, and while prospectively collecting data on this, we did not observe any significant adverse events. We view this as a positive learning point and change in our practice as a result of the COVID-19 pandemic.

Safety of emergency, elective and day case operating during the winter period at East Suffolk and North Essex NHS Foundation Trust: lessons from the outcomes of 4,254 surgical patients from the first COVID-19 wave.

BACKGROUND: There is limited evidence on perioperative outcomes of surgical patients during the COVID-19 pandemic to inform continued operating into the winter period. METHODS: We retrospectively analysed the rate of 30-day COVID-19 transmission and mortality of all surgical patients in the three hospitals in our trust in the East of England during the first lockdown in March 2020. All patients who underwent a swab were swabbed on or 24 hours prior to admission. RESULTS: There were 4,254 patients and an overall 30-day mortality of 0.99%. The excess surgical mortality in our region was 0.29%. There were 39 patients who were COVID-19 positive within 30 days of admission, 12 of whom died. All 12 were emergency admissions with a length of stay longer than 24 hours. There were three deaths among those who underwent day case surgery, one of whom was COVID-19 negative, and the other two were not swabbed but not suspected to have COVID-19. There were two COVID-19 positive elective cases and none in day case elective or emergency surgery. There were no COVID-19 positive deaths in elective or day case surgery. CONCLUSIONS: There was a low rate of COVID-19 transmission and mortality in elective and day case operations. Our data have allowed us to guide patients in the consent process and provided the evidence base to restart elective and day case operating with precautions and regular review. A number of regions will be similarly affected and should perform a review of their data for the winter period and beyond.

Time consumption for non-conveyed patients within emergency medical services (EMS): A one-year prospective descriptive and comparative study in a region of Sweden.

INTRODUCTION: Over time, ambulance assignments have increased in number both nationally and internationally, and a substantial proportion of patients encountered by emergency medical services are assessed as not being in need of services. Non-conveying patients has become a way for emergency medical services clinicians to meet this increasing workload. It has been shown that ambulances can be made available sooner if patients are non-conveyed, but there is no previous research describing the factors that influence the non-conveyance time. STUDY OBJECTIVE: To describe ambulance time consumption and the factors that influence time consumption when patients are non-conveyed. METHODS: A prospective observational review of 2615 non-conveyed patients' ambulance and hospital medical records was conducted using a consecutive sample. Data were analysed with the Kruskal-Wallis test, Mann-Whitney U test and Spearman's rank correlation (rho) for linear correlations. RESULTS: The mean NC time for all ambulance assignments during the study period was 26 minutes, with a median of 25 minutes. The shortest NC time was 4 minutes, and the longest NC time was 73 minutes. NC times were significantly faster during the day than at night. CONCLUSIONS: This study provides new knowledge about time consumption when patients are non-conveyed. Although there are time differences when patients are non-conveyed, the differences observed in this study are small and not of clinical value. Ambulances will most often become available sooner if patients are non-conveyed. Although patients might be eligible for non-conveyance, policy-makers might have to decide when it is appropriate to non-convey patients from time, resource, patient safety and patient-centred care perspectives.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System.

BACKGROUND: We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. MATERIALS AND METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. RESULTS: A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. CONCLUSIONS: POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT. LEVEL OF EVIDENCE: Epidemiologic study, level III.

A clinical practice guideline using percentage of predicted forced vital capacity improves resource allocation for rib fracture patients.

BACKGROUND: Predicting rib fracture patients that will require higher-level care is a challenge during patient triage. Percentage of predicted forced vital capacity (FVC%) incorporates patient-specific factors to customize the measurements to each patient. A single institution transitioned from a clinical practice guideline (CPG) using absolute forced vital capacity (FVC) to one using FVC% to improve triage of rib fracture patients. This study compares the outcomes of patients before and after the CPG change. METHODS: A review of rib fracture patients was performed over a 3-year retrospective period (RETRO) and 1-year prospective period (PRO). RETRO patients were triaged by absolute FVC. Percentage of predicted FVC was used to triage PRO patients. Demographics, mechanism, Injury Severity Score, chest Abbreviated Injury Scale score, number of rib fractures, tube thoracostomy, intubation, admission to intensive care unit (ICU), transfer to ICU, hospital length of stay (LOS), ICU LOS, and mortality data were compared. A multivariable model was constructed to perform adjusted analysis for LOS. RESULTS: There were 588 patients eligible for the study, with 269 RETRO and 319 PRO patients. No significant differences in age, gender, or injury details were identified. Fewer tube thoracostomy were performed in PRO patients. Rates of intubation, admission to ICU, and mortality were similar. The PRO cohort had fewer ICU transfers and shorter LOS and ICU LOS. Multivariable logistic regression identified a 78% reduction in odds of ICU transfer among PRO patients. Adjusted analysis with multiple linear regression showed LOS was decreased 1.28 days by being a PRO patient in the study (B = -1.44; p < 0.001) with R2 = 0.198. CONCLUSION: Percentage of predicted FVC better stratified rib fracture patients leading to a decrease in transfers to the ICU, ICU LOS, and hospital LOS. By incorporating patient-specific factors into the triage decision, the new CPG optimized triage and decreased resource utilization over the study period. LEVEL OF EVIDENCE: Therapeutic/Care Management. Trauma, Rib, Triage, level IV.

COVID-19 infection rates in patients referred for psychiatric admission during a regional surge: The case for universal testing.

Some psychiatric hospitals have instituted mandatory COVID-19 testing for all patients referred for admission. Others have permitted patients to decline testing. Little is known about the rate of COVID-19 infection in acute psychiatric inpatients. Characterizing the proportion of infected patients who have an asymptomatic presentation will help inform policy regarding universal mandatory versus symptom-based or opt-out testing protocols. We determined the COVID-19 infection rate and frequency of asymptomatic presentation in 683 consecutively admitted patients during the surge in the New York City region between April 3rd, 2020 and June 8th, 2020. Among these psychiatric inpatients, there was a 9.8 % overall rate of COVID-19 infection. Of the COVID-19 infected patients, approximately 76.1 % (51/67) either had no COVID-19 symptoms or could not offer reliable history of symptoms at the time of admission. Had they not been identified by testing and triaged to a COVID-19 positive unit, they could have infected others, leading to institutional outbreak. These findings provide justification for psychiatric facilities to maintain universal mandatory testing policies, at least until community infection rates fall and remain at very low levels.