NIMH, Sri Lanka Guidelines - 07.04.2022. Version 2.0

NATIONAL INSTITUTE OF MENTAL HEALTH, SRI LANKA INSTITUTIONAL GUIDELINES - DOCUMENT

NATIONAL INSTITUTE OF MENTAL HEALTH SRI LANKA: INSTITUTIONAL GUIDELINES

Contributors Dr. H M K Wickramanayake - Director - NIMH (2013 - 2019) Dr. Dhammika Wijesinghe - Director (Actg) - NIMH (2019 to date) Dr. M D A Krishanth - Deputy Director - NIMH (2018) Dr. B A O Wijewickrama - Deputy Director - NIMH (2019 to date) Dr. M Ganeshan - Senior Consultant Psychiatrist - NIMH Dr. P K Ranasinghe - Senior Consultant Psychiatrist - NIMH Dr. C K Ranasinghe - Senior Consultant Psychiatrist - NIMH Dr. J Horadugoda - Senior Consultant Psychiatrist - NIMH Dr. Renuka Jayasinghe - Senior Consultant Psychiatrist - NIMH Dr. Sajeewana Amaransinghe - Consultant Psychiatrist - NIMH Dr. Saman Weerawardena - Consultant Psychiatrist - NIMH Dr. Pushpa De Silva - Consultant Psychiatrist - NIMH Dr. Lushan Hettiarachchi - Consultant Forensic Psychiatrist - NIMH Dr. Wajantha Kothelawala - Consultant Child and Adolescent Psychiatrist - NIMH Dr. Nadeera Attanayake - Medical Officer - Psychiatry - NIMH Dr. Thanuja Siriwardena - Medical Officer - Planning - NIMH Dr. Rikaz Sheriff - Medical Officer - Health Informatics - NIMH Dr. Upeka Meththananda - Medical Officer - Disaster Management - NIMH Dr. Sujani Perera - Medical Officer - Public Health - NIMH Mr. Indika Wickramasinghe - Administrative Officer - NIMH Ms. Sandya Padmarani - Chief Special Grade Nursing Officer - NIMH Ms. M W S R Ruwangani - Special Grade Nursing Officer - NIMH Editor Dr. B A O Wijewickrama - Deputy Director - NIMH (2019 to date) Editorial Support Dr. Rikaz Sheriff - Medical Officer - Health Informatics - NIMH Dr. Thanuja Siriwardena - Medical Officer - Planning - NIMH Dr. Upeka Meththananda - Medical Officer - Disaster Management - NIMH Dr. Sujani Perera - Medical Officer - Public Health - NIMH Mr. Sarith Wijesinghe - Occupational Therapist - NIMH Mr. Ashan Basnayake - Occupational Therapist - NIMH Compilation and Print Setting NIMH PDU - Quality Management Section NIMH Media Unit

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NATIONAL INSTITUTE OF MENTAL HEALTH, SRI LANKA MINISTRY OF HEALTH - SRI LANKA

NIMH Institutional Guidelines Version 2.0 © National Institute of Mental Health, Sri Lanka National Institute of Mental Health, Sri Lanka Mulleriyawa New Town Tel: 0112 578 234 - 7 Fax: 0112 578 238 Email: info@nimh.health.gov.lk Web: http://nimh.health.gov.lk Facebook: https://www.facebook.com/pg/NIMH.Angoda , Instagram: https://www.instagram.com/?hl=en YouTube: https://www.youtube.com/c/NationalInstituteofMentalHealthSriLanka (A state institution under the Ministry of Health of the Democratic Socialist Republic of Sri Lanka)

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Table of Contents Preface.......................................................................................................................................................... 8 Scope of the Guidelines .................................................................................................................................. 8 Message from the Director – NIMH ............................................................................................................... 9 History of National Institute of Mental Health - Sri Lanka ............................................................................ 10 Vision, Mission & Objectives ....................................................................................................................... 12 Values & Strategic Thrust Areas .............................................................................................................. 13 Institutional Organogram ............................................................................................................................ 15 Institutional Service Structure ..................................................................................................................... 16 Mental Diseases Ordinance (Mental Health Act of Sri Lanka) ....................................................................... 33 Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care ...... 36 Multi-Disciplinary Approach in Patient Care ............................................................................................... 42 Medico-Legal Responsibilities within NIMH, Sri Lanka................................................................................ 43 Section A - Clinical Care Services ................................................................................................................ 44 Admission and Discharge - Level of Care identification ............................................................................. 45 Admission Procedure to National Institute of Mental Health, Sri Lanka .................................................... 46 Night Admissions to NIMH (4 pm to 8 am) ............................................................................................... 48 NON Admissions at Outpatient Department ............................................................................................. 50 Admission procedure to Perinatal Psychiatric Unit (PPU) ......................................................................... 51 Admission procedure Adolescent Mental Health Unit (Arunodhaya) ......................................................... 52 Admission procedure to Learning Disability Unit (LDU) ........................................................................... 53 Admission Procedure to Psycho-Geriatric Unit ......................................................................................... 54 Admission Procedure to Isolation Units .................................................................................................... 55 Admission Procedure to Mental Health Covid Treatment Units ................................................................. 56 Admission Procedure to Villas .................................................................................................................. 57 Admission Procedure to Paying Cubicles .................................................................................................. 58 Patient Property Management.................................................................................................................. 59 Visitations to see Patients ......................................................................................................................... 60 Temporary Leave for Patients .................................................................................................................. 61 Discharge Procedure ................................................................................................................................ 63 Community File Follow Up ...................................................................................................................... 64 Death of a Patient .................................................................................................................................... 65 Risk Assessment Form to be used at Admission ......................................................................................... 66 Consent for Treatment and Clinical Procedures ........................................................................................ 70 Management of Violent and Aggressive Patients ....................................................................................... 71 Rapid Tranquilization of Patients ............................................................................................................. 71 Monitoring and Observation of Patients in Wards .................................................................................... 72 National Institute of Mental Health - 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Suicide and Deliberate Self Harm – Prevention Guidelines ........................................................................ 73 Absconding – Prevention Guidelines ......................................................................................................... 76 Falls – Prevention Guidelines ................................................................................................................... 83 Management of patients kept in Seclusion ................................................................................................. 86 Management of patients requiring Temporary Restrain ............................................................................ 88 Referral of patients for Other Specialities ................................................................................................. 90 Provision of ECT for patients ................................................................................................................... 91 Medical Unit and its Services under the Consultant Physician ................................................................... 93 Management of Patients at the OPD who have been transferred into NIMH by another Institute................ 94 Issuing of drugs with the use of RC number at the OPD ............................................................................ 95 Psychiatric Social Work Services .............................................................................................................. 96 Community Mental Health Services ......................................................................................................... 97 Treatment and Service provision to the Substance Misuse Clients at NIMH ............................................... 99 Drug Dependent Persons (Treatment and Rehabilitation) Act No 54 of 2007 ............................................ 100 Occupational Therapy Services .............................................................................................................. 101 Rehabilitation Services ........................................................................................................................... 102 Rehabilitation Services Settings .............................................................................................................. 103 Special Rehabilitation Programmes ........................................................................................................ 105 Rehabilitation Committee ...................................................................................................................... 106 Medium Stay Units for Males and Females ............................................................................................. 108 Financial Management in Rehabilitation Activities ................................................................................. 115 Role of Physiotherapy ............................................................................................................................ 116 Dental Services ...................................................................................................................................... 117 Pharmacy and its Services ...................................................................................................................... 118 Laboratory Services ............................................................................................................................... 120 Radiography Services ............................................................................................................................ 122 CT (Computed Tomography) Scans for Patients ..................................................................................... 123 EEG (Electroencephalography) Services ................................................................................................. 124 ECG (Electrocardiography) Services ...................................................................................................... 125 Medical Nutrition Services ..................................................................................................................... 126 Nutrition and Dietetics Services .............................................................................................................. 127 National Mental Health Helpline – 1926.................................................................................................. 128 Patient Transportation for Referrals, Transfers and Discharge ............................................................... 129 Deegayu Elders’ Day Centre .................................................................................................................. 131 Gender Dysphoria Treatment Services ................................................................................................... 132 Day ECT Services .................................................................................................................................. 134 Navodaya Day Treatment Centre ........................................................................................................... 135 National Institute of Mental Health - 5

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Gender Based Violence Prevention Unit.................................................................................................. 138 External Clinics and Outreach Services .................................................................................................. 139 Long Term/ Lifetime Care ..................................................................................................................... 141 Section B – Healthcare Quality and Safety.................................................................................................. 142 National Policy on Healthcare Quality and Safety ................................................................................... 143 Quality Circles and Work Improvement Teams ...................................................................................... 144 Clinical Governance Unit ....................................................................................................................... 145 Complain Procedure for patients/ service recipients ................................................................................ 148 Quality Indicators Monitoring................................................................................................................ 149 Reporting of Adverse Events/ Incidents .................................................................................................. 150 Reporting of Readmissions ..................................................................................................................... 151 Implementation of National Injury Surveillance...................................................................................... 152 Consultants Units-Colour Code .............................................................................................................. 153 Maintenance of Notice Boards ................................................................................................................ 155 Disaster Management Protocols ............................................................................................................. 156 Committee on Prevention of Sexual Harassment in the Workplace .......................................................... 187 Trade Union Action by Staff Unions within NIMH .................................................................................. 190 Staff Welfare and Safety ........................................................................................................................ 191 Section C – Education, Training, Research and Health Promotion .............................................................. 192 Code of Conduct for Trainees................................................................................................................. 193 Code of Conduct for Researchers ........................................................................................................... 197 Usage of the NIMH Library ................................................................................................................... 198 Training Management Committee of NIMH ........................................................................................... 199 Ethical Review Committee of NIMH ....................................................................................................... 201 Health Promotion Unit Services.............................................................................................................. 203 Section D – Public Health and Infection Control ......................................................................................... 205 Infection Control Committee .................................................................................................................. 206 CSSD Services ....................................................................................................................................... 207 Waste Management Guidelines .............................................................................................................. 208 Waste Management ............................................................................................................................... 208 Waste management in NIMH ................................................................................................................ 208 Cleaning the Hospital Premises .............................................................................................................. 210 Outbreak Management .......................................................................................................................... 212 Prevention of spread of Conjunctivitis .................................................................................................... 217 Screening and Treatment of Tuberculosis ............................................................................................... 218 Cannula Site Observation ...................................................................................................................... 220 Rational Use of Antibiotics ..................................................................................................................... 221 National Institute of Mental Health - 6

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Wound Management and Care for MRSA .............................................................................................. 222 Hospital Environment Committee .......................................................................................................... 223 Green Circles......................................................................................................................................... 223 Control of Stray Animals ....................................................................................................................... 224 Section E – General Administration ........................................................................................................... 225 General Advice for all staff..................................................................................................................... 226 Staff Administration .............................................................................................................................. 227 Financial Administration ....................................................................................................................... 228 Planning and Development Services ....................................................................................................... 229 NIMH IT Policy ..................................................................................................................................... 231 NIMH Media Unit ................................................................................................................................. 236 Best practices-for challenging inaccurate or unethical reporting on mental health issues .......................... 240 Donations and Sponsoring of Meals to Patients ....................................................................................... 243 Medical Boards...................................................................................................................................... 244 Housing and Accommodation ................................................................................................................. 245 Damage to Property by Patients ............................................................................................................. 246 Maintenance Services ............................................................................................................................. 247 Information Communication Technology Maintenance Unit.................................................................... 248 CCTV Maintenance and Access.............................................................................................................. 249 Subsistence and Transport Expenses for Discharged Patients .................................................................. 250 Security Services .................................................................................................................................... 251 Section F – Annexures ............................................................................................................................... 252 Mental Diseases Ordinance .................................................................................................................... 253 ................................................................................................................................................................. 255 ................................................................................................................................................................. 255 ................................................................................................................................................................. 256 ................................................................................................................................................................. 258 ................................................................................................................................................................. 259 ................................................................................................................................................................. 261 Patient Care Service Units Distribution updated in January 2022 ............................................................ 262

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Preface The National Institute of Mental Health, Sri Lanka is the only dedicated health institute for psychiatry and mental health in Sri Lanka and it is also the foremost center for specialized tertiary level care. We have many special units at NIMH which provide the much needed specialized psychiatric care for patients.

The Mental Hospital, Angoda which started in 1926 as an asylum was upgraded as a National Institute by a decision of the Cabinet of Ministers as per the letter No: අමප/08/1849/311/088 dated 2008.10.30 of the Secretary of the Cabinet of Ministers.

The Vision and Mission statement of NIMH as updated and approved by the Director General of Health Services by his letter DGHS/NIMH/2017-115 dated 09.02.2017 expands the role of NIMH beyond a role of a Teaching Hospital and focus on evidence based patient care, capacity building, advocacy, community engagement, multi-sector collaboration and research related to mental health services in Sri Lanka.

The National Institute of Mental Health, Sri Lanka has three arms, the NIMH main institute, Mulleriyawa New Town, The Half Way Home, Mulleriyawa (Unit II/Section C) and the Nurses Training School, Mulleriyawa. The Total approved cadre under the purview of NIMH is 1728; (NIMH Main: 1457, HWH: 239, NTS: 32). The Total patient beds strength is 1409; (NIMH Main: 969, HWH: 440).

Since all admissions made to NIMH are done under the Mental Diseases Ordinance the medico-legal responsibilities of the institute is far greater than another institution. The Director of NIMH is the custodian of the patients in accordance with the ordinance.

Considering the vast area of activities and services that are administered under the Director – NIMH including the Clinical Services, Ancillary Clinical Services, Rehabilitation and Social Services, Long Term Care Services, Education, Training and Research Services, Clinical Governance, the Nursing School based Mental Health Nursing Training, Financial Services, General Administrative Services, Logistics and Maintenance Services, Planning and Development Services including Quality Management and Productivity, Infection Control Services and human resource management services including staff welfare, we feel the need to have written guidelines to ensure best practices are followed for the benefit of the patient.

NIMH guidelines first came in place as a policy folder developed in 2009 under the stewardship of Dr. Jayan Mendis, Consultant Psychiatrist and Founder Director of NIMH. These guidelines have been reviewed and updated by an eminent panel of Medical Administrators, Consultants, Senior Medical Officers and Staff Officers involved in administration to be published as an electronic document which is accessible to all staff for reference.

Scope of the Guidelines These guidelines are for use at NIMH and need to be understood by all groups of staff. Guidelines will be updated periodically and this shall exist as a living document. It is only through all types of staff working together that patient care will improve. The following staff officers will be responsible for disseminating and implementing the guidelines: Director, Deputy Director Consultants, Medical officers, Dental Surgeons Accountant, Administrative Officer Special Grade Nursing officers (SGNO) Chief PSW, All Chief PSM officers, All Section Heads Ward Sisters/ Ward Masters, In- Charge Nursing Officers

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Message from the Director – NIMH The National Institute of Mental Health, Sri Lanka has a long and rich history. The institute has gone through many challenges to come forth as the Nation‘s Leader in Mental Health Care. In 2008 we saw a major shift in the path of the then Mental Hospital (Teaching), Angoda when it was upgraded as a National Institute by a decision of the Cabinet. In 2009 keeping in line with the development of the institute a policy folder has been introduced to guide all employees of NIMH in ensuring highest quality of care is given to the patients. After 10 years of usage in 2019 a revision of the policy folder was envisaged to make it more relevant and user friendly for the staff.

This digital NIMH Institutional Guidelines Book is a culmination of that effort. It is issued with the purpose of internal usage, referencing for trainees and application on day to day work by the Medical, Nursing, Allied Health and other categories staff.

The main purpose of this is Quality Assurance and Patient Safety Improvement. This guidelines book will also help staff to better streamline their duties so that unnecessary hassle can be avoided.

I thank all contributing authors and the editorial team for the effort taken in making this project a success.

Dr. Dhammika Wijesinghe Director (Actg) 07.04.2022

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History of National Institute of Mental Health - Sri Lanka History reveals that therapeutic measures for mental illness were practiced in Sri Lanka in the 4th century BC. The new western medical treatment began in the 1800s in hospitals. The law is under ―Lunatic Ordinance of 1873‖ which was amended nine times till 1956 where the wording is substituted as ―Mental diseases Act – Act no 27 of 1956‖.

The first mental asylum was the Leprosy Hospital, Hendala; a hospital for leprosy patients and an area had been separated for mentally ill. Then as the inpatient count had gone up markedly the services were expanded to asylums in Borella and Jawatta.

In 1917 to expand the in-patient space for mentally ill it was decided by the then governors to build another hospital in Angoda to reside 1800 patients. The Angoda Mental Asylum was declared open on 31 st January 1926 for 1728 patients. In 1942 April, at the second world war the Angoda Mental Asylum was bombed by Japanese by mistake. Seventy patients were injured while ten died. As compensation they decided to build a hospital in Mulleriyawa. As the patient numbers were rising heavily the bed strength was upgraded from 1800 to 2125 in 1954. Mulleriyawa Unit 1 was opened to host less disturbed patients with open wards of 840 bed capacity and another hospital was opened in Pelawatta of 3507 bed capacity. Mulleriyawa Unit 2 was open for patients with chronic mental illness who stayed longer and in 1962, 284 patients were there.

In 1982 September, a part of the female ward three storied building collapsed and six patients died. The whole three buildings were demolished by the recommendation of an appointed committee. Female patients residing in those buildings were sent to Mulleriyawa Unit 2 and all the male patients were taken to Angoda.

A new single story building complex was built in 1987 with the patronage of a donor and is the current ward complex.

The village name ―Angoda '' was changed to ―Mulleriyawa new town‖ in 1985 by the then government of Sri Lanka but the still famous name among the public is Angoda.

In 2004 following the Tsunami to Sri Lanka; Mental Health received international attention and was developed markedly. Mental health services were planned to be distributed to the entire island, thus Hendala and Mulleriyawa Unit 1 were converted to General Hospitals gradually.

A Mental Health Policy was drafted in collaboration with the Sri Lanka College of Psychiatrists and approved by the Government in 2005. Then the mental health services were decentralized and community psychiatry services were established and establishment of a National Institute for Mental Health was proposed. Angoda Mental Hospital was upgraded to National Institute of Mental Health, Sri Lanka to be the nerve center for clinical care and for specialized services and training & research in mental health by a Cabinet decision on 31st October 2008 and was published in the health sector with a letter by the Director General of Health Services in January 2009.

The Mulleriyawa Unit 2 was renamed as ―Halfway Home‖ in 2008 and restructured to host clients for rehabilitation and social reintegration. Then over the years in-patient total was taken down from 2000 to 400 odd numbers by reintegrating them to society.

Since then mental health services, psychiatry therapeutic care, rehabilitation and fight against social stigma have developed markedly over the years. Infrastructure and human resource development were slowly rising. The current Vision and Mission with the Objectives were developed by the representation of all the staff categories in 2017 for the next 10 years. The institutional guidelines are being revised accordingly.

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Reference: 1.Suwa Diviyata Suwa Manasak (Jathika Manasika Saukya Vidyayathanaya- Angoda); Chamari Shyama Nilanthika Vithanage – 2018 2. Medico-legal Journal of Sri Lanka, 2017;5(1) – Development of Civil Commitment Statutes (Laws of Involuntary detention and treatment in Sri Lanka:- A Historical Review; de Alwis L.A.P. 3. South Asian Journal of Psychiatry (Volume 2:1) – Country Profiles – The evolution of Psychiatric Services in Sri Lanka; Harischandra Gambheera 4. Decision of the Cabinet of Ministers 08/1849/311/088

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Vision, Mission & Objectives Vision To Lead the Nation in Mental Health Care

Mission To provide comprehensive and evidence based Mental Health Services appropriate to the Local Context through state of the art approaches to patient care, capacity building, advocacy, community engagement, multi-sector collaboration and research delivered by competent and reliable staff

Objectives 1. Provision of Excellent Acute, Intermediate, Rehabilitative, Community Based, Preventive and Specialized Care Services in Mental Health.

2. Foster a Competent, reliable and happy staff that work as a team to ensure highest quality of services to our clients.

3. Establish the highest standards of evidence-based care for psychiatric and neuropsychiatric disorders and rehabilitation.

4. Promote Life Skills Development, Gender Based Violence Prevention, Child Maltreatment Prevention and Substance Abuse Prevention.

5. Human resource capacity building by training in diverse fields related to Mental Health and promotion of subspecialties in Psychiatry.

6. Promote and Develop Research in Mental Health.

7. Increase Mental Health Information Availability and strive to eliminate the stigma attached to the Mental Illnesses.

8. Expand services to our clients in relation to their Physical Health, Nutrition, and Oral Health as well as other supplementary Services.

9. Work with the Ministry of Health and provide consultancy services for policy planning and monitoring strategies in the field of Mental Health and facilitate execution of the National Mental Health Policy.

10. Develop and strengthen inter-disciplinary, inter-institutional and international collaboration with organizations across the country and the globe to foster scientific research, training in advanced technology and exchange of ideas in the areas of Mental Health.

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Values & Strategic Thrust Areas Values 1. We put our clients first and try to make a homely atmosphere.

2. We believe that patients with mental health problems have a right to a normal life with dignity.

3. We value and are committed to providing the public‘s mental health services.

4. We expect honesty, professionalism, and ethics in our work environment.

5. We value teamwork and endeavor to build partnerships, client and community participation to attain our goals.

6. We celebrate diversity and treat all people with fairness, dignity, and compassion.

7. We value and promote Gender Equity.

8. We strive to ensure high quality and effective use of our resources.

9. We are committed to accountability of our actions and for achieving our planned outcomes.

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Strategic Thrust Areas

A Safe, homely and therapeutic environment

A Competent, happy and reliable staff

Patient Centered evidence based treatment plans

(Objective 1,3)

(Objective 2)

(Objective 1,3,4,8)

Strong links with the client families and the communities (Objectives 1,7,10)

National leadership in Mental Health Advocacy, Training and Research

Continuous Mental Health Promotion (Objective 1,4,10)

(Objective 5,6, 9,10 )

Measures

Client Satisfaction Surveys Number of Absconds Number of Violent Incidents Number of Complaints

Staff Satisfaction Surveys Number of Inservice training MDT representation in clinical care

Clinical Care Audits

Readmission Rate

Number of Suicides

Follow up clinic attendance

Number Secluded Number Restrained Review of all Deaths Developments in Sub Specialities

Number of Domiciliary Visits Community Feedback

Number of Training Done Number of Research Done Number of External Participants

Mental Health Literacy Assessment Level of Stigma Eradication Community Satisfaction Surveys

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Institutional Organogram

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Institutional Service Structure

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Mental Diseases Ordinance (Mental Health Act of Sri Lanka) NIMH admissions and patient care is governed under the Mental Diseases Ordinance (Last amended as Act 27 of 1956). The current Mental Diseases Ordinances is given as Annexure I in Section F .

Voluntary Admissions Voluntary Admissions are possible under Section 23 of Mental Diseases Ordinance, An individual should be age sixteen or above to request for voluntary admission. This request is made on the H 68 Form.

The Admitting Officer should be satisfied that the voluntary admissions is beneficial to the patient and that he/she has the mental capacity to request admission. For those below sixteen years of age if the guardian is requesting admission it needs recommendation of a Medical Officer.

Involuntary (Temporary) Admissions Temporary Admissions which are involuntary can be made to NIMH based under Section 28 of the Mental Diseases Ordinance. As per the current practice the Admitting Officer should invoke the Section 28 by filling out the H82 form. This form can be filled by Any Medical Officer allocated for that duty by the Director who has a valid Sri Lanka Medical Council license under section 29 of the Medical Ordinance. As the Ordinance requires two independent signatures the second signature should be made by the Medical Officer of the Ward within 24 hours of admission after an independent assessment of the patient. . All Temporary admissions must be seen by the Consultant Psychiatrist or Unit Senior Registrar or the On Call Senior Registrar within 48 hours of admission. The temporary admission order once affirmed by the Senior Review remains valid for a period of 01 year. When a patient is admitted as a temporary order there should be an application made for admission by the spouse or close relative (next of kin). In the event the spouse or close relative is not available any acceptable person can make the application provided adequate reason is given in writing as to why the next of kin is not available.

The Judgment for Involuntary Admission should be done so based on following criteria: 1. The Patient appears to be suffering from mental illness 2. The patient‘s mental illness requires IMMEDIATE TREATMENT 3. The patient's mental illness can be treated by admission to hospital and treatment is not available in a LESS RESTRICTIVE SETTING 4. Admission to hospital is required for: a. The patient‘s health and safety and b. To prevent deterioration of patient‘s mental or physical state and/or c. For the safety of members of the public 5. The patient has refused or is unable to consent to treatment The Protocol to follow in Involuntary Admission 1. Ensure the patient‘s medical and psychiatric needs are catered for (i.e. Complete the Psychiatric Case Sheet and initial treatment - H8 Form and if needed PICU Form 2. Ensure the request for admission of a person to an approved mental health unit is filled by next of kin/ other representative 3. Complete the recommendation for admission of a person involuntarily

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Admissions via District Courts District Courts have jurisdiction of the persons that are of unsound mind and their property as per the Mental Diseases Ordinance. As such the District Court has authority to direct admissions to NIMH as the only designated ―Mental Hospital‖ within Sri Lanka. Section 02 to 22 of the Mental Diseases Ordinance, deal with District Court Admissions. Admissions sent by the District Court should not be refused by the Admitting Officers unless in exceptional circumstances where such decision will be taken by the Director and relevant Consultant Psychiatrist. The learned District Judge of Colombo will review patients admitted to NIMH by District Court order once in every two week and wards must forward the patient before the court with a report from the Consultant Psychiatrist whether the patient is of sound or unsound mind. Wards can use the standard court report format developed for this purpose. Those reported as sound mind will be released by courts following due process.

Admissions via Magistrate or High Courts Magistrate and High Courts will refer admissions to NIMH for those having an alleged criminal offense and suspected to have mental illness. Such admissions will be received by the Forensic Psychiatry Unit.

Magistrate Courts sometimes function as hybrid District Courts on service needs and the Admitting Officer can clarify the order by looking at the charge. If the Court order carries an AR or LY number with a charge of Insanity or of Lunacy then it is a civil case and can be admitted to general wards. Any queries regarding these can be clarified with the Forensic Psychiatric Team.

Involuntary Treatment Patients admitted by District Courts, Magistrate Courts or as temporary admissions are subjected to involuntary treatment. This is to state that the patient‘s consent is not needed to provide the necessary treatment. This is primarily regarding the treatment of mental illnesses. Treatment of other physical illnesses also can be done on an involuntary basis provided the Medical Officers are satisfied that the patient does not have the capacity to decide on his/her treatment.

The capacity for the patient to give consent will be decided by the Consultant Psychiatrist.

If a patient is admitted voluntarily and the treating team identifies that the patient‘s mental state has changed to the state where involuntary treatment is indicated such a decision should be taken by the Consultant Psychiatrist and approval of the Director taken after filling the H82 form.

Patients who do not have capacity to give consent for invasive procedures and surgeries a recommendation of the treating Consultant for the procedure and consent of the Director is required for the procedure to be performed. Decisions taken to intervene as lifesaving urgent procedures by Medical Officers are accepted.

When a decision is taken by any Medical Officer with regard to involuntary treatment it is of paramount importance to remember the fundamentals of Medical Ethics.

1. Beneficence - Decisions must be taken in the best interest of the patient to do good to him/her.

2. Non-Maleficence - Decisions must be taken without prejudice or ill will and no harm should be done purposefully.

3. Autonomy - Though the patient does not have the capacity to decide, his/her individuality, privacy and dignity must be respected as much as possible.

4. Justice - Decisions must be taken in a just and fair manner.

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As the institution provides involuntary treatment the following risks to the patients must be mitigated by all staff. It is a fiduciary responsibility of all as most patients are detained against their will. NIMH is accountable to the Republic and the next of kin of the patient to ensure the safety of the patient. As such the following risk of the patient should be assessed on admission and periodically and appropriate corrective action taken.

1.

2.

3.

4.

5.

Absconding Risk Suicidal and Self Harm Risk Homicidal and Violence Risk Medical Risk Fall Risk

A patient should be given the right if requested to appeal against involuntary treatment to the Director NIMH or Director General of Health Services. Such a request may be reviewed by a panel of experts appointed by the Director - NIMH or DGHS. District Court and Magistrate Court orders are subject to review by the Court of Appeals and Supreme Court.

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Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care Adopted by UN General Assembly resolution 46/119 of 17 December 1991 Principle 1. Fundamental freedoms and basic rights 1. All persons have the right to the best available mental health care.

2. All persons with a mental illness should be treated humanely and respectfully.

3. All persons with a mental illness, shall have the right to protection from economic, sexual and other forms of exploitation, physical or other abuse on degrading treatment.

4. There shall be no discrimination on the grounds of mental illness.

5. Every person with a mental illness shall have the right to exercise all civil, political, economic, social and cultural rights as recognized in the Universal Declaration of Human Rights.

6. Any decision that, by reason of his or her mental illness, a person lacks legal capacity, and any decision that, in consequence of such incapacity, a personal representative shall be appointed.

7. Where a court or other competent tribunal finds that a person with mental illness is unable to manage his or her own affairs, measures shall be taken, so far as is necessary and appropriate to that person's condition, to ensure the protection of his or her interests.

Principle 2. Protection of minors Special care should be given within the purpose of the Principles and within the context of domestic law relating to the protection of minors and protecting the rights of minors.

Principle 3. Life in the community Every person with a mental illness shall have the right to live and work, to the extent possible, in the community.

Principle 4. Determination of mental illness 1. A determination of a mental illness shall be made in accordance with internationally accepted medical standards.

2. A determination of mental illness shall never be made on the basis of political, economic or social status, or membership in a cultural, racial or religious group, or for any other reason 3. Family or professional conflict, or nonconformity with moral, social, cultural or political values or religious beliefs prevailing in a person‘s community, shall never be a determining factor in the diagnosis of mental illness.

4. A background of past treatment or hospitalization as a patient shall not of itself justify any present or future determination of mental illness.

5. No person or authority shall classify a person as having, or otherwise indicate that a person has, a mental illness except for purposes directly relating to mental illness or the consequences of mental illness.

Principle 5. Medical examination No person shall be compelled to undergo medical examination with a view to determining whether or not he or she has a mental illness.

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Principle 6. Confidentiality The right of confidentiality of information concerning all persons to whom the present Principles apply shall be respected.

Principle 7. Role of community and culture 1. Every patient shall have the right to be treated and cared for, as far as possible, in the community 2. A patient shall have the right, whenever possible, to be treated near his or her home or the home of his or her relatives or friends and shall have the right to return to the community as soon as possible.

3. Every patient shall have the right to treatment suited to his or her cultural background.

Principle 8. Standards of care 1. Every patient shall have the right to receive such health and social care as is appropriate to his or her health needs, and is entitled to care and treatment in accordance with the same standards as other ill persons.

2. Every patient shall be protected from harm, including unjustified medication, abuse by other patients, staff or others or other acts causing mental distress or physical discomfort.

Principle 9. Treatment 1. Every patient shall have the right to be treated in the least restrictive environment.

2. The treatment and care of every patient shall be based on an individually prescribed plan, reviewed regularly, revised as necessary and provided by qualified professional staff.

3. Mental health care shall always be provided in accordance with applicable standards of ethics for mental health practitioners Mental Health knowledge and skills shall never be abused.

4. The treatment of every patient shall be directed towards preserving and enhancing personal autonomy.

Principle 10. Medication 1. Medication shall meet the best health needs of the patient. It shall be given to a patient only for therapeutic or diagnostic purposes only. Medication shall never be administered as a punishment or for the convenience of others.

2. All medication shall be prescribed by a mental health practitioner authorized by law and shall be recorded in the patient‘s records.

Principle 11. Consent to treatment 1. No treatment shall be given to a patient without his or her informed consent, except as provided in paragraphs 6, 7, 8, 13 and 15 of the present principle.

2. Informed consent is consent obtained freely, without threats or improper inducements, after appropriate disclosure to the patient of adequate and understandable information in a form and language understood by the patient.

3. A patient may request the presence of a person or persons of the patient's choosing during the procedure.

4. A patient has the right to refuse or stop treatment, except as provided for in paragraphs 6, 7, 8, 13 and 15 of the present principle.

5. A patient shall never be invited or induced to waive the right to informed consent.

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6. Except as provided in paragraphs 7, 8, 12, 13, 14 and 15 of the present principle, a proposed plan of treatment may be given to a patient without a patient's informed consent if the following conditions are satisfied: a. The patient is at the relevant time held as an involuntary patient b. An independent authority, having in its possession all relevant information, 7. Paragraph 6 above does not apply to a patient with a personal representative empowered by law to consent to treatment, except as provided in paragraphs 12, 13, 14 and 15 of the present principle.

Treatment may be given to such a patient without his or her informed consent if the personal representative, having been given the information described in paragraph 2 of the present principle, consents on the patient's behalf.

8. Except as provided in paragraphs 12, 13, 14 and 15 of the present principle, treatment may also be given to any patient without the patient's informed consent if a qualified mental health practitioner authorized by law determines that it is urgently necessary in order to prevent immediate or imminent harm to the patient or to other persons.

9. Where any treatment is authorized without the patient's informed consent, every effort shall nevertheless be made to inform the patient about the nature of the treatment.

10. All treatment shall be immediately recorded in the patient's medical records.

11. Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them and their nature and extent shall be recorded in the patient's medical record.

12. Sterilization shall never be carried out as a treatment for mental illness.

13. A major medical or surgical procedure may be carried out on a person with mental illness only where it is permitted by domestic law. Where it is considered, that it would best serve the health needs of the patient.

14. Psychosurgery and other intrusive and irreversible treatments for mental illness shall never be carried out on a patient who is an involuntary patient in a mental health facility.

15. Clinical trials and experimental treatment shall never be carried out on any patient without informed consent.

16. In the cases specified in paragraphs 6, 7, 8, 13, 14 and 15 of the present principle, the patient or his or her personal representative, or any interested person, shall have the right to appeal to a judicial or other independent authority.

Principle 12. Notice of rights

1. A patient in a mental health facility shall be informed as soon as possible after admission, in a form and a language which the patient understands, of all his or her rights.

2. As long as a patient is unable to understand such information, the rights of the patient shall be communicated to the personal representative.

3. A patient who has the necessary capacity has the right to nominate a person who should be informed on his or her behalf, as well as a person to represent his or her interests to the authorities of the facility.

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Principle 13. Rights and conditions in mental health facilities 1. Every patient in a mental health facility shall, in particular, have the right to full respect for his or her: a. Recognition everywhere as a person; b. Privacy; c. Freedom of communication; d. Freedom of religion or belief.

2. The environment and living conditions in mental health facilities shall be as close as possible to those of the normal life of persons of similar age and in particular shall include: a. Facilities for recreational and leisure activities; b. Facilities for education; c. Facilities to purchase or 'receive items for daily living, recreation and communication; d. Facilities, and encouragement to use such facilities, for a patient's engagement in active occupation suited to his or her social and cultural background.

3. In no circumstances shall a patient be subjected to forced labour.

4. The labour of a patient in a mental health facility shall not be exploited.

Principle 14. Resources for mental health facilities 1. A mental health facility shall have access to the same level of resources as any other health establishment, and in particular: a. Qualified medical and other appropriate professional staff in sufficient numbers b. Diagnostic and therapeutic equipment for the patient; c. Appropriate professional care; d. Adequate, regular and comprehensive treatment, including supplies of medication.

2. Every mental health facility shall be inspected by the competent authorities with sufficient frequency to ensure that the conditions, treatment and care of patients comply with the present Principles.

Principle 15. Admission principles 1. Where a person needs treatment in a mental health facility, every effort shall be made to avoid involuntary admission.

2. Access to a mental health facility shall be administered in the same way as access to any other facility for any other illness.

3. Every patient not admitted involuntarily shall have the right to leave the mental health facility at any time Principle 16. Involuntary admission 1. A person may be admitted involuntarily to a mental health facility a.

That, because of that mental illness, there is a serious likelihood of immediate or imminent harm to that person or to other persons; or b. That, in the case of a person whose mental illness is severe and whose judgment is impaired, In National Institute of Mental Health - 39

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the case referred to in subparagraph (b), a second such mental health practitioner, independent of the first, should be consulted where possible. If such consultation takes place, the involuntary admission or retention may not take place unless the second mental health practitioner concurs.

2. Involuntary admission or retention shall initially be for a short period.

3. A mental health facility may receive involuntarily admitted patients only if the facility has been designated to do so by a competent authority prescribed by domestic law.

Principle 17. Review body 1. The review body shall be a judicial or other independent and impartial body 2. The initial review of the review body as required by paragraph 2 of principle 16 above 3. The review body shall periodically review the cases of involuntary patients 4. An involuntary patient may apply to the review body for release or voluntary status, at reasonable intervals as specified by domestic law.

5. At each review, the review body shall consider whether the criteria for involuntary admission set out in paragraph 1 of principle 16 above are still satisfied.

6. If at any time the mental health practitioner responsible for the case is satisfied that the conditions for the retention of a person as an involuntary patient are no longer satisfied, he or she shall order the discharge of that person as such a patient.

7. A patient or his personal representative or any interested person shall have the right to appeal to a higher court against a decision.

Principle 18. Procedural safeguards 1. The patient shall be entitled to choose and appoint a counsel to represent the patient.

2. The patient shall also be entitled to the assistance, if necessary, of the services of an interpreter.

3. The patient and the patient's counsel may request and produce at any hearing an independent mental health report.

4. Copies of the patient's records and any reports and documents to be submitted shall be given to the patient and to the patient's counsel, except in special cases.

5. The patient and the patient's personal representative and counsel shall be entitled to attend, participate and be heard personally in any hearing.

6. If the patient or the patient's personal representative or counsel requests that a particular person be present at a hearing that person shall be admitted.

7. Any decision on whether the hearing or any part of it shall be in public or in private and may be publicly reported shall give full considerations to the patient's own wishes.

8. The decision arising out of the hearing and the reasons for it shall be expressed in writing.

Principle 19. Access to information 1. A patient shall be entitled to have access to the information concerning the patient in his or her health and personal records maintained by a mental health facility. This right may be subject to restrictions.

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2. Any written comments by the patient or the patient's personal representative or counsel shall, on request, be inserted in the patient's file.

Principle 20. Criminal offenders 1. The present Principle applies to persons serving sentences of imprisonment for criminal offences, or who are otherwise detained in the course of criminal proceedings against them, and who are determined to have a mental illness 2. All such persons should receive the best available mental health care.

3. Domestic law may authorize a court or other competent authority, acting on the basis of competent and independent medical advice, to order that such persons be admitted to a mental health facility.

4. Treatment of persons determined to have a mental illness shall in all circumstances be consistent with principle 11 above.

Principle 21. Complaints Every patient and former patient shall have the right to make a complaint through procedures as specified by domestic law.

Principle 22. Monitoring and remedies

1. States shall ensure that appropriate mechanisms are in force to promote compliance with the present Principles, for the inspection of mental health facilities, for the submission, investigation and resolution of complaints 2. The institution of appropriate disciplinary or judicial proceedings for professional misconduct or violation of the rights of a patient.

Principle 23. Implementation 1. States should implement the present Principles through appropriate legislative, judicial, administrative, educational and other measures, which they shall review periodically.

2. States shall make the present Principles widely known by appropriate and active means.

Principle 24. Parameter The present Principles apply to all persons who are admitted to a mental health facility.

Principle 25. Saving of existing rights There shall be no restriction upon or derogation from any existing rights of patients, including rights recognized in applicable international or domestic law, on the pretext that the present Principles do not recognize such rights.

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Multi-Disciplinary Approach in Patient Care

NIMH recognises the need for a multidisciplinary approach in patient care. We believe the Patient Centered Approach to be more productive and that all team members have a role to play. The Consultant Psychiatrist is recognised as the team leader in patient care teams.

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Medico-Legal Responsibilities within NIMH, Sri Lanka With regard to the above subject, attention is drawn to the Ministry of Health General Circular NO:01-102002 & General Circular NO:01-05-2003 as well as the responsibilities of state officers stipulated in the Code of Criminal Procedure in Sri Lanka as well as guidelines issued by Sri Lanka Medical Council.

1. The Psychiatric Case Sheet (H8) and the BHT that is attached with it is a special medico-legal document that may be produced before the Courts & other Legal Officers for many purposes. As such much care should be given to document your findings and incidents very clearly in the BHT. 2. As per the existing NIMH policies & guidelines, all admitting officers & ward nursing officers are reminded about the importance of documenting all existing injuries of patients upon admission to NIMH in detail in the BHT and the injury surveillance forms.

3. All incidents that result in physical injury to a patient must be documented clearly and in detail in the BHT & informed to the Director.

4. If a patient complains of any harm done to him/her that has legal implications it is the responsibility of the medical staff to initiate the review of the patient urgently by the Consultant JMO after a MLEF is issued by the police.

5. The medical staff must be mindful of reporting any suspicious injury to a patient that may be due to possible assault/ torture while being admitted at NIMH. 6. Any incident of a patient when reported to the Director if found to be suspicious of a criminal act, it will be directed to be referred to police & JMO, after discussing with the relevant Consultant.

7. Incidents that are part of the therapeutic process which may have the need for the patients to be subdued and restrained physically to prevent self-harm, harm to others or absconding are considered as part of the involuntary treatment process under the Mental Diseases Ordinance. Such incidents should only be reported to the Director and for Clinical Governance Review through the Quality Management Unit.

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Section A - Clinical Care Services

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Admission and Discharge - Level of Care identification 1. Acute Care Category

1. Having a mental illness with risk to self or others

Maximum stay 28 days

2. For assessment

Combined Wards are included in this category who will have a maximum stay of 6 months

3. Case conference after patient breaches the 28-day limit by Consultant Psychiatrist & Team

Hostile or aggressive, suicidal, selfneglect, & severe social issues Seek advice from a senior officer if necessary

2. Intermediate Care Category Maximum stay - 6 months

1. Patient who are not expected to go previous functional level within 28 days 2. Patients who need Intermediate level rehabilitation 3. There must be a review every 3 months of the patients who are staying more than 6 months 4. A list to be maintained with Director on clients staying more than 6 months to be submitted by all Intermediate Wards monthly via SGNO

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Admission Procedure to National Institute of Mental Health, Sri Lanka 1. The Out Patient Department (OPD) will handle the Admissions. The OPD is expected to function 24hr / 07days of the week/ 365 days of the year.

2. When a patient is brought in, the on Duty Nursing Officers will attend to the patient with the help of the Support Staff. A quick initial assessment should be made and the patient and family should be informed to wait for a review by the Medical Officer.

3. If the patient is showing signs of high risk, the patient should be taken into the Psychiatry Intensive Care Unit (PICU) by the nurses and the on-call Medical Officer informed immediately.

4. Admitting Medical Officers are expected to attend to patients at OPD at the earliest possible instance to minimize waiting time.

5. Admissions are to be documented in the H8 Form. If taken into PICU, the PICU form also should be filled.

6. The patients will be allocated to Units based on the residential area for all civil admissions.

7. New patients are to be admitted to the concerned ward serving that area from which she/he comes from, taking the residential address of the patient into account.

8. With regard to the ex-NIMH patients, admission procedure is as follows: Despite previous admission to a different unit or followed up at a particular psychiatric clinic or treated by a consultant in the private sector, patients are to be admitted to the relevant unit serving the area from which she/he comes from considering the residential address of the patient.

9. The area basis for admission to each unit will be determined by the Director in consultation with the Board of Consultants and updated to the OPD. 10. Nursing Officers are expected to determine the area basis based on the residential address given.

Special consideration should be given to ensure the area of residence is taken as from where the patient is to be followed up after discharge. Any discrepancies regarding the residential address to be resolved by the relevant admitting Medical Officers in the best interest of the patient under the advice of the On Call Senior Registrar/Consultant.

11. If a patient is brought and the residential address can not be determined the patient should be admitted on the basis of the Non-Address Rotation. All attempts should be made to determine the area of residence before this option is selected. While in the ward once patients addresses are confirmed patients may be internally transferred accordingly.

12. In all cases, admission will be limited to those who need in-patient care at NIMH. It is absolutely the duty of the admitted medical officers under the supervision of the consultants to decide the necessity of the admission. In the event of any difficulty the admitting officer should get the opinion of the next senior officer to decide admission.

13. All Magistrate Courts (MC) and higher court patients should be admitted to Forensic Psychiatry Unit(s).

14. District court patients should be admitted as any other involuntary patient. If it is difficult to find the patient‘s residential address, patients may be admitted according to rotational basis. Once a patient's residential address is found he/she may be internally transferred accordingly.

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15. Admission / transfer to Long Term Care Wards (Ward 22 / Section C): Each Consultant Unit will have a quota for admission.

16. Patients who are brought by the Police will be admitted on rotational basis if the residential address is not known.

17. Patients, who are staying in care homes / residential facilities, should be admitted on a rotational basis to all units. They will be readmitted to the same unit if the patient comes within three months of the previous admission.

18. Managing returning of absconding patients If a patient is missing from the ward a. If the patient returns to the institution within 24 hours of the noted missing time, he/she should be accepted in the same BHT with proper documentation (accepted time & date, physical examination, mental state examination, and any other relevant history). b. If the patient returns after 24 hours of the noted missing time, he/she should be accepted as a new admission with a new BHT number. c. If the missing time is doubtful and history after absconding is unreliable, the admitting officer should document a new admission.

19. If a dispute arises regarding an admission, it should be referred to senior opinion for arbitration.

20. Temporary Admissions made under Mental Health Act usually must carry a request made by Next of Kin. The next of kin for the purposes of the Mental Health Act may be the spouse, children, parents or close blood relative. In the absence of a next of kin the admitting officer with senior opinion may be satisfied with a suitable person who is known to the patient. Police Officers and Grama Niladhari may also forward patients for admissions. In the absence of a next of kin all attempts should be made to contact such a person while inward.

21. When an admission is done at OPD a Nursing Officer from the relevant ward will join the admitting officer to support in the admission process and to do a joint assessment at OPD. The Nursing Officer will help in providing background history in previous admissions and the Nursing Officer will fill the ―joint assessment form‖.

22. Once admitted to the ward the patient will be allocated a Key Medical Officer and Key Nurse to be the case coordinators of the patient.

The residential address is defined as a place where patients receive continuous care and follow up.

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Night Admissions to NIMH (4 pm to 8 am) 1. During Day Time each of the General Psychiatry Units, Forensic Psychiatry Unit and the Adolescent Mental Health Unit should have Medical Officers (01 to 02) available full time on On Call to the OPD. 2. The following units will be combined for night admissions: A.

Units I and II

B.

Units III and VI

C.

Units IV and V

D.

Units VII and VIII

Following Units will have Night on Call Medical Officers Separately E.

Medical Unit

F.

Forensic Psychiatry Unit

G.

Section C - Halfway Home

3. Admissions from Monday to Saturday will be done on alternate days by each combined unit from 4pm- 8am. At any stage the night admissions cannot be mutually exchanged between other dyads.

4. Night admissions on Sunday and public holidays will alternate between the two respective units.

5. Senior registrar being allocated each day on a roster basis should provide the supervisory role for any clinical matter.

6. Admissions to the Psycho geriatric wards will be done on area basis by the respective on call doctor; however, any emergencies/ problems from these wards will be looked after by the on-call doctor of Unit 1 & Unit 2.

7. Admissions to the LDU, PPU & AMHU should be attended to by the on-call doctors according to area basis.

8. Any emergencies / problems from the following wards/unit wards to be attended to as follows:

Ward

Night Cover-up Unit

Ward 22

Units IV & V

Male Villas

Units VII and VIII

Female Villas

Units III and VI

LDU & AMHU

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Psycho-Geriatric Ward(s)

Units I and II

PPU

Area Basis

Isolation Wards

Area Basis

9. All admissions, emergencies, referrals and other actions taken during the day/night should be handed over to the incoming on call officer in the morning.

10. As there are fewer night shift Medical Officers, attempts must be made to complete all essential treatments during day shifts before handover.

11. As night Shift Medical Officers will have to attend to emergencies both at OPD and Ward, sound clinical judgment should be taken based on clinical status of the patient to prioritize where to attend first. Nursing Officers must ensure a clear picture is given to the Medical Officer when informing about the patient.

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NON Admissions at Outpatient Department 1. Not all contacts presenting to OPD will warrant admission 2. Admitting Officers should admit only those clearly need admission 3. OPD Contacts that are not admitted ―NON Admissions‖ should be assessed and their needs attended to.

4. Non Admissions should be documented in the Non Admission book by the Medical Officer. Be mindful to document a clear summary as the record may be used for medical-legal and investigative purposes.

5. Non Admissions may be referred with or without medication to a clinic which is under the relevant Consultant Psychiatrist.

6. Non admissions can also be referred to the Navodaya Treatment Centre or Deegayu Elders Day Centre.

7. Non Admissions that are referred to another Consultant‘s Clinic or to another tertiary institute should be done so with senior opinion.

8. Non Admissions can be issued medication using the RC Number.

9. Staff members presenting with acute ailments that require medication can be reviewed by the Medical Officer under Non admission category. Such reviews need not be documented in the Non Admission Book.

10. Staff requiring ambulance transport to another hospital should be documented in a separate book and approval taken from the Director.

11. Substance misuse related non admissions should be attended to based on the specific circular about follow up as per the Ministry of Health guideline.

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Admission procedure to Perinatal Psychiatric Unit (PPU) 1. Patients who are pregnant or having infants can be admitted directly to the PPU. 2. Patients will be under the care of a Consultant according to the area basis.

3. Admission to PPU will be decided according to availability of beds.

4. Usually, priority will be given to patients with infants.

5. Relative(s) are allowed to stay with the patient.

6. It is not mandatory that all pregnant patients be admitted to PPU. 7. When a baby is kept with the mother the same BHT with a B number should be utilized to attend to the medical, nursing needs of that baby.

8. Neonatologist or Paediatrician opinion regarding the baby should be sought from Lady Ridgeway Hospital for Children or Colombo East Base Hospital. As NIMH does not have an in house Paediatrician cover clinically unstable babies should not be kept at PPU. 9. Beds at PPU are limited and precious and should be utilized in an equitable manner.

10. High level of infection control protection is expected due to risk of infections to neonates and infants.

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Admission procedure Adolescent Mental Health Unit (Arunodhaya) 1. The AMHU has 6 rooms and a maximum of only 2 patients should be admitted to each room.

(Maximum of 12 patients for the unit) 2. Out of 6 rooms 3 are to be allocated for male patients and other 3 for females.

3. However, the number of male / female rooms can be changed according to the need at a given time.

4. Patients presenting to NIMH OPD between age 14 and 18 can be admitted to AMHU if a vacancy is available as per routine OPD protocols. In exceptional circumstances patients beyond this age group may be admitted to the AMHU after authorization of the Director/NIMH at the recommendation of the Consultant Child & Adolescent Psychiatrist (from 12 upto 21).

5. Without a bed vacancy a patient cannot be admitted to the AMHU. The patient will then be admitted on an area basis with a family member.

6. Maximum duration of stay for a patient at the AMHU is 03 Months. At the end of which further prolongation of stay may be recommended by the treating Consultant Child & Adolescent Psychiatrists with authorization by Director/NIMH. 7. Patients with high violence risks and other risks that require seclusion and close observation should not be admitted to AMHU unless such admission is suggested by the Consultant Child & Adolescent Psychiatrist for specialized care.

8. Relatives of patients may be permitted to stay with the patients at the recommendation of the treating team with authorization of the Director.

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Admission procedure to Learning Disability Unit (LDU) 1. This unit has 6 rooms and a maximum of only 2 patients should be admitted to each room.

2. The allowed age in any circumstance shall be less than or equal to 21 years of age.

3. The maximum duration of stay for a patient admitted to this unit is 3 months.

4. It is mandatory to have a relative staying with the patient except when recommended by Consultant Child & Adolescent Psychiatrist with authorization by Director/NIMH. It is the duty of the nursing staff to educate the relatives on how to manage acute/ emergency situations and provide opportunities to learn rehabilitation activities during this stay.

5. When there are no vacant beds in the unit and another patient needs to be admitted, the most settled patient in the unit should be transferred to an acute or intermediate ward on an area basis.

6. Please note that without vacancies patients cannot be admitted to the unit.

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Admission Procedure to Psycho-Geriatric Unit 1. Patients who developed their first episode of mental illness after the age of 65 years can be directly admitted.

2. Patients in any age group presenting with features of dementia can be referred for admission.

3. Patients who have suffered from a chronic mental illness but later on presenting with features of ‗dementia‘ and needing special attention can be admitted.

4. Each consultant psychiatrist is allocated 2 beds each from male and female wards and according to the patient‘s residential address they are admitted under the care of the relevant consultant psychiatrist.

5. Patients who fulfil the admission criteria can be directly admitted to ward 17/20 from the OPD if vacant beds are available.

6. If there are no vacancies the patient should be admitted to the relevant consultants‘ acute ward and the patient‘s name should be entered to the ‗waiting list‘ of ward 17/20.

7. When including a patient to the waiting list, priority will be given when all 2 beds in each ward allocated for the consultant are occupied. However, if there is a vacant bed under a different consultant, the patient will be admitted for that vacancy.

8. However, if the consultant who has a vacancy includes a patient to the waiting list, he will be given priority for admission as soon as a bed is vacant.

9. It is highly recommended that a patient should have a bystander wherever possible.

10. Patient stay should be reviewed as to the justification of the stay after 3 months.

11. There must be a review every 3 months of the patients who are staying more than 6 months.

12. A list to be maintained with the Director on clients staying more than 6 months to be submitted monthly.

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Admission Procedure to Isolation Units 1. Isolation Units are created for the purpose of isolating patients who may have contracted infections that can lead to large outbreaks within the institute.

2. Patients with infections such as Chickenpox, Viral Conjunctivitis, MRSA skin infections, and respiratory infections such as Covid 19, Influenza and any infection deemed potentially risky by the Consultant Microbiologist or Consultant Physician should be isolated.

3. Any Medical Officer can take the decision to isolate patients depending on clinical condition.

4. Upon isolating a patient Medical Officer - Microbiology and Infection Control Nursing Officers should be informed.

5. The Consultant Microbiologist and Infection Control Committee of the Institute will issue protocols and guidelines from time to time about the use of Isolation Units.

6. Admissions to Isolation Units should be restricted to the shortest possible time needed to manage the infection.

7. While in isolation visitation will be restricted.

8. Isolation Unit Nursing In Charge s must ensure the availability of all upto date infection management

and control guidelines issued by the Ministry of Health and the Institute Infection Control Committee.

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Admission Procedure to Mental Health Covid Treatment Units 1. National Institute of Mental Health will be giving care to asymptomatic and mildly symptomatic covid positive patients without other major comorbidities who need acute inpatient psychiatric care in a secure Environment.

2. The following categories of patients will not be admitted to the National Institute of Mental Health with regard to the covid status irrespective of their mental illness. a. Severe Covid illness (Critical) b. Patients with significant medical comorbidities c. Pregnant individuals d. Patients in the immediate postpartum period (< than one month) 3. The patients need to be prior assessed by the consultant psychiatrist and the medical team designated to the medical institution or quarantine centre where the patient currently resides and get down only the asymptomatic and mildly symptomatic patients after the opinion of the relevant consultant psychiatrist and consultant physician at NIMH. 4. Admissions of the patients will be subjected to the availability of beds in the covid 19 treatment wards.

5. Covid 19 positive pregnant patients with mental illness and patients in the immediate postpartum period (one month within the delivery) should not be admitted to the NIMH. Instead, they should be managed at the designated Gynaecology and Obstetrics ward for covid positive patients at the Colombo East Base Hospital, Mulleriyawa.

6. The psychiatric management should be covered up by the relevant psychiatry team according to the patient‘s catchment area.

7. Covid 19 positive mentally ill patients in the community who directly seek psychiatric treatment from the NIMH will be assessed by the relevant psychiatric team. A joint decision will be taken by the consultant psychiatrist and the consultant physician on further management depending on the clinical state of the patient.

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Admission Procedure to Villas 1. Male Villas Complex has 33 beds capacity and Female Villas Complex has 35 bed capacity.

2. Villas Wards are subsidized paying wards that will accept patients only up to the maximum bed capacity allocated to the Villas 3. If a family wishes to admit a patient to the Villas they should give a written request to the Director.

4. This request should carry the recommendation of the relevant area based Consultant Psychiatrist of the NIMH. 5. Coordination of getting the recommendation of the Consultant should be done by the Psychiatric Social Worker of the Unit.

6. Upon receiving the letter of request with due recommendation the patient will be put to a waiting list.

Male and Female Villas waiting lists will be maintained separately.

7. The waiting list for the Villas will be strictly adhered to and any decision to bypass the waiting list will require the approval of the Director and the Board of Consultants of NIMH. 8. Patients with Learning Disability will not be admitted to Villas.

9. Patients who require palliative and one to one care will not be admitted to Villas.

10. Patients will be managed as open home based care at Villas and as such patients with major risks will not be kept at Villas.

11. Villas are best suited for low to medium income families as a subsidized long term care unit.

12. Consultant Psychiatrist may request review of patient, home setting as well as recommendation from Divisional Secretariat before recommending admission to Villas.

13. Next of Kin must ensure continuity of payment as well as supply of other drugs/ consumables as determined by the institution.

14. Villa stay must be reviewed every 05 years and patients who would benefit from going home should be released.

15. Villa admissions must be kept as Voluntary Admissions.

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Admission Procedure to Paying Cubicles 1. Based on the availability, the Director and Board of Consultants may designate the separate Cubicles as paying cubicles after getting permission from the Director General of Health Services.

2. These cubicles can be used by all Consultant Psychiatrists on an equal share basis to house patients with a bystander under paying basis.

3. Payment amount will be determined according to the Ministry of Health guidelines.

4. Very high risk patients shall not be kept in these paying cubicles.

5. A bystander is mandatory 6. Maximum duration of stay will be 28 days

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Patient Property Management 1. Patient property must be attended to as per the existing guidelines and regulations of the Ministry of Health 2. All material property must be put in the safe under the supervision of the Administrative Officer.

3. All monetary property is to be kept at the Shroff.

4. The Medical Officer attending must document the available property on the BHT with assistance of the Nursing Officer.

5. Relevant forms should be filled by the Nursing Officer and the property sent in a safe manner to the Inquiries Office.

6. Property brought in the night may be kept in ward in a safe manner until the safe can be opened in the morning.

7. Property of extreme value (such as gold jewellery) should be put to the safe as soon as possible.

8. All staff must avoid holding on to patient property unnecessarily and send it to the office for safe keeping as soon as possible.

9. As most patients will have poor capacity at the time of admission officers must be extra careful about ensuring the safety of patient property.

10. Property will be released only upon discharge of the patient.

11. Release of property will be done only during stipulated office hours.

12. If a death of a patient occurs his/her property will be handed over to the next of kin upon adequate proof of identity is produced to the Director.

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Visitations to see Patients 1. NIMH welcomes visits to patients by their families, friends.

2. Visitation hours are usually from 6.00 am to 6.00 pm, however restrictions may be enforced by the Director based security or other circumstantial issues.

3. Patients should not be forced to meet visitors and the consent of the patient should be sought for visitations as much as possible.

4. Visitors are not allowed to take photographs or video record within the hospital premises without the written permission of the Director 5. Media personnel and other special groups are not allowed to enter NIMH without the permission of the Director 6. Patient‘s identity should not be revealed or any information given to non-relative visitors without the expressed permission of the Consultant Psychiatrist.

7. A visitor entering a ward must inform the On Duty senior Nursing Officer before meeting the patient.

8. Nursing Officers on duty must ensure visitors are given the needed support and information.

9. If requested an opportunity must be given for family members to meet the treating Medical Officers and Consultants.

10. Any behaviour that induces stigma or ridicules patients by visitors is strictly prohibited.

11. Visitors should carry some form acceptable Identity verification for security purposes.

12. Visitors are prohibited from bringing illegal substances, alcohol, betel leaves, cigarettes and other detrimental items to patients.

13. Nursing Officers on Duty at the Ward have the right to ask the visitors to leave if any violation of regulations or patient rights is suspected.

14. Consultant Psychiatrists may restrict visitors to patients based on clinical grounds.

15. Requests made by next of kin to restrict visitors to patients may be accepted at the discretion of the Consultant Psychiatrist.

16. Any appeals or complaints a visitor has should be directed to the Consultant Psychiatrist or Director.

17. Final discretion with persons entering NIMH rests with the Director.

18. When providing information to the family, it should be done by the senior most officer available in the ward to ensure veracity and consistency.

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Temporary Leave for Patients a. At a time, a patient can be sent on a leave for a period of 14 days from the time denoted in BHT. Leave is only applicable for Temporary Admissions. b. The maximum time a patient can extend this leave shall not exceed 14 days from the returning after the 1st leave. c. If a patient does not return from leave as per the noted date in the BHT; it is allowed to keep the BHT open for 14 days from the noted return date. During this time the relevant unit must make the maximum effort to ensure the patient returns. d. If the patient has not returned as per time given in section (c), the BHT should be closed and a diagnosis card posted to the given address; a new BHT will be issued in case the patient returns after the given grace period. e. Patients, who request continuous leave beyond the allowed leave, can be allotted a community file and the BHT can be closed. f. The system of leave currently in use at NIMH which has been the routine practice for a long time has supportive and beneficial effects in the Patient Care process. g. Please note that the giving of leave must be decided by or in consultation with the treating Consultant or his/her Senior Registrar. It is encouraged to use Community Files for patients requiring longer close follow up through NIMH. The duration of the period of leave will be at the discretion of the treating Consultant. h. The seals shown below can be used to document the leave clearly on the BHT.

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Date:

Time:

Date: Director/ NIMH

The patient is fit to be given a short leave. It is beneficial for his/her management plan.

...........................................

Consultant/ SR/ Reg/ MO

Sir

Please authorise a short leave for this patient for ............ days. (pending approval) Thank you

Patient and/or his/her guardian have been educated about the discharge drugs and signs of relapse and the date for next visit and other relevant information.

..............................

Reg/MO – Unit.......

...................................

Ward NO Patient or guardian needs to make a note here in their preferred language with regard to understanding the procedures and practices to be followed while at home.

Leave Authorized

Date for return: ............................

-------------------------------Director – NIMH Date:

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Discharge Procedure 1. Discharge planning should be done from admission itself so that it may be processed when the patient shows signs of improvement.

2. Voluntary Patients can be discharged by the Consultant Psychiatrist or upon a request made by the patient after documenting the same.

3. Involuntary Patients (Temporary Admissions) shall only be discharged by the Consultant Psychiatrist opinion.

4. District and Magistrate Court ordered admissions will be referred back to the Court, if discharge is possible for consideration.

5. During MDT team meetings if it is decided to discharge a patient the medical officer responsible should take all attempts to discharge the patient as quickly as possible.

6. A discharge summary/diagnosis card must be completed prior to the discharge of the patient. You should make all attempts to fill all the gaps in the diagnosis card. Writing the official diagnosis on the card is a must for all patients.

7. Last page of the BHT (H8 form) must be completed during patient‘s discharge 8. ICD – 10 Diagnoses Should Be Given In All Patients. It is the responsibility of the Medical Officer to enter ICD-10 diagnosis on the H8 form upon discharge.

9. NIMH does not recognise the procedure ―Left Against Medical Advice (LAMA)‖ and it should never be documented as such on BHT. 10. Must clearly write the follow up plan and/or referral in the diagnosis card. Sometimes a specific referral letter / care plan may be needed in complex cases.

11. Nursing Officers must complete the discharge checklist at the time of the discharge after performing the stipulated tasks.

12. A clear handing over of patients should be documented in the BHT by the Nursing Officers.

13.Discharge cards/ clinic books should not carry the note ―DO NOT Admit to NIMH‖ ; instead can use ―Do not admit without senior opinion‖

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Community File Follow Up 1. When a patient is discharged, follow up can be arranged from a relevant local clinic. However if you wish to review the patient in one to two weeks‘ time a patient can also be discharged where they can be reviewed as per a clinic setting in their subsequent visits to the ward. A clinic file should be maintained in the ward or Community Centre issued from the Community Mental Health Unit with a unique community file number for such patients.

2. This system is a very useful and innovative method to ensure compliance in patients and reduction of cost by prevention of admissions.

3. As per the Directive of the Drugs and Therapeutics Committee oral medication can be issued up to one month using the community file number.

4. Depot injections of Fluphenazine Decanoate, Flupenthixol Deconate and Zuclopenthixol Decanoate can be issued to CPN Drug Book for the Community File Number.

5. The Issuing of the Unique Community File Number will be done by the Inquiries Office through a Central Community File Registration Book.

6. The File number should follow the current pattern which consists of letters indicating the Consultant, a serial number and the year of registration.

7. If a client is discharged the Community File must be sent to the Record Room for safe keeping as per routine protocols followed for BHTs. 8. The Community Mental Health File should be used with due diligence just as a BHT/ Clinic File as it may be used in all internal and external legal proceedings if needed.

9. The Community Mental Health Files that are used for follow up of patients immediately after discharge where the patient visits NIMH for scheduled reviews must be kept in the Acute Psychiatric Wards under the responsibility of the Nurse/Sister in charge.

10. Community Mental Health Files that are used for Community based management through domiciliary visits must be kept at the Community Mental Health Unit under the responsibility of the relevant CPN. 11. Drug supply issued from a Community File which is usually restricted to a maximum of two weeks can be increased to a period of one month when issued on the recommendation of a Consultant Psychiatrist. This is based on the letter No DGHS/NIMH/2017-115 dated 18.01.2017 issued by the office of the DGHS. 12. When issuing drugs for a period of 1/12 for a patient through a community file a note must be of the recommendation to do so by the Consultant in the Community File at the initial issuing. When prescribing for one month, the seal of the Consultant must be placed on the prescription to indicate recommendation of the Consultant. The prescription can be signed by any Medical officer of the Consultant‘s team.

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Death of a Patient 1. When a death of a patient occurs within NIMH, the On Call Medical Officer attending should inform the On Call Senior Registrar, Patient‘s Consultant, Consultant Judicial Medical Officer and Director via telephone. On the BHT the death should be communicated to the Director and authorization should be requested for an inquest from the Director. The On Call MO should also write to the office to arrange for an inquest.

2. By law for all deaths occurring at NIMH it is required that an inquest be conducted. When a patient admitted to NIMH dies at another hospital after transferring from NIMH an inquest should be held at that hospital. When a patient dies while admitted to NIMH an inquest must be held regardless of any external pressures. However you should take personal interest in expediting the process so that every effort is taken to handover the body of the deceased to the relatives within 24hrs where families request to do so.

3. After the initial proceedings a report should be written/ typed to the Magistrate conducting the inquest. The report should ideally be written by the patient‘s allocated Key Medical Officer.

However in his or her absence it is the responsibility of the On Call Medical Officer or Registrar attending to the death to ensure that the report is written at the earliest.

4. The report should be written to the Registrar of the Magistrate Court Colombo. It should be signed by the Medical Officer/ Registrar writing the letter. It would be a good practice to get it countersigned by the patient‘s attending Primary Consultant. The letter should be forwarded to the Courts through the Director, NIMH. 5. The report should have a detailed summary of the patient's treatment at NIMH from admission till the time of death written in plain English. Use of clinical terms should be avoided if possible. If foul play is suspected in the death of the patient that should be mentioned in the report. A copy of the report should be filed with the BHT. 6. If a patient, having transferred to ward 18 dies fairly early it would be appropriate for the Psychiatric MO/ Registrar to prepare the report. However when a patient dies in Ward 18 after a longer duration of stay the Court Report should be prepared by the Ward 18 Medical Officer in consultation with the Psychiatric Medical Officer/Registrar. The report should be signed by both officers and it would be a good practice to get it countersigned by the patient‘s attending primary consultant.

7. The inquest for a death will be done under the purview of the Magistrate Court, Colombo. A post mortem will be conducted by the Judicial Medical Officer and a report submitted to the courts. The Magistrate will visit to review the death and once proceedings are cleared will issue an order to release the body.

8. The relevant subject officer in the Inquiries Section and the Overseer Office will coordinate the handling of diseased bodies.

9. Once clearance is received through the Magistrate order the body may be handed over to the family after checking all documentation including the instructions given by the court.

10. If the deceased does not have a next of kin to accept the body with permission of the court the body will be directed for burial through the local government bodies utilizing the state funds.

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Risk Assessment Form to be used at Admission

Risk Assessment Form – National Institute of Mental Health (If even one is positive get senior opinion) Name: Suicide

DOB: Yes

No

Sources of Information: Don‘t Know

Yes

Previous attempts on their life

Expressing high levels of distress

Previous use of violent methods

Helplessness or hopelessness

Misuse of street drugs alcohol

Family history of suicide

Major psychiatric diagnosis

Separated / Widowed / Divorced

Expressing suicidal intent

Unemployed / Retired

Planned intent

Recent significant life event

Belief no control over life

Major physical illness / disability

No

Don‘t Know

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Neglect

Yes

No

Don‘t Know

History of self-neglect

Lack of positive social contacts

Failing to drink properly

Unable to shop for self

Failing to eat properly

Too few / inappropriate clothes

Difficulty managing health

Difficulty managing hygiene

Inadequate accommodati on

Having financial difficulties

Lacking basic amenities

Difficulty communicating needs

Pressure of eviction / repossession

Denies problems others suggest

Aggression / Violence

Yes

No

Don‘t Know

Previous incidents of violence

Paranoid delusions about others

Previous use of weapons

Violent command hallucinations

Yes

No

Don‘t Know

Yes

No

Don‘t Know

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Misuse of street drugs / alcohol

Signs of anger / frustration

Man under 35 years of age

Sexually inappropriate behavior

Known personal trigger factors

Preoccupied with violent fantasy

Expressing intent to harm others

Past dangerous / impulsive acts

Other Known Risks

Yes

No

Don‘t Know

Yes

Self-injury (e.g. cutting, burning)

Exploitation by others

Self-harm (e.g. eating disorder)

Exploitation of others

Stated abuse by others

Cultural isolation

Abuse of others

Non-violent sexual offense

Harassment by others

Deliberate fire starting

Harassment of others

Accidental fire risk

No

Don‘t Know

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Risk to children

Other damage to property

Failure to attend appointments

Disengagement with services

Completed by:

Designation:

Date:

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Consent for Treatment and Clinical Procedures 1. Mental Capacity of a person is about the ability to

a. b. c. d.

Understand information about a particular decision Remember that information long enough to make the decision Weigh up the information to make the decision Communicate their decision.

2. Capacity to Consent by the patient is determined finally by the Consultant Psychiatrist.

3. A person is not to be treated as unable to make a decision unless all practicable steps to help him/her do so have been taken without success.     

A person must be assumed to have a capacity unless proven otherwise.

Whenever possible, help the patient to make their own decisions.

Do not treat a person as lacking capacity just because they make unwise decisions.

If a doctor makes a decision for someone who does not have the capacity, it should be for the best Interest of the patient.

Treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedom.

4. Remember to the attend to the following; Helping people make their own decision, Finding least restrictive option, Minimum Deprivation of liberty 5. Always refer to the guidance issued from the Sri Lanka Medical Council and the Ministry of Health.

6. In a situation where the patient admitted at NIMH is not having the capacity to give consent for a procedure or intervention this consent should be documented in a dual system where the Recommendation of the treating Consultant Psychiatrist and the Authorization of the Director or Deputy Director is given.

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Management of Violent and Aggressive Patients Ensure the safety and dignity of the patient and the safety of the staff members are priorities.

1. De-escalation - (verbal / non -verbal communication skills) aimed at reducing anger and averting aggression.

2.

Manual restraint - A skilled, hands -on method of physical restraint can be used by trained healthcare professionals to prevent patients from harming themselves, endangering others or compromising the therapeutic environment.

3. Mechanical restraint is the least used method-with the use of authorized equipment , (e.g. Restraint belts applied in a skilled manner)

Rapid Tranquilization of Patients This guidelines refers to use of medications by parenteral route-usually intramuscular or exceptionally intravenous, if oral medication is not possible or appropriate and urgent sedation with medications is needed.

1. Initially try with oral- Olanzapine Rapitab/ Lorazepam 2. IM- Haloperidol alone or with Lorazepam or Midazolam (NB all medications to be taken into separate syringes when administering to the patient.)

3. In some instances may use -IM promethazine 4. When prescribing medications for rapid tranquilisation -initially write as a single dose do not repeat until the effect of the initial dose has been reviewed.

5. Monitoring is MANDATORY - BP/PR/ RR / Temperature/ Level of hydration/level of conscious level every 15 minutes, At least for one hour until there are no further concerns about physical health .

For more clarifications – Please read MAUDSLEY, NICE & BAP GUIDELINES. Drugs regimen commonly used for rapid tranquilization within a Unit should be decided by the Lead Consultant Psychiatrist of the unit.

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Monitoring and Observation of Patients in Wards Reference is made to the DGHS Circular 01-15/2004 dated 08.07.2004 as well as internal circulars 06/ 2003 and 01/2004 of NIMH 1. High risk patients should be kept in beds closest to Nursing Station to keep them within the purview of the on duty Nursing Officers 2. Any change in a patient that deems risky by the Nursing Officers should be informed to the on call Medical Officer in person or over the phone.

3. Handling of severely disturbed patients or highly suicidal patients need close supervision by Medical Officers.

4. Any complications or drug side effects noted in patients should be updated to Medical Officers by the Nursing Officers.

5. All morning admissions should be shown to the On Call Medical Officer in the afternoon. All Afternoon admissions should be shown to the night on call Medical Officer. All night admissions should be shown to the morning on call Medical Officer by the Nursing Officers.

6. All fall risk patients need to be kept under close observation.

7. Significant clinical events should be updated to the on duty Special Grade Nursing Officer by the Nurses in addition to informing the On Call Medical Officer.

8. Night rounds in acute wards are best done after 8.00 pm to get a clear picture of the ward patients.

9. Nurses must regularly update about risk patients in the ward to the Medical Officers on duty. Medical Officers are expected to review these patients as per standard protocol.

10. Medical Officers are expected to document their review notes clearly on the BHT. 11. Nurses are expected to document their observation notes in the relevant charts.

12. Medical Officers may contact the Senior Registrar or the Consultant Psychiatrist for senior opinion on any clinical matter and they may call the Director/ Deputy Director for any administrative issue whenever necessary.

13. Any issues related to the support staff allocation or movement should be reported to the Administrative Officer.

14. All Incidents must be reported and followed up.

15. Standard protocols should be followed in routine bed making, cannula supervision and temperature and vitals monitoring done daily.

16. As much as possible patients should be provided bed sheets and pillows.

17. Special Grade Nursing Officers must do random ward rounds to check and ensure Nursing Care is provided up to the standards.

18. Level of Close Observation: (To be done by Nursing Officers with the support of Attendants and

Health Service Aids as ordered by the Medical Staff ) I. Low level observation-baseline level, frequency - once every 30 - 60 minutes.

II. High level intermittent observation -to patients who are risky but do not represent an immediate risk. Frequency - 15 to 30 minutes.

III. Continuous observation- when patient having immediate threat and needs to be kept within eyesight or at arm‘s length IV. Multi-professional continuous observation. - When a patient is at high risk of harming themselves or others and needs to be kept within the eyesight of 2 or 3 members and arm‘s length of at least one staff member.

(Level III and IV observation can only be ordered by Consultant Psychiatrist or Senior Registrar)

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Suicide and Deliberate Self Harm – Prevention Guidelines Definition of Deliberate Self Harm Deliberate self-harm refers to an intentional act of causing physical injury to oneself without wanting to die.

Definition of Suicide Suicide is the intentional taking of one‘s own life General measures for the prevention of suicides Ward environments should be assessed by staff regularly to ensure that safety features of the ward are enhanced and that materials that patients may use to self-harm or suicide are not accessible for patients.

Environmental Measures 1. Eliminate structures that are capable of supporting a hanging object such as exposed utility pipes, sprinkler heads, clothing & towel hooks.

2. Ensure that door-locking mechanisms, patient monitors, alarms, and CCTV are functional.

3. Remove items that can be used as hanging or strangulation devices such as drapery cords, belts, shoe laces, ties, handkerchief, bathrobe sashes, drawstring pants, bras, straps & clothing (belts & neck ties) & ladders.

4. Keep out of reach of the patient; items that can be used in an attempted suicide such as drugs, alcohol, sharp instruments (razors/blades), bolts on the inside of doors, & cleaning fluids.

5. Instruct visitors not to bring in restricted items without staff review.

6. Avoid leaving portable cleaning & maintenance equipment unattended.

7. Use beds closest to nursing stations.

Patient care measures 1. Monitor patients who have co-morbid diagnoses that increase the risk of suicide such as depression and substance abuse.

2.

Patient with high suicidal risk

3. Use continuous 1:1 observation protocol for very high risk patients a.

Keep patients at arm‘s length at all times.

b.

Staff observers should not be engaging in other duties.

c.

Patients should be repeatedly assessed for suicidality every xx.

d. Change the observation staff person to avoid burnout, wandering concentration, and to allow patients to interact with different people.

4. If ever a patient expresses suicidal ideation, take it seriously and further explore thoughts for level of intent, and presence of a concrete plan.

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5. Monitor patient‘s behavioural signs and symptoms in addition to self-report indicators of suicidality.

6. The medical team should review such patients as frequently as required.

7. Nurses have a key role to play in reducing self-harm and suicides and should carry out the following: 7.1. Care Planning/ Risk identification 7.1.1. On admission an assessment / care plan should be completed to include all risk including of suicide or self-harm and the degree of risk

risk

7.1.2. The nurses should ensure that the risk is fully recorded as follows: a.

Feelings of hopelessness

b.

Suicidal ideas and plans

c.

Expressions of suicide intentions

d.

History of Self harm and suicidal attempt

e.

Loneliness and social isolation

f.

Family history of suicides

g.

Difficult circumstances such as bereavement, financial difficulties or other family problems

h.

Withdrawal from alcohol or drugs

7.2. Ensure that all involved Staff are informed of a patient with a suicide risk 8. Where risks are identified in the assessment/care plan, preventive actions must be taken promptly: 8.1.1. Observations a.

Patients with suicidal risks should be observed constantly.

b. The frequency of observation should be determined by the degree of risk identified in the care plan. c.

Be aware of certain signs which may indicate that a patient may wish to commit suicide (E.g. suicidal threat, closing bank accounts, refusing to eat or drink)

d.

Regular discussions with patients in order to identify suicidal thoughts

e. Accompany/supervise patients when they are away from the ward area or being transported to other hospital / clinics f. Be aware that the suicidal risk may increase after commencement of treatment in patients with depressed 8.1.2. Monitor the patient‘s safety needs Do not leave the drug tray within reach of the patient and make sure that daily medication is swallowed a.

Remove straps and belts that can be used for suicides

b.

Do not allow the patient to lock themselves inside

c. Keep this type of patient in areas of the ward that are easy to observe (near the nurse‘s duty room) d.

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e.

Encourage the patient to talk about their suicidal plans/ methods

f.

Encourage verbal communication of suicidal ideas

g.

Appreciate the patient‘s his positive qualities

h.

Prevent drug misuse

i.

Ensure that on discharge the patient will not be homeless

j.

Ensure physical illnesses are dealt with before discharge

9. Patient/Family Information a.

Lead the patient/relative to understand their care plan on admission and at appropriate intervals

b. Medication or other treatment and observations should be explained properly to the patient/relative c. To identify a supporting person from the staff and ensure that the patient knows that they can approach this person with any concerns d.

Improve relationships with the family, friends and carers and educate them regarding identification of early signs and expressions of suicidal ideas. They also need to be informed of how to contact any support group (medical staff, social worker, community mental health team support, 1926 line or ward nurses) when needed and they can bring the patient back to the hospital whenever necessary.

What to do if a patient has committed or Attempted Suicide/ Self Harm 1. If nursing staff are aware that a patient has self-harmed or committed suicide they should do the following: 1.1. Deliberate Self Harm a.

Do not delay treatment or transfer because it is a self-inflicted injury

b.

Notify the medical officer and consultant responsible for the patient

c.

Complete an accident/ incident form

1.2. Committed Suicide a.

Do not delay treatment or transfer because it is a self-inflicted injury

b.

Follow the standard medico-legal procedure

c.

Notify the medical officer and consultant responsible for the patient

d.

Notify the Director through SGNO

e.

Complete an accident/ incident form

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NATIONAL INSTITUTE OF MENTAL HEALTH SRI LANKA: INSTITUTIONAL GUIDELINES

Absconding – Prevention Guidelines 1. Introduction Absconding is when a mentally ill patient goes missing from the ward/treatment unit secretly or without an agreement of care providers of the hospital and whose whereabouts are unknown. All over the world absconding of mentally ill persons are considered as a serious patient safety issue as they carry an increased risk of harm to self as well as the community (Holmes, 2016). Although absconding can take place in many different care settings, this module will focus on the absconding of patients under care in a mental hospital setting and discuss the person, clinical and treatment factors that may contribute to its occurrence.

National Institute of Mental Health (NIMH) is the apex body for treating mentally ill patients across the country. It looks after most of the patients from all nine provinces of Sri Lanka. These patients are detained in the hospital against their will under the Mental Disease Act of Sri Lanka (Weerasundera, 2012). According to the Mental Disease Act of 1956 patients can be admitted to the hospital voluntarily and involuntarily.

Mentally ill patients who lack insight are admitted involuntarily. They do not have the capacity to decide whether, they need admission and treatment nor can they leave the hospital. The responsibility of protecting a patient admitted involuntarily lies entirely upon the hospital staff.

Therefore, under no circumstances should a patient be allowed to abscond.

2. The clinical and legal status of absconding The decision to make a patient as having absconded from the care facility is depending on a person‘s intent, his legal and clinical status (Patient Safety Education Program, 2019). a.

Person‘s intent - whether the person has expressed intent to the treatment and care providing team that person wants to leave care.

b.

Legal status – Whether the patient has got admitted voluntary or involuntary.

c.

Clinical status – the level of risk that a person poses to self or others as well as the person‘s ability to care for himself/herself.

3. Declaration of absconding a.

A person who got admitted involuntary and is missing from the care facility/unit may be considered to have absconded since their legal status is involuntary.

b.

An involuntary patient is missing from the care facility/unit and his clinical status consistent with a high risk for harm to self or others or an inability to care will be classified as the patient has absconded.

c.

A voluntary patient who has left the care facility/unit and his clinical status consistent with a high risk of harm to self or others also will be classified as to have absconded.

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4. Contributing factors for absconding Literature provides two categories of factors that have contributed to increasing the risk of absconding. The first category is related to the person (push factors) and the second category of factors is external to the person (pull factors) and includes the clinical culture and the treatment provided.

5. Factors related to the person (push factors) Includes some demographic factors and clinical risk factors.

5.1 Socio-demographic factors 5.1.1 The age of the patient Younger patients less than 35 years and elderly patients with dementia tend to abscond more than others.

5.1.2 Gender of the patient Male patients pose a high risk to abscond than females 5.1.3 The race of the patient Language barriers poses a risk to abscond 5.2 Clinical risk factors 5.2.1 Diagnosis of the patient Patients with schizophrenia, borderline personality disorder, dementia, and psychotic disorder pose a very high risk of absconding.

5.2.2 Substance use and addiction Patients with a history of substance use, 0alcohol dependence, smoking, and betel chewing are also associated with increased risk of absconding behaviour, presumably out of the need to acquire the substance.

5.2.3 Wandering behaviour Patients with progressive cognitive impairment exhibit wandering behaviour and engage in exit-seeking that is characterized by a wilful intent to leave a secure treatment unit/facility without permission.

5.2.4 Intent to self-harm or commit suicide or homicide Patients with a true intent on wanting to self-harm, die or kill others may seek chances to leave the treatment facility to carry out such an attempt.

5.2.5 Medication issues When a person lacks insight due to the illness, in his view, he is neither ill nor requires treatment or intervention. Therefore, the introduction of pharmacological or other intervention in the care facility will cause the patient to seek means to disengage from the treatment or the intervention including absconding.

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6. Factors external to the patient (pull factors) 6.1 Clinical culture The policies, guidelines of the institution and attitudes and approaches that clinical staff bring to the care facility have a vast impact on the care outcome of the patients. As well as those cultural practices may lead patients to abscond from the care facility. As an example, nursing styles that are custodial rather than therapeutic may increase the risk of absconding, as well as clinical cultures that focus on blaming others rather than collaborative care.

6.2 Treatment-related factors Absconding tends to occur in early days of admission to the institution where adjustment to the care facility is incomplete and the therapeutic relationship is not established. The risk of absconding is also higher during the transitions in care, referrals and shift changes.

Issues such as failing to take the time to understand the patient, establish trust with the patient, and include the patient in developing goals of care may underscore the importance of a recovery-oriented and culturally responsive focus of care that establishes a strong therapeutic relationship leading to attempts to abscond from the care facility.

6.3 Lack of homely environment such as leisure, entertainment, lack of favourite meals or beverages and selling places to buy such.

6.4 Home-related concerns, homesickness, social relationships or issues due to employment/unemployment, lack of visitors or ways to contact them are also associated with an increased risk of absconding.

7. Responsibilities of individual groups of staff 7.1 Medical Staff Assessment and Review To ensure a full medical assessment on admission with appropriate medication including PRN drugs/ sedatives Review by the Medical Officers and consultants as frequently as necessary. Risk assessment should be done by the medical officer at the admission and if necessary, in the ward assessment process. It can be scaled up or down accordingly.

If transfer is considered to a less secure environment (rural unit or to intermediate care) medical staff should consider whether this will increase the likelihood of the patient absconding. E. g. Some patients may abscond to avoid ECT. 7.2 Nursing staff Nurses have a key role to play in reducing the number of patients absconding and should carry out the following actions: 7.2.1 Risk identification/care planning Absconding risk assessment (See Annexure II), identification of the level of risk and patient observation/care plan should be started with the joint assessment at the admission desk and National Institute of Mental Health - 78

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completed in the ward. The reassessment of risk needs to be carried out in the ward whenever needed until the risk is scaled down to ‗small‘. The nurses should ensure that the risk is fully recorded as follows: Identification signs of the patient Level of risk (using risk assessment tool) Whether the patient states the intention to abscond or go home Risk of violence (refer the management of violence guidelines) Risk of suicide (refer the suicide prevention guidelines) Where risks are identified in the assessment/care plan, the necessary actions must be immediately implemented after discussing with the multidisciplinary mental health care team to minimize the risk of absconding and others.

7.2.2 Observation (Please refer the observation guide below) The risk level should be recorded on the whiteboards of the wards and then for each duty shift a member of staff should be allocated to observe the patient‘s risk as per observation guide. They should be observed constantly as the risk level indicates.

Type of supportive observation required e.g. patient behaviour and mental state.

Regular discussions with patients so that staff can assess when patients are not being honest (reintentions to abscond).

Need to accompany patients when they are at risk of absconding and visiting other areas on the site e.g. national hospital/ dental unit.

Where patients are attending appointments elsewhere the number attending should be counted on departure return.

7.2.3 Patient Information a. Lead them to understand their care plan on admission and at appropriate intervals b.

Explain about the necessity of the x ray or medication prior to the procedure Medication restrictions and observations should be explained properly to the patient c.

To identify a supporting person (another patient or member of staff) ensure that the patient knows that they can approach this person with concerns d. Explain what needs to happen before they can be discharged e. Maintain a good relationship with family friends and care providers.

7.3 Support Staff a. Support staff also has a major role in prevention of absconding as they should always be in the wards with the patients. They need to support ward nurses in observation of patients. They are often in close proximity to the patient and may therefore be the first to notice that patients want to abscond. This should be reported to the nurses or medical staff. b. Support staff is responsible for ensuring that entrances and exits to passageways are locked. This is very important in preventing absconding patients. c. Support staff will be given training to support patients and nurses in this important role.

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7.4 Security Staff Security staff have a role to play in preventing absconding patients by keeping the gates closed.

Security staff need to issue visitors passes to all outsiders who enter the hospital premises in order to differentiate absconding patients from visitors or other. However, if they suspect that any patient is absconding, they should: a. Ask the person who they are and if a patient, which ward they are from b. Retain the patient at the gate area c. Inform Director, AO, OPD doctor, SGNO immediately, relevant ward nurse d. Accompany patient to the OPD/WARD for identification 8. Absconding prevention strategies 8.1 Establishment of a strong therapeutic relationship with the patient Establishment of a strong relationship and rapport between the patient and the clinician is essential in the first moment of the contact as it continues throughout the care process. Following strategies can be used to build the relationship and rapport with the patient. a. Introduce yourself to the patient and your role and the purpose of assessment in order to reduce the anxiety and uncertainty. b. Ask the patient how he/she wants to be addressed? c. Take time to listen to the patients‘ story and be empathically d. Assess the patient in a comfortable & private environment 8.2 Promote patient-centered approach instead of disease-centered approach Some interventions and procedures may bring traumatic experiences for some patients.

Multidisciplinary care teams should not exert their power to control and treat the patient. Instead, the care team should make opportunities where power and control could be shared with the person and make him/her feel valued and respected. Hence, it is vital to involve patients whenever possible and their relatives as much as possible in developing care plans and strategies to prevent absconding.

8.3 Respect cultural differences A person is usually deeply connected to the cultures which he/she brought up. It is important for the care team to be responsive to the patient‘s culture by engaging culturally similar personnel that can help the care team to understand the person‘s cultural perspective and develop strategies for improving the person‘s willingness to stay in the care facility.

8.4 Proper structuring of the patient‘s day Scientific engagement of patients in recreational and leisure activities may help to reduce the absconding risk.

8.5 Minimization of restrictive procedures as absconding preventive measures The balance between patient‘s rights and safety needs to be established depending on the risk levels.

Control measures used to prevent absconding for high risk patients may not be appropriate for moderate or low risk patients. The precautions should be as non-restrictive as possible and help the patient to engage in possible experience. As an example, a low risk patient can be granted a short leave using sign-in and sign-out book while a patient with a moderate risk could be referred to a National Institute of Mental Health - 80

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leisure activity where a member of the multidisciplinary team can monitor the patient while he/she is engaged in a positive therapeutic experience (Bowers, Alexander & Simpson, 2019).

8.6. Development of patient friendly physical environment The hospital administration must endeavour to improve the physical environment of the instrument as the following measures may help the reduction of absconding of patients. a. Improvement of ward physical conditions including toilets, washrooms, dining rooms, seclusion rooms. b. Construction of buildings to improve bed capacity as per the master plan to implement the concept ―one bed for one patient‖. c. Facilitation of communication with family members and close relatives by means of establishing a prepaid telephone system within the hospital. d. Improvement of the menu, taste and presentation of hospital food and beverages preserving nutrition values. e. Improvement of the condition of the hospital cafeteria and food enabling patients themselves to enjoy a menu of different tastes once in a while.

9. Management of incidents of absconding Management of absconding includes the following methods; a. Use of intensive support b. Leave c. Sedating medication (Refer the guideline of chemical sedation) as well as containment methods such as; Seclusion (Refer the guideline of seclusion) Restraint (Refer the guideline of restraining) Increased observation levels (Refer patient observation No.10 of this guideline) Locking of ward doors or parts of units 9.1 Risk assessment for absconding at the admission and in the ward It is needed to assess the risk of absconding of the patient while doing the joint assessment at the Out Patient Department (admission) by the nurses using the risk assessment tool (Annex I) apart from the assessment of the admitting doctor.

9.2 Observation of moderate and high-risk patients for absconding When the risk of absconding is high or moderate the ward-nurses need to assess the risk of absconding daily and observe the patient constantly according to the given observation guide. The monitoring frequency can be scaled up or down with the level of absconding risk of the patient. Seek medical advice for three times a day until the risk of absconding is settled. Consider review of the care plan with the multidisciplinary team when the risk of absconding is not settling for more than 72 hours.

9.3 Collection of patient identification characteristics Patient identification characteristics may help hospital staff to identify the patient when absconded.

Therefore, it is vital to gather information and record on prominent signs of the patients (teeth, skin color, hairstyle and type, prominent skin scars, skin nevi and lesions etc.). Use of a non removable National Institute of Mental Health - 81

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and uncrackable bracelet with a GPS tracking is another option that needs to be considered at the institutional level.

9.4 Activation of search plan 10. Patient Observation levels Use the following patient observation guide to observe patients in the ward with an increased level of absconding (nurse observation).

10.1 For patients with a high risk of absconding (when the risk assessment Score is 3) Seek for medical advice of the ward medical team three times a day until the risk is settled. Review & revise the treatment & care plan whenever needed with the multidisciplinary team. With the instruction of the medical team and with your career experience, you may scale down or scale-up the patient observation level.

10.2 Level of close nursing observation should be decided as observation guidelines (level I to IV) 10.3 Intermittent observation (when the risk assessment score is 2 or less) a. An experienced or less experienced nursing officer can engage in observation at regular intervals. b. Observation time intervals can be determined by the nursing officer depending upon the risk factors and the behaviour of the patient. c. Keep observation at the determined intervals for another six hours. d. Whenever needed, review the treatment and care plan with the multidisciplinary team. e. If the risk level of the patient is improving, scale down the observation to ―negotiated‖.

10.4 Negotiated observation When the risk level of the patient is one & the behaviour and insight is appropriate, nurses can negotiate the frequency of the engagement with patients.

11. Quality improvement As outlined in the guideline, this is a part of the patient safety and quality improvement process of the institution. Improvement of the quality of the system will improve the positive relationship between the patient and the care provider. Further, incident reviews or audits within an organization can explore a number of factors to make recommendations for how a change of organizational procedures and policies need to roll-out.

12. Review of incidents 12.1 Find time to review cases of absconding with your ward care team.

12.2 Suggest senior management of the institution the ways to reduce the rates of absconding through planning units.

12.3 Forward unit suggestions to monthly clinical audit.

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Falls – Prevention Guidelines Definition A fall may be defined as ―an untoward event, which results in the patient coming to rest unintentionally on the ground or other lower surface‖ (Morris et al, 1980) Risk factors for falls: Causes of slips, trips and falls 1. Environmental: a. State of the floor or ground (Uneven surfaces or irregular features on stairs) b. Any contaminants (objects or liquids) c. Height of furniture d. Lack of handrails and e. Type of footwear.

2. Lighting: poor lighting and visual effects may affect the patients‘ ability to walk safely.

3. Medication: sedation and antipsychotic medication may affect a patients mobility 4. Physiological: a. Extremes of age. b. Poor eyesight in elderly c. Brittle bones in elderly make the consequences worse.

5. Other patient factors: These include confusion, general strength which may be associated with a medical condition.

Responsibilities of specific groups of staff 1. On Admission a. Do the Fall Risk Assessment by the Nursing Officer b. If any of the factors are present then the patient would need a comprehensive assessment by nursing officer 2. On-going Ward Assessment a. The treating team will frequently review the risk of falling in the ward setting. b. Assessment and review should be guided by a fall risk assessment tool c. High risk group Risk assessment 1. Multifactorial risk assessment 1.1 Detailed history 1.2 Assessment of gait, balance, mobility and muscle weakness 1.3 Assessment of functional status and fear of falling 1.4 Assessment of visual impairment 1.5 Assessment of cognition and neurological examination 1.6 Assessment of urinary incontinence National Institute of Mental Health - 83

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2. Medication review Medical assessment on admission with regard to risk/benefit analysis of medications with due consideration as to whether they increase the risk of falls If at least one factor is present from annexure (above) then Medical assessment on admission with regard to conditions that might lead to increased risk of falling (e.g. epilepsy) Review of clinical condition or/ and medication by the medical team as frequently as required.

3. Multifactorial interventions 3.1 Risk/benefit analysis of medications in regard to sedative medications - try to avoid benzodiazepines in old age patients 3.2 Review medication frequently to avoid side effects.

3.3 Allocate a bed with side rails ; but use caution as confused patients may try to climb over it and may get injured.

3.4 Consider giving a bed close to the wash rooms 3.5 Strength and balance training by the physiotherapist when indicated Use of walking aids for necessary patients after assessing the risk of injury with the aids (may be applicable to geriatric unit) a. b. c. d.

Staff to support the patients who cannot mobilize without support Observation through CCTV or direct observation Manage incontinence Correction of visual impairment

Management after a fall 1. Preparing FLOW CHARTS on what to do following a fall and to display them in the wards.

1.1 Immediate management – A, B, C, 1.2 Inform Medical Officer 1.3 Carry Out detailed assessment regarding injuries 1.4 Necessary investigations depending on assessment- CT brain, X-rays 1.5 Head injury observation if needed 1.6 Fill the incident form as soon as possible.

1.7 Assess the causes for the fall and modify the factors to prevent future risk in the patient.

3. Staff training a. Doctors , nurses and support staff training once a year b. Educating the staff on falls risk assessment, measures to minimize falls risk, techniques of holding a patient.

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2. Support Staff should a. Liaise with nursing staff in reducing risks of falling b. Ensure that the floor is kept dry all the time c. Assist patients for safe mobility d. Yearly for the permanent staff and for new staff

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Management of patients kept in Seclusion Definition of Seclusion Seclusion is the supervised confinement of a patient in a room which may be locked to protect patient/s and/or others from significant harm. Its sole aim is to contain severely disturbed/violent behaviour that is likely to cause harm to others.

Underlying Principles Seclusion stay may constitute an imposition on a person‘s rights and dignity and should only be used as a last resort for the shortest possible time and for the purpose of promoting and maintaining a person‘s health and wellbeing, or in the short term, the health and wellbeing of others. Seclusion should not be used as a punishment or threat; as part of a regular treatment programme or because of shortage of staff. In certain circumstances when other measures have failed seclusion may be used. Seclusion of a Voluntary patient for a short period per say does not warrant consideration for a temporary detention.

Seclusion procedure If ward Nursing Officers on duty decide that staff or patients are at risk of violence and de-escalation techniques have failed to calm the patient, then they may put the patient in seclusion. Once secluded the following steps should be followed.

1. The On Call Medical Officer should be notified immediately and they should come and assess the patient and consider rapid tranquilization or duration of seclusion stay 2. A note must be made in the BHT by Nursing Officers and Medical Officer 3. Nursing Officers should inform to Special Grade Nursing Officers in their routine reporting system 4. Medical Officers need to keep the Consultant/ Senior Registrar updated

Observation for Secluded Patients 1. A trained Nursing Officer should be observing the seclusion physically or via CCTV at all times within close vicinity. Provision should be made to over breaks and shift handover of Nursing Officers.

2. Support Staff should be available to assist if required.

3. A Seclusion Register entry should be commenced as soon as patient is admitted to seclusion 4. A full review should be carried out if a patient is to be secluded for more than 02 hours 5. A Nursing Officer should physically review the seclusions every 02 hours with the assistance of a Support Staff

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6. A Medical Officer should routinely review the patient every 08 hours with accompaniment of the Nursing Officer and Support Staff and more frequently if need arises.

7. Any secluded patient kept in seclusion for more than 12 hours needs to be reviewed by the Consultant/ Senior Regitar 8. If rapid tranquilization is given and sedation is setting in patient should immediately be moved to a observation bed for monitoring 9. Highly suicidal patients should be best avoided from seclusion stay

Seclusion Room 1. Should be well lit and ventilated 2. Patients should be kept separated from other patients 3. Patients should have minimum furniture on case by case basis unless they are likely to harm themselves or damage it 4. Patient should be able to call for help from Nursing Officers or Support Staff 5. Tear proof clothing and blankets should be provided if possible 6. Food and Water or other drinks should be provided regularly and toilet and washing facilities should be provided on request 7. All articles which are potentially dangerous should be removed

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Management of patients requiring Temporary Restrain Definition of Restrain Any action, word or deed that is used for the purpose or intent of restricting the free movement of another person.

Underlying Principles Restrain may constitute an imposition on a person‘s rights and dignity and should only be used as a last resort for the shortest possible time and for the purpose of promoting and maintaining a person‘s health and wellbeing, or in the short term, the health and wellbeing of others. Restrain should not be used as a punishment or threat; as part of a regular treatment programme or because of shortage of staff. In certain circumstances when other measures have failed, restraint may be used. Restrain of a Voluntary patient for a short period per say does not warrant consideration for a temporary detention.

When to consider Restraining Restraining should be actively discouraged and only used if absolutely necessary, and then be limited to the minimal period possible. For example where: 1. Patient is not responding to the maximum recommended dose of medications used in acute disturbed behaviour 2. Further administration of antipsychotics/ benzodiazepines is likely to cause adverse medical/ physical consequences 3. Preservation of a lifesaving invasive line (i.e. IV Cannula, Urine Catheter, NG Tube, Neck Line)

Restraint Procedure If ward Nursing Officers on duty decide that staff or patients are at risk of violence and de-escalation techniques have failed to calm the patient, then they may restrain the patient after getting verbal approval from the On Call Medical Officer. Once restraint the following steps should be followed. Mechanical Restraining of patients should be done in a humane manner with minimum discomfort to the patient and highest regard to safety.

1. The On Call Medical Officer should come and assess the patient and consider rapid tranquilization and/or duration of restraint 2. A note must be made in the BHT by Nursing Officers and Medical Officer 3. Nursing Officers should inform to Special Grade Nursing Officers in their routine reporting system 4. Medical Officers need to keep the Consultant/ Senior Registrar updated

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Observation of Restrained Patients 1. A restraint patient warrant close observation and monitoring 2. Level of Close monitoring to be decided by Medical Staff and carried out by nursing officers with the help of support staff 3. A trained Nursing Officer should be within sight and sound of patients who are being restrained so that they can observe the patient until restraints can be removed 4. Mouth Care, Bladder Care, Bowel Care should be attended to.

5. Harmful behaviour from other patients should be averted at all times.

6. Patient‘s dignity and respect should be ensured 7. Vital signs and Hydration should be monitored and maintained

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Referral of patients for Other Specialities 1. All patients at NIMH are admitted under the relevant unit Consultant Psychiatrist and the Consultant Psychiatrist of the Unit shall be considered as the primary Consultant 2. All referrals to other Consultants should be done in accordance with the guidelines of the Ministry of Health and Sri Lanka Medical Council 3. All referral should be done by or with the expressed permission of the treating Consultant Psychiatrist 4. Referral of patients to Consultant Physician of NIMH/ Consultant Anaesthetist of NIMH/ Consultant Haematologist of NIMH/ Visiting Consultant Microbiologist from NIID/ Visiting Consultant Dermatologist from NIID

a. Referrals done on working days from 8 am to 2 pm should signed by the Consultant Psychiatrist/ Unit Senior Registrar/ On Call Senior Registrar b. Medical Officers may refer to Medical Officer of the relevant speciality after 2 pm or on off days where opinion in urgent (However they need to take consent from Unit Consultant/ Senior Registrar or On Call Senior Registrar before referring) c. In life threatening emergencies opinion can be sort over the phone and medical unit Medical Officers as well as Medical Officers - Anaesthesia may be informed to attend urgently d. Section C Medical Officers may contact the above Consultants and their teams directly considering the practical issues that arise in managing the Half Way Home at Mulleriyawa.

5. Patients that require other specialist opinion should be referred to Consultants at Colombo East Base Hospital, Mulleriyawa, National Institute of Infectious Diseases, Angoda or National Hospital of Sri Lanka based on the requirement 6. Referrals to other hospitals should be done on cost benefit basis as these referrals need provision of transport and accompaniment of multiple staff 7. Referrals to Consultant Judicial Medical Officer should be done by the Attending Consultant Psychiatrist considering the medico - legal issues that arise through that referral. It is good practice to keep Consultant JMO informed over the phone about the referral immediately when the referral is made. If need be the Police must be informed to issue a MLEF (Medico Legal Examination Form) as per SLMC guidelines.

8. Referrals to the Medical Nutrition Unit and Dental Clinic can be done by any Medical Officer.

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Provision of ECT for patients 1. Provision of Electroconvulsive Therapy (ECT) to patients is considered an essential category treatment modality within NIMH 2. The decision to give ECT as an involuntary treatment procedure shall be decided by the Consultant Psychiatrist or if the need arises by a Senior Registrar in consultation with the Consultant Psychiatrist 3. ECT provision may be done as Voluntary Treatment procedure where indicated with the due consent taken from the patient.

4. Once a decision is taken to give ECT the ECT provision form must be filled completely by the Medical Officers and due signature taken. Patients should not be accepted by the ECT Unit without the duly filled form.

5. ECT Ward and Mini-theatre is to be kept open from 7.00 am to 1.00 pm for ECT provision and till 2.30 pm for cleaning purposes from Monday to Saturday including Public Holidays. ECT Unit may be opened for special cases on Sundays upon request by a Consultant with the approval of the Director. Medical Officers - Anaesthesia are expected to be available at Medical Officers Duty Rooms Complex after 2.30 pm for relevant work and on call purposes.

6. Patients are usually given ECT every other day unless decided otherwise by the Consultant Psychiatrist.

7. Patients sent for ECT on Saturdays should be sent for the next ECT on Tuesdays unless there is an acute indication.

8. Any patient sent for ECT with absconding risk or suicidal risk should be accompanied by a ward staff member to and from the ECT Unit to ensure their safety.

9. Patients who are brought to the ECT Ward should not be returned by the Nursing Staff or Supportive Staff due to various reasons without informing the Medical Officer - Anaesthesia.

10. In such patients after assessment Medical Officer - Anaesthesia should communicate with the Registrar/ Medical Officer of the respective ward if the ECT cannot be given and such decisions should be immediately informed to Consultant Psychiatrist/ Senior Registrar.

11. As ECT is an emergency procedure even during Trade Union Action all attempts should be made to maintain services to services without disruption.

12. Delaying of ECT of a patient should be decided by the Consultant Psychiatrist or Senior Registrar.

13. Fitness of the patient for general anaesthesia needed for ECT should be decided by the Consultant Anaesthetist and may be supported by assessment of Consultant Physician.

14. For those patients that require ECT in a setting where Intensive Care Unit facilities are available such ECT should be arranged at NHSL or CEBH Theatre by the treating team.

15. Following factors should be kept in mind with regard to ECT Provision. a. To Ensure that the ECT is available for Patients as an emergency treatment modality where ECT is given at least within 24 hr once decided by a Consultant b. To ensure patients who are brought to ECT are given utmost care so that the patient will return safely back to the ward he was sent National Institute of Mental Health - 91

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c. Pre ECT Documentation by the Ward Medical and Nursing Staff Must be complete d. The approved number of maximum ECT sessions per day are 45 and any further increase in this number must be avoided as much as possible e. All Drugs required for Emergencies must be readily available for use at the ECT Ward. f. Correct Patient identification before the ECT is of paramount importance and it should be checked at least three times before patient is given ECT. g. With regard to Anaesthesia: Maximum effort to ensure patient safety; Importance of Pre Anaesthesia Check lists; Importance of Post Anaesthesia Observation, Monitoring ; Be mindful of Risk of Airway Obstruction in post ECT period h. Confirmation of patient Identity by Medical and Nursing Staff to ensure proper patient identification 16. ECT ward should have the list ready for the next day prepared and confirmed with the relevant wards. The allocated number of ECT per Consultant and modality of sharing slots will be decided by the Board of Consultants and coordinated by the Senior Registrars.

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Medical Unit and its Services under the Consultant Physician 1. In addition to the Medical Ward at ward 18 a Medical Clinic is also established at NIMH. 2. The Medical Clinic will function 8.00 am to 11.30 am from Monday to Friday except Public Holidays.

3. All routine referrals of inward patients and referrals regarding staff members should be sent to the Medical Clinic.

4. Urgent and emergency referrals at any time of the day on all seven days including public holidays/ all 24 hours can be sent to Ward 18 to be attended to by the On Call Medical Officer at Ward 18. It is good practice for the Medical Officer/ Registrar of the Psychiatry unit to inform over the phone regarding the referral to the On Call Medical Officer of the Medical Unit.

5. Two Medical Officers from the Medical Unit will be available at the Medical Clinic while rest will be in ward duty.

6. If requested by the Psychiatric Medical Officer/ Registrar, a Medical Officer from Ward 18 should attend to patients with difficult Medical Complications in other wards by visiting the ward in instances where the patient cannot be sent to Ward 18.

7. Admitting Officers can get advice from the Medical Team with regard to any Medical Complications and such advice should be taken from ward 18.

8. All referrals written to the Consultant Physician by other Consultants and Senior Registrars should be sent to Ward 18 for VP opinion where possible.

9. Good Communication and Spirit of team work is encouraged amongst all Medical and Nursing staff to ensure optimum patient care services in implementing this program.

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Management of Patients at the OPD who have been transferred into NIMH by another Institute 1. In order to better streamline the above category of admissions please note the following.

2. All patients transferring into NIMH with a Transfer form should be admitted and a BHT issued. This is the standard procedure when handling any transfer of patients.

3. However if required such a patient can be transferred back or transferred out from the OPD itself if clinically indicated. In such a situation a new transfer form should be filled.

4. It is the responsibility of the Admitting Officer and the On Call Senior Registrar to ensure that the patient being immediately transferred back is physically and mentally stable.

5. It is best practice to ensure that a senior clinical opinion is always taken prior to immediate transfer back on immediate transfer out of patients and to liaise with the relevant receiving clinical team via telephone prior to transfer.

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Issuing of drugs with the use of RC number at the OPD As the Pharmacy is having trouble ensuring authenticity of prescriptions written at the OPD through the RC number for a period of 03 days or 07days, such the prescriptions issued by the Medical Officers – OPD, D/S with the RC number should carry the following seal.

1.

For OPD Signature:……………………………………..

Name Dr: ……………………………………...

MO/OPD, NIMH, Mulleriyawa

2.

For Dental Clinic Signature:……………………………………..

Name Dr: ……………………………………...

Dental Surgeon, NIMH, Mulleriyawa

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Psychiatric Social Work Services 1. Psychiatric Social Work is an important part of the multidisciplinary treatment process for patients at NIMH 2. NIMH is a major centre for Psychiatric Social Work Services in Sri Lanka and is a training centre.

3. Psychiatric Social Workers are tertiary level staff officers who are under the administrative supervision of the Director through the Chief Psychiatric Social Worker and clinical supervision of the Consultant Psychiatrist of the allocated Unit 4. Duties of the Psychiatric Social Workers are stipulated in General Circular 01-15/2019 of the Ministry of Health 5. Psychiatric Social Work Services is provided through a.

Inward Review and patient and family support

b.

Support in returning of the patient to the community

c.

Provision of psychosocial support in the field

d.

Psychosocial rehabilitation

e.

Legal support and intervention

f.

Mental Health Promotion

g.

Maintenance of records and data

6. Psychiatric Social Work is an integral part of the rehabilitation process.

7. Psychiatric Social services are to be made available all working days.

8. Patients may be referred to PSW review and intervention by Consultant Psychiatrist or Senior Registrar or Registrar or Medical Officer - Psychiatry/ Medical Officer - Mental Health 9. After the initial assessment by the PSW suitable care plan will be carried out under the guidance of the Consultant Psychiatrist

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Community Mental Health Services 1. Community Mental Health Services are developed to extend the services provided at the institution to the community.

2. This is done so to reduce the treatment gap, increase access to patients to services and to make the services more patient centric.

3. Ministry of Health directive, General Circular No 01-04/2003 dated 08.04.2003 issued by the Director General of Health Services recognises the work done by the Community Mental Health Team under the directive of the Consultant Psychiatrist and authorization of the Director to be considered as part of their routine institutional duties.

4. Community Mental Teams are recognised as follows.

5. When working in a TEAM please remember ―Together Everyone Achieves More‖ 6. Medical Officers - Psychiatry (Duty list as per General Circular No 02-27/2013 dated 17.01.2013 by the Director General of Health Services) and Medical Officers - Mental Health (Duty list as per General Circular No 01-03/2005 dated 18.11.2004 by the Director General of Health Services ) are expected to engage in Community Mental Health Work as part of their fiduciary duties.

7. Community Psychiatry Nursing Officers (CPN) are officers assigned to perform mental health care services including mental health promotion, prevention, curative care and rehabilitation to the targeted community under the clinical guidance of the Consultant Psychiatrist/ Medical Officer Psychiatry/ Medical Officer - Mental Health (CPN Job Description, Ministry of Health, 2017) 8. Psychiatric Social Workers, Occupational THerapists are also considered part of the Community Teams.

9. Community Mental Health Teams carry following activities under the supervision of the Consultant Psychiatrist. a. Home Visits b. Community Domiciliary Visits and Depot Program c. Outreach Clinics d. Community Based Rehabilitation e. Community Based Psychosocial Evaluation and Aid f. Default Tracing g. Supporting the 1990 Suwasariya teams for admission of patients to NIMH

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10. NIMH shall also have a Community Mental Health Center as a coordinating center for all community based activities which shall be maintained by the CPN Coordinator.

11. Community Mental Health Teams must function as an extension of the relevant Psychiatry Unit under the leadership of the Consultant.

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Treatment and Service provision to the Substance Misuse Clients at NIMH The Director General of Health Services by his letter dated 06.05.2020; No DDG/NCD/75/2020 under the title ―Arrangement of psychiatry outpatient clinics to treat illicit drug users during COVID-19 pandemic‖ has highlighted the importance of providing treatment for clients seeking help with regard illicit substance use. As per the norms and practices of NIMH following guidelines are issued to streamline the services provided by NIMH to said clients.

Substance misuse clients who present to the OPD will be registered following proper triage protocols and the relevant area basis On Call Medical Officer will attend to this patient for assessment and treatment.

1. Patients that only have substance use problems without psychiatric or medical comorbidities should be managed in accordance with the circular DDG/NCD/75/2020 of the Director General of Health Services and referred to the relevant clinic as per the attached circular using the given referral form.

Drugs if needed can be issued from the OPD Pharmacy.

2. The algorithm created by the Substance Abuse Treatment Unit at Navodaya Centre can be used to assess the client at OPD. Needed Referrals Forms, Prescription Forms and Assessment Forms are also attached in annexure.

3. The OPD staff must maintain a separate register of clients reviewed under this circular for purely illicit substance related purposes.

4. Provision of Reports for requests made under the Drug Dependent Persons (Treatment and Rehabilitation) Act No 54 of 2007 as per the previous internal circular will remain the same and will be independent to this service.

5. Admission of patients for management of withdrawal symptoms should only be done in very needy situations and these admissions must be done with the concurrence of the relevant Consultant/ Senior Registrar.

6. The treatment of persons with substance abuse issues is a matter of national importance and all staff are advised to take a humane and non-judgmental approach in dealing with these clients.

7. Clients coming from the Kolonnawa Divisional Secretariat Area are to be referred to and followed

up at the Navodaya Centre Substance Clinic.

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Drug Dependent Persons (Treatment and Rehabilitation) Act No 54 of 2007 Based on the request made by the Police Department and Magistrate Court, Colombo, NIMH is required to provide a report regarding Drug Dependent Persons to the Consultant Judicial Medical Officer which will be submitted to the courts. Based on the report the Magistrate is empowered to send the person for compulsory rehabilitation at a government institute.

These clients will be brought to NIMH by the Police with a letter from the Consultant Judicial Medical Officer to the OPD. (Only on Tuesdays) The clients should be reviewed by the On Call Medical Officer/ Registrar as per the usual roster of the OPD on area basis and the assessment should be made as an outpatient in consultation with the relevant Consultant/ Senior Registrar. The special formats developed for this purpose should be used to conduct the assessment and the report should also be issued based on the attached format.

The clinical team can decide on the course of action based on the status of the client. If further information/ tests are required that can be mentioned in the said report and a reassessment date can be given to bring back the patient to NIMH. These clients should be registered as outpatients on an RC number at the OPD. OPD staff should file and record the request form issued by the JMO, the assessment form and a carbon copy of the issued report with the relevant RC number. These records should be kept as confidential reports.

This activity should be carried out as a fiduciary act as part of the civil medico – legal responsibilities of NIMH.

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Occupational Therapy Services 1. Occupational Therapy is an important part of the multidisciplinary treatment process for patients at NIMH 2. NIMH is a major centre for Occupational Therapy related to Mental Health Services in Sri Lanka and is a training centre.

3. Occupational Therapists belong the professions supplementary to medicine (PSM) services and are under the administrative supervision of the Director through the Superintendent Occupational Therapist and Chief Occupational Therapist and clinical supervision of the Consultant Psychiatrist of the allocated Unit 4. Occupational Therapy is provided through a. Inward Therapy b. Section and Unit based therapy at the Occupational Therapy Unit 1 and 2 at Sections A and B and Unit 3 at Section C c. Horticulture Therapy d. Outpatient Occupational Therapy 5. Occupational Therapy is an integral part of the rehabilitation process.

6. Occupational Therapy services are to be made available all seven days during day time.

7. Patients may be referred to Occupational Therapy by Consultant Psychiatrist or Senior Registrar or Registrar or Medical Officer - Psychiatry/ Medical Officer - Mental Health 8. After the initial assessment by the Occupational Therapist suitable therapy plan will be carried out under the guidance of the Consultant Psychiatrist

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Rehabilitation Services 1. Rehabilitation is carried out in four (04) levels at NIMH: Level 1 – to improve the basic activities of daily living (Ex- self-care) Level 2 – to improve extended activities of daily living (Ex- money handling, communication skills, social skills, like skills etc.)

Level 3 – to provide vocational training Level 4 – to prepare for re-employment and social re integration 2. Suitability of clients for rehabilitation should be assessed by the Occupational Therapist with the Multidisciplinary Team (MDT) at the ward rounds.

3. Clients will be selected for rehabilitation and suggested for referral to one of the rehabilitation units (stated below) according to the functional assessment, client‘s interest, social and family factors and the targeted goal. The referral should be done by the Medical officer by filling the relevant referral forms.

4. Comprehensive functional assessment should be done by the occupational therapist and the goals should be set.

5. All the clients referred for rehabilitation should be registered at the Rehabilitation Centre and the database should be maintained by the staff. All the statistics should be maintained at the Rehabilitation Centre and should be the coordinating body for all the rehabilitation processes, activities and programmes.

6. Timely ―Individual re assessments‖ should be done as per the initial rehabilitation plan by the relevant Occupational Therapist. Therefore the progress of the client‘s plan should be assessed and documented.

7. Family meetings and domiciliary visits should be done whenever necessary by the MDT members to facilitate the plan and to assess the social and family issues and the status.

8. On discharge of the rehabilitated client, a discharge plan should be formulated and documented to send with the client. (May refer to a local clinic or local rehabilitation unit or release to society.)

9. Follow up should be done even with the peripheral clinics or Psychiatric Social Workers.

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Rehabilitation Services Settings

Rehabilitation Facility

Occupational Therapy Units Units I, II and III (Unit III specific to Section C)

Rehabilitation Activities done

Assessment of clients Closed group sessions on 1. Anger management 2. Social skills 3. Life skills 4. Activities of daily living General Rehabilitation General vocational training (Rug weaving, Patchwork, Handcraft, Leather work) Recreational activities Indoor and outdoor games Special programmes and activities

Rehabilitation Coordinating Centre

Goal targeted individually cared rehabilitation supervision Data collection and monitoring of Rehab activities Central focal point for the Rehabilitation Committee of NIMH Coordination the NAITA vocational training (Handcraft, Tailoring, Computer Assistant Application, Pastry & Baker) Job oriented skills training (Book binding, Cookery, Paper Quilling products) Planning and Implementation of Recreational activities and games Family meetings and Home visits Support in Level 3 & 4 rehabilitation

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Horticulture Therapy Units Unit I - Main Centre Unit II - at Section C Minor Units in Ward settings

Goal targeted individually cared rehabilitation through nature and gardening.

Level 2 & 3 rehabilitation General vocational training (Plant nursery, Mushroom, Composting, vegetable cultivation) Recreational activities

Day Rehabilitation Centre

Clients are taken as out patients on day basis Level 3 & 4 rehabilitation Job oriented skills training (Soft toys, Tailoring, Cultivation, Rug weaving, Shoe making, Cooking) Coordination with Service users community organizations to empower them and follow up.

Forensic Rehabilitation Unit

Rehabilitation of inward clients of Forensic Psychiatry Unit as a closed unit.

Yoga programme for clients (in ward clients from other units are also allowed.)

Fitness centre for clients (open for staff as well) Recreational activities and games Open school programme for in ward clients General rehabilitation activities

Ward Based Rehabilitation

Level 1 & 2 rehabilitation General rehabilitation activities for those who cannot be sent out of the ward.

Recreational activities.

Therapeutic games Hand Craft

Psycho geriatric Unit

Functional assessment of Geriatric clients Rehabilitation of Geriatric clients Structuring the day of geriatric clients

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Special Rehabilitation Programmes 1. Any special programme organized for rehabilitation and recreation should have a PROGRAMME PLAN SUMMARY well prior and approved by the Director and Rehabilitation Committee.

2. Budget allocations for special programmes should be prepared prior and approved by the director to proceed with the accounts branch.

3. Donations can also be utilized.

4. All the financial related processes should follow the FINANCIAL REGULATIONS, Institutional guidelines, protocols and internal circulars.

5. Documentation should be handled and maintained properly with the original file at the relevant subject clerk and if necessary, a skeleton file can be maintained at the organizing unit.

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Rehabilitation Committee Standard Operating Practices - Rehabilitation Committee of the National Institute of Mental Health (NIMH) Main purpose - Coordination of the Rehabilitation Programs conducted at NIMH. Objectives 1. To coordinate the multitude of Rehabilitation Programs conducted at NIMH 2. To develop new and innovative strategies to promote Rehabilitation 3. To organize Events to commemorate special days and observations at NIMH 4. To supervise the transparency of Money Handling in relation to Rehabilitation activities Committee Shall Consist of 1. Sponsoring Authority and Chairperson: Director 2. Co-Chairperson: Lead Consultant Psychiatrist – Rehabilitation 3. Deputy Chairperson: Deputy Director 4. Coordinator of Senior Registrars of Psychiatry: Lead SR – Rehabilitation 5. Assistant Chairperson: Medical Officer – Rehabilitation Coordination 6. Internal Auditor: Accountant 7. Co- Secretary: Elected from Nursing Officers 8. Co- Secretary: Elected from Occupational Therapists 9. Co- Treasurers: Elected from Occupational Therapists 10. Co- Treasurers: Elected from Psychiatric Social Workers and Nursing Officers 11. Committee Coordinators: Medical Officer – Rehabilitation Coordination, Chief Occupational Therapist, Halfway Home representatives (Medical Officer, Nursing Officer) Committee Members 1. Medical Officers –Rehabilitation (02) 2. Medical Officer in Charge – Navodaya (01) 3. Medical Officers representing the eight general Psychiatry units, Forensic psychiatry unit, Adolescent Mental Health Unit and Psychogeriatric Unit.

4. One Medical Officer from the HalfWay Home – Mulleriyawa 5. All SGNOO of NIMH and SGNO of HWH – Mulleriyawa 6. Nursing Sister/Ward Master/ Officer in charge of; Rehabilitation Center, Horticulture Therapy Unit, Forensic Rehabilitation Unit, Navodaya and Outpatient Department.

7. Rehabilitation Nursing Officers of all intermediate and combined care wards, psychogeriatric wards, adolescent mental health units.

8. All Occupational Therapists 9. All Psychiatric Social Workers 10. All Physiotherapists

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Guidelines for the Committee 1. Decisions of the Committee shall be through dialog and consensus.

2. Director and the lead Consultant Psychiatrist shall have the authority to moderate and supervise all matters.

3. The Committee shall meet at least once a month on a set date.

4. Minutes of the meetings shall be kept by the secretary and confirmed in the following meeting and then forwarded to the Director – NIMH after it is signed by the Co-Chairperson.

5. The Quorum for a meeting shall be 15 and the Chairperson or the Deputy Chairperson must be present at all meetings.

6. The Committee shall always put the patients first and take an altruistic approach in its activities.

7. The committee shall function under the guidance of the Director within standard administrative rules.

8. All monies generated in rehabilitation must be dealt with in transparent manner decided as recommended by the Director – NIMH 9. All rehabilitation related monies require to be audited by the Accountant of NIMH. 10. Each of the rehabilitation units/wards shall forward a monthly report to the monthly committee meeting on the progress of their activities including a summary of the finances to be maintained in records and the report shall be approved by the committee.

11. A quarterly report of all financial activities supervised by the committee shall be submitted to the Accounts Department

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Medium Stay Units for Males and Females Operational Policy for the Male and Female Intermediate Rehabilitation Homes of National Institute of Mental Health, Sri Lanka (Medium Stay Mental Health Rehabilitation Units) Introduction There shall be two Intermediate Rehabilitation Homes (IRH) respectively for males and females situated within the premises of National Institute of Mental Health (NIMH) which serve the purpose of providing temporary residence for the patients who are on rehabilitation programmes.

National context 1. National mental health policy of Sri Lanka has elaborated on community based mental health services where accessible and affordable services will be provided to the mental wellbeing of all citizens.

2. For the people with mental illness a broad range of rehabilitation and psychosocial care services will be developed at district level close to the community to support ongoing rehabilitation, depending on identified levels of local need.

3. Focus of care is on activities of psychosocial rehabilitation to ensure growth and personal development of individuals by using recovery models and life skills training.

4. Attention will be paid on the person rather than the disease building trust and involving them in making choices, living in a place of his /her choice and emphasizing the need for personal support and intimacy 5. Family and community participation in the rehabilitation process is identified as vital and given significance in the policy.

(Adopted from Guidelines for Medium Stay Mental Health Rehabilitation units, Directorate of Mental Health. Ministry of Health) Two Intermediate care homes at National Institute of Mental Health will be model homes for intermediate care rehabilitation for the trainees of all the disciplines of the health sector as well as other sectors with which we need close collaboration.

This intermediate rehabilitation centre is open for the whole country as the National Institute of mental health.

Rehabilitation Aims 1. To work collaboratively with residents (affected by severe and enduring mental health illness) and family members to provide recovered focus care 2. To work in partnership with residents, using and building upon their own individual strengths and abilities and involving the significant people in their lives in all aspects of their care, where possible and where desired by the resident 3.

To inspire hope in individual residents, so they can plan and achieve their wishes and goals for the future, lead meaningful and fulfilling lives and reach their full potential whilst learning to adapt and live with the changes that a mental illness may bring

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5. To identify and link with employment providers, social services, voluntary organizations and other relevant services/providers required to ensure residents gain defined activity based life roles and/or gain employment 6. To work towards supporting residents in mainstream settings rather than in segregated services 7. To provide intensive client centred care, negotiating meaningful and achievable goals with realistic and achievable time scales in order to enhance the personal growth and development of the residents and promote self-confidence within a safe resourceful and supportive environment 8. To safeguard and promote rights and autonomy of residents 9. To ensure a comprehensive and scientific approach to needs of the residents is maintained during their stay 10. 10. To respect the diversity of residents 11. To facilitate residents, the opportunity to perform their chosen religious or spiritual and cultural practices and rights 12. To provide opportunities for appropriate recreational activities 13. To promote safety whilst encouraging positive risk taking 14. To offer a system of regular reviews, in consultation with the multidisciplinary teams, residents and family/carers 15. To invest in a multi-disciplinary team by encouraging staff involvement and adapting open communication, respecting each other‘s diversity and prioritizing the training and development of all staff 16. To increase awareness and understanding of the role of a rehabilitation ethos both within service provision and the wider community 17. To optimize medication and facilitate recovery through empowering residents to take their own medicine specially by improving knowledge and understanding regarding their illness, medication 18. To work in partnership with government, social services, voluntary organizations, private sector and other relevant services towards sustaining a successful and supportive recovery The process of social inclusion, community engagement will ultimately lead to alleviate the stigma and discrimination in the society (Adopted from Guidelines for Medium Stay Mental Health Rehabilitation units, Directorate of mental health, Ministry of health)

Specific objectives 1. To offer to those patients identified as ready for discharge for a period of supported living (six months) in a shared house out of the ward environment, to practice their independent living skills, conversational skills, social skills and work behaviour skills which are needed to move back into the community or to their families where possible 2. To improve their functioning in a role valued by society and selected by the individual and to attain their full potential through a holistic approach with the support of the multidisciplinary team National Institute of Mental Health - 109

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3. To boost the resident‘s self-image and self esteem 4. To build on their own identified strengths and capabilities whilst acquiring other life skills needed to move back into the community or to their families where possible with the support of the multidisciplinary team.

5. To give an opportunity for the multidisciplinary team to get hands on experience to practice SMART goal setting on individual clients a. b. c. d. e.

Specific Measurable Achievable Realistic Time frame

6. To give an opportunity for the members of multidisciplinary team to learn through long term follow up of clients 7. To provide an opportunity for the team to do research on rehabilitation specially on how rehabilitation helps to ensure compliance through trust worthy therapeutic relationships, prevent relapses and reduce readmissions

Male Intermediate Rehabilitation Home (IRH) of National Institute of Mental Health named ―Sumithuru Sewana‖ Structure1. Two adjoining buildings with separate entrances. Each Comprises of two double bedrooms, a living space, a kitchen space with small sink, and outdoor toilet and a shower.

2. The house is surrounded by land which could be cultivated as a home garden.

3. The building is situated adjacent to the 4-acre horticulture plot A Male Supportive staff member who is selected by the Rehabilitation Committee of NIMH after calling for applications through open notice based on selection criteria as decided by the Rehabilitation Committee, shall live in the same plot in a separate house. He shall work as the ―house caretaker‖ who is available 24 hours for resident‘s needs.

Female Intermediate Rehabilitation Home (IRH) of National Institute of Mental Health named ―Pathum Piyasa‖

Structure 1. Female Intermediate Rehabilitation Home is part of a building with two bedrooms and two indoor bathrooms which is arranged to accommodate six female clients.

2. The building is furnished with basic facilities.

3. The home is surrounded by land which could be cultivated as a home garden.

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shall live in the house in a separate part. She shall work as the ―house caretaker‖ who is available 24 hours for resident‘s needs.

Criteria for Referral 1. Patient with a diagnosis of long-term mental illness recommended by a Consultant Psychiatrist and the multidisciplinary team, 2. Age limit of 18 to 55 years.

3. Admission is approved by the rehabilitation team headed by consultant psychiatrist rehabilitation NIMH and Director – NIMH 4. The client should be assessed as having the potential and motivation to live outside the hospital (either for employment in community or to hold responsibilities within the family) 5. The client would benefit from the opportunity to regain or gain skills needed for independent living.

6. At the time of entrance to the IRH, the entire rehabilitation care plan and the discharge care plan from IRH should have been decided by the relevant multidisciplinary team, with the guidance of the rehabilitation team.

7. Informed written consent should be taken from the clients when they are in remission and of sound mind.

8. Concurrence should be taken from a next of kin if available.

9. Stay is voluntary and residents should be compliant with medication.

10. Risk assessment should be carried out by the relevant multidisciplinary team, and exclude high risk of suicide, self-harm, aggression, or risk to others or property.

11. Patients who are referred from District courts or long-term care taking homes are also accepted, provided the place/position in the relevant care taking place is reserved for the referring patient (in case the patient should be returned.)

12. Only males are included in the male intermediate rehabilitation home and only females are included in the female intermediate rehabilitation home.

Exclusion Criteria 1.

2.

3.

4.

5.

6.

Acute psychiatric patients Severe personality disorder Brain injury Dementia Severe Learning Disability High risk of suicide, self-harm, aggression, or risk to others or property.

Criteria for Discharge 1. After 6 months of stay in IRH client should be discharged according to the pre-planned discharge care plan 2. If a client has completed six months stay but not achieved the expected outcome or for any other reason if the need arises rehabilitation team will decide on extension of the stay for not more than 2 months provided client is benefited by that otherwise client will be discharged to the Psychiatry Unit.

3. The individual is not receptive to the training and support offered and/ or wishes to return to the ward.

4. The individual presents with challenges or behaviours which are not acceptable to the other residents of the house.

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Management Structure There should be a steering committee hereinafter referred to as ―Rehabilitation team NIMH‖ who is responsible to the consultant psychiatrist in charge of the homes and ultimately to the Director NIMH to manage the overall functioning of the intermediate care home.

1. The steering committee will be made up of the consultant psychiatrist, medical officer rehabilitation, occupational therapist, psychiatric social worker, community psychiatric nurse, nursing officer from the rehabilitation centre and the house caretaker.

2. Steering committee tasks will include monitoring and evaluation of the service, providing a support mechanism for the staff working there and developing the service over time, making necessary adjustments and improvements based on shared experiences.

3. Potential residents will be educated about the structure and soft skills for being with others by an occupational therapist for a period of one week prior to the entry. If possible they will be admitted in one intermediate care ward for a week depending on the bed capacity during that time.

4. First two months there will a weekly close supervision on a fixed day by the rehabilitation team NIMH 5. There will be a timetabled MDT meeting once a month with individual residents and attended by their family members where possible, to review progress.

6. Members from relevant area MDT/ referred team should participate this meeting 7. Minutes will be made of the meeting and a summary will be presented in the monthly rehabilitation meeting.

8. A special meeting in between those scheduled can be called if the need arises; for example, sudden availability of vacancies 9. Other interested people such as employers of the residents can be invited to these meetings should the need arise.

10. If a new client is selected by the steering committee residents who are already there will be given a chance to meet the new client before getting her admitted 11. Accommodation Cost including lodging, electricity, water, security and house maintenance costs will be borne by the National Institute of Mental Health.

12. If the client is employed the meals/food should be provided by themselves. If the patient is not able to bare the expenses of food that will be provided by the next of kin or through sponsoring or a fund 13. Surprise visits to employee workplaces should be made by the MDT 14. Each client should have a case file (preferably a Community File) with a recording of the progress.

15. Routine Medication needed for patients can be issued through registering in Clinic or through a Community File number.

16. In an event when a client develops an acute psychiatric, medical or surgical emergency that requires urgent medical attention it will be the duty of the treating psychiatry team to attend via the NIMH OPD. Such events shall be coordinated by any available member of the Rehabilitation Team, NIMH. 17. If Clients are to attend medical/ surgical clinics at other hospitals it will be the responsibility of the treating psychiatry team‘s CPN and PSW to arrange those with their team.

Roles and responsibilities Director 1. Custodianship of the Homes 2. Administrative supervision of all staff 3. If a resident does not have a next of kin to provide guardianship where necessary such as for employment purposes

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Consultant Psychiatrist 1. To be the in-charge consultant psychiatrist with overall responsibility for the Service 2. To provide technical supervision to the members of the MDT with the intention of assisting staff to realize their full professional potential Medical Officer - Rehabilitation 1. To facilitate and coordinate the admissions, reviews and discharges 2. Risk assessments 3. To be vigilant on all types of clinic follow ups or any other clinical contacts and arrange the visits with the support of the community psychiatry nursing officer Occupational Therapist - Intermediate rehabilitation Home 1. To provide a lead for the rehabilitation program in collaboration with the MDT members 2. Development of individual care plans for the residents once their place has been confirmed 3. To conduct a specific training program for all residents on one afternoon a week. (NB. Residents on employment will need to be released from their work responsibilities with the permission from the employer) 4. To review progress and make necessary adjustments of the client within the rehabilitation program making necessary adjustments.

5. To submit a summary report of the progression to the MDT members at the monthly review meeting 6. To undertake home visits if appropriate together with the social worker.

7. To provide weekly supervision to the house warden and be the contactable person for any emergency at the residence 8. To report to higher authorities if any emergency situations take place 9. To arrange alternative measures for supervision if a client does not attend for work. Clients should not be allowed to stay alone at the residence at working hours Nursing Officer - Rehabilitation Centre 1.

2.

3.

4.

To act as the link with the ward regarding the medication regime for all the residents To attend to any medical needs of the residents To undertake home visits with another member of the MDT where necessary To support the community psychiatric nursing officer to make arrangements with relevant area multidisciplinary teams for all types of clinic follow ups of residents

Community Psychiatric Nurse 1. Be a part of the individual care plan development for the residents once their place has been confirmed 2. To ensure drug compliance 3. To coordinate and give support to the family where applicable 4. To coordinate psycho social support during reintegration of the client to the society 5. To undertake home visits if appropriate together with the social worker.

6. To make arrangements with relevant area multidisciplinary teams for all types of clinic follow ups Psychiatric Social Worker 1. Be a part of the individual care plan development for the residents once their place has been confirmed 2. To coordinate support to the family where applicable both during admission, the stay, discharge and reintegration into the community and provide follow up.

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3. To support the client in the social and legal service needs such as getting an identity card, bank account, getting the right to vote etc.

4. To coordinate the individual to obtain and maintain employment either in the hospital or in the community with the support of the other members of the MDT. 5. To set with the occupational therapist and nurse, individual care plans for the residents once their place has been confirmed 6. To undertake home visits when necessary together with the occupational therapist and community psychiatric nurse.

House Caretaker 1.

2.

3.

4.

5.

6.

7.

8.

9.

Supporting the residents on arrival at the house Developing a therapeutic relationship with the residents Acting as the person on site, contactable by residents or members of the MDT at any time of the day Being available to the residents for two defined periods each day, morning and evening for training/ support purposes in activities of daily living, and to ensure the welfare of residents.

Check on the residents, medication intake at appropriate times.

Encourage the residents to participate in the general maintenance of the residence.

To check daily whether all the clients have attended for their duties if not to inform occupational therapist - IRH Arrange cover up for absences and notifying the occupational therapist - IRH Submitting a weekly written report to the occupational therapist in an agreed format

Health Service Aid from Rehabilitation Centre 1. To train in and support the preparation of the meals ensuring that all the residents are involved.

2. This Support Staff Member should be a designated individual to ensure continuity of the service provided in a routine familiar manner 3. If needed to accompany the resident for clinical contacts if the area MDT is unable to carry it out due to practical reasons Grievances 1. There should be an understanding by members of the steering group to listen to the experiences and provide support whenever needed 2. Any complaints by the residents should be noted and taken before the MDT for resolution if possible and within the time frame of not more than 2 weeks 3. Any resident who feels they have been unfairly treated will be helped to speak out in the appropriate forum and be heard.

N.B. Each staff member with responsibilities in the Service to be given a clear ―Job description‖ to obviate role overlaps and poor communication.

These Homes are state property and are an investment by the state for the benefit of the patients, as such all effort should be taken to do the maximum for the patient within set departmental rules and guidelines.

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Financial Management in Rehabilitation Activities All money generating and handling activities related to rehabilitation services should be done so with the fullest level of transparency and under the existing rules and regulations of the state.

All precautions should be taken to avoid misuse or abuse of a patient's rights and mismanagement of funding Financial activities related to rehabilitation shall be subjected to the supervision of the rehabilitation committee and the Accountant of NIMH. NIMH recognised ―Mano Mithuro Organization -Welfare fund for the mentally ill‖ registered as a patient welfare organization as a supportive mechanism to finance rehabilitation activities at NIMH Sales outlets for rehabilitation products are recognised as follows ―NIMHewana‖ Cafe Outlet, ―Sithmal Nimawum‖ Sales Outlet , Communication Centre at OT Unit Section C Rehab Sales Outlet Income generated via rehabilitation activities from all the units should be utilized in the following manner. a. 60 % for reinvestment for raw material or needed items b. 35% to be given to the patient c. 5% to be reverted to the investing party (to be paid as royalty to NIMH Shroff or Mano Mithuro Organization) d. An Additional 3% to the selling price may be added and retained by the above sales centers when they are selling products produced in different settings and brought in for sale by clients. This money should be used for payment for patients who are employed as sales agents.

Payment amounts for Sales Agents will be determined by the Rehabilitation Committee.

A monthly ―pola‖ may be organized by the Rehabilitation Committee for sales of items directly by clients who are having money handling skills.

Where the need arises Raw material needed for rehabilitation activities should be purchased through accounts branch.

The previous months financial summary on rehabilitation by each unit should be presented to the monthly rehabilitation committee in a standard format. All documentation should be signed by the responsible officer. The treasurer of the rehabilitation committee should check all the financial balances and forwarded to the secretary and then to the chairperson (The Director) through Medical Officer- Rehabilitation Coordination.

Monthly financial summaries from all the rehabilitation units should be filed and kept safe at the Treasurer and quarterly audited by the Accountant.

Patients who are under NIMH care who are employed and earning as Level IV Rehabilitation should be directed by PSW to have a bank account in a state bank.

Patients kept with BHT if required to withdraw money from the bank needs approval from the relevant Consultant and Director in a defined format. Patients discharged can handle their money on their own accord with needed support from the Rehabilitation Team and Community Mental Health Team.

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Role of Physiotherapy The aim of the Physiotherapy Unit is to assist the clinical team in promoting the mobility and independence of patients at NIMH. Physiotherapy is available as a day service in all Sections of NIMH Any Consultant/ Senior Registrar/ Registrar/ Medical Officer may refer inward patients to Physiotherapy at NIMH Outpatients and staff that require physiotherapy services need to have valid referral and should get Director Approval.

Services Available: 1.

2.

3.

4.

5.

6.

7.

Routine physiotherapy.

Routine physiotherapy at ward for non-ambulatory clients.

Performing chest physiotherapy to obtain sputum samples for investigations.

Infrared treatment.

Ultrasound treatment.

Short wave diathermy treatment.

Muscle stimulation treatment·

Advanced physiotherapy treatment plans should be subjected to the supervision of the Consultant Physician.

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Dental Services The National Institute of Mental Health, Sri Lanka offers dental care services to inward psychiatric patients, staff as well as out-patients coming from the Community.

Two Dental Chairs are operational at NIMH Main Unit and s single chair is available at Section C. The dental clinic at NIMH provides the following services to their clients.

1.

2.

3.

4.

5.

Oral Extraction Temporary & Permanent restorations Periodontal treatment/ Scaling Nerve filling Oral medications

Dental Clinic is operational on all working days from Monday to Saturday.

Dental Clinic is open for outpatients from the community from 8.00 am to 10.00 am Inward patients should be sent for Dental Clinic review after informing from 10.00 am onwards.

Dental Surgeons will visit wards in the afternoons to review patients with regard to their oral health.

Identified patients with oral health issues should be referred to the Dental Clinic by the unit Medical Officers.

Where Consultant opinion is needed such patients will be referred to the National Dental Hospital of Sri Lanka.

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Pharmacy and its Services Further to internal circular MA/12/2019, please note the following with regard to functions of the outpatient pharmacy in serving the patients & staff of NIMH The outpatient pharmacy is to function as follows.

8.00am-5.00pm

- All working days including Saturday

8.00am-4.00pm

- Sundays & PH

1. As the NIMH OPD functions 24hrs / 07 days, patients coming to NIMH after 4.00pm / 5.00pm (as per above schedule) if medication is required without admission that patient should be provided with medication from the relevant Admission Unit according to the area basis of admissions.

2. Such OPD Drug prescriptions should be received next morning by the OPD Pharmacy & the drugs should be provided to the relevant ward so that the drugs count in the relevant ward will be balanced.

3. OPD Drugs prescriptions should carry the MO/OPD seal always & prescribing Medical Officers name. (Ref: Internal Circular: NIMH/PDU/PU/2017/024) 4. Ward discharge prescriptions should carry the relevant Consultant seal & the name & signature of MO writing the prescription.

5. In the current situation as per the approval received form the DGHS and the institutional Drugs and Therapeutics Committee Meeting, Drugs can be issued for a maximum period as follows,

a. OPD RC Number: 07 days for patients 03 days for staff (Ref: Internal Circular MA/12/2019 dated 11/04/2019) b. H633 Prescription Sheet: One Month (GBVPU, Navodaya, Clinics, Deegayu Day Centre) (Ref: Internal Circular: NIMH/PDU/PU/2017/049 & Ministry letter DGHS/NIMH/2017-115) c. Community Files: One Month-special community file number (Ref: NIMH/PDU/PU/2017/009 & DGHS/NIMH/2017/115) d. Discharge /Leave Patients: 02 weeks for BHT Number

6. Issuing of medication to staff should be done under vigilant clinical discretion of Medical Officers as availability of ―regular‖ medication of NIMH OPD is limited.

7. All Medical officers/ Pharmacists/ Nursing Officers need to be vigilant to prevent misappropriation of drugs.

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8. As many of the drugs in use at NIMH are high alert /dangerous category drugs, extra precautions need to be taken while making sure availability of drugs to patients who seek treatment from NIMH is not hampered or delayed unnecessarily.

9. In Drugs books Local purchase drug request should carry the Consultant and Director /Deputy Director Signature and for other drugs book each unit should identify & in-from the pharmacy of the signatures of the unit SR and SMO who will be requesting/ authorization relevant drugs.

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Laboratory Services The aim of Laboratory is to provide medical laboratory testing services in accordance with the applicable standards to satisfy the expectation of clinical staff and the administration.

Services Offered: Biochemistry related testing.

-

UFR

-

SFR

- Dengue NS1 Antigen

- Urine Ketone Bodies

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Serum Electrolytes

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Serum Lithium

-

-

Serum Urea

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Serum Creatinine

- Serum AST (SGOT)

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Serum ALT (SGPT)

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Serum ALP

- Bilirubin (Total, Direct)

- S. Protein (Total, Albumin)

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CK-NAC

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CRP

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CSF – Protein

- Cholesterol (Total, HLD, TG)

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Troponin I

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Stool Occult Blood

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Urine hCG

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Sterile Fluid (Report, Glucose, Protein)

Serum Glucose

Haematology related testing.

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FBC

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ESR

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INR

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PT/INR

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APTT

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Bone Marrow Films

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Iron Stain

Stool Culture

- CSF Report & Culture

Microbiology related testing.

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Urine Culture

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Pus Culture

- Sterile Fluid Report & Culture

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-

Rapid HIV Ag/Ab

-

- PCR & Blood Culture

RAT for Covid19

MRSA Screening

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-

AFB (Sputum, Urine, Sterile Fluids)

·

Coordinating specimens sent to MRI, RIA, CEBH, NIID & NHSL based laboratories

The Laboratory functions full 24 hours, 07 days of the week. Lipid Profile tests are only done on Mondays.

Usually any Consultant/ Senior Registrar/ Registrar/ Medical Officer may order clinically indicated tests.

From time to time based on test patterns and availability of regents temporary restrictions may be imposed by the Director on identified tests.

As Laboratory tests are costly, Medical Officers need to ensure the decision to order a test is taken based on a clear clinical indication.

The Laboratory Services are subjected to the Clinical Supervision of the Consultant Haematologist and Visiting Consultant Microbiologist.

Laboratory is expected to follow all guidelines and regulations issued by the Ministry of Health.

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Radiography Services The aim of the X-Ray Department is to provide a diligent & quality radiographic service to NIMH. Services Offered: 1. Routine and urgent X-Rays.

2. Provide radiographic service cover-up for NIID and CEBH Mulleriyawa.

Routine X Rays are performed from 8 am to 12 noon and 2 pm to 4pm on weekdays and from 8 am to 12 noon on Saturdays, Sundays and public holidays.

Urgent and emergency x-rays as well as inward chest x-rays can be arranged after discussing with the oncall radiographer.

Usually any Consultant/ Senior Registrar/ Registrar/ Medical Officer may order clinically indicated X Rays.

Priority is given to NIMH Inward patients. However outpatients and staff can undergo X Ray if indicated with a request written by the NIMH OPD or NIMH Clinic.

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CT (Computed Tomography) Scans for Patients Availability of CT Scan facilities at NIID, Angoda Please note that with the introduction of a CT machine to NIID, Angoda we have requested and obtained some services to be available to NIMH Town as well in the following capacities.

1. Non Contrast CT Brain – 05 studies per day on Every Tuesday and Thursday – 8.00 am to 10.00 am 2. Contrast Enhanced Ct Brain or other regions CT can be accommodated on the same day – Tuesday and Thursday with prior appointment – (For these the prior appointment is mandatory) 3. Where sedation of the patient is required that must be arranged from NIMH and a Medical Officer and the clinical team from NIMH should accompany the patient 4. All patients should be sent for CT after admission to PCU – NIID hence a transfer form is needed 5. For any urgent CT requests: a. Non-Contrast – The radiographer on duty at NIID should be contacted for an appointment b. Contrast Studies – The Consultant Radiologist at NIID should be contacted for an appointment 6. CT reports will be issued within 03 working days (If only the film is requested that should be mentioned in the request form) Availability of CT Scans at NHSL 1. NHSL CT Scan services can be requested for patients of NIMH 2. Urgent CT Scans can be done by transferring the patient to NHSL. Patients should be sent with a transfer form.

3. Routine Non-Contrast CT Scans can be done by sending patients in the evenings for the routine list.

Patients should have a properly authorized CT request form.

4. Contrast CT should be done with prior appointment confirmed from NHSL 5. Where sedation of the patient is required that must be arranged from NIMH and a Medical Officer and the clinical team from NIMH should accompany the patient. If not arrangements should be made with Ward 59 of NHSL and Anesthesia teams of NHSL 6. MRI slots are also available for patients at NIMH which should be pre booked. Relevant MRI requests should be used to send the request.

Decisions for CT and MRI are to be taken by the Consultants or by Senior Registrars in consultation with the Consultant.

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EEG (Electroencephalography) Services E.E.G Department of National Institute of Mental Health provide EEG services for the inpatient of wards and out patients of psychiatric Clinics, and CEBH and NIID We are doing Routine EEG and Urgent EEG of Adult, children, Neonates for diagnostic purpose

Types of EEG 1.

2.

3.

4.

5.

Routine or Urgent EEG with activation procedure (Hyperventilation/Photic stimulation) Sleep deprived EEG and Sleep record (natural and drugs induced) Paediatric and Neonates EEG Short term Video EEG Brain death confirmation EEG

Usually any Consultant/ Senior Registrar may order clinically indicated EEG. EEG Services are available as a day service on all working days.

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ECG (Electrocardiography) Services

The aim of Electrocardiography (ECG) Unit is to provide all ECG needs of NIMH. Services Offered:

1. Routine ECGs at the unit & for non-ambulatory clients are done at the ward.

2. Urgent ECGs are done at the ward.

ECG Services are available on all working weekdays from 8.00 am to 4.00 pm and on Saturday, Sunday and Public Holidays from 8.00 am to 12.00 noon to be done by Cardiographers at Sections A and B. Section C ECG are to be attended to by Medical Officers and Nursing Officers.

Urgent ECG for patients when cardiographers are off duty will be attended to by the On Call Medical Officer in Section A and B. Nursing Officers will assist and arrange the ECG machine to be brought from OPD or Ward 18.

Any Medical Officer may order ECG.

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Medical Nutrition Services 1. MO (Medical Nutrition) will attend to all aspects of Clinical Nutrition Management of patients at NIMH and Section C – Halfway Home.

2. MO (Medical Nutrition) will function under guidance of the Consultant Physician with regard to patient management.

3. A Medical Nutrition Clinic will be conducted all weekdays at NIMH except on Public Holidays and on every second and fourth Wednesday at Section C - HWH except on Public Holidays.

4. The Medical Nutrition Clinic will function from 8.30 a.m. to 12.00 noon. In Addition the MO (Medical Nutrition) will visit wards to review patients in the afternoons and Saturdays when requested to do so.

5. MO (Medical Nutrition) will be working closely with the Nutritionists and the Diet Branch to regulate and maintain high standards in the Patient and staff diets prepared from the kitchen.

6. All patients that require Medical Nutritional intervention should be referred to the clinic for evaluation and management.

7. E.g.: Patients with Obesity, Malnutrition, and Patients requiring special diets in related debilitating neurological and other disorders, Infants admitted to PPU to better streamline their feeding.

8. Staff will require a referral from a MO/OPD to be reviewed at the Medical Nutrition Clinic.

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Nutrition and Dietetics Services All individuals with mental health conditions should be screened for nutrition issues and be referred as needed to the nutrition unit for further management.

When to refer to Nutrition unit, 1. Malnutrition: It can be screened with specific tools. It includes both under-nutrition and overnutrition. a. Malnutrition Universal Screening Tool (MUST) b. Mini Nutritional Assessment (MNA) – for elderly patients over the age of 65 years.

2. Patients on feeding tubes 3. Has a condition that would directly benefit from nutrition intervention, a. Diabetes mellitus b. Eating Disorder c. Dementia, stroke with paralysis or Parkinson‘s d. Other: Inflammatory bowel disease, Cancer, Pancreatitis, celiac disease, Dyslipidaemia.

4. Has a condition where nutritional intervention can help treatment, a. Heart disease b. Hypertension 5. Swallowing or chewing problems 6. Abnormal lab results, a. b. c. d. e. f. g.

Blood sugar Albumin Lipid profile Haemoglobin Ferritin HbA1C Vitamin B12

7. On-going poor food or fluid intake

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National Mental Health Helpline – 1926 NIMH has launched round the clock National Mental Health Helpline with short code 1926 from 15th 0f October 2018 to support the population, who are in need of Mental Health services in addition to its regular activities.

Currently 1926 Call line has 05 active lines 24/7.

The unique feature and main advantage of linking to 1926 over other support lines is its close integration with regional mental health support services, via our network of Psychiatric Clinics, Psychiatric Social Workers, and Community Psychiatric Nurses we can directly link our callers to get help in their localities.

Helpline covers a wide spectrum of mental health inquiries.

Routine Duty at Call Centre is done by Nursing Officers under the supervision of a Medical Officer and Consultant Psychiatrist.

The most challenging cases such as a caller attempting suicide are handled by a senior member of the 1926 team such as Medical Officer, Registrar in psychiatry, Senior Registrar in Psychiatry or Consultant Psychiatrists.

1926 SMS chat line made available from 08.00 am to 4.00 pm 07 days of the week.

All Clinical teams and Community Mental Health Teams are advised to cooperate with the 1926 to help patients who contact NIMH through 1926. The relevant Consultant Psychiatrist for the client based on their area of

residence should be contacted by the on call Medical Officer or the Senior Registrar when needed.

The administrative functions of the 1926 centre will be under the supervision of a Lead Consultant Psychiatrist and a Nursing Officer in Charge appointed by the Director.

Special Grade Nursing Officers must ensure that the 1926 line is manned by Nursing Officers with training, uninterrupted.

Services provided must be based on pre-designed approved guidelines and protocols.

Quality Assurance will be done by reviewing the recordings on periodical basis Monthly summaries of activities should be sent for review by the Director through the SGNO by the on-duty Nursing Officers. After review by the Director the data will be sent to the Health Informatics Section of the PDU for records.

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Patient Transportation for Referrals, Transfers and Discharge 1. Transportation for patients are provided as per the standard regulations and guidelines of the Ministry of Health 2. Further the Mental Diseases Ordinance has also recognized provisions to provide transport for the patients especially after discharge.

3. Transport is handled by a Subject Officer at the Main Office - Inquiries Section under the direct supervision of the Administrative Officer.

4. All requests for transport during day time should be made in writing by filling the relevant form or documenting on the BHT. In the night this is done via the telephone exchange under the supervision of the night duty PHMA. .

5. Except in urgent cases all transport needs should be pre booked.

6. Provision of transport is costly and it is the duty of all staff officers to ensure that transport facilities are not misused.

7. Urgent need for Ambulances will be arranged by the Office/ Exchange once informed via telephone.

Even urgent ambulance usage should authorized by the Director/ Deputy Director or Senior Medical Officer On Call 8. Routine ambulance bookings should be made preferably the day before. Director Authorization should be sought beforehand.

9. When a patient is sent for a referral the treating Psychiatry Team should assess the suitability of the patient to be sent to another institution via ambulance based on the assessed psychiatric risk. The relevant unit Medical Officers should decide the level of accompaniment spending on the risk and if need be should get opinion from Consultant or Senior Registrar. Following decisions can be documented based on psychiatric risk assessment and the medical conditions. a. Routine transport with one support staff member b. Routine transport with two support staff members c. Separate Ambulance transport with two support staff members d. Separate Ambulance Transfer with accompaniment of a Nursing Officer and Support Staff Member/s e. Separate Ambulance Transfer with accompaniment of a Medical Officer, Nursing Officer and Support Staff Member/s f. Differ transfer until patient is stabilized psychiatry wise or medical wise 10. The Consultant/ Senior Registrar/ Medical Officer who orders the transport carries liability to the state with regard to the transport cost incurred and as such decisions must be taken carefully.

11. Routine transport for patients to for NHSL is expected to leave NIMH on or before 8.00 am on working days.

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12. Transport of discharged patients can be provided in the following manner. a. Provision of bus fare for patient to reach home on his/her own accord or with staff member b. Provision of railway warrant for patient to reach home on his/ her accord or with staff member accompanying c. Provision of Ambulance to transfer patients to further care and follow up to closest psychiatry unit to the patient‘s area of residence d. Provision of ambulance/bus/ van to drop patients home accompanied by PSW/CPN/ Support Staff 13. For above requests must be made via the BHT as well as the relevant forms.

14. Transportation for staff for official matters will be considered as per existing regulations.

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Deegayu Elders’ Day Centre 1. Deegayu Elders‘ Day Treatment Centre functions under the supervision of the Lead Consultant Psychiatrists of the Psycho-geriatric Unit.

2. It is expected to function as a day facility and will provide day services needed for the elderly patients.

3. The Unit will have clinic services functioning on all working days from 8 am to 4 pm. The centre will be open on Sundays and Public Holidays for restricted services.

4. The main aim of Deegayu Senior Citizens‘ Day Rehabilitation and Care Centre is to provide rehabilitation and psychotherapy for the elderly client particularly those suffering from dementia.

5. Patients can be referred to the Deegayu centre from the clinics or OPD 6. The centre will function as a treatment centre as well as a training centre for geriatric psychiatry.

Services Offered: 1.

2.

3.

4.

5.

6.

Rehabilitation and Occupational therapy Dementia Clinic Activities for inward clients Home visits Caregivers awareness programs Senior Citizens Mental Health Promotion

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Gender Dysphoria Treatment Services

1. Basic Structure and functioning of the Specialized Clinic for clients with gender dysphoria at the National Institute of Mental Health a. The clinic is held at the Navodaya day centre at the National Institute of Mental Health, Angoda every Friday at 8 AM-12 Noon under the supervision of Lead Consultant Psychiatrist from NIMH. b. Three new and followed up clients will be assessed per day. c. Care will be provided by a multidisciplinary specialty team. d. Initial assessment will be done by a registrar and a senior registrar according to the guideline. e. Clients will be assessed by the Consultant at least once during the first six visits. f. Hormonal therapy will be started by a senior registrar or the consultant psychiatrist. g. Referrals for surgeries will be done by the consultant psychiatrist. h. Psychiatric social worker will address the social issues and involves in issuing gender identification certificate 2. Assessment Initial assessment will be done by a registrar and a senior registrar using comprehensive history, mental state examinations, physical examination and investigations during to the first 3. Management Management will be guided by a senior registrar and the consultant psychiatrist.

4.1 Management Options a. Changes in gender expression and role (real life experience which may involve living part time or full time in another gender role, consistent with one‘s gender identity) b. Hormone therapy to feminize or masculinize the body c. Surgery to change primary and/or secondary sex characteristics (e.g., breasts/chest, external and/or internal genitalia, facial features, body contouring) d. Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; enhancing social and peer support; improving body image; or promoting resilience.

4.2 Legal Aspects Gender Recognition Certificate (H1257) - General Circular 01-34/2016 DGHS, Ministry of Health a. b. c. d. e.

Clients should be stable in the preferred gender role.

Should be followed up in the clinic continuously for 6 months with or without hormonal therapy.

The consultant psychiatrist should recommend for the GRC at the end of first 6 months The process will be coordinated by the psychiatric social worker.

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If necessary the consultant psychiatrist/ senior registrar can issue a letter mentioning the client‘s condition temporarily till he/she is eligible for the GRC. 4.3 Psycho-Social Support Provide information and referral for peer support For these clients an experience in peer support groups may be more instructive regarding options for gender expression than anything individual psychotherapy could offer. They should be encouraged to participate in community activities, if possible. Resources for peer support and information should be made available.

Eg; Heart to heart 4.4 Follow-up care Clients will be assessed monthly in the clinic with necessary history, mental state, physical examination and investigations.(mentioned above) 5. Management of children and adolescents Management of children and adolescents with gender dysphoria will be done liaising with a child and adolescent psychiatrist.

References Standard of care; WPATH 2011; DSM 5; DGHS Circular on issuing of GRC

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Day ECT Services NIMH provides Electroconvulsive Therapy (ECT) on an outpatient basis for those patients where ECT is indicated. These services are provided from Monday to Saturday including public holidays (except Sundays) free of charge at the outpatient ECT Unit (OPE Unit).

1. Patients who have already started on course of ECT as inpatients and new patients for whom ECT is indicated can be referred to OPE Unit from OPD/Clinics/Day Centres.

2. Patient should be referred only by a Consultant Psychiatrist attached to NIMH and he/she shall be responsible for the overall management of the patient.

3. A Psychiatrist attached to any other institution should only refer the patient for outpatient ECT through a Consultant Psychiatrist attached to NIMH , 4. Patients cannot be referred to outpatient ECT while receiving inpatient care at any other institution, government or private.

5. The referring Consultant should complete the pre ECT assessment form anaesthesia and ECT and ensure the patient arrives at OPE Unit with necessary investigations. (The patient should come fasting and with necessary investigations i.e. ECG, FBC for those above 35 years and other relevant investigations) 6. The patient may be returned if the pre ECT assessments are incomplete or if there is any contraindication for ECT/anaesthesia. The facilities for investigations will not be available for patients arriving at OPE Unit.

7. The patient‘s informed consent and the concurrence of the accompanying relative is essential for outpatient ECT. 8. The patient should arrive at the OPE Unit on or before 8.30 am accompanied by a relative in close who will be in close contact with the patient for the next 24 hours.

9. Personal transport should be available for patients to return home after ECT. 10. The On Duty Nursing Officer will inform the relevant On Call Medical Officer - Psychiatry on arrival of the patient for the completion of the records and for necessary examination. The Medical Officers may contact the referring Consultant for any further clarifications.

11. The Duty Nursing Officer will accompany the patient to the theatre and priority will be given to the outpatients. The patient shall be monitored in the observation area by the recovery nurse.

12. The patient may leave the OPE Unit with the recommendation of the anaesthetist. An appointment for the next ECT should be made prior to leave.

13. Any patient developing complications during or after ECT shall be admitted to the NIMH under the care of the referring Consultant.

14. If a patient does not comply with the next appointment for more than a week the course is considered to be over unless the patient or a relative corresponds with the unit.

15. The Outpatient ECT Unit can accommodate only 02 patients at a time from each Consultant.

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Navodaya Day Treatment Centre Day treatment centre is an outpatient facility, attached to the National Institute of Mental Health (NIMH), which provides psychological treatment for a wide range of mental health problems. The therapies are to be carried out according to international standards and are in accordance with latest scientific evidence. It is recommended that the highest levels of ethical standards are maintained at all times and confidentiality of information is strictly preserved.

1. The centre provides training in many areas of psychotherapy for postgraduate trainees in psychiatry and Medical Officers, Medical Students and other health workers.

2. It also aims at developing community awareness programmes in mental health.

3. Furthermore, the facility is effectively used for research purposes in relation to psychological treatment of psychiatric disorders.

4. All therapies are carried out exclusively by Postgraduate trainees in Psychiatry, Medical Officers Psychiatry or Medical Officer - Mental Health under the supervision of a Consultant Psychiatrist.

5. Patients seeking treatment at Navodaya will be allocated on rotational basis not adhering to the area basis and personal preference of the patient will be considered.

6. Individuals other than the therapist who wish to observe the session, need prior consent from the patient and the therapist.

7. The services are provided from 8.00 am to 4.00 pm on weekdays including public holidays and from 8.00 am to 12.00 noon on Saturdays.

8. If the relevant PG trainee is not available within the hospital premises a registrar or MO from that unit of the MOIC of Navodaya will attend to immediate issues.

9. Patients coming in non-working hours are given appointments after consulting the relevant medical officer.

10. Professional boundaries must be strictly maintained. If any transference or countertransference develops this should be immediately communicated to the Senior Registrar/ Consultant and a new therapist appointed 11. Group Therapy will be arranged for Alcohol, Substance related mental health problems 12. Duties of the MOIC a. Service Development b. Decision and proposal making c. Psychotherapy for patients when needed d. Supervision of Nursing and Support staff e. Collaboration with Director, Deputy Director, Consultants, Senior Registrars, Registrars f. Organizing and conducting community awareness programs g. Review statistics 13. Duties of Nursing Officers a. Arranging and duties of the supportive staff b. Providing and maintaining facilities c. Arranging the documents that are needed for therapy d. Maintaining records and statistics National Institute of Mental Health - 135

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e. Assisting the Therapists where needed f. Giving appointment after confirming with therapists g. Maintain confidentiality of clinical documents 14. Duties the PGIM Trainee/ Therapist a. Assessment of the patient and organizing the management plan b. Inform the summary of the information to the relevant Consultant or Senior Registrar and plan the management further c. Provision of Therapy and Evaluation of Progress 15. Consultants/ Senior Registrars will supervise the therapies, advise on service development and train Navodaya Schedule

Day

Monday

Tuesday

Psychiatry Unit

Clinic

New Appointments

VI

Psychotherapy

2

8.00am-12.00pm

IV

Alcohol & Substance Prevention Clinic

10

1.00pm- 4.00pm

V

Psychotherapy

2

Child & Adolescent Psychiatric Clinic

5

8.00am-4.00pm

Psychotherapy

2

8.00am-12.00pm

IV

2

8.00am-12.00pm

III

2

1.00pm- 4.00pm

VI

2

AMHU

Wednesday VIII

Thursday

II

Psychotherapy

4

Time

8.00am-4.00pm

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Friday

Gender Dysphoria Clinic

6

8.00am-12.00pm

Psychotherapy

2

1.00pm- 4.00pm

Couple & Sex Therapy

2

8.00am-12.00pm

Sundays & Public Holidays – Only selected appointments

8.00am-12.00pm

Saturday

I

I

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Gender Based Violence Prevention Unit The main aim of Gender Based Violence Prevention Unit (GBVPU) is to establish a friendly environment for survivors of gender-based violence & reduce incidence of gender-based violence. (GBV) Services Offered: 1. The GBVPU provides survivors of GBV quality, culturally and age appropriate counselling, psychotherapy, medical, social, and legal support to victims of GBV. 2. The GBVPU counsels‘ perpetrators to reduce the incidence of GBV. 3. The GBVPU arranges group counselling for family meetings.

4. Coordination of "The Committee regarding sexual harassments in the workplace" at NIMH is done by the GBVPU. Any Clinical unit can refer patients with GBV issues to this unit. It is functioning on all working days from 8.00 am to 4.00 pm GBVPU accepts referrals of inward patients, OPD and Clinic patients as well as patients sent from the community.

GBVPU is manned by trained nursing officers under the supervision of a Medical Officer and Lead Consultant Psychiatrist.

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External Clinics and Outreach Services

Psychiatry Unit Unit VI

Clinic/ Medicate Programme

Date

Resources

Delgahawatta

1st, 3rd Friday

Doctor, CPN, PSW

Kaduwela

1st Thursday, 4th Tuesday

CPN

Modara nd

2 Friday

Doctor, CPN, PSW, Pharmacist Doctor, CPN, PSW

Modara 2nd Wednesday CPN, PSW Athurugiriya 1st, 3rd Tuesday Doctor, CPN, PSW Wellampitiya 4th Friday Doctor, CPN, PSW NHSL Every Thursday Unit III

Gampaha

1st Wednesday, 2nd Thursday Doctor, CPN, PSW

Ever Tuesday NHSL Unit VII

Grandpass

3rd Wednesday

NHSL

Every Friday

Doctor, CPN, PSW, Pharmacist Doctor, CPN, PSW

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Unit V

Pannipitiya

Every Thursday

Rajagiriya

1st, 3rd Thursday

Doctor, CPN, PSW, Pharmacist Doctor, CPN, PSW, Pharmacist Doctor, CPN, PSW

NHSL

Every Wednesday Doctor, CPN

Unit VIII

Pannipitiya / Colombo

1st , 3rd Friday

Methsewana

Every Other Monday Doctor, CPN, PSW

Unit IV

Unit I

NHSL

Every Thursday

NHSL

Every Tuesday

Doctor, CPN, PSW

Lunawa

Every Friday

CPN

NHSL

Every Monday Doctor, CPN, PSW

Unit II

Forensic Unit

Colombo 12

3rd Wednesday

NHSL

Every Monday

Colombo 10

4th Thursday

Prison Hospital

Tuesday/ Thursday (M)

JMO Clinic

Tuesday Afternoon

NHSL

Wednesday Afternoon

Doctor, CPN, PSW

Entire Team

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Long Term/ Lifetime Care 1. Long term/ life time care for patients at NIMH is strictly discouraged in the institutional setting.

2. All attempts should be made to discharge patients back to family/ community/ community assisted living.

3. Multiple attempts should be made for discharge with the help of local area Psychiatry teams. At Least three discharge attempts done genuinely are envisaged before transferring to long term care.

4. Patients whose discharge attempts have failed may be considered to be placed at NIMH Long term wards after considering the following. a. Joint Report from Key MO/ CPN/ PSW about the social background and previous discharge attempts b. Report from relevant are Divisional Secretariat/ Grama Niladhari c. Where relevant order from the relevant Court d. Availability of a Bed in the long term ward 5. Long Term Care wards will only house patients per bed capacity. No floor patients are allowed.

6. Long Term wards shall have a stipulated recreation and rehabilitation plan.

7. Even while in long term wards attempt should be made to transfer the patient to community based living after rehabilitation.

Long Term Wards - Section A 1. Ward 22 = 90 beds - Males (10 beds per each general psychiatry unit and 10 beds for forensic unit patients transferred after Visitors Board approval) Section C (Unit II) 1.

2.

3.

4.

Ward 31 – Learning Disability Care Ward - Females Ward 32 – Dependent Care Ward - Females Ward 33 – Medical Ward + Isolation Unit (Transit) Ward 34 – 42 : Long term care wards divided among General Psychiatry Unit Consultants

Section C will also have the following for rehabilitation and recreation. a. Occupational Therapy Unit (Unit III), and Horticulture Unit (Unit II) b. NEST - Partnership with external non-governmental organization for rehabilitation activities c. Netherlee Cottage linked Community House - partnership for community placement with external party sponsored by ST ANDREW‘S SCOTS KIRK and NETHERLEE CHURCH, Glasgow, Scotland

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Section B – Healthcare Quality and Safety

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National Policy on Healthcare Quality and Safety The Directorate of Healthcare Quality and Safety is the focal point of Quality Management and Patient Safety within the Ministry of Health, Sri Lanka NIMH as part of the Ministry of Health is participatory to the Quality Improvement measures taken by the Directorate and works hand in hand with the Ministry of Health - Directorate of Healthcare Quality and Safety as well as the National Productivity Secretariat of Sri Lanka in striving for better Healthcare Quality, increased patient safety and increased productivity.

The national policy on healthcare quality and safety recognises the following key result areas.

1. Customer/ Patient Satisfaction 2. Leadership, Governance and systems 3. Clinical Effectiveness 4. Risk Management and Safety 5. Enabling Culture for Quality Improvement 6. Staff Development and Wellbeing 7. Research for quality improvement and patient safety NIMH also is keen to engage in quality improvement aspects in all of the above areas. For this purpose in the Planning and Development Unit a separate section has been established for Quality Management to function as the focal point for Quality and Safety.

NIMH tries to promote and develop the 5S Concept, Kaizen methods, Total Quality Management as well as Green Productivity within the institute

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Quality Circles and Work Improvement Teams All Units and Wards are expected to have quality circles and affiliated work improvement teams formed within them.

The Quality Management Section of the Planning and Development Unit will guide the units and wards in forming these circles and will review and monitor these performances.

The roles objectives and follow up of the quality circles and work improvement teams will be updated and informed from time to time by the Quality Management Section.

All section Heads and Units/Ward In Charges are responsible to ensure the participatory quality circles are held from time to time to address problems/ issues within units in a productive manner.

All categories of staff are expected to participate in these circles.

Reports of meetings held should be forwarded to the Director through the section heads for review and they will be forwarded to the Quality Management Section for evaluation and feedback.

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Clinical Governance Unit Preamble The National Institute of Mental Health, Sri Lanka after it was upgraded to a national institute in 2008 developed internal policies and guidelines to ensure quality of services to clients. A policy folder was introduced in 2009 which also established a system of clinical governance. This document tries to streamline the establishment of a Clinical Governance Unit at NIMH. Purpose and Scope To set up a sustainable, effective Clinical Governance Unit at NIMH under the Quality Management Section of the Planning and Development Unit that reaches all of its targeted objectives.

The NIMH Clinical Governance Unit will function as a role model for other health institutions across Sri Lanka.

Definition of Clinical Governance Systematic approach where managerial and clinical accountability, organizational culture and systems which enable probity, are implemented with a focus on assurance/improvement of patient and staff safety.

Goals and objectives of the Unit 1. Managing patient safety and quality improvement ensuring best uses of services, clinical resources as well as ensuring the professional/institutional reputation 2. Outcomes are tracked within various established frameworks and committee structures to ensure that patients, who come to NIMH, experience care that is safe, timely, effective, efficient, patientcentered, value-based and equitable 3. To continuously transform the culture, ways of working and systems of healthcare delivery so as to ensure that quality assurance, patient safety and quality improvement become an integral and natural part of everyday work Pillars in Clinical Governance at NIMH 1. Quality assurance and improvement a. Integrated approach by the institution b. Infrastructures foster development of evidence-based practices (systematically find and use contemporaneous research findings as the basis for clinical decision-making) c. Innovations are valued and shared with all d. Clinical data are sound and used to monitor patient care and clinical outcomes 2. Professional accountability a. Leadership skills are developed in line with professional and clinical requirements b. Poor clinical performance is identified to prevent further harm c. Professional and practice development are aligned to governance frameworks 3. Creating a safe environment for staff and patients a. Clinical risk management systems are in place b. Complaints are taken seriously and action taken to prevent recurrence of the root causes National Institute of Mental Health - 145

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4.

Nurturing an honest and open culture a. Proactive approach to reporting, dealing with and learning from adverse events

Organogram of the Clinical Governance Unit Operating Guidelines 1. The Lead Consultant who is appointed by the Director – NIMH with the concurrence of the Board of Consultants of NIMH from among the Senior Consultant Psychiatrists of NIMH shall head the Clinical Governance Unit.

2. A Clinical Governance Review Committee shall be established consisting of the Lead Consultant – Clinical Governance as the Chair, One Consultant Psychiatrist, One Non – Psychiatry Consultant, Medical Officer – Quality Management as the Secretary, Medical Officer – Health Informatics, One Special Grade Nursing Officer, Nursing Officer – Quality Management, One Occupational Therapist, One Pharmacist and One Psychiatric Social Worker appointed by the Director – NIMH. 3. The total number of the committee is 10 and the quorum shall be 5.

The Committee shall be appointed for period of one year and renewed annually under the guidance of the Director - NIMH 1. The Director and Deputy Director of NIMH may participate in the Review Committee as ex officio member in an advisory role regarding administrative action.

2. The Committee members shall function in this committee as part of administering their fiduciary duties.

3. All decisions of the committee shall be by consensus. Vote based decisions are highly discouraged however in extraordinary situations decisions may be taken by 2/3 majority vote.

4. If a complaint with regard to Clinical Governance error is made against a member of the committee that committee member must withdraw from all committee activities until such time he/she is cleared of such a charge.

5. Complaint and inquiry Procedure of the Clinical Governance Unit a. All complaints must be received by the Director – NIMH b. Complaints can be made by a NIMH staff member, Quality Management Section, a patient, a guardian or any state officer. c. A written complaint can be made to the committee preferably attested by the Justice of Peace. d. The Director – NIMH at his/her discretion reviews the complaint and decides whether it is to be processed through administrative inquiry or through the clinical governance unit. e. Complaints are required to be made within 1 month of the alleged event. f. The names of the Committee members must be displayed on the notice board of NIMH so that all staff/ patients/guardians are aware of them. g. Anonymous complaints will be rejected in total. h. The inquiry process with regard to a complaint must be completed within 3 months of receiving a complaint. i. The Committee shall meet at least once a month to review complaints and as and when necessary.

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j. The Director of NIMH shall ensure a safe and secure place for the meeting to be held without outside interference. k. Evidence from the clinical records and evidence given by staff and patients involved in an incident shall be reviewed with due diligence and in detail. l. After giving due consideration to evidence the committee shall deliberate on the said incident. m. After which the decision shall be forwarded to the Director, NIMH for disciplinary action or with other recommendations. n. A suitable penalty may be recommended to the Director by the Committee for consideration to a person found guilty of an offense. o. Penalties may vary from verbal warning, written warning, internal transfer, transferring to another institution or interdiction depending on the severity of the offense.

Conduct of a Committee Member 1. All committee members must behave with the utmost confidentiality when dealing with a complaint made.

2. Matters pertaining to on-going investigations should not be discussed anywhere else except during committee meetings.

3. An Impartial and unemotional approach must be taken with regard to all complaints and personal bias must be avoided at all times.

4. When in doubt expert opinion can be taken with regard to any matter.

Other functions of the Clinical Governance Unit

1. The Clinical Governance Unit shall conduct clinical audits from time to time in collaboration with other units of NIMH 2. The Clinical Governance Unit shall conduct a Clinical Governance Meeting monthly at NIMH where relevant topics with regards to quality improvement will be taken into discussion 3. Statistics with regards to clinical events, clinical indicators and other special monitoring data will be reviewed monthly by the clinical governance unit.

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Complain Procedure for patients/ service recipients 1. If a patient/ service recipient or family member wishes to make a complaint regarding any issue they

have the following options. a. Verbal clarification with Ward or Unit Senior Nursing Officer or In Charge Nursing Officer b. Verbal clarification or complaint to the Psychiatric Social Worker c. Verbal clarification or complaint to Special Grade Nursing Officer d. Verbal clarification with Ward On Call Medical Officer e. Verbal clarification with the Unit Senior Registrar f. Verbal clarification or complaint to Unit Consultant Psychiatrist g. Written Complaint or request to Consultant Psychiatrist h. Verbal clarification or complaint to Director i. Written Complaint or clarification to Director j. Written complaint to Director General of Health Services 2. Complaints will be reviewed in a transparent manner to ensure accountability 3. Complaints will be reviewed to ensure the patient's rights are upheld and that standards of care are maintained.

4. Any significant incident detected through a complaint may be reviewed through a departmental inquiry.

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Quality Indicators Monitoring Selected Standards and Indicators in accordance with the Circular No: 02-122/2013 of the Ministry of Health – Modified to NIMH Following standards and indicators are monitored within NIMH for quality assurance purposes.

1. Adequate supply of boiled cool or filtered safe water 2. General Appearance and cleanliness 3. Examination of patients 4. Nursing care 5. A mechanism of collect data on patient safety in place 6. Infection Control 7. Provision of adequate hygiene food 8. Secure access provide for the differentially able & senior citizens 9. Name/Sign board and directional boards standardized 10. Notification of adverse events

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Reporting of Adverse Events/ Incidents All significant events and incidents happening within the ward/ units should be reported to the Director.

This is a requirement as per the NIMH policies made in line with the Mental Diseases Ordinance.

Further it is also a requirement as per Ministry of Health guidelines.

Ward based Adverse events should be reported using the approved form for NIMH (Pink Form).

Nursing Officers are expected to fill and send this form via the Special Grade Nursing Officer to the Director which will be reviewed by the Quality Management Unit Serious adverse events / incidents MUST be reported to the Head of the Institution and the relevant Consultant as soon as possible.

All the adverse events related to specific medical management should be reported by the Consultant, Senior Registrar, Registrar or Medical Officer. All such reports must be seen by the respective Consultant or any other Senior Medical Officer assigned by the consultant.

The adverse events associated with the non-medical management (such as fall, injury, absconding) can be reported by the Nursing Sister or the Nursing Officer.

The nature of the adverse event must be mentioned briefly in the relevant cage. The immediate measures taken to manage the adverse event / incident should be mentioned in the next cage in brief.

In addition to the Pink form the H1259 form issued under general circular 01-38/2016 of the Ministry of Health can be utilized to report incidents by any staff member of the hospital. The Laboratory and Pharmacy related incidents should be reported on the H1259 form. All H1259 forms should also be directed to the Quality Management Section of the PDU.

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Reporting of Readmissions Director General of Health Services, by General Circular No: 01-38/2016 has requested prompt implementation of the Readmission Surveillance in all Health Institutions.

As such the ―Readmission Form‖ (H1261) is to be used at NIMH 1. A Readmission is defined as unplanned subsequent hospital admission in the same or a different hospital within 30 days after discharge from hospital due to the same illness.

2. Transfers from Unit II, Readmitting on the same BHT while on/after Leave will be excluded in this regard.

3. This form must be filled by the Admitting Medical Officer and Key Nursing Officer attending the admission from the ward to all patients detected to be Readmissions.

4. The rubber seal stating ―Readmission‖ should be placed on the BHT for admissions that are compatible with the above definition.

5. The relevant Consultant of the Unit will supervise the implementation of the Readmission Form as per the MOH circular.

6. Medical Officers are requested to ensure completeness of the form.

7. Nursing Officers are responsible to ensure that these forms are sent to the Quality Management Section of the Planning and Development Unit in a timely manner.

8. The PDU – Quality Management Section will coordinate the Readmission Surveillance and the PDU - Health Informatics Section will ensure timely flow of information as per the MOH guidelines.

9. Readmission information will be reported monthly to the Clinical Governance Meeting and Quarterly return will be sent to the MOH – Directorate of Healthcare Quality and Safety.

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Implementation of National Injury Surveillance Secretary of the Ministry of Health, by General Circular No: 01-20/2016 has requested prompt implementation of the National Injury Surveillance System in all Health Institutions.

As such the ―Information of Injury‖ form (H1258) is to be used at NIMH. 1. This form must be filled by the Admitting Medical Officer to all patients detected to have injuries at the OPD. (This form will replace the current form available) 2. This Form must be filled by the On Call Medical Officer for all injuries occurring to patients during hospital stay. (In Ward Setting, At Day Treatment Units) 3. The Form should be filled in duplicate and the original should be sent to the Public Health Section of the Planning and Development Unit. The copy should be kept with the BHT. 4. If the patient with the injury is being transferred to another hospital the form should be filled in triplicate and one copy should be attached to the Transfer Form.

5. In a situation where Death is resulted due to Injury this form will be filled by the Judicial Medical Officer.

6. The relevant Consultant of the Unit will supervise the implementation of the NIS as per the MOH circular.

7. Medical Officers are requested to ensure completeness of the form.

8. Nursing Officers are responsible to ensure that these forms are sent to the Public Health Section of the Planning and Development Unit in a timely manner.

9. The PDU - Public Health Section will coordinate the NIS and the PDU - Health Informatics Section will ensure timely flow of information as per the MOH guidelines.

10. NIS information will be reported monthly to the Clinical Governance Meeting and Quarterly return will be sent to the MOH – NCD Unit.

11. The Injury Surveillance Team of NIMH will consist of Deputy Director, MO – Public Health, MO – Planning, MO – Quality Management, MO – Health informatics, MO – Disaster Management, CSGNO, NO – QM, HPNO and MRO.

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Consultants Units-Colour Code Following colour codes are to be utilized to identify each unit with their clinical records and discharge cards.

Allocated unit

Name of the Consultant

Unit I

Dr. Kapila Ranasinghe

Unit II

Dr. Sajeewana Amarasinghe

Unit III

Dr. Jayananda Horadugoda

Unit IV

Dr. Saman Weerawardhana

Unit V

Dr. Pushpa De Silva

Unit VI

Dr. Pushpa Ranasinghe

Unit VII

Dr. Renuka Jayasinghe

Unit VIII

Dr. M. Ganeshan

Adolescent Unit

Geriatric Unit

Dr. Wajantha Kothelawala

Dr. Kapila Ranasinghe/ Dr Pushpa Ransighe

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Forensic Unit

Dr. Lushan Hettiarachchi

Medical Unit

Consultant Physician

Isolation Unit

Consultant Microbiologist

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Maintenance of Notice Boards Multiple notice boards exist in NIMH all sections providing a valuable opportunity for low expense, high-visibility communications.

Following rules are applied with regard to notice boards.

1. Boards must be positioned in a site best suited to address the targeted ordinance.

2. Each board should have an identified responsible officer/ committee.

3. Boards can only be put up with Director Permission.

4. Notices going on to general notice boards need permission from the Director/ Deputy Director or Administrative Officer.

5. Each notice that is put up should have a time limit and be removed once that time passes.

6. Mental and general health promotion is highly welcomed.

7. Any notice, cut-out or poster can only be put up on designated notice boards.

8. Sarcastic and derogatory notices targeting any individual is strictly prohibited.

9. Notice Boards should be audited by the Quality Management Section of the Planning and Development Unit every six months.

Reference: Internal Circular NIMH/PDU/QMU/2019.27

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Disaster Management Protocols Hospital Disaster Management Committee 1. The Director – Chairperson 2. Deputy Director 3. All the consultants 4. MO Planning 5. MO Disaster Management 6. MO Public Health 7. MO Health Informatics 8. MO Training and Research 9. SMOs + Dental Surgeon 10. Accountant 11. Administrative Officer 12. All SGNO 13. Representatives from Unit 2 (MOIC &SGNO) 14. Chief Pharmacist 15. All In charge sisters and In charge nursing officers 16. Quality & Safety Nursing Officer 17. Infection Control Nursing Officers 18. Chief MLT 19. Chief Radiographer 20. Public Health Inspector 21. Chief Telephone operator 22. All Overseer officers 23. Security Officer in charge 24. Chief cleaning service supervisor 25. Representative from Police - Mulleriyawa 26. Representative from Fire Brigade – Jayawardenapura Kotte

The SMOs and in-charge nurses of each unit are the disaster management focal points for the relevant units and their role is to coordinate and collaborate the disaster management activities with the staff of their units.

1. Hazard Profile Several types of hazards pose a challenge to the hospital a. b. c. d. e. f. g. h. i. j.

Internal Fire Building Collapse Lightning Falling down of branches of trees COVID 19 outbreaks Patient violence Patient absconding Other hospital acquired infections Dengue outbreaks Mass medical emergencies National Institute of Mental Health - 156

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k. Food poisoning 2. Disaster or Emergency preparedness and response plan The disaster or emergency preparedness and response plan was developed based on the revisions of Risk Assessment done in Oct 2021.

If a new hazard is identified, this plan should be updated accordingly.

2.1 Disaster Preparedness A. Disaster management cell Director‘s Office.

This will become the COMMANDING ROOM, Information dissemination center and Center for media information in an event of emergency or disaster.

If the administrative building is affected, the alternative place will be the Planning and Development unit.

A-1 Chief leader The Chief leader for the emergency or disaster situation will be the Director.

In the absence, The Deputy Director should take over the responsibility of the Chief Leader.

If both are not available for the situation, the person who has been appointed to be responsible will be MOon call, or MO available for the moment or else Administrative Officer or On call SGNO. The Director should be informed as soon as possible. Once the Director is available he/she should take over the tasks and responsibilities of the Chief leader A-2 Commanding team 1. The Director 2. Deputy Director 3. Senior Consultant Psychiatrist / On call Senior Registrar 4. MO Planning 5. MO Disaster Management 6. Accountant 7. Administrative officer 8. Chief SGNO/On call SGNO 9. Chief pharmacist 10. Chief Overseer/Night in charge Overseer 11. Chief security officer B. Declaration of a disaster or emergency Decision of the declaration of a disaster is taken by the Commanding Team considering the situation.

Declaration of a disaster is done by the Chief Leader.

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C. Activation of Disaster or Emergency preparedness and response plan Activation of the Disaster preparedness and response plan will be done by the Chief leader with the decision of the Commanding Team. The message will be issued to telephone exchange by the Chief Leader.

D. Roles in disaster preparedness and response D-1 General All the staff should be well aware of the hospital disaster preparedness and response plan. All the categories should know their roles in a situation of a disaster or emergency. Disaster drills or simulation activities should be carried out once a year.

D-2 Telephone exchange Telephone exchange is one of the possible ways of receiving a message on disaster or emergency. And they are responsible for the dissemination of the message of declaration of a disaster or emergency to the staff.

An updated list of contact numbers of Commanding team (Annexure-d) and Hospital disaster management team (Annexure-d) should be maintained separately in an easily accessible place. Contact details of Fire brigade, Police station- Angoda and Civil Defence Unit–Mulleriyawa (Annexure-d) should be kept ready in an easily accessible place. Engaged and busy numbers should not be trying continuously and should dial the next number in the list and later try the missed one. The well-wishers and volunteers should be contacted by the Commanding team on their request.

D-3 Public Address System The Media Unit is responsible for delivering the message efficiently to the staff, once the Chief Leader ordered it to do so. When the media unit is closed, the responsibility lies on The public address system should be maintained by the general office. In a failure of the public address system in a disaster situation the alternative way will be ringing of the kitchen bell prolonged for 1-2 minutes (instructions given to the kitchen staff and staff at the overseer office).

D-4 Planning and Development Unit (PDU) PDU is responsible for ensuring smooth flow disaster preparedness and response activities and entire coordination of the process. Following sections of PDU will be actively involved in the process.

D-4.1 Planning & Quality management section The Planning section is responsible for the coordination of staff training programs in assistance with the Training Unit. They should be responsible for the maintenance of displaying the hospital ground plan, direction boards and emergency sign boards.

A contact list of well-wishers and volunteers should be prepared who can help in providing vehicles, refreshment or manpower in disaster or emergency. A copy should be given to the commanding team as well as the telephone exchange.

D- 4.2 Disaster Management section The Disaster management section and the MO Disaster management are responsible for the arrangement of training programs for the staff and multi-disciplinary coordination with the assistance of the Planning section.

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Emergency exit points and direction boards should be marked clearly in all the units. Safe areas and the directions towards the safe areas should be marked clearly. All the staff members should be well aware of those directions. Maintenance of those should be ensured. Any new points should be updated.

Disaster management section is responsible for the planning and updating of disaster preparedness and response plans.

D- 4.3 Public Health section This section is responsible for the maintenance of minimal cross infections and hospital acquired infections in the hospital.

Once disaster or emergency is terminated cleaning and disinfection of the hospital premises should be observed, supervised and ensured. Responsibility lies on the Public health section with the Public Health Inspector.

D- 4.4 Health Informatics section The Health Informatics section is responsible for maintaining the data on bed strength and the bed occupancy rates and the staff availability should be maintained daily.

D-5 Outpatient department (OPD) Outpatient department is the main service provider in relief activities in the external disaster situations. They should assist whenever necessary by human resources, drugs, equipment or any other necessary measure.

All the staff should be confident in basic life support and advanced life support and skillful in managing disaster or emergency. The OPD staff should be given priority in training and awareness programs on disaster or emergency management.

If a mass casualty incident occurs in the near vicinity of the hospital, the staff of OPD is responsible to deliver basic care to all the patients and save lives of patients as much as possible. Only lifesaving measures should be done and then should act to transfer the patients immediately to the relevant hospital nearby after informing them. (May be the Colombo East General Hospital – Mulleriyawa or National Hospital – Sri Lanka) Disaster cupboard is located at the OPD. It should contain the Disaster stocks, Emergency drugs and Emergency equipment as mentioned in the (Annexure b) .

Keys of the Disaster cupboard should be available in a safe place under the responsibility of Nurse in charge- OPD, but must be available in the OPD premises easily accessible by any available Nursing officerOPD with permission.

The Emergency drugs should be checked weekly and short expiry drugs should be replaced and the Emergency equipment should be checked weekly for the proper functioning. Autoclaved items (Cotton wool, gauze packs etc) should be replaced weekly. The responsibility is with the NI OPD. D-6 All the wards Wards should keep a buffer stock of items and medicines necessary in patient management.

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Emergency medicines and items (as mentioned in the emergency drugs checklist) should always be ready and regularly checked for the proper function of the equipment; for example oxygen cylinders, oxygen regulators, laryngoscopes, etc.

The wheel chairs and trolleys of the wards should be named and numbered for accountability. Responsibility is on the Sister/Nurse in charge of the unit.

The equipment (Ex- Laryngoscope, Sucker apparatus, Multi monitors, Saline stands, Ambu bags etc) should also be named and those should be given on request in disaster or emergency. Dispatch those with the nursing officers and responsibility of getting those equipment back lies on the nurse in charge of the unit as well as the staff members who used the equipment.

D-6 Mental Health training Unit (MHTU) The Mental Health Training Unit is responsible for the staff training on the disaster management activities with the assistance of the Planning and Development Unit.

D-7 Indoor dispensary (IDD)/ Drug stores Chief pharmacist is responsible for provision of drugs, surgical items and other medical items in a disaster or emergency. Initial arrangements should be done to get down necessary buffer stocks to be used in a disaster.

She/he should arrange to send the stocks to a safe place if evacuation is needed and to get those back down.

Fire extinguishers should be checked once a week. The staff should be trained to handle those in case of a fire. Emergency exit should be established.

D-8 Radiology unit Senior Radiographer is responsible for the preparedness of the unit for disaster or emergency. They should keep buffer stock of necessary items as mentioned in section E. The Senior Radiographer should keep a list of contact numbers of all the staff members in the unit and should get down to a disaster or emergency.

The fire extinguishers should be checked once a week. The staff should be trained to handle those in case of a fire.

D-9 Laboratory Chief MLT is responsible for arranging the staff to carry out a huge load of investigations in a disaster or emergency.

Laboratory should be ready with a buffer stock of necessary items as mentioned in section L. He/she should have a list of contact numbers of all the laboratory staff and make necessary arrangements to get them down in a disaster or emergency.

CMLT is responsible for the necessary arrangements for fire safety within the laboratory. The fire extinguishers should be checked once a week. The staff should be trained to handle those in case of a fire Biological and chemical hazards of the unit should be identified and should take necessary steps to minimize the risk.

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D-10 Electricity & Water Chief Overseer is responsible for the continuous electricity and water supply in a power failure and/or interruption in water supply in disaster or emergency.

The function of the generators should be checked once a month and any dysfunction should be addressed as an urgent matter. Buffer stock of fuel should be maintained.

Water supply should be assisted with the local government authorities.

D-11 Maintenance unit Public Health Management Assistant(PHMA)-Maintenance subject & Overseer in charge of Maintenance unit are responsible for the coordination of hospital maintenance work as soon as possible. Work related to disaster preparedness should be addressed as a priority.

D-12 Transport section All the details of the available ambulances and its working condition should be kept documented and updated regularly by the subject clerk.

All the contact details of ambulance drivers and supporters should be kept in a list at the transport section, telephone exchange and should be informed with the request of the administrative officer.

If disaster or emergency is declared and a response plan is activated; ambulances should be ready with full tank fuel with the knowledge of the administrative officer.

All the documents and running charts should be maintained correctly and travelers should be accountable.

Responsibility lies with the PHMA-Transport subject E. Preparedness for Evacuation

All the hospital staff members are responsible for the safe evacuation of all the patients as the immediate priority. Safety should be the primary concern in all the steps of the plan and response.

Reference Horizontal evacuation – Evacuation of patients away from the threat within the same building.

Vertical evacuation – Evacuation of patients from the entire building to another safe building within the hospital premises.

Complete evacuation – Evacuation of the entire hospital.

Immediate evacuation – No preparation, evacuation is done immediately.

Rapid evacuation – Evacuation done with 1-2 hours preparation.

Gradual evacuation – Preparation time is extended. Evacuation is done over several hours or may be days.

Prepare only – Patients are prepared and packed but not moved.

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E-1 Safe areas a. Safe area A – The area under the front tree at the main entrance. b. Safe area B– The area near the rear gate left to the Bo tree and next to the stores. c. Safe area C – The area outside the rear gate in front of the mortuary and right to the Horticulture entrance. d. If the entire hospital is being evacuated; temporary safe area will be the T.B. Illangerathne ground.

E-1.1 Safe areas and Drainage areas for the safe areas The safe areas are marked in the Hospital ground plan. (Annexure c)

Safe area A

Safe Area B

Safe area C

Administrative building

Kitchen & Diet branch

Adolescent Mental Health Unit (Arunodaya)

OPD

Wd 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20

Intermediate Stay Home

Wd 01, 02, 03, 04, 05, 06

Night in charge‘s rooms

Mortuary

Overseer office male/female

OT 1 & 2

Horticulture Therapy Project

Pharmacy

Photocopy center

Shroff office

Laboratory

Main hall

Main Stores

Health assistant‘s rest room

Consumable Stores

Driver‘s room

Oxygen room

Dental Clinic

CECB Office

(Male & Female)

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Radiology unit

Mental Health Training Unit

Doctor‘s duty room

Research Unit

PHI Office

Planning and Development Unit

EEG room

Record room Male & Female villas SGNO‘ s Office – B side PPU Canteen Rehabilitation Center

Forensic Psychiatry Wards a. Ward 21 & 25- Contact prison - Welikada & ask for help ASAP, Contact the Police-Mulleriyawa & tri-forces. b. Evacuate the inmates of ward 21(male) to the 2nd floor of the record room building and inmates of ward 25(female) to the OT-1 through the corridor area under the protection of armed prison guards and police guard. c. Then transfer to the prison hospital- Welikada E-2 Patient Assembly Points Patient Assembly Point for all the patient care units will be the corridor space in front of the wards. The other units for example, Villas, PPU ..etc should occupy the front space as patient assembly points. Patient categorization should be done in the wards accordingly and sent to the patient assembly point.

Patients from each unit should be kept together safely till they are moved to relevant safe areas. If the corridor space is also under threat the alternative assembly point should be the next safest open space in the garden. Any alterations should be informed in advance to the Director through a disaster management medical officer.

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arrange the front car park accordingly with a table and three chairs for the documentation process to be carried out. Tables and chairs will be provided by the doctor’s duty rooms complex.

E-4 Patient destination hospitals All the patients should be transferred to nearby hospitals if complete evacuation is needed.

The destination hospitals are the Colombo East Base Hospital (CEBH) –Mulleriyawa and Half Way Home Mulleriyawa.

Chief leader is responsible for the information delivered to the CEBH of the condition and transferring.

Before transferring patients the summary of the patients should be informed to the destination hospital by the Evacuation coordinators. The appropriate patient care should be delivered by the destination hospital staff. Once the Evacuation plan is terminated the patients should be re transferred.

E-5 Evacuation pathway

a. All the evacuation pathways towards safe areas and the emergency exits are displayed. b. Trolleys and wheelchairs necessary to evacuate the patients should be provided by the unaffected units.

Evacuation pathway is marked in the hospital lay out plan (Annexure c).

E-6 Traffic and Crowd Control Traffic and crowd control should be done by the Hospital police Post and Hospital Security post. Whenever necessary, Police – Mulleriyawa should be informed by the Commanding team to control the traffic and crowd.

Main entrance should be cleared for the arrival of rescue teams and ambulances to transport to and from the hospital premises.

Other gates: Entrance at ETC, Gate at ward 22, Gate at villas and Rear gate The Commanding team should decide the entry and pathway of the rescue vehicles and teams depending on the site of internal disaster, (Ex: Main entrance or Entrance at ECT unit) and inform the Chief Security officer. Other gates should be kept closed.

E-7 Teams in evacuation plan E-7.1 Commanding team Commanding team will be the same as in section A-2.

Chief leader, MO Planning, MO Disaster management should remain in the Commanding room while the others move to their offices. Consultant Psychiatrist and/or On call senior registrar should move to safe area A & B to care for the patients.

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E-7.2 Evacuation Coordinators For the complete evacuation of the hospital, 3 evacuation coordinators should be appointed as follows.

Evacuation Coordinator

Person Appointed

Safe area

A

On call SMO/ On call section A In charge NO

A

B

On call Second SMO/On call matron

B

C

On call Section B In charge NO

C

For the Horizontal Evacuation only the relevant Evacuation coordinator is responsible.

E-7.3 Team of Unit Leaders a. All the units/wards should have a team leader to coordinate the evacuation. b. It may the medical officer, nursing sister/master/officer available for the moment

E-7.4 Patient preparation and packing team The staff members on duty will be the patient preparation and packing team for the respective unit.

They are responsible for the preparation of patients to be transferred to the Assembly point and then to the safe area and if necessary to the destination hospital. (or may be back to the unit once disaster or emergency is terminated. Medical records for continuation of treatment and investigation along with the current situation should be mentioned in a summary.

One person from the unit should be appointed for record keeping on patient details to be sent to the Information center.

E-7.5 Teams for safe areas

Safe area leader

Person Appointed

A

The Consultant Psychiatrist/SR/MO of on call unit from unit 01 /unit 02.

B

The Consultant Psychiatrist/SR/MO of on call unit from unit 03 /unit 06.

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C

The Consultant Psychiatrist/SR/MO of on call unit from unit 04 /unit 05.

Team members will be one nurse from OPD to each assembly point(If there are no reported casualties), one nurse from the units of drainage area, Occupational therapists/Physiotherapist/Social workers. At least one security officer should be there for each safe area.

Unit leaders should report to the relevant safe area after the last patient of their unit is evacuated.

Patients should be looked after till they are transferred to the destination hospital or moved back to the units.

Documentation should be done properly on patient details and transfer details.

Necessary medical equipment and medical drugs should be provided from the OPD disaster stock. Any necessary additional equipment or drugs should be sent along with the patients.

E-7.6 Discharge site team Team leader will be the Consultant Psychiatrist/SR/MO of the Non on call unit from unit 02 /unit 08.

Discharge site team will consist of one nursing officer from the following units. a. b. c. d.

Ward 02 Ward 06 Ward 12 Ward 15

One Nursing officer from each above mentioned unit should be allocated by the Unit leader.

The team members should look after the patients sent from the wards to be discharged. All the records should be kept and necessary instructions should be given to the patients and caregivers regarding the situation of the hospital.

Voluntarily admitted patients can be sent home after proper documentation.

All the adolescent (paediatric) patients should be handed over to the parents/legal guardian only.

F-7.7 Transport teams Health Assistants from the affected units will be the Patient escort team. Volunteers can be appointed by the Commanding room members for additional necessities. Patient escort team members should assist in transporting patients in evacuation and transferring patients to and from safe areas or to and from Discharge sites. Those who need priority in evacuation should be attended first.

2-3 Health Assistants should be appointed to each safe area for Patient Transfer Assistants team for loading patients to the ambulances and vehicles (Health assistants from OPD, MHTU, PDU, Administrative office, Accounts branch, and Doctor‘s duty room) Chief Overseer is responsible for coordinating the transport team members and appointing members for the Transfer Assistants team.

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E-7.8 Messengers team 1-2 Health Assistants from each unit should be appointed as the Messengers for the unit by the in charge officer of the unit.

All the messages should be written and none should be given verbally.

Overseer is responsible for the coordination of the messenger team and appointment of a team leader.

E-7.9 Information centre team Information centre will be located at the security post of the hospital.

3-4 members from the administrative office should be the Information team members.

Responsibility of allocating team members and appointment of the team leader is on the Administrative officer. The team members should be ready with the necessary stationary and other ancillary requirements.

Information on patient details and the sites where the patient is being transferred should be mentioned. All the visitors and family members should be provided with the information necessary.

Media and VIPs should be directed to the Commanding room.

F Preparedness for casualties F-1 Buddy Units The Buddy unit is responsible for informing the Chief leader/on call MO/on call SGNO/on call overseer and the telephone exchange regarding the situation and should attend the affected unit for necessary help. The person who got the information should follow the steps of the RESPONSE PLAN (section 2.4).

Ward 01 – Ward 03 Ward 02 – Ward 04 Ward 05 – Ward 07 Ward 06 – Ward 08 Ward 09 – Ward 11 Ward 10 – Ward 12 Ward 13 – Ward 15

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Ward 14 – Ward 16 Ward 17 – Ward 20- Dheegayu Unit Ward 18 – Ward 19 (ECT) Ward 22 – Ward 21 Isolation 1&2– Learning Disability unit – Perinatal Psychiatric unit Female Villas – Male Villas -Ward 25 Adolescent Unit– Intermediate stay home units

F-2 Teams in management of casualties/mass medical emergency 1. Commanding team As mentioned in section A-2.

Consultant Physician should be in the Commanding team of management of mass medical emergencies.

2. Triage team a. Triage Officer(TEAM LEADER)- Consultant Anesthetist/On call Medical Officer – Ward 18 b. Triage Nurse- Nursing officer from ward 18 c. Health Assistant from Ward 18 3. P1 (RED) team a. b. c. d. e.

Clinical commander (TEAM LEADER)- Consultant Physician/ On call MO of the affected ward Medical officers- On call MO of the affected ward Nursing officers- 2 from affected ward Registration officer- nursing officer from the respective ward Health assistants 2

Any additional teams if necessary should be called from the staff from the buddy unit/OPD Responsibility of appointing members is on the sister/ nursing officer in charge of the ward.

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4. P2 (YELLOW) team a. Medical officer on call from the buddy unit (TEAM LEADER) b. Nursing officers- OPD+Nursing officers from affected ward if available. In an inadequacy nursing officers from the buddy unit should be taken. Altogether 2-3 is enough. c. Health assistants 2-3 from the affected ward or in inadequacy, others from the budding unit. d. Registration officer- clerical staff Appointments should be done by the Sister/Nursing officer in charge of the buddy unit. OPD staff should be called by the Sister/Nursing officer in charge of the buddy unit.

5. P3 (GREEN) team a. Any available On call medical officer (TEAM LEADER) – should be coordinated by the Commanding team b. Nursing officer- 1 from OPD + 2 nursing officers from any available unit (should be coordinated with the Chief/On call SGNO or Night in charge Nursing officer) c. Health assistant – 2 from the OPD or any available unit (should be coordinated with the Chief/On call Overseer Registration will be done by the nursing officers of the same team.

6. P4 (BLACK) team a. Nursing officer- medical unit (TEAM LEADER) b. On call PHMA c. Health assistant – from medical ward One from each category is adequate for the P4 team. Registration should be done by the same nursing officer.

7. Transport team Health assistants Staff members according to the availability should be taken from the unaffected units. Total of 4 members maximum should be allocated as the transport team.

Responsibility of allocation of members and nominating the leader is to the Chief/On call overseer.

Transport team members should be responsible for the trolleys and wheelchairs brought from the units.

8. Messengers team Health assistants

Staff members from the unaffected units should be taken according to the availability. Maximum of 4 members should be allocated.

Responsibility of allocation of members and nominating the leader is to the Chief/On call overseer.

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Revisal and updating of the plan a. Hospital Disaster Preparedness and Response Plan should be revised once a year and whenever necessary in between. b. Simulation exercises and Drills should be conducted once a year. Any shortcomings identified should be corrected and the plan should be updated accordingly. c. Responsibility lies with the Disaster Management section and the MO Disaster Management together with the Hospital Disaster Management Committee.

Disaster Response Management of casualties and evacuation can happen hand in hand in an internal disaster at NIMH. Notification of a disaster Incidents of mass medical emergencies will be notified by the staff members of the unit itself.

He/she should inform the sister/nursing officer in charge of the unit. The information should flow to the MO On call of the unit immediately as well as to the Director.

The Director should decide on declaration of a disaster with the brief discussion of the Commanding team. If the condition can be managed with the assistance of a budding unit it should be encouraged. Or else the plan should be activated in the same manner.

Activation of Disaster preparedness and Response Plan Decision of the declaration of a disaster is taken by the Commanding Team considering the situation.

Activation of the Disaster preparedness and response plan will be done by the Chief leader with the decision of the Commanding Team.

If the director is not available, do as mentioned in section A-1

Dissemination of information Once the plan is activated the Telephone exchange will: a. Call or send an SMS to Inform relevant staff on their direct contact numbers b. Inform Activation of the Disaster Plan through the Speaker system. ―This is National Institute of Mental Health exchange, MAJOR INCIDENT DECLARED, IMMEDIATELY REPORT‖ c. Continuous activation of the ambulance siren All non-emergency outside calls should be diverted and the General line kept free for emergency calls.

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Evacuation The commanding team should immediately gather to the Commanding room and decide on; a. b. c. d. e. f.

declaration of a disaster activation of evacuation plan The degree of response level of evacuation type of evacuation evacuation time frame

Once Evacuation plan is activated; a. The Chief Leader should inform the Telephone exchange to inform the Hospital Disaster Management Committee. b. Public address system operators should be informed to deliver the message. c. Members of the commanding team should collect their action cards and relevant action cards. d. Distribute the relevant action cards to the relevant members e. Act according to the action cards f. Coordinate with the commanding center whenever necessary.

1. Vertical evacuation Patients of affected units should be transferred to the safe wards (Relocation wards) as follows.

If those are also under threat unit leaders and evacuation coordinators should decide on a safe relocation place and inform the Commanding team.

As an immediate measure all the patients of affected units should be evacuated to the relevant safe area and should complete the HEAD COUNT and confirm the presence of all and then only be transferred to the relocation wards.

Wards to be evacuated

Relocation wards

Ward 01, 02, 03, 04

Ward 10 & 12 [Ward 10 & 12 to be sent to ward 09 & 11]

Ward 05, 06, 07, 08

Ward 14 & 16 [Ward 14 & 16 to be sent to ward 13 & 15]

Ward 09, 10, 11, 12

Ward 02 & 04 [Ward 02 & 04 to be sent to ward 01 & 03)

Ward 13, 14, 15, 16

Ward 06 & 08[Ward 06 & 08 to be sent to ward 05 & 07]

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Ward 18 (Medical ward)

Ward 19 (ECT ward) (ECT may be temporarily stopped till the emergency situation is terminated and the unit get repaired. Therefore patients may need transfer to other hospitals for ECT for the time being.)

Ward 17(Male Psycho-geriatric unit)

Ward 04

Ward 20 (Female Psycho-geriatric Ward 12 unit) Villas

Garden in front of villas => to relevant intermediate wards

Isolation units, Ward 02&16, to relevant intermediate wards Seclusion CAT 3 patients OPD/ Occupational therapy units/ to relevant intermediate wards Physiotherapy units/ Horticulture therapy unit/ Rehabilitation units

LDU/PPU

to relevant intermediate wards

Adolescent unit

Main OT

Day treatment center

the safe area will be the garden area at the right side of the unit. They should be sent back home safely once the head count is completed

MHCTU 1&2

Ward 1

Ward 21

2nd floor of record room building => prison hospital Welikada

Ward 25

OT 2 => Prison hospital Welikada

· Visitors in affected units- gather to safe areas through the evacuation pathway marked in arrows and move out of the hospital premises as soon as possible.

2.

Evacuation of patients from the wards

Patient categorization should be done by the unit leaders.

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a. Patients/visitors nearest smoke and fire should be moved first to the designated area. b. Ambulatory patients should be moved next. c. Patients should be moved to the allocated safe area with assistance of staff members and handed over to the nursing officer of the relevant unit. d. Non-ambulatory patients should be moved last. e. Patients in restraints should remain in restraints and be transported by bed with male/female assistant appropriately. f. Patients in seclusion will be transported with appropriate amounts of male and female personnel when indicated. g. Every room should be searched including bathrooms and under beds to ensure all patients have been accounted for and evacuated. h. Patient‘s monitoring charts and bed head tickets or treatment summary sheets should be taken to the relevant safe area with the patient.

3. Evacuation of affected personals from the units Chief leader should inform the appropriate rescue team immediately.

Rescue teams will attend and be involved in evacuation. Staff should only be attended if the situation is safe.

Necessary assistance can be given with the guidance of the rescue team.

Rescue team will be the Fire brigade, Tri forces, Special task force of Police or any other recognized organization.

Management of casualties Triage 1.

2.

3.

4.

5.

6.

Assess the patient at a glance.

Look for the vital signs.

Decide on the category which the patient falls.

Tag accordingly.

Send to the relevant area.

Triage should be done within 2-3 minutes

P3 DELAYED

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Patient walk - in

Yes

Pulse rate

No

60-100/min <60 or >100/min

P2 URGENT

Spontaneous Breathing

Yes

Open airway Breathing

No

60-100/min

<60 or >100/min

P1 IMMEDIATE

Respiratory rate

<12 or >30/min 12-30/min

Pulse rate

<60 or >100/min 60-100/min

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P2 URGENT

Pulse rate

<60 or >100/min 60-100/min

Mental state

doesn‘t obey commands Obeys command

P3 DELAYED

The areas of the ward/OPD should be designated beforehand.

Suggestion: Nurse‘s station

P2 P1

YELLOW AREA

RED AREA

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Entrance First few beds (3-4) can be designated as the RED AREA and next will be the YELLOW AREA while the opposite side can be taken as GREEN AREA, BLACK AREA will be the outside corridor space.

The areas should be displayed in the ward at the Nurse‘s station. In an emergency in the ward the triaged and colour tagged patients should be sent to the relevant areas for the ease of management by the respective teams. The temporary mortuary (BLACK AREA) should be cleared to the hospital mortuary; once the death is confirmed and necessary documentation is over.

1. Initial treatment a. Triage at the treatment area. b. Assess the patient completely. c. Stabilize the condition. d. Record the findings. e. Treat accordingly.

CHANGE THE COLOUR CODING IF NECESSARY AND SEND TO THE RELEVANT AREA ACCORDINGLY. 2. Documentation Registration officers of the allocated units should keep records of all the treatment done and triage colour code in the bed head tickets.

3.

Messengers a. Messengers should stand at the near distance of the affected unit. b. The message should be in written form and sent to the relevant person. (none of the message should be given verbally) c. Messengers should carry the written message immediately to the relevant person and report back as soon as possible. d. Messengers should be occupied with empty OPD chits with them.

4. Transport team a. Transport team should stand at the affected unit without disturbing the treatment and patient flow. b. Once a patient is transported they should report back to the allocated area without undue delay.

5. Termination of the Emergency situation Declaration of termination of the Emergency situation should be done by the Chief Leader with the discussion of the Commanding team. Once; a. The last patient affected by the respective cause is treated and stabilized from the situation,

danger

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b. Hospital/the affected unit is ready to start with usual functions Clean up a. Premises of the affected unit should be well cleaned. b. Responsibility is to the Officer in charge of Cleaning service and the supervision is done by the Public health section hand in hand with the Public health inspector.

Disaster stocks a. All the buffer stocks, disaster stocks and routine stocks should be checked and replaced. b. Responsibility is to nursing officers in charge of respective units. c. Disaster cupboard should be rearranged with necessary replacements. Responsibility lies on the Triage nurse and Nurse in charge – OPD. Inventories a. Inventory of all the units should be checked. b. Any discrepancy should be reported and should act accordingly. c. Responsibility is to nursing officers in charge of respective units.

Return to routine work a. Once the emergency situation is terminated; all the staff should support to return the units to normalcy and start with the routine work.

Evaluation of the action a. Evaluation meetings should be called within 24-48 hours of the 'Termination'. b. Short comings and points to be reviewed should be addressed. c. The preparedness and response plan should be revised accordingly.

Annexures a. Action cards b. Evacuation plan I.

Chief leader a. Inform the telephone exchange to inform the staff accordingly. b. Inform the relevant authorities and get their opinion and assistance. ( Ex- Fire brigade, Police, Military services & etc) c. Liaise with the relevant hospitals to transfer patients and to bring down ambulances if necessary and to ready the team to accept the patients. d. Inform the relevant higher authorities. (Ministry of Health etc) e. Ensure security of the staff and the hospital premises with the police post and hospital security post. f. Decide on the transfer of casualties to other hospitals if the hospital is unable to handle it. g. Estimate the degree of damage initially as a rough measure and later proper estimate with expert assistance. h. Give information to the media and VIPs.

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II. Commanding team a. b. c. d. e. f.

Immediately report to the Commanding room once the information of a disaster is received.

Decide on declaration of disaster or emergency.

Decide on activation of evacuation plan.

Assess the situation.

Estimate the damage.

Chief leader, MO Planning and MO Disaster management should remain in the Command room (Command room members). g. Other members should take their usual places.

III. Command room members a. Assist the Chief leader. b. MO Disaster management should be the telephone operator. c. MO Planning should liaise with the well-wishers and volunteers to get down vehicles for transport of casualties if necessary. d. Coordinate the staff and the rescue teams. e. Coordinate with higher authorities and any relevant authorities (Ex- Police). f. Inform the nearby hospitals (patient destination hospitals) on transferring patients regarding the patient condition. g. Coordinate the volunteers (getting them down and guide them to Administrative officers. h. Get updated information regularly and be ready to disseminate to media or VIPs whenever necessary IV. Telephone operator Inform the Commanding team to gather in the Commanding room immediately. ―EMERGENCY SITUATION IS INFORMED. IMMEDIATELY GATHER TO DIRECTOR‘S OFFICE FOR AN EMERGENCY MEETING.‖ “

ප මඅ

ම

(අ

ප

:

ම

)

ප

.

.”

a. Inform the media unit/OPD to deliver the message through the Public address system. b. Inform the Hospital Disaster management committee dialing their personal numbers. ―THIS IS HOSPITAL EXCHANGE, EMERGENCY IMMEDIATELY REPORT TO RELEVANT AREA‖ “ ) V.

ම .

ප

. ම

ප

SITUATION (අ

අ

IS

ප

DECLARED. :

.”

Public address system operator Disseminate the message immediately through the Public address system. ―EMERGENCY SITUATION IS DECLARED WITHIN THE HOSPITAL PREMISES. IMMEDIATELY READY TO BE EVACUATED.‖ “

ප

(අ ම

ප .

:

) ම

. .”

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If only a part of the evacuation plan is activated, mention the area affected and to evacuate only the affected area. But disseminate the message to the entire hospital.

VI. Accountant a. b. c. d. e.

Report to the Commanding room once the information of a disaster is received.

Be in the Commanding team in decision making.

Report to the usual office after the Commanding team decisions are made.

Coordinate all the financial necessities.

Ensure proper documentation.

VII. Administrative Officer a. b. c. d. e.

Report to the Commanding room once the information of a disaster is received.

Be in the Commanding team in decision making.

Report to the usual office after the Commanding team decisions are made.

Coordinate all the administrative requirements.

Appoint members for the Information centre team from the Administrative office and nominate a leader. f. Make a note for the name list of Volunteers, give necessary information and send them to the Chief overseer. g. Coordinate ambulance teams.

VIII.

Evacuation coordinators a. b. c. d. e. f.

Communicate all the allocated units on evacuation.

Monitor the progress of the evacuation process.

Decide on the available time period and manage the safe evacuation as much as possible.

Coordinate with the Unit leaders.

Communicate with the relevant Safe area, Discharge site for the updates.

Communicate with the Patient Destination hospitals to inform the condition of the patients.

IX. Chief SGNO/On call SGNO a. Coordinate all the nursing staff. b. Allocate and redistribute nursing officers to the units necessary. c. Allocate one nurse for discharge team members from the relevant units. (Wd 02, 06, 12, 15) X. Unit leaders a. Assess all the patients rapidly. b. Nominate dischargeable patients. c. Summarize all the necessary medical treatment and investigations done on patients and ensure medical records are ready. d. Minimize the medical treatment list as much as possible. (Only essential treatment should be continued) e. Prioritize patients to be evacuated. f. Decide on the patient transport mode from the unit to the Patient Assembly point. (Trolley/ Wheelchair/ Walking/ Through stairs/ by elevators etc.) g. Ensure all the patients are evacuated safely to the safe area or to the Discharge site. h. Once the last patient is moved out of the unit, report to the relevant Safe area to assist patient care till transfer/return to the wards.

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i. Compare the headcount of the unit at the safe area with the available data from the unit. Verify all patients and unit members are evacuated safely. j. If necessary, appoint a sub leader and delegate authority to him/her.

XI.

Safe area team leaders a. b. c. d. e. f. g. h.

Accept patients from the units with documents.

Ensure registering all the patients and keeping records.

Ensure delivering patient care at the Safe area.

Ensure sending information to the Information centre at a regular interval. (Ex: once in every 10th patient etc.)

Allocate specific areas to each unit for their patients.

Ensure patient safety and security at the safe area. Make sure the patients are surrounded by a circle of staff members of the relevant unit.

Transfer the patients according to the necessity with maximum use of available transport facilities.

Coordinate with the other safe area team leaders and evacuation coordinators.

XII. In charge officers of the units (Patient care units) a. b. c. d. e.

Assist the unit leader in patient assessment.

Prepare and pack the patients according to the decision of the unit leader.

Allocate a nursing officer to make notes on patient details.

Ensure all the records are done in a summary as decided by the unit leader.

Make rapid discharge notes and transfer the discharged patients to the Discharge site accompanied by Transport team members. f. Transfer the patients to the Safe area accompanied by a Transport team member by the transport mode decided by the Unit leader. g. Ensure the safety of the staff members of the unit. h. Ensure the safety of the inventory as much as possible.

XIII.

Discharge site team leader a. Accept patients from all the units with records. b. Ensure registering and record keeping of patients. c. Ensure updating data to the information centre in a regular interval. (Ex: once in every 10th patient etc.) d. Discharge voluntary patients with records and instructions. e. Hand over the patients to the caregivers with proper instructions. f. Hand over any unattended adolescent/paediatric patients to the dedicated staff member to look after. g. Ensure maintenance of details on patient discharges written.

XIV. Chief overseer a. b. c. d.

Coordinate all the Health assistants.

Nominate the transport team (4members) and the team leader.

Nominate the messenger team (4members) and the team leader.

Nominate the patient transfer assistant team (2-3 members for each safe area from OPD, MHTU, PDU, Administrative office, Accounts branch, Doctor‘s duty room) e. Allocate and redistribute the Health assistants to necessary units. g. Allocate the Volunteers to the Transport team and the Messenger team.

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XV. Information centre a. b. c. d.

XVI.

Get ready with the necessary facilities. (Stationary for documentation, chairs if necessary) Get down information from the safe areas and Discharge site.

Deliver information for the Families and caregivers of the patients.

Guide the Media and VIPs to the Commanding room for information. Do not disseminate any information to them.

Hospital security post a. b. c. d. e. f.

Control the crowd and prevent unnecessary panicking.

Facilitate the removal of vehicles from the hospital premises.

Facilitate the entry of fire brigade vehicles and guide them to the affected area.

Act accordingly to safeguard the hospital as well as the crowd.

Facilitate ambulance transport of the hospital and patient transferring.

Control and guide the patient‘s families and friends.

Mass casualty management/Internal Riot situation.

I.

Chief leader a. Get the necessary information of the emergency or incident from the relevant unit; a.1. Type of incident a.2. Number of patients/persons affected. a.3. Time and place of incident. b. c. d. e. f. g.

II.

Inform the telephone exchange – inform the Commanding team(section H).

Call an emergency meeting with the Commanding team.

Decide on declaration of disaster with the Commanding team.

Decide on activation of the response plan with the Commanding team.

Inform the telephone exchange to inform the Consultant Physician and on call medical officers.

Inform the relevant authorities of an internal riot situation. (Police/STF)

Telephone exchange Inform the Commanding Team (section H) by telephone call; ―Emergency situation is informed from the ward …... Immediately gather at the Director's office for an emergency meeting.‖ “

අං ......... ප

.

ම

ම අ

.”

a. Inform the AO office to inform all the staff by the public address system. b. Be ready to give and get messages from the affected unit and the response teams.

III. Commanding team a. Assess the severity of the incident. b. Decide on declaration of a disaster or emergency. c. Decide on activation of response plan.

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d. Get down the relevant officers and distribute the action cards accordingly. e. Allocate any available medical officer to the P3 team as the team leader.

IV.

Command room members a. b. c. d. e.

V.

Assist the Chief leader.

Coordinate the staff and the rescue teams.

Coordinate with higher authorities and any relevant authorities (Ex- Police).

Inform the nearby hospitals on transferring patients regarding the patient condition if needed.

Get updated information regularly and be ready to disseminate to media or VIPs whenever necessary.

Public address system operator Disseminate the message immediately through the Public address system. ―EMERGENCY SITUATION IS DECLARED WITHIN THE HOSPITAL PREMISES. IMMEDIATELY GATHER TO THE RELEVANT AREA.‖ “

VI.

අං .........

.අ

.“

Accountant a. b. c. d. e.

Report to the Commanding room once the information of a disaster is received.

Be in the Commanding team in decision making.

Report to the usual office after the Commanding team decisions are made.

Coordinate all the financial necessities.

Ensure proper documentation.

VII. Administrative Officer a. b. c. d. e.

Report to the Commanding room once the information of a disaster is received.

Be in the Commanding team in decision making.

Report to the usual office after the Commanding team decisions are made.

Coordinate all the administrative requirements.

Coordinate ambulance teams.

VIII. Chief Matron/On call Matron a. b. c. d. e.

Coordinate all the nursing staff.

Allocate and redistribute nursing officers to the units necessary.

Get down additional nursing officers if necessary.

Coordinate with the unit in charge officers for the requirements and updated information.

Convey the messages and information to the commanding room members and/or chief leader.

IX. In charge officers of the units a. b. c. d. e. f. g.

Inform the chief leader regarding the situation of the unit.

Coordinate all the nursing and health assistants of the unit.

Allocate members to the P1, P2, P3 and P4 teams.

Allocate triage nurse.

Get down necessary equipment, trolleys, and wheelchairs if necessary.

Coordinate with the Chief nurse/on call SGNO for any additional staff members needed.

Coordinate with the Chief overseer for any additional health assistants needed.

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h. Ensure documentation of the patient‘s condition. i. Convey necessary messages and updates of information to the commanding room members.

X. Chief overseer/on duty overseer a. b. c. d.

XI.

Coordinate all the Health assistants.

Allocate and redistribute the Health assistants to necessary units.

Allocate 4 health assistants for the TRANSPORT TEAM and appoint a team leader.

Allocate 4 members for the MESSENGER TEAM and appoint a team leader.

Medical ward staff (ward 18) a. Take the leadership in the medical management of the casualties in the affected unit. b. Consultant Physician will be the ―COMMANDING OFFICER‖ thus the P1 team leader. c. Allocate team members for the TRIAGE TEAM – On call MO as the Triage officer, triage nurse and a health assistant. d. Allocate members for the P4 TEAM – Nursing officers as the team leader and a health assistant.

XII. Patient care wards a. b. c. d. e.

In the affected unit, On call MO will be in the P1 Team.

In the affected unit, 2 nursing officers and 2 health assistants for the P1 team should be allocated.

Rest of the nursing staff should be allocated for the P2 team.

In the buddy unit, On call Mo will be the P2 team leader.

In the buddy unit, necessary nursing staff and health assistants should be allocated to the P2 team. f. Allocation should be done by the in charge nursing officer of the unit/buddy unit. g. Get down a clerical staff member as registration officer through Commanding room members.

XIII.

OPD a. Allocate 2-3 nursing officers and 2-3 health assistants for the P2 team in the affected unit. b. Allocate 1 nursing officer and 2 health assistants for the P3 team of the affected unit. c. Information on necessity will come through Chief SGNO/on call SGNO.

Disaster stock I.

Emergency drugs

1. IV fluids – N. saline, Hartmann's solution, 5% Dextrose, 50% Dextrose, Dextran, Mannitol, 2. IV/IM Pethidine 3. IV Promethazine 4. IV/IM Morphine 5. IV/IM Diazepam 6. IV Atropine 7. IV Adrenaline 8. IV Noradrenaline 9. IV Hydrocortisone 10. IV Sodium bicarbonate 11. Diclofenac suppositories 12. Respiratory solutions – Salbutamol, Ipratropium 13. Antiseptic lotions – Povidone iodine, Chlorhexidine National Institute of Mental Health - 183

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14. Lignocaine gel 2% 15. 1% Lignocaine injection solution 16. Distilled water vials II. Emergency equipment 1. Ambu bags – Adult/ Paediatric 2. Oxygen cylinders, Regulators, Stands 3. Airway tube 4. Face mask – Adult/Paediatric 5. IV set 6. IV cannula (16G, 17G, 18G, 20G, 22G, 24G, Butterfly) 7. Tourniquet 8. Endo-tracheal tube (6.0, 6.5, 7.0, 7.5) 9. Saline stand 10. Splints 11. Nebulizer apparatus 12. Surgical Gloves (6.5, 7.0, 7.5) 13. Disposable gloves 14. Syringes (1cc, 3cc, 5cc, 10cc, 50cc) 15. IV Needles 16. Plasters (Elasto plaster, Leuco plaster) 17. Cotton wool 18. Gauze swabs 19. Gauze bandages 20. Gauze packs 21. Suturing set 22. Stethoscope 23. Blood pressure apparatus 24. Thermometer 25. Torch, Battery with razor 26. Suction apparatus 27. Suction catheters 28. Tongue depressor 29. Laryngeoscope 30. Ophthalmoscope 31. Cervical collars – Hard/ Soft (Several sizes) 32. Urinary catheters (12G, 14G, 16G, 18G) 33. Uri bags III. 1.

2.

3.

4.

5.

6.

7.

8.

Other Disaster files, number tags and colour tags Mackintosh Linen for patients Staff Identification tags Multi monitors ECG apparatus ECG leads Defibrillator

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Important Contact Numbers

Police station- Mulleriyawa

011 257 8279

Fire Service Department Jayawardanapura Kotte

0112879444

Fire Service Department – Colombo Municipal Council

110/ 0112422222/ 0112422223

Chief officer- Fire brigade

0112691637

Bomb disposal squad – Army

0112434251

Nearby health care facilities

CEBH Mulleriyawa

011 2 578226

National Institute of Infectious diseases (NIID)

011 2 411224

Half way home Mulleriyawa

011 2 578242

National Hospital Sri Lanka (NHSL)

011 2 691111

CD Angoda Divisional Hospital - Thalangama

011 2862313

CD Kaduwela Disaster information

Disaster Management Centre (DMC)

011 2 136136

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Disaster Preparedness and Response Division (DPRD) – Ministry of Health

011 2675449 – Ext: 226

Department of Meteorology

011 2 694846

National Building and Research Organization (NBRO)

011 2 588946

Geological Survey and Mines Bureau (GSMB)

0112886289 / 2886290

Resources

National water supply and drainage board – Gothatuwa New Town

011 2530106 0 11 2572152

Ceylon Electricity Board – JayawardenapuraKotte area office

011 286 6212

MOH office Kolonnawa

011 2 411281

Divisional Secretariat Office – Kolonnawa

011 2 572281

Pradeshiya sabha – Kotikawatta Mulleriyawa

0112410288

National Poisons Information Centre

0112686143

Medical Research Institute

011 2 693532

Emergency Ambulance Service

1990

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Committee on Prevention of Sexual Harassment in the Workplace This committee is established at NIMH, Mulleriyawa New Town with reference to the National Policy against Sexual Harassment in the work place developed by the Human Rights Commission of Sri Lanka.

Standard Operating Practices for the Committee 1.

The functions of the committee shall be, 1.1.

Promotion & Advocacy of Gender Equity within NIMH

1.2.

Prevention of incidents in connection with sexual harassments by improving the knowledge among staff regarding the matter in collaboration with the Training Unit and the Gender Based Violence Prevention Unit of NIMH

1.3.

To conduct the preliminary inquiry into complaints of sexual harassment and submitting reports along with relevant recommendations when requested by the Director of NIMH

2.

The Committee shall consist of the following where both male and female representation is encouraged adequately. All such appointments shall be made by the Director of NIMH as per the following guidelines.

2.1.

2 representatives of the medical staff of one being a Consultant Psychiatrist

2.2.

(Shall be nominated by the Director)

2.3.

2 representatives of nursing staff

2.4.

(Shall be nominated by the Director with the concurrence of CSGNO)

2.5.

1 representative of the clerical staff

2.6.

(Shall be nominated by the Director)

2.7.

1 representative of the paramedical and other staff

2.8.

(Shall be nominated by the Director)

2.9.

2 representatives of the support staff

2.10.

(Shall be nominated by the Director with the concurrence of the AO)

2.11.

1 independent nominee by the Director who is not a staff member of NIMH preferably from a legal background

3.

The total number of the committee is 9 and the quorum shall be 5.

4.

The committee shall be chaired by the Consultant Psychiatrist. A secretary shall be selected from amongst the major staff present in the committee by the Director.

5.

The Committee shall be appointed for a period of one year and renewed annually under the guidance of the Director.

6.

A Committee member can resign at any time after informing the Chairperson and the Director of NIMH in writing.

7.

If a post is vacated it should be immediately filled as per the above guidelines by the Director.

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8.

All decisions of the committee shall be by consensus. Vote based decisions are highly discouraged however in extraordinary situations decisions may be taken by 2/3 majority vote.

9.

If a complaint with regard to sexual harassment is made against a member of the committee that committee member must withdraw from all committee activities until such time he/she is cleared of such a charge.

10.

The Committee shall meet at least once a month to review progress and as and when necessary.

11.

Complaint and inquiry Procedure a. At all times complainants must be given the option of getting legal aid through the Police when a complaint is forwarded to the committee for review. If a police investigation is ongoing the committee will abstain from investigating such a complaint. b. All written complaints must be made to the Director. c. Such complaints must only be with regard to sexual harassment related to co-workers. d. Complaints are required to be made within 1 month of the alleged event. e. The names of the Committee members must be displayed on the notice board of NIMH so that all staff are aware of them. f. Anonymous complaints will be rejected in total. g. The inquiry process with regard to a complaint must be completed within 3 months of receiving a complaint. h. The Director of NIMH shall ensure a safe and secure place for the meeting to be held without outside interference. i. Evidence from the alleged victim and alleged perpetrator shall be reviewed with due diligence and in detail. j. After giving due consideration to evidence the committee shall decide that the alleged perpetrator is guilty of the charge made, only if the alleged offence is proven without reasonable doubt. k. Once such a decision is made it shall be communicated to the victim, perpetrator in writing. l. After which the decision shall be forwarded to the Director, NIMH for disciplinary action. m. A suitable penalty may be recommended to the Director by the Committee for consideration to a person found guilty of the offence. n. Penalties may vary from verbal warning, written warning, internal transfer, transferring to another institution or interdiction depending on the severity of the offence. o. If either party, i.e. alleged victim or alleged perpetrator is dissatisfied with the decision of the committee such party can appeal to the Director at which time the Director may at his/her discretion appoint a special three member committee to review the appeal. p. In an extraordinary situation where the committee is dissatisfied with the decision taken by the Director with regard to the recommendation made, the Committee may appeal to the Director General of Health Services for a review of the decision.

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q. If in case of a revenge alleged to have been taken on the complainant because of a sexual harassment complaint the Committee shall request the Director to take immediate disciplinary action in this regard after reviewing the incident. r. If a valid Complaint is made against the Director of NIMH with regard to Sexual harassment the Committee will abstain from deliberating on it and refer the matter to the Supervising Deputy Director General of Health Services of NIMH for review.

12. Conduct of a Committee Member a. All committee members must behave with the utmost confidentiality when dealing with a complaint made. b. Matters pertaining to on-going investigations should not be discussed anywhere else except during committee meetings. c. An Impartial and unemotional approach must be taken with regard to all complaints and personal bias must be avoided at all times. d. When in doubt expert opinion can be taken with regard to any matter.

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Trade Union Action by Staff Unions within NIMH NIMH strongly discourages Trade Union Action within NIMH due the special group of patients NIMH caters to. NIMH encourages dialogue to resolve internal issues and requests central unions to exempt NIMH from all island trade union action similar to children‘s hospitals, maternal hospitals and cancer institutes.

The following factors should be considered in this regard.

1. NIMH caters only for patients with Mental Illness. Mentally Ill patients are a highly vulnerable group of patients subject to harassment, stigma and neglect.

2. Vast majority of NIMH admissions are as Involuntary Admissions done against the will of the patient under the Mental Health Act. Duty of care of staff to the patients as such should be considered much higher than in other hospitals.

3. NIMH also has multiple admissions sent by the District, Magistrate and High Courts and these patients remain in the custody of the Courts. Any lapse in care of these patients may be considered as contempt of courts.

4. Most patients of NIMH do not have good family support and visitors are very limited. As such the patients depend heavily on the institution to look after them.

5. NIMH houses very high risk patients with Suicidal Risk, Homicidal Risk and Risk of Severe Violence. Constant care from all categories of staff is needed to manage these risks.

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Staff Welfare and Safety 1. NIMH is keen to ensure a happy and safe environment for the staff to work in.

2. All departmental staff at NIMH are entitled to benefits that are guaranteed through the Establishment Code.

3. All incidents of staff getting harmed should be reported to the Quality Management Section and Director.

4. Staff are entitled to relevant vaccinations as stipulated by the Ministry of Health.

5. Staff facing major psychological trauma due serious clinical events will be supported under the guidance of a Consultant Psychiatrist at Navodaya or GBV Unit.

6. Medical Officers On Call are duty bound to assess and treat staff members who sustain injury during patient care processes.

7. Staff are entitled for accident leave and compensation as per Ministry guidelines if an accident occurs while on duty.

8. Staff are also encouraged to have the Agrahara Insurance Coverage.

9. Grievances of staff should be directed to the Director through the relevant supervising Staff Officers.

10. Branch Representatives of Trade Unions are allowed to bring forth individual or common grievances to the Director, however prior appointment should be taken to meet.

11. Following common welfare organizations are available with the focus on Staff Welfare. a. NIMH Staff Welfare Association (subjected to governance by the Ministry of Health Circular No 1887 of 1995 from DGHS) b. Section C Staff Welfare Association c. NIMH Buddhists Association d. NIMH Arts Circle e. NIMH Sports Club (subjected to governance under Pub Ad Circular 13/94) 12. In addition NIMH has following two category specific Welfare forum a. Doctors‘ Welfare Committee b. Nurses - Heda Saviya 13. Staff are allowed to use the FRU Gymnasium for exercise and physical recreation. a. They should attend off duty hours b. Gymnasium will be opened for staff after 3.00 pm c. Rs 500 should be paid to the Shroff and a gymnasium membership taken to use it.

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Section C – Education, Training, Research and Health Promotion

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Code of Conduct for Trainees National Institute of Mental Health is a premier mental health training institution in Sri Lanka. NIMH welcomes all approved trainees.

While you undergo your training at this institution it is of primary importance that you inculcate correct attitudes towards mental health care, and those suffering due to psychiatric illness.

Towards these objectives we would like you to go through the following details about our institution, its services and expected conduct of a professional working in mental health.

Introduction to National Institute of Mental Health National Institute of Mental Health (NIMH) was started in 1926 as the Mental Hospital-Angoda, being the main institution serving patients with mental illness in Sri Lanka. It has gone through many evolutions and developments over its nearly 100 years of history. It was re-named National Institute of Mental Health in 2008 and is considered the final referral centre as well as a centre of excellence in mental health care in Sri Lanka.

NIMH serves the whole country with referrals and admissions from all areas of the country. The services provided at NIMH include acute psychiatry care, follow-up (provided at hospital clinics as well as community clinics), psychotherapy, rehabilitation, and supported employment.

It is a health care institution under the Ministry of Health and functions as any other hospital in the country.

An important difference is that NIMH is authorized by Law to admit and keep patients with psychiatric illness without the consent of the patient concerned (involuntary admissions). However this is an infrequent event and most patients receive care in hospital on a voluntary basis.

There are multiple staff categories employed at NIMH under the administration of the Director and Deputy director. These include consultants in psychiatry and other disciplines, post-graduate trainees in psychiatry and other specialities, medical officers, dental surgeons, special grade nursing sisters, nursing sisters and nursing officers, social workers, physiotherapists, occupational therapists, pharmacists, medical laboratory technologists, EEG and ECG technicians, etc. and support staff.

Additionally there are trainees of various categories completing training periods of different durations.

Also there are volunteers from different organizations who provide valuable service and contribute to patient care.

The primary objective of the NIMH is patient care. Other activities such as training, staff development, educational activities and research are additional activities of the institution.

Your responsibilities while in NIMH Safety of patients 1. Safety of patients who are attending to inward and clinic services of NIMH is of primary concern.

You should not at any time compromise the safety of patients in any way. This includes giving any medication which you are not authorized to give, involving patients in activities without authorization or supervision and taking in-ward patients out of the hospital without authorization.

2. Be mindful of patients who pose risks of suicide, falls, aggression and absconding.

3. Always follow the advice and seek guidance from doctors and nurses before taking responsibility for patients.

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4. Please bring any concerns you have regarding safety issues of patients to the notice of the medical team and nursing staff.

Confidentiality 1. You are expected to maintain confidentiality for all information which you come across regarding patients and their families. Under no circumstances should you divulge any such information to others. This includes your family members, friends, spouses, and fellow students and trainees. This applies even after you leave NIMH, following your training period.

2. You are permitted to discuss patients and their illnesses with your colleagues and trainers if this is required as part of your training requirements. Even then it would be good practice to not use identifying details of patients in large forums.

3. You are prohibited from taking any photographs without permission within the hospital. You require the permission of the director to take photographs of the hospital premises.

4. If you need to take photographs of any clinical signs or take recordings it should be with the informed consent of the patient and under the direct supervision of a medical officer.

5. You are prohibited from posting any information/recordings/photographs of patients or their families on social media. Similarly you should not engage in online discussion/chats/webinars/webcasts regarding patients. If there is any requirement to do so you should obtain permission from your training supervisor.

6. You should not take photographs or make copies of bed head tickets. Please note the bed head tickets (BHT) are government property and you are not permitted to make copies without the permission of Director-NIMH. 7. You are permitted to note down details from the bed head ticket for academic/training purposes only.

If you need to take photographs of any clinical investigation for academic purposes, it should be under the direct supervision of a medical officer.

8. Any recordings/photographs should be edited to remove the identifying details of patients before publishing/printing them.

9. If there are any patients who are personally acquainted with you it is best if you don‘t get involved in their clinical management. If the treating clinicians want your input as part of the management of the patient, you will be invited to do so.

10. If one of your acquaintances asks you to find information regarding a patient known to them while you are at NIMH, it is best that you do not do so. Refer all such requests to the doctors or nurses involved in the patient‘s care.

Conduct 1. The patients of this institution and their relatives expect a level of care from all staff and trainees attached to this institution. Therefore you have a responsibility towards the service users of this institution while you are attached to NIMH. 2. The patients and families who utilize our services will be happy to contribute to your training as much as possible most of the time. Consider this a privilege given to you. Do not abuse this privilege.

3. You are expected to treat all patients, whether voluntary or involuntary and their relatives with respect, humanity and equality.

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4. Behavioural abnormalities of patients should never be a source of amusement. Never make fun of patients.

5. Patients should not be invited to perform for you (sing/dance) regardless of whether they consent for it or not. It can be permissible only at times when it‘s part of their therapeutic/management plan.

Always obtain guidance from the treating team when in doubt.

6. You may be tempted to relate what a patient has said/mimic a patient for amusement of your friends and family. This is wrong. Patients may say/do things in an abnormal manner which is an indication of their illness and should invite our compassion rather than amusement.

7. There may be times you are expected to listen to distressing information of patients‘ lives (abuse/trauma/sexual/drug habits etc.). You are expected to learn from this information in order to make you a more effective professional. You should not be judgmental about patients going by this information (calling a patient murderer/rapist/thief etc.)

8. There may be times when patients express religious/political/social views which are against your own personal beliefs. You should never discriminate against patients based on this or try to change/convert them to your point of view. It may be an abuse of your relationship with the patient if you were to argue with patients about these matters.

9. It is forbidden for you to enter into any type of sexual or romantic relationship with a patient or a family member, whether within the hospital, outside the institution or on clinic follow-up. If you receive any sexual invitation from any service user, inform about it to the ward medical/nursing staff or to your training supervisor.

Professionalism 1. As a person receiving professional training your patients and their family members will expect a level of professionalism from you. This includes your dress, manner of talking with them and how you conduct yourself within the hospital and outside.

2. Be respectful and fair in your dealings with service users to enable them to build a trusting relationship with you. Covering your face while interacting with them or use of gloves when it‘s unnecessary to do so, is disrespectful and should not be done. If you are in doubt about whether you should use barrier precautions e.g. where possibility of infection transmission is present, you should clarify this with the doctors or nurses involved.

3. There are multiple staff categories contributing to patient care in NIMH. You need to be polite and courteous in your interaction with all of them. There may be times when the staff in a ward are very busy and unable to help you with your training activities. Please be patient and be mindful that they need to prioritize patient care first.

Contributing to proper patient care 1. The service users of NIMH expect to be provided care by all those associated with the institution.

You, even as a temporary member of the care team may be able to do much to help our service users.

2. Please be ready to help and contribute as much as possible to the management of patients. This may be in helping within the wards, rehabilitation programmes, therapeutic programmes or teaching activities.

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Learning You are in this institution for the purpose of learning and training. It is your responsibility to ensure that the time you spend is spent effectively. The primary source of learning and training will be the interactions with the service users. Additionally there may be teaching activities conducted in the wards, in the Health Education Centre, and in specialized units in the hospital. NIMH has a library with a collection of material on Psychiatry and related subjects. Please use all these resources to help you in your training.

Your safety 1. NIMH strives to ensure the safety of everyone who is working and training within the institution. If at any time you feel unsafe due to actions of a service user in the institution, remove yourself from the area, and ask any member of staff for help.

2. NIMH is a large institution spread over a large geographical area. It is possible to feel lost if you are not oriented in the environment. Ensure that you are aware of where you are and know how to get back to familiar areas.

Where to take complaints to 1. If you have any complaints regarding safety of patients, your own safety, or concerns about conduct of staff, you can bring them to the notice of a doctor or nurse in the unit concerned or your training supervisor. If you need urgent advice you can contact any senior member of the medical staff or the Director through the telephone exchange.

2. If you need clarification regarding your training, schedules or leave, you can obtain advice from your training supervisor or the medical officer-training.

We hope the above guidelines will help you while you are at NIMH, and wish you success in your training programme.

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Code of Conduct for Researchers 1. The four cardinal principles of biomedical ethics are autonomy, non-maleficence, beneficence, and justice. Researchers should be ever mindful of these.

2. Diagnosing a person with mental illness while recruitment in research, one must keep in mind various psychological and social consequences of the diagnosis over that person. If any matter of doubt in diagnosis, the person's interest must be favoured over research interest.

3. The relationship between the investigator and participants should be based on honesty, trust, and respect. Hence, any research group who wishes to conduct any research on persons with mental illness must consist of at least one researcher who is competent and trained to understand the rights of persons with mental illness.

4. Researchers must establish trust with participants by explaining about confidentiality of information gathered during the interview. Consent for legal obligations regarding privilege communications needs to be obtained beforehand.

5. Privacy should always be maintained while gathering information from the participants, and interviews in front of others including relatives should be avoided. Privacy of Data collected and stored should be ensured.

6. Mental illness often compromises persons' decision-making capacity, insight related to need for treatment. Researchers should be ever mindful of this fact and try to mitigate issues arising in a positive manner with the best interest of patients at heart.

7. All Research conducted within NIMH must receive approval from the NIMH Ethical Review Committee. In addition administrative permission of the Director - NIMH should be taken.

8.

Clinical Audits done with secondary data can be performed with administrative permission of the Director.

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Usage of the NIMH Library 1. Library hours are from 7.00 am – 4.00 pm every weekday except Sundays and public holidays 2. Annual membership fee is Rs.100/= and all members should renew annually.

3. Only one membership card will be issued per staff member.

4. Two staff members who are working in NIMH should sign for membership applications as guarantees 5. Books issue only for card owners 6. If lending books damaged or lost, member should replace new copy of same book or other book which has same valuation 7. If membership card lost, Rs.50.00 should pay to issue new membership card 8. Lending books a. Two books at a time for maximum of 2 weeks b. Same book will not be issued more than 2 consecutive times for the same member c. Books marked with red ‗R‘ are not available for lending, only for references in library d. Overdue date books will be charged Rs.5.00 per day e. Two journals will be issued at a time only for members f. Check your books conditions and return date before leaving the library 9. Using Reading area a. All library members can use reading area b. Others can get temporary membership(valid for 3 months) to use reading area (Rs.100.00 for membership) c. Taking meals, sleeping and using mobile phones inside the library are strictly prohibited d. Please maintain silence in the library and do not disturb others

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Training Management Committee of NIMH Preamble: NIMH is the premier mental health institution in Sri Lanka. NIMH conducting large number of training activities including post graduate training in psychiatry, undergraduate training for medical and nursing students, training for the student nurses of nursing training school, Mulleriyawa, and in service training programmes for the staff of NIMH. In addition, NIMH is conducting several theory and clinical examinations.

Training management committee (TMC) has been implemented to streamline above training related activities of NIMH. Objectives/Duties 1. Function as a central supervisory body for all the training activities conducted at NIMH 2. Identify training needs.

3. Promote training activities and educational opportunities.

4. Providing support and supervision for the training programs.

5. Monitor, evaluate and review training activities.

6. Cooperate with other stakeholders to coordinate training Electing the committee The Director - NIMH with the Board of consultants of the NIMH shall invite and appoint members subject to approval of the Institutional Management Committee. Members will be appointing for initial term for a period of 2 years. Members are eligible for re-appointment. At the end of two (02) years the committee is reconstituted, and the new committee should consist of at least five (05) who have a minimum of one years‘ experience as members of previous TMC`s to maintain the expertise and to facilitate the efficient functioning of the TMC. Orientation & training for management committee members need to be provided where necessary.

Meetings The committee will work at regular meetings, reasonably frequent meetings are essential for a committee to work. (Once in every two months) Quorum A minimum of five (5) members are required for a quorum.

Decisions All decisions should be taken by a properly represented TMC meeting.

Where general agreement is not attainable, a simple majority decision from members present for the meeting should suffice.

Membership of the committee (15 in total) The Committee comprise of following members: National Institute of Mental Health - 199

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1. Director – NIMH (Co –Chair) 2. Deputy Director – NIMH 3. Lead Consultant Psychiatrist- Training Unit of NIMH (Co –Chair) 4. Lead Consultant Psychiatrist – Research Unit NIMH 5. One Senior Consultant Psychiatrist 6. One Non Psychiatry Consultant 7. Medical Officer – Training (Secretary) 8. Medical Officer – Research 9. Medical Officer – Quality Management 10. Principal – NTS – Mulleriyawa 11. Chief Special Grade Nursing Officer 12. Chief Psychiatric Social Worker 13. Superintendent Occupational Therapist 14. Nursing Officer – IC – Training Unit 15. Nursing Officer – IC – Research Unit

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Ethical Review Committee of NIMH 1. The Ethics Review Committee (ERC) of the NIMH is a board specialized in reviewing scientific & ethical aspects of research protocols specially ones specific to mental health.

2. The ERC of the NIMH has received approval from the Education, Training and Research Unit of the Ministry of Health and is also a member of the Forum for Ethics Review in Sri Lanka (FERCSL).

3. The ERC is responsible to review research proposals submitted to them for ethical consideration, and to make suggestions on improvement of research protocol in keeping with current ethical standards 4. The ERC is appointed for a two year term by the Director - NIMH in consultation with the Board of Consultants subject to the approval of the Deputy Director General - Education, Training and Research of the Ministry of Health.

5. Functioning of the ERC of NIMH is governed under the following guidelines

a. National Guidelines for the Establishment and Functioning of Ethical Review Committees in Health Care Institutions in Sri Lanka - Education Training and Research Unit of Ministry of Health, Sri Lanka b. Standard Operating Practices and Terms of Reference developed by NIMH - April 2015.

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Guidelines for Submission of Applications to the ERC An Application to the ERC should consist of the following documents: 1. Application Form - Five (5) hard copies (Application forms can be downloaded below from NIMH website) 2. Research Proposal (Protocol) – 15 copies Applicants have the option of submitting Fifteen (15) hard copies of the detailed proposal OR Four (4) hard copies of the detailed proposal and eleven (11) copies of a single paged summary 3. Each detailed proposal should contain copies of the following documents in all three local languages (where relevant) a. Participant Information Sheet b. Consent Form c. Questionnaires d. Assent Form e.

Advertisement for Recruitment 4.

CV of the Principal Investigator

5.

Soft Copy of all documents in PDF format (CD/DVD)

6.

Letter of approval from Board of Study - For Postgraduate Researches only:

7. Letter from supervisor For researches done for academic purposes (Postgraduate or Undergraduate) Please Note: Applications for academic purposes will be only considered if the institute is registered under the University Grants Commission of Sri Lanka.

Applications should accompany a letter from the supervisor. Qualifications of the supervisor should be clearly mentioned in the application as well as in the said letter. (Preferably a CV should be attached).

For Undergraduate researches the Supervisor‘s personal contact details should be included in the Participant Information Sheet.

Letter from Board of Study should be attached (compulsory for Postgraduate researchers).

Submission of Research Proposals in Sinhala language are not encouraged but will be considered under certain circumstances (e.g. Undergraduate Researchers). However, a summary of the detailed proposal in English and English version of all forms and tools should be submitted for consideration POST APPLICATION GUIDELINES: All applicants who are successful in obtaining Ethical Approval from the ERC-NIMH, should submit a progress report or a final report to the ERC within one year of the date of approval.

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Health Promotion Unit Services Health promotion embraces not only action to strengthen individual skills and capabilities, but also actions to change social, environmental and economic conditions to alleviate their impact on individual and community health. According to the Ottawa charter, the key strategies for health promotion are to advocate for health, to enable people to take control of all determinants of health and to mediate between different interests in society for the pursuit of health.

Under the directives of the Health Promotion Bureau of the Ministry of Health, a Health Promotion Unit is established to develop health promotion within NIMH. NIMH Health Promotion Unit shall focus on both on mental health as well as physical health issues.

Health Promotion Unit is under the supervision of the Medical Officer - Public Health and is manned by an In Charge Nursing Officer who has liaison Nurses in all wards and units.

A Health Promotion Committee chaired by the Director and consisting of Deputy Director, Senior Consultant Psychiatrist, Consultant Physician, Medical Officer - Public Health, MOIC - Navodaya, Medical Officer - Planning, Medical Officer - Nutrition, Medical Officer - Training, Senior Dental Surgeon, Special Grade Nursing Officers, Nutritionist, Nursing Sister/ Ward Master - OPD, CPN Coordinator, Nursing IC - Geriatric Unit, Health Promotion Nursing Officer, Quality Management Nursing Officer, Infection Control Nursing Officer and Public Health Inspector will direct the institute‘s Health promotion activities under the following objectives.

General Objective To establish sustainable healthy environments in hospitals which address the physical and psychosocial needs of all stakeholders of a hospital setting Specific objectives 1. To empower the hospital community 2. To establish a setting which provides patient centred care in a healing environment 3. To establish a safe, supportive and healthy environment which promotes healthy lifestyle for all stakeholders in a hospital setting 4. To engage with all relevant health and non- health partners in establishing a sustainable health promotion setting Important Health Days identified for specific health promotion: 1. World Cancer Day: 2. World Tuberculosis Day. 3. World Autism Day: 4. World Health Day. 5. Earth Day: 6. World Malaria Day. 7. World Hypertension Day 8. World schizophrenia Day 9. World No Tobacco Day. 10. World Blood Donor Day. 11. International Day against Drug Abuse and Illicit Trafficking 12. World Hepatitis Day. 13. World Suicide Prevention Day :

04 February 24 March.

02 April 7 April.

22 April 25 April.

17 May 24 May 31 May. 14 June.

26 June 28 July.

10 September National Institute of Mental Health - 203

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14. World Patient Safety Day 15. World Alzeimer‘s Day 16. World Heart Day 17. World Elders and Children‘s Day: 18. World No-Alcohol Day 19. World Mental Health Day: 20. World Diabetes Day 21. International Day for the Elimination of Violence against Women 22. World AIDS Day. 23. International Day of Disabled Persons 24. Universal Health Coverage Day

17 September 21 September 29 September 01 October 02 October 10 October 14 November 25 November 1 December.

03 December 12 December

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Section D – Public Health and Infection Control

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Infection Control Committee The central governance of the institute's public health and infection control issues will be done through the Infection Control Committee.

The Infection Control Committee meeting shall be held every quarter and will be conducted as per the Hospital Infection Control Manual of the Ministry of Health.

The Infection Control Committee will be co-chaired by the Director and Visiting Consultant Microbiologist.

The Secretary shall be the Infection Control Nursing Officer.

Deputy Director, All Consultants, Senior Registrars, Senior Medical Officers of Units, MO - Planning, MO Public Health, MO - Microbiology, MO - Disaster Management, MO - Health Informatics Administrative Officer, All Special Grade Nursing Officers, Ward and Unit IC Nursing Officers, PHI will participate in the Infection Control Meeting.

All Infection Control related issues will be reviewed and policy decisions for the institute will be taken at this meeting with regard to public health measures and infection control.

There shall be an Infection Control Unit established which will be the coordinating point for the infection Control Committee.

The head of the Infection Control Unit shall be the Consultant Microbiologist.

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CSSD Services 1. CSSD (Central Sterile Services Department) is considered a centrally significant place with regard to infection control in the hospital. This unit is the place where, linen, dressing packet, every instrument gets autoclaved. CSSD issues dressing items for all wards in our hospital.

2. The CSSD caters to the need of dressing items such as gauze swabs, gauze towel, cotton packets in our hospital to 42 units.

3. Central Sterile Supplies Department receives the dressing packets on selected dates of the week from the wards and distributes them after the sterilization process to wards and units.

4. They issue the items on all the days of the week with the request book signed by a nursing Officer.

5. CSSD shall prepare gauze packets and cotton packets on a monthly basis 6. The autoclave machines in the CSSD will be validated once in six months by doing the spore test.

7. CSSD will be subject to close supervision of the Special Grade Nursing Officers and Infection Control Nursing Officers.

8. CSSD will be periodically reviewed by the Visiting Consultant Microbiologist and Medical Officer Public Health.

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Waste Management Guidelines Waste Management

Details on waste management are included in following internal circulars.

NIMH/PDU/PH/waste-01: Using carts to collect general waste NIMH/PDU/PH/WM/2017/02: National programme on waste management NIMH/PDU/PH/Gen -04/2018-03: Banning on carrying polythene to hospital premises.

NIMH/PDU/PH/Gen-04/2018-06: Supervision of the sewage system Waste generated in our institution is categorized as hazardous (infectious) and non-hazardous (general) waste. The hazardous wastes generated are Infectious waste, Sharps and Pharmaceutical waste. The nonhazardous wastes generated are food waste, glass waste, plastics and tins.

Safe health care waste management procedures aim to minimize infections and reduce public health risks.

The procedures include the following measures: 1.

2.

3.

4.

Waste minimization and segregation.

Waste collection and onsite transportation.

Waste storage.

Waste treatment and disposal.

According to the Ministry of health guideline, the national colour code for segregation of waste, yellow is for infected waste, yellow with a red strip is for sharp waste, black is for general waste, green is for biodegradable waste, red for glass waste, orange for plastics, , brown for tins and metals.

Waste management in NIMH Waste to be segregated according to the national colour code for segregation in separate colour bins.

Actions to be taken for waste minimization. Waste collection and onsite transportation to be done by designated persons according to the internal circulars wearing appropriate personal protective equipment.

Waste to be stored in the waste collection rooms under lock and key until taken by the relevant authority for proper disposal.

Infectious waste to be collected ward wise into the yellow colour closed bins with a yellow bag inside.

Daily infectious waste to be carried out from the wards to the clinical waste collection rooms by a supportive staff member wearing gloves and masks from 10.00am -10.30am, 1.00pm to 3.00pm. The clinical waste collection room to be kept locked and key than the above mentioned hours. The sharps to be collected ward wise into sharp bins and to be carried to the clinical waste collection room once the three quarters of the bin is filled. Clinical waste to be transported for incineration only by an authorized licensed company through the Ministry of Health. The company should carry out the clinical waste regularly, weekly without an interruption.

General waste collected in wards to be collected in black colour garbage bag into the appropriate bin and it should be carried daily from 1.00pm to 2.00pm by supportive staff members, to the waste collecting carts placed at following five locations.

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5. Between the female villas and ward 25 Cleaning service staff to be carry the cart to the general waste collection room from 1.00pm to 3.00pm (NIMH/PDU/PH/waste-01). General waste to be carried out by the local authority once in two days.

Food and kitchen waste to be collected in green colour closed bins. It should be carried to the general waste collection rooms by the cleaning staff members form 1.00pm to 3.00pm. Food waste to be sold for animal foods daily. The responsible person should carry out the food waste daily, without an interruption.

Glass waste- To be collected in red colour closed bins in wards. Used drug vials and injection bottles to be send to the pharmacy and will send to MSD through the pharmacy. Other glass waste to be send to waste collection room and sell through a tender procedure coordinate by accounts branch.

Tins and metals- To be collected in brown colour closed bins in wards as well as in the kitchen (salmon tins). The above waste to be send to waste collection room and sell through a tender procedure coordinate by accounts branch.

Plastics/ saline bottles / plastic cans - To be collected in orange colour closed bins in wards and waste to be sent to waste collection room and sell through a tender procedure coordinate by accounts branch.

Pharmaceutical waste –Pharmacy should monitor the expiry date of drugs and other pharmaceutical items and take maximum effort to minimize the Pharmaceutical waste. Generated waste to be sent to Medical Supplies Division for disposal.

Coconut husks – Generated in kitchen to be collected at the coconut husk collecting room and to be sell through a tender procedure coordinate by accounts branch.

Waste water -to be carried through a closed drainage system where it will be treated and discharged through a sewage system.

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Cleaning the Hospital Premises Cleaning of hospital premises is done by a Private Company which has been selected by the tender process by the Ministry of Health. It is to be selected on an annual basis.

Details on cleaning of hospital premises is included in following internal circulars.

MA/17/2016 01/2016: Cleaning body fluids other than urine, to be done by supportive staff members adhering to infection control protocols under the guidance of nursing staff .

PDU/PHS/16-Cle-01: Hospital daily cleaning duty series for cleaning staff NIMH/PDU/PH/Clean- 01/2020-01 : Hospital daily cleaning duty series for cleaning staff –(revision) 1. According to the NIMH/PDU/PH/Clean- 01/2020-01: Hospital daily cleaning duty series for cleaning staff (revision); 2. Cleaning of the wards to be according to the above duty series 3. Cleaning of the ward to be observed by Infection control liaison nurse under the supervision of In charge nursing officer of the ward.

4. Daily cleaning checklist to be maintained in every ward. Cleaning supervisors to inspect the ward day & night and sign in the register in the ward. In charge nurse on duty at that time has the responsibility to supervise the signature register.

Special matters 1. Need to wash all the waste bins other than the infectious waste bin.

2. Need to remove dust(clean) on the walls and remove cobwebs daily.

3. Duty hours should be from 6.30am to 6.30pm day time with two members and 6.30pm to 6.30am night time with one member.

4. The cleaner should bring a book to record the attendance and should sign before leaving the premises.

5. Cleaning supervisor should supervise the cleaning daily, day and night and should sign in the register in the wards after the supervision.

6. Cleaning staff members need to clean the garden and the drains around the wards.

7. Cleaning of the pantry and the body fluids (other than urine), need not to be cleaned by cleaning staff members.

8. Chemicals and equipment for cleaning will be distributed in the last week of a month under the supervision of the Infection Control Nursing Officer. The ward requirement can be taken on that day, through a supportive staff member with a written request.

9. Comments on cleaning of the wards, supervision of the supervisors, quality of the chemicals and equipment, attendance and the performance of the cleaning staff to be included in the sheet given monthly by the of Infection Control Nursing Officers, to the wards. The summary of the above National Institute of Mental Health - 210

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document needs to be sent from the Infection control unit, to the Director through the Special Grade Nursing Officers.

10. The time table of the daily cleaning duty series is included in the NIMH/PDU/PH/Clean- 01/202001.

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Outbreak Management Preparing for possible infectious disease outbreaks Notification of an infectious disease Emerging of an infectious disease in a ward/ unit should be notified by a nursing officer of the ward/unit through a telephone call and H 544 (notification form) to the Infection Control Nursing Officer at the Infection control unit of the Hospital.

Considering the reported new cases, the Infection Control Nursing Officer at the Infection control unit of the Hospital will inform the MO Microbiology, MO Public Health regarding the emergence of new cases.

The Consultant Microbiologist will be informed about emerging cases of infectious disease by the MO Microbiology. The Consultant Microbiologist will decide on an outbreak situation considering the emerging cases. Consultant Microbiologist will inform the Director, regarding the infectious disease outbreak.

The Director should decide on declaration of an infectious disease outbreak. Further management will be decided after a brief discussion with the outbreak management team.

The Director should inform the telephone exchange to call the outbreak management team.

The outbreak management team will gather at the Directors conference room.

Outbreak management team 1. The Director 2. Deputy Director 3. Consultant Microbiologist 4. Consultant Physician 5. All the Consultant Psychiatrists 6. Senior Registrars/ Registrars from relevant ward/wards 7. Senior MO from the relevant ward/wards 8. MO Planning 9. MO Disaster management 10. MO Microbiology 11. MO Public Health 12. Accountant 13. Administrative officer 14. Chief Matron/On call matron 15. Chief pharmacist 16. Chief MLT 17. ICNO 18. PHI 19. Chief overseer/Night in charge overseer Members of the outbreak management team need to take necessary actions to control the outbreak situation coordinating with the outbreak management team whenever necessary.

The Actions can be taken Restrict/stop the admission of patients to affected wards. Avoid internal/ external transfers from and to above wards. Identify an unaffected ward and direct the admissions to identified ward until further notice.

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Limit the number of readmissions of leave patients by extending the leave of possible patients, after getting senior opinion.

Take actions to reduce the total number of patients in unaffected wards by discharging and sending leave of possible patients. Medical Officers of all wards need to coordinate this with the Consultants and Psychiatric Social Workers.

Restrict the visitors coming to affected wards until further notice.

When isolating patients during an outbreak situation, if the isolation unit is filled up to its full capacity, can transfer the reported docile patients to IDH hospital.

Public address system operator should be informed to deliver health messages during an outbreak situation after getting approval from the director.

After declaring the Outbreak situation, General measures need to be taken by the staff, functioning of the ECT unit, procedure of using Ambulances are the following.

General measures to be taken by the staff Medical Officers in wards/Unit 1. Early diagnosis of infection. Start appropriate medication early.

2. Isolation of infected patients. Isolate the patient in the ward or seclusion room until the isolation facility available in the isolation ward or transfer to IDH hospital.

3. When the isolation unit is filled up to its full capacity, can transfer infected docile patients to IDH hospital.

Avoid mobilizing patients from your ward to other wards or units (ECT/ Rehabilitation Unit/ for the purpose of clerking patients etc.) unless absolutely necessary. Permission should be taken from the relevant consultant prior to mobilizing patients. The time period to avoid mobilization will decide by the consultant Microbiologist according to the incubation period of the disease.

1. Wear the personal protective equipment appropriately ( gloves, mask, gown ) 2. Provide personal protective equipment to the patient.

3. Practice the correct method of hand washing and hand disinfection in five moments. Use liquid hand washing or soap and running water appropriately.

(Five moments – before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after touching a patient, after touching patient surrounding.)

1. Fill the Notification form (H-544) whenever the case is suspected and hand over it to a nursing officer to enter in the ward notification register.

2. Take measures to reduce the total number of patients in all the wards by discharging and sending leave of possible patients by coordinating with Consultants and Psychiatric Social Workers.

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· When sending absolutely necessary patients to ECT from affected wards, high risk (exposure to disease) patients should be send later in the ECT list. When preparing high risk (exposure to disease) patients for ECT, starting time for fasting should be later than the non risk patients for disease.

1. Dispose waste appropriately.

2. Contact Consultant Microbiologist, MO Microbiology or MO Public health or Infection Control Nursing Officer in any quarry.

Nursing Officers in wards/Units 1. Early identification of infected patients during nursing care.

2. Wear the personal protective equipment appropriately ( gloves, mask, gown ) 3. Provide personal protective equipment to the patient and the susceptible /immune-compromised individuals in the affected wards.

4. Practice the correct method of hand washing and hand disinfection in five moments. Use liquid hand washing or soap and running water appropriately.(Five moments – before touching a patient, before clean/aseptic procedure, after body fluid exposure/risk, after touching a patient, after touching patient surrounding.)

5. Provide the alcohol hand rub to susceptible / immune-compromised individuals to clean the hands frequently.

6. Check the availability of appropriate drugs in the ward during an outbreak situation.

7. Change bed linen and disinfect them frequently during an outbreak situation.

8. Clean the beds and mattresses frequently.

9. Wash and disinfect the wards frequently with the help of the supportive staff during an outbreak situation.

10. Disinfect the seclusion room after sending the infected patient from the ward.

11. Collect the notification form and send to the infection control unit.

12. When sending absolutely necessary patients to ECT from affected wards, high risk (exposure to disease) patients should be send later in the ECT list. When preparing high risk (exposure to disease) patients for ECT, starting time for fasting should be later than the non risk patients for disease.

13. Contact hospital Infection Control Nursing Officer, MO Public health, MO Microbiology in any quarry.

Supportive staff in wards/Units 1. Wear the personal protective equipment appropriately ( gloves, mask, gown ) 2. Provide personal protective equipment to the patient.

3. Practice the correct method of hand washing and hand disinfection in five moments. Use liquid hand washing or soap and running water appropriately.

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(Five moments – before touching a patient, before a clean/aseptic procedure, after body fluid exposure/risk, after touching a patient, after touching the surrounding patient.)

1. Wash and disinfect the wards frequently according to the instructions given by the nursing staff during an outbreak situation.

Chief Pharmacist 1. Check availability of buffer stocks of oral/ intravenous drugs, local applications, disinfectants, personal protective equipment, locally prepared and commercial hand rub need during an outbreak situation.

2. Keep buffer stocks of oral/ intravenous drugs, local applications, disinfectants, personal protective equipment, locally prepared and commercial hand rub needed during an outbreak situation.

3. Liaise with the Infection control Nursing Officers, In-charge Nursing Officers of affected wards during an outbreak situation.

Chief MLT 1. Check availability of buffer stocks of reagents, solutions need during an outbreak situation.

2. Keep buffer stocks of reagents, solutions need during an outbreak situation.

3. Liaise with Consultant Microbiologist, MO Microbiology, Medical Officers /In charge Nursing Officers of affected wards during an outbreak situation.

Functioning of the ECT unit 1. When receiving absolutely necessary patients to ECT from affected wards, high risk (exposure to disease) patients should be send later in the ECT list. All the staff in the ECT unit needs to adhere to standard precautions while handling the patients.

2. Wash and disinfect the unit appropriately when handling the high risk (exposure to disease) patients.

3. Contact hospital Infection Control Nursing Officer, MO Public health, MO Microbiology in any quarry.

Procedure in using ambulances 1. When ordering ambulances to transport patients/ susceptible patients in affected wards, the informing officer in the affected ward, needs to order a separate ambulance to transport the patients/ susceptible patients and inform the transport authority in the inquiry room about the patients /susceptible patients plan to transport.

2. Transport authority in the inquiry room need to take measures, not to send non risk patients in the above ambulance.

3. After the transportation is over, the ambulance used to transport patients/susceptible patients, need to be cleaned and disinfected according to the instructions given by the Infection Control Nursing officer.

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Vaccination of Patients for Hepatitis B Vaccination against Hepatitis B 1. Details on Vaccination against Hepatitis B is included in following internal circulars.

2. Letter dated 2014/06/27- Hepatitis B vaccination for all the patients in acute and intermediate wards and patients in unit II. 3. NIMH/PDU/PH/Gen-04/2018-01- Write the Hepatitis B vaccination status in the Diagnosis card.

4. NIMH/PDU/PH/Gen-04/2018-02- Hepatitis B vaccination for all the patients and staff 5. NIMH/PDU/PH/Gen-04/2019-06 – Screening clients in selected wards for Hepatitis B 6. NIMH/PDU/PH/Gen-04/2019-07 – Vaccination of all patients in NIMH for Hepatitis B, Vaccination schedule.

7. Due to identification of new patients with Hepatitis B, from different wards, Clinician and Administration has taken a decision to vaccinate all patients and staff against Hepatitis B. 8. Procedure on vaccination against Hepatitis B 9. Consent for the hepatitis B vaccination needs to be taken at the admission for newly admitted patients and for currently inward patients consent to be taken at the ward. Consent can be taken by MO at the OPD or MO in the ward.

10. Before ordering the vaccine, allergy history for yeast (bread) and previous hep B vaccine, to be asked and if no allergies, can order the vaccine by MO at the OPD or MO in the ward in the BHT. Contact consultant Microbiologist for further clarification.

11. Hepatitis B vaccine is given at the day time in the ward setting and for night admissions vaccine to be given at the following day.

12. Vaccines are issuing to the wards daily, by the ICNOs attached to the Infection control unit and vaccine is given at the ward by the ward staff with the supervision of ICNOs. 13. Following the vaccination, a card is issued to the patient and vaccination details will be included in the BHT on the provided rubber stamp. When the Hep BsAb reports are available, mention the antibody status in the card and the rubber stamp. For non responders of the vaccine put a label on the BHT. 14. If the patient discharged before completing the vaccine course inform caretaker about the relevant dates to get down the patient for vaccination 15. A register to be maintained at the Infection control Nursing Officers about the hepatitis B vaccination of patients and healthcare workers and also the non-responders.

16. For the Healthcare workers- The vaccine schedule is 0,1, 6 months from the first dose. Following getting 3 doses of vaccine check the antibody status after 4 weeks of the third dose. Antibody status can be checked from the MRI after filling the form and sending the sample through the lab. Collect the antibody report from the lab once received.

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Prevention of spread of Conjunctivitis General Prevention Instructions 1. Don't touch your eyes with your hands.

2. Wash your hands often.

3. Use a clean towel and washcloth daily.

4. Don't share towels or washcloths.

5. Change your pillowcases often.

In the Ward Setting 1. Patients identified to be infected should be kept separated with adequate ventilation and sunlight.

(Isolation is not mandatory) 2. Relevant Eye Drops should be applied as per medical advice 3. Infected patients should be: a. Bathed Daily b. Arrange a Change of clothes daily c. Face and Eyes to b washed three times a day 4. When an infected patient is found in the ward all patients in that ward should be encouraged to use hand rub every fifteen minutes and regularly wash hands under the supervision of Nurses. Eyes should be checked every half an hour.

Reference: Internal Circular PDU/PH/ICU/PHA-01

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Screening and Treatment of Tuberculosis Infection Control in Tuberculosis General measures 1. Patients with suspected /confirmed respiratory tuberculosis, regardless of the sputum status, should not be admitted to an open ward containing immune-compromised patients, transplant or oncology patients until pronounced non-infectious by the physician in charge, preferably in consultation with the Microbiologist.

2. The Infection Control Team should be informed. Staff and visitors who are non-immune should be warned of the risk.

3. Duration of infection control precautions in pulmonary TB should be for two weeks after start of effective antimicrobial treatment and sputum microscopy should be negative for AFB. In immunosuppressed patients duration of infection control should be till sputum microscopy is negative for AFB. Infection control precautions Isolation Isolate in a single room with negative air flow ventilation in relation to the surrounding areas. As there are no negative pressure rooms available in Sri Lankan hospitals, a room with 2 strong exhaust fans could be used instead. Alternatively, a single room with good ventilation may be used.

1. Room with a washbasin and preferably, with an attached toilet 2. The door must be kept closed at all times. Preferably self-closing doors.

3. Ensure adequate supply of hand wash antiseptics and single use towels.

4. Ensure a clinical waste bag is kept inside the room.

5. A sputum mug containing 5% Phenol (Lysol) for sputum should be provided. This is ideally autoclaved before disposal. If facilities are not available for autoclaving they should be disposed of by burning or deep burying after disinfection using 5% phenol or 1% hypochorite for 30 min.

Currently provide the disposable plastic cup to collect the sputum and send them for incineration.

6. Visitors should be restricted, as far as possible.

Babies of sputum positive mothers need not be separated from the mothers and breastfeeding should be continued with the baby on prophylactic INAH therapy, with the mother wearing a mask.

Protective clothing 1. Gloves are not usually necessary, but should be worn for contact with respiratory secretions or contaminated articles.

2. Plastic aprons and gowns should be worn for contact with patients and their environment to avoid contamination of clothing.

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with uncontrolled cough to reduce aerosol spread. Wearing a mask for the staff is recommended when direct exposure to respiratory secretions is unavoidable. eg: during physiotherapy or bronchoscopy. Masks should be close fitting. Wearing a mask is not a substitute for good infection control.

Hand hygiene 1. Hands must be washed after touching the patient or potentially contaminated articles and before taking care of another patient.

2. Wash hands thoroughly with an antiseptic and dry with a single use towel.

Equipment 1. Ideally, Disposable respiratory equipment and accessories should be used. o Where this is not possible, they should be thoroughly cleaned and disinfected or sterilized before reuse.

Movements 1. Limit movement within the hospital, eg to X-ray department, to a minimum Contact tracing 1. Contact tracing is an integral part of the routine management of the patients with tuberculosis. The person responsible for local contact tracing should be named by the hospital authorities.

Hospital Infection Control Manual © SLCM / 2005 TB Clinic at NIMH A clinic has started at NIMH premises, to screen and continue treatment for Tuberculosis liaised with the National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) and MO chest clinic attached to Colombo East Base Hospital. A Medical Officer from NPTCCD visits once a week for the above clinic.

1. All the patients residing in long term wards are screened for TB and start treatment for newly diagnosed patients.

2. Previously diagnosed patients are followed up at the clinic and continue the treatment.

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Cannula Site Observation Insertion of a Peripheral venous cannula 1. In adults, upper extremity insertion sites are preferable than lower extremity.

2. Hands should be washed with soap and water before and after insertion and between procedures.

3. Use a new pair of disposable clean gloves.

4. Selected insertion sites must be disinfected with 70% alcohol and allowed to dry.

5. After insertion, cannula must be secured, to stabilize it at the insertion site and covered with a sterile dressing.

6. The date of insertion must be recorded on the BHT and if possible on the dressing.

7. Cannula sites must be inspected daily for evidence of infection and recited at the first site of inflammation.

8. Gauze dressing should be changed in 48 – 72 hours or when damp, loosened or visibly soiled.

9. Flushing or irrigation of the system is preferably avoided.

10. The IV system must be maintained as a closed system. All entries should be at the injection ports.

Wipe port with 70% alcohol before and after use. All entry ports should be kept closed when not in use.

11. IV administration sets should be changed every 48 – 72 hours.

12. IV administration sets used for parenteral nutrition and administration of blood, blood products or lipids must be changed within 24 hours.

13. Peripheral cannulae are usually kept for no longer than 72 hours. If used for longer periods, they should be replaced every 48 – 72 hours in adults. However in children the cannula can be left in situ until IV therapy is completed or a complication occurs.

14. IV cannula should be removed as soon as possible and a sterile dressing should be applied.

As a part of development of quality and safety in Infection control, Cannula site observation chart to be maintained by nursing staff, for all patients who have a cannula in situ. This is in keeping with the international guidelines in maintenance of IV lines.

1. Cannula site observation form to be filled with the patients BHT by the Nursing Officer.

2. Nursing Officer in Charge of each ward/unit will be responsible for the implementation of this form.

3. SGNOO are requested to supervise the implementation of this important surveillance activity.

4. Medical staff need to ensure close observation of cannula sites in the daily rounds to detect and prevent cannula site infections.

5. Public Health Section of the planning and development unit will be tasked with the auditing the forms under the guidance of the Consultant Microbiologist.

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Rational Use of Antibiotics 1. Rational antibiotics use strategies enhance the effective, safe, and cost-effective use of medicines, preserve the effectiveness of antimicrobials, and contribute to good health outcomes.

2. Antimicrobial resistance is becoming a global and local threat and it is the responsibility of all clinical staff to ensure rational usage of antibiotics.

3. As such all prescribing officers should be extremely mindful of the relevant guidelines with regard to rational antibiotic usage.

4. The Following are important guidelines that all Medical Staff, Nursing Staff and Pharmacy Staff should update themselves on. a. General Circular 01-56/2016 by DGHS, Ministry of Health regarding Introduction of authorization of prescribing Red light antibiotics b. General Circular 02-166/2013 by DGHS, Ministry of Health regarding guidelines for the use of antibiotics in Central Nervous System Infections c. DGHS/Col.Micro/2014-114 dated 11.03.2014 regarding national antibiotic guidelines on Endocarditis d. DGHS/Col.Micro/2014-114 dated 12.09.2014 regarding National antibiotic guidelines on skin and tissue infections 5. Stewardship of the Antibiotic Usage at NIMH shall be under the Infection Control Committee and the Consultant Microbiologist.

6. Medical Officers are alway encouraged to get Consultant Microbiologist and Consultant Physician opinion when using multiple antibiotics.

7. When prescribing antibiotics Medical Officers are also instructed to fill the antibiotic card which will be utilized to monitor antibiotic usage.

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Wound Management and Care for MRSA Management of Methicillin resistant Staphylococcus aureus (MRSA) 1. Treatment Patients infected with MRSA should be treated with relevant antibiotics guided by an antibiotic sensitivity test.

2. Screening Patients for colonization a. Nose – both nostrils swabbed with one swab b. Perineum or groin – both sides swabbed with one swab c. Axilla – both axillae swabbed with one swab d. Throat e. Skin lesions – swabbed as wounds, ulcers, rash, IV or drain site f. Catheter Specimen of Urine – if indwelling catheter present g. Sputum – if productive 3. Swabs are moistened with sterile saline before obtaining specimens.

4. Eradication 5. The Microbiologist should be consulted before instituting eradication protocol.

6. Colonized patients should undergo a 5 Day MRSA Eradication Protocol:7. Daily baths with 4% chlorhexidine in detergent solution or 4% povidone iodine applied neat to the skin with a washcloth.

8. On days 1, 3, 5 wash hair with 4% chlorhexidine or 4% povidone iodine followed by normal shampoo.

9. Apply 2% mupirocin nasal ointment to anterior nares three times per day. A match-head size portion of ointment/cream to be applied to each nostril using a disposable cotton swab. Alternatively, chlorhexidine cream, neomycin / chlorhexidine cream or povidone iodine cream can be used.

10. Apply 2% mupirocin on colonized or infected skin lesions (avoid use on deep/extensive wounds) 11. Change personal clothing and bed linen daily.

12. After 5 days stop eradication treatment.

13. 48 hours after completing the eradication protocol, repeat the screening. If a patient has had antibiotics for MRSA do not re-screen till 48 hours after IV treatment has ceased.

14. Continue isolation until 3 complete sets of negative swabs are obtained. There should be at least 3 days between each set of swabs.

15. Refer Hospital Infection Control Manual © SLCM / 2005

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Hospital Environment Committee This was established for the purpose of landscaping, development of the internal road network, improvement of hospital environment, solid waste management, sewage system management, dengue mosquito control, enhanced green productivity, wastewater management, energy and water saving measures.

The members of the Hospital Environment Committee are - The Director, Deputy Director, Consultant Psychiatrist, Consultant Physician, Consultant Microbiologist, Medical Officer Planning, Medical Officer Rehabilitation Coordination & Disaster Management, Medical Officer Public Health, Medical Officer Health Informatics, Dental Surgeon, Accountant, Administrative Officer, Chief Nursing Officer, Special Grade Nursing Officer, Nursing Officer Quality Management, Infection Control Nursing Officer, Health Education Nursing Officer, In-charge Horticulture unit, Chief MLT, Chief Pharmacist, Chief Psychiatric Social Worker, Chief Occupational Therapist, Public Health Inspector, Management Assistant, Chief Overseer, overseer, Chief Cleaning Service Supervisor.

The circulars on Hospital Environment Committee NIMH/PDU/PH/HEC/001 - Establishment of the Hospital Environment Committee NIMH/ PDU/PH /Env-04/ 2020-01 - Updating the members of the above committee

Green Circles Green circle/ Haritha Mithuru Kawaya was established as per the decision taken at the Hospital Environment Committee meeting. The members of the Haritha Mithuru Kawaya need to engage in the improvement of the hospital environment, dengue mosquito control, enhance green productivity, and energy saving measures. The hospital area was divided into seven zones and (A to G ) each zone had to be maintained by the relevant team members of the zone.

The circulars on green circles NIMH/ PDU/PHDM /PH -05/ 2016-01 – Establishment of the Haritha Mithuru Kawaya NIMH/ PDU/PH/HFC -01/2017/07 – Plant trees in Green August NIMH/ PDU/PH /Env-04/ 2020-01- Updating the members of Haritha Mithuru Kawaya

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Control of Stray Animals Stray dogs and cats cause health hazards within the hospitals.

Circulars issued by ministry of health 1. PA/E &OH/11/2015 – Controlling of Stray Cats and Dogs within the Hospital Premises 2. Though there is an immunization and sterilization programme it has not been very effective in controlling Stray Cats and Dogs.

3. Food waste to be securely collected and stored until proper disposal.

4. Health care staff and others need to refrain from feeding and providing shelter to stray dogs and cats within the hospital premises to prevent breeding of stray animals.

Actions to be taken to control stray animals (cats, dogs) 1. To conduct immunization and sterilization programmes by the public health section liaise with the Public Health Inspector.

2. Refrain from feeding stray animals (cats, dogs) by the staff and the patients.

3. Dispose food waste securely only to the waste bins.

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Section E – General Administration

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General Advice for all staff 1. Staff who are working in NIMH are expected to give their undivided allegiance to the state at all the time and on all the occasions when the state has a claim on his/her service.

2. All staff are expected to behave with professionalism and dignity 3. Wastage of state resources must be strictly avoided by staff.

4. Patients must be given the foremost place within the institution.

5. Any claim made for extra duty or overtime or other allowance should be made in good conscience being truthful about duty.

6. All written communications should follow the proper chain of command.

7. Should perform any duties assigns diligently efficiently 8. An officer is required to familiarize themselves with an to observe to provisions of all the Guidelines of NIMH, Financial Regulations, Establishment Code, Circular Instruction and other Departmental Manual and Instruction 9. Should at all the time acting a manner befitting of publish office, should not commit any act that would bring publish service or post he holds in to disrespect 10. An officer should not do anything which will bring his private interest into conflict with his public duty or which compromises his office 11. An officer should not use liquor or narcotic drugs during his working hours or within NIMH premises 12. Offers or member or his family shall not accept any presents, gifts or other benefits from patients or their family members 13. A work attire should be strictly adhere to when attending to work 14. The staff member must be punctual and prompt in delivery of services 15. Must be prepared to accommodate any form of aggravated or normal cases (patients) at NIMH 16. Every staff member is under the obligation to protect the environment and maintain the properties of NIMH 17. All the public officer working in NIMH, shall adhere to provisions Mental Health Ordinance, Vision and Mission and Guidelines of NIMH, Establishment Code and Financial Regulations and Public Administration and Treasury Circulars

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Staff Administration 1. As the National Institute of Mental Health is part of the Department of Health Services of the Ministry of Health Sri Lanka the staff administration will be done in accordance with the rules and regulations of the Public Services Commission and the Ministry of Health.

2. All staff must abide by the Constitution of the Democratic Socialist Republic of Sri Lanka which is the highest law in the land.

3. Attention is also drawn to the Pub Admin Circular 11/2015about the responsibilities of public officers and rights of service recipients.

4. Official Languages policy should be adhered to as per Pub Admin Circular 18/2020.

5. Staff should adhere to relevant uniform and dress code protocols as per Pub Admin Circular 13/2019 (1).

6. Betel Chewing, Smoking and tobacco related items are strictly prohibited to staff as per General Circular 01/14/2018 of the Secretary of Health.

7. All staff officers should be available for public access on the declared ―public day‖ of the week.

8. Relevant communications with regard to administrative matters should be done in accordance with the chain of command as per departmental regulations.

9. Leave should be taken as per existing regulations and prolonged leave unless for special circumstances is discouraged.

10. As psychiatric and mental health care is exhausting, 24 hour duty is discouraged and will need approval from supervising staff officers.

11. Staffs are expected to actively adhere to the Vision and Mission of NIMH as well the Internal Guidelines issued with regard to conduct on all matters.

12. All routine staff administrative matters will be done by the General Office Personnel Branch and Establishment Branch. A Sub Office to support the main office will be maintained at Section C. 13. For purposes of supporting human resources management some staff administrative matters will be delegated to the SGNO offices of Section A, B and C for Nursing Offices and Overseer Offices of Section A, B and C for support staff.

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Financial Administration 1. Financial Administration of the NIMH is done as per the Financial Regulations of the State, Treasury Circulars and Ministry of Health Circulars.

2. Necessary funding is received from the Ministry of Health.

3. The Chief Accounting Officer for NIMH is the Director.

4. The Accountant will supervise all financial matters at NIMH as the certifying officer.

5. The Shroff Office will be kept open for monetary transactions on all working weekdays from 8.30 am to 3.00 pm 6. All staff are expected to act in a manner where there is minimum wastage of government funds.

7. The Secretary of Health will issue annual instructions on the financial processes and NIMH will follow the said delegation circular for financial administration.

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Planning and Development Services 1. The Standard Operating Practices for the Planning and Development Unit is developed based on the Terms of Reference stipulated in the General Circular Letter No: 02-88/2015 of the Ministry of Health.

2. The Planning and Development Unit (PDU) of the National Institute of Mental Health will function under the direct supervision of the Director and Deputy Director of NIMH. 3. Cadre identified for the NIMH PDU are, Medical Officer – Planning (Section Head), Medical Officer – Health Informatics, Medical Officer – Public Health, Medical Officer – Disaster Management , Medical Officer – Quality Management, Medical Officer – Media Coordination, Nursing Officer – Quality Management, Two Infection Control Nursing Officers, Development Assistant – Planning, Medical Record Officer, Information Communication Technology Assistant, and 03 to 04 Health Assistant Staff.

4. It will consist of five sections. a. Planning Section b. Quality Management Section c. Health Informatics Section d. Public Health Section e. Disaster Management Section 5. The Planning and Development Unit will perform a supportive function to the Director of NIMH by communicating and coordinating all subsystems at NIMH. 6. The Planning and Development Unit of NIMH will broadly look into following functions. a. Establish and Maintain the hospital management information system b. Plan out Services provided and developments required c. Be the Coordinating Hub of NIMH d. Preparation of the Annual Report and the Periodical Reports e. Monitor and evaluate Hospital Services, Quality and Safety f. Panning of Procurements g. Train hospital staff in planning and management h. Promote and undertake research 7. The PDU will have regular unit meetings on a set date to review progress and will have a Monthly Progress Review Meeting chaired by the Director/ Deputy Director which will be attended by all relevant officers including the MOOIC, Accountant, AO, SGNOO. 8. The Following Committees and Meetings will be monitored and coordinated by the PDU. a. Clinical Governance and Deaths Conference b. Progress Review Meeting in Management, Planning and Development c. Hospital Environment Committee d. Hospital Disaster Management Committee e. Hospital Donations Review Committee f. Section Heads Meeting g. Quality Management Steering Committee National Institute of Mental Health - 229

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9. PDU will support the following units/Officers in coordinating the below mentioned committees. a. Hospital Management Committee - Deputy Director b. Hospital Food Committee – Nutrition Division c. Hospital Drugs and Therapeutics Committee - Chief Pharmacist d. Hospital Rehabilitation Coordination Committee – MO – Rehab e. Buildings and Maintenance Review Meeting – AO f. Hospital Infection Control Committee – Infection Control Unit

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NIMH IT Policy Internet access is provided primarily to support the clinical services, teaching and business activities of NIMH and its workforce to meet its institutional objectives.

NIMH takes seriously its responsibility for ensuring the confidentiality, integrity and availability of information and information systems provided over the Internet and used for its intended purposes.

The wide range of information and other material available over the Internet raises concerns about the security and appropriateness of access to certain web content and the implications for NIMH and its staff as inappropriate use of the Internet can cause problems ranging from minor distractions up to and including legal claims being made against staff and/or NIMH if a national or international law is violated.

Should do a. Be aware of who you are allowed to share information with and how it is shared b. Report any information security incident/breaches including malicious websites and phishing emails to manager, Hospital Information and Digital Health (HIDH) Department, NIMH. c. Behave in a responsible manner when using the NIMH's Internet systems.

Should not do a. Ignore, turn off or bypass any information security controls put in place or recommended by NIMH b. Download or install software from the Internet without informing and prior approval of HIDH Department. c. Automatically expect privacy when using NIMH's Internet systems for personal matters. d. Using any kind of VPN without prior approval from the manager, Hospital Information and Digital Health (HIDH) Department, NIMH. NIMH will lawfully monitor and report Internet use and investigate suspected policy breaches or unlawful behaviour ensuring that; a. Internet access is justified and cost effective b. There is established and documented good practice in place for the distribution of information through the Internet c. The confidentiality and security of NIMH information is not compromised d. Where limited and reasonable, personal use of the Internet is permitted, as long as such access complies with NIMH policy.

Definition a. The Internet is a general term that covers access to numerous computers and computer systems worldwide that are accessed electronically. Such systems include the World Wide Web (WWW), email, File Transfer Protocol (FTP), newsgroups, Gopher, etc. b. NIMHnet (the NIMH Local Area Network) c. NIMH intranet (NIMHweb) is the NIMHt‘s internal intranet system used to access information. d. Junk-mail or spam messages - refers to unsolicited commercial web mail, jokes, chain letters or advertisements.

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Roles and Responsibilities

Committees

Information Technology Governance (ITG) Committee.

● The ITG Committee is responsible for ensuring that this policy is implemented, including any supporting guidance and training deemed necessary to support its implementation. ● The committee will ensure that the standards and requirements for information and acceptable internet are understood across NIMH whilst also ensuring that appropriate and effective mechanisms are in place for the identification, reporting and mitigation of risks relating to internet use to ensure the highest level of safety and security for all staff and the IS systems of NIMH. ● The ITG Committee reports to the Directors Administration.

Individual Officers

Health Informatics Officer (HIO) Medical Officer – Health Informatics

● Health Informatics Officer is responsible for ensuring that comprehensive audit tools are in place which enforce the policy and monitor Internet usage. ● The (HIO) will authorize audits investigating any serious incidents requiring investigation. ● (HIO) is responsible for periodically monitoring Internet use to ensure compliance with this policy and to assist HR in any disciplinary investigations regarding Internet use.

● All staff must adhere to this policy.

All staff

Policy and/or Procedural Requirements 1. Where the policy refers to ―staff‖ or ―user‖ this means all members of staff employed by NIMH, any person carrying out work activities on NIMH occupied premises who are not directly employed by NIMH e.g. students, work placements or volunteers, or any person providing a service to NIMH under contract.

2. Internet access is provided primarily to use for clinical/ patient care services, research, teaching and training and business of NIMH to develop the skills and knowledge of its workforce to the benefit of its intended objectives. NIMH considers the Internet as an important means of communication and National Institute of Mental Health - 232

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recognizes the importance of proper Internet content and speedy replies in conveying a professional image and delivering good customer service.

3. Acceptable Internet Usage 3.1 Use of the Internet by staff is permitted and encouraged where such use is suitable for intended purposes and supports the goals and objectives of NIMH. The Internet is to be used in a manner that is consistent with the NIMH‘s standards of service, training and business conduct and as part of the normal execution of an employee's job responsibility i.e. to communicate with other NIMH affiliated/ related organizations, to research relevant topics and obtain useful health-care-related information.

3.2 Whilst reasonable personal use of the Internet is permitted, staff should be aware that NIMH monitors the use of the network and NIMH reserves the right to withdraw personal use of NIMH network resources.

3.3 Reasonable personal use is defined as use that is not in work time, is not excessive and does not interfere with the users‘ ability to complete their work. Also, any personal use should be such that it does not interfere with the performance of the IT systems or staff duties and is not for personal financial gain. If staff are in any doubt about what constitutes acceptable and appropriate use, they should seek the advice and guidance of the HIDH Manager.

3.4 Staff should not assume privacy in their use of NIMH systems, even when accessing the systems in their personal time, i.e. out of working hours; however, NIMH will recognize staff‘s privacy and will not intentionally access information considered to be, or marked ―personal‖ or ―private‖ but reserves the right to do so if there are: 3.4.1 Credible grounds to suspect that they may reveal evidence of any unlawful activity, including instances where there may be a breach of NIMH policy constituting gross misconduct.

3.4.2 Where there is reason to suspect a file that contains harmful material such as a computer worm or virus etc.

3.4.3 Where the law requires it, or any other reason as outlined in section 4 (Unacceptable Internet Usage) 4. Unacceptable Internet Usage 4.1 While the NIMH‘s Content Filtering software will block. (If staff accidentally access material/ sites unblocked by the system but they feel may be considered to be of an offensive nature or otherwise unacceptable to access, they should note the time and website address and exit from the site and then inform the MIM Services Helpdesk.)

4.2 The activities below constitute unacceptable use of the NIMH‘s Internet.

4.2.1 Downloading or keeping Any offensive, obscene or indecent images, data or other material.

4.2.2 Any data capable of being transformed into obscene or indecent images or material. (This includes obscene language, pornography, hostile material relating to gender, sex, race, sexual orientation, religious, political convictions, disability or information that would cause or promote incitement of hatred, violence or any other intimidatory material that is designed or could be used to cause offence, annoyance, inconvenience, needless anxiety or which would contravene any NIMH policy, in particular equal opportunities or harassment, or break any law.)

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4.2.3 Staff must not display any kind of sexually explicit image or document on any NIMH system (other than for properly authorized or lawful research). In addition, sexually explicit material may not be archived, stored, distributed, edited or recorded using NUH network or computing resources.

4.2.4 Staff must not create, download or transmit (other than for properly authorized and lawful research) any defamatory, sexist, racist, offensive or otherwise unlawful images, data or other material.

4.2.5 Staff must not, under any circumstances, use interactive chat applications (e.g. MSN, Viber, Whatsapp etc) this includes all web-based interfaces for Instant Messaging applications and social network applications (e.g. Facebook, Tweeter etc.) other than in the areas authorized by NIMH. 4.2.6 Staff must not, under any circumstances, use audio/ video streaming software applications (e.g. youtube) other than in the areas and VLANs authorized by NIMH. 4.2.7 NIMH staff must not, under any circumstances, use torrent applications (P to P) for downloading. If the staff requires any bulky downloads, they can contact Manage HIDH to get it done.

4.2.8 Staff must not use NIMH‘s Internet and computing facilities to violate the laws and regulations of Sri Lanka or any other nation in any material way. Use of any NIMH resources for such illegal activity is grounds for disciplinary action and NIMH may be required to report such activity as well as cooperate with legitimate law enforcement agencies.

4.2.9 Staff must not use Internet of NIMH and computing facilities to knowingly conduct downloads or uploads which may have adverse implications for NIMH, including the; 4.2.9.1 Download or distribution of pirated software or copyright data, documents, images, videos etc.; any software must be properly licensed and/or registered and must only be used within the terms of its license.

4.2.9.2 Use of the NIMH‘s Internet facilities to download entertainment software or games, or to play games against opponents over the Internet.

4.2.9.3 Upload of any software licensed to the NIMH or data owned or licensed by NIMH without proper authorization.

4.2.9.4 Propagation of any virus, worm, Trojan horse, trap-door or other malicious program code for the purpose of corrupting or destroying other user‘s data or hardware.

4.2.9.5 Creation or transmission of ―junk-mail‖ or ―spam‖ messages.

4.2.9.6 Download/streaming of video or audio material for entertainment (non- work related) purposes.

5. Staff must not use NIMH‘s Internet facilities to disable, defeat or overload any computer system or network, or to circumvent any system intended to protect the privacy or security of any NIMH IT security facilities as well as any activity that would risk bringing NIMH into disrepute or place the NIMH in a position of liability.

6. Staff must not reveal confidential NIMH information or data (i.e. personal, patient, research, teaching, sensitive or business critical) and any other material covered by existing NIMH policies and procedures on the Internet.

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7. Staff must not share user IDs or passwords obtained for access to Internet sites. Staff are reminded that they are solely responsible for any Internet activity conducted under their individual username and password and must not, under any circumstances, let another person know or use their password to gain access to any part of NIMH‘s systems. If you wish to access Internet facilities and find that a previous user has left their session open/logged in - do not use this session - you must logout and begin your own session.

8. Staff must not use the Internet to conduct private or freelance business for the purpose of commercial gain including passing trade secrets to a competitor or supplier. All of the above includes internet access from VPN or via remote access to NIMH's network.

9. Only those staff who are authorized to give media statements may write or present views on the Internet on behalf of NIMH. Non-ICT Services staff that have been granted ‗admin rights‘ should seek appropriate advice from ICT Services technical colleagues before downloading and installing any software from the internet.

10. If experiencing any sort of abnormal behavior it should be informed to MIM immediately.

11. All internet activities (VPN, download, torrent, online streaming and social media) is monitored from 27th December 2018 onward, and identified device MAC addresses will be permanently remove from the NIMH network.

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NIMH Media Unit Purpose and scope To set up a sustainable, effective communication and Media Coordination Unit at NIMH that reaches all of its intended audiences and meets its targeted objectives across the country.

The NIMH media unit acts at a national level and will work towards promoting mental health issues that impact all of Sri Lanka.

Goals and objectives 1. Reduce stigma surrounding mental illness and promote overall mental wellbeing.

2. Setting norms and standards for mental health reporting in Sri Lanka.

3. Monitor mental health articles/documentaries/dramas movies/news items in all three languages that appear in the Sri Lankan media and respond appropriately to any unethical forms of reporting.

4. Educate and provide necessary skills/ guidance to the media about reporting mental health issues through sensitization sessions.

5. Educate and develop the skills of mental health professionals about the media and the role they play in stigma reduction and mental health promotion through presentations as part of regular trainings offered at NIMH. 6. Promote positive activities and success stories coming from the NIMH, including promotion of both locations at Angoda and Mulleriyawa, as well as activities at mental health facilities across the country.

7. Proactively promote the key messages of this strategy to all of our identified audiences.

Key messages Mental health in general 1. Mental health affects everyone. Mental health is all about how each one of us functions in our dayto-day lives.

2. Anyone can get a mental illness, no matter their gender, education level or economic status.

3. People who have experienced mental illness can recover completely or control it with proper medication. They can also contribute to society and live normal lives.

4. If you are experiencing mental health problems, there are people who can help.

5. Everyone has a role to play to end discrimination.

Key messages NIMH 1. The National Institute of Mental Health is focused on the overall mental health of Sri Lankans.

2. The institute plays an integral role in Sri Lanka by providing specialized psychiatric services to individuals and the community with professionalism and care, and is the centre for mental health training, promotion and research in the country.

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Audiences Media - The media will be the primary audience for this strategy. They offer a powerful platform and play a vital role in creating awareness and providing information about the reality of mental health issues.

Community groups and individuals - By specifically targeting community members, we can raise awareness about mental health issues directly to the people who need to be educated.

Employees - It‘s been noted that employees often aren‘t aware of what‘s happening at the institute in other areas. This plan will address that issue and get news out to staff in a visible way. The plan will also aim to show the importance of all roles in the hospital - from support staff to director. Every employee plays an important role in delivering exceptional patient care.

Patients - In many ways the patients‘ stories are the most effective way to reduce stigma and deliver on the goals set out in this plan. As well, for patients to have their success stories told could be extremely beneficial as it concretely shows that recovery is possible. Consent forms will need to be signed before using any patient stories or photos.

Challenges Language - Due to the often quick turnaround times of media/communication work, it will be imperative to have a Sinhalese, Tamil and English speaking and writing resource persons to help deliver this strategy.

Budget - The size and distribution of the newsletter and other tactics will depend on cost and available budget.

Lack of research - Statistics regarding many mental health issues as well as research regarding stigma are not readily available in Sri Lanka. This makes it difficult to confidently identify key messages and communication channels.

Tactics Media monitoring – Coordinate with the Health Informatics Section and monitor the media daily in all three languages and post relevant mental health articles on the NlMH website.

Media response - Draft and send letters to the editor on behalf of the NlMH media unit in response to any unethical reports regarding mental health.

Media training on mental health - Plan and deliver sensitization sessions for journalists across the country on the topic of mental health reporting using the resources already produced.

Mental health professional media training - Plan and deliver media awareness training for all mental health professionals as part of regularly scheduled training at NlMH.

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NlMH website – Coordinate with the Health Informatics Section of the PDU and periodically revise the website with new information regarding mental health in Sri Lanka and the various events that are occurring. Also, build a regular schedule to update content on the site in a timely fashion.

NIMH Facebook and Instagram Page - Coordinate with the Health Informatics Section of the PDU and periodically regularly update and maintain the NIMH Official Facebook and Instagram Page.

NIMH newsletter/Mental Health Magazine – With the Coordination of all PDU Sections biannual or quarterly newsletter to be published that will highlight events/projects happening in the mental health field in Sri Lanka as well as NIMH Promotion of designated days - To raise awareness about mental health issues - the NIMH media unit will issue news releases or provide support to Mental Health Directorate and the Health Education Bureau on specially designated days related to mental health.

1. World Health Day – April 7th 2. World No Tobacco Day – May 31st 3. International Day Against Drug Abuse and Illicit Trafficking – June 26th 4. World Suicide Prevention Day - September 10th 5. International Day of Older Persons and Children- October 1st 6. World No Alcohol Day – October 2nd 7. World Mental Health Day - October 10th 8. International Day for the Elimination of Violence against Women - November 25th 9. Special media advisories - News releases - Media advisories and news releases will also be issued by the NIMH for other newsworthy and time sensitive events not suitable for the newsletter.

Measurement This strategy will be measured by determining how many tactics listed above are introduced and sustained.

Operationalization 1. The Media Coordination Unit will function in line the Vision, Mission, Goals, Values and Objectives of NIMH 2. The Unit administration will be under the Director and the Media Unit Steering Committee.

3. The Media Unit Steering Committee will be appointed by the Director – NIMH. 4. The Steering Committee will consist of the following a. b. c. d. e. f. g. h. i. j. k.

Director – NIMH Deputy Director – NIMH Consultant Psychiatrist – 02 Consultant Child and Adolescent Psychiatrist Medical Officer – In Charge – Media Unit Medical Officer – Psychiatry – Navodaya Day Centre Medical Officer – Public Health Medical Officer – Disaster Management Special Grade Nursing Officer – 02 Chief Psychiatric Social Worker Chief Occupational Therapist

5. The Steering Committee will guide the Media Unit Working Group with direction and guidance.

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a. b. c. d. e. f. g.

Medical Officer – IC Nursing Officer – QM Nursing Officer – Health Promotion Community Psychiatric Nurse – 01 Occupational Therapist – 02 Other Category – 01 SKS – 05 to 06

7. The Media Unit will only have very limited staff and will function with staff who are covering up while in other permanent duties.

8. The Media Unit will look into the following functions. a. Coordination with Digital, Social and Print Media about promotion of Mental Health and NIMH Services b. Mental Health Promotion c. General Health Promotion in collaboration with Health Promotion Unit d. Maintenance of Facebook, Instagram pages and Website in collaboration with Health Informatics Section of PDU e. Develop of Print and digital media for NIMH f. Media Coverage of activities held at NIMH as well as those hosted or co-hosted by NIMH outside NIMH g. Coordinating media and filming activities within NIMH by external parties for which the Director has given permission. (This parties will have to abide the rules and regulations developed by the Media Unit)

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Best practices-for challenging inaccurate or unethical reporting on mental health issues Unfortunately, some journalists in Sri Lanka still report about people with mental health problems either negatively or sensationally. This adds to the prejudice that already exists about people with mental health problems.

Research proves that one of the best ways to combat unethical mental health reporting is to make a formal complaint/protest to the media outlet in question. By hearing that their news item or television/radio show has had a negative impact on someone caring for, or with a mental illness, media outlets have been shown to be much more cautious when dealing with mental health issues the next time around.

There are a number of ways you can conduct this protest effectively.

Correcting inaccuracies While inaccurate reports or details in news items are almost always as a result of human error, and most times don't fall in the category of being unethical, you can still address mistakes when they occur.

Print (Newspapers) Most journalists strive for accuracy in their reporting, but you may be misquoted at some point. These errors are rarely deliberate. Your concern should be that the meaning of what you said to the reporter was conveyed accurately, not so much whether the exact words were used. If the reporter completely missed the point, let the reporter know (in as helpful a manner as possible).

Where you feel that your views or facts you've given have been seriously misrepresented. you can request that the editor of the newspaper prints a correction.

Television, Radio & Social Media A common error when being interviewed on television , radio or social media is to allow a reporter's false or inaccurate statements to stand uncorrected. Speak up. If a reporter creates a false premise (assumption) to a question, first correct the assumption and then correct reframe and answer the question.

Example If a reporter cites information or statistics with which you are not familiar, do not assume they are being reported correctly. Simply state that you are unfamiliar with the information.

After an interview, you may ask the journalist if you can contact him or her with more information you might think of later. Good journalists are interested in all the facts.

‘Letters to the Editor’ Letters to the editor in newspapers and magazines are a good way of correcting inaccuracies, and responding to prejudicial portrayals of mental illness or to comment on issues covered by the publication. While only a certain limited number of letters are actually selected for publication, letters to the editor provide a simple way to communicate to a wide audience.

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concise. To increase the chances of publication, letters should comply with the publication guidelines refer to previous articles or current events and include contact information.

Tips for Letters to the Editor 1.

2.

3.

4.

5.

6.

7.

8.

Keep letter tightly composed Use specific examples One main point per letter Use accurate unto-dale information Don‗t make personal attacks on those opposing your viewpoint Always sign your name include contact details (mobile number it you have one) Please see the attached example that addresses an unethical suicide news item that you could alter to fit your situation.

Example - Letter to the editor Dear xxxxxx, We are writing to express our disappointment regarding your report of a child who recently committed suicide.

Not only is the reporting of the story irresponsible, it is also extremely unethical and potentially dangerous to the people in our country dealing with a mental illness. By providing personal details of the victim including the name and where they lived, you have put the already devastated family in an even worse position.

Your report also details how the child committed suicide - which research shows - will encourage others in a similar situation to do the same thing.

The picture you've used is also very graphic and hurtful to the family.

We encourage you to consider the following statements the next time your news organization is made aware of a suicide. a. b. c. d. e. f.

Don't make judgments on the cause. Suicide is a complex issue.

Don‘t present suicide as an accepted Way to solve personal problems.

Don't reveal the method — it can lead to copycats.

Do talk to mental health experts Do consider reporting on trends rather than individual suicides.

Do promote help and support for people who might be affected by your story.

The media in all its forms has helped change the way we understand and talk about many issues, such as race, gender and HIV/AIDS. And in Sri Lanka, the media contributed to breaking down the myths and misconceptions about leprosy in 1903. We believe the time is now for Sri Lankan media to show that same leadership in regards to mental health issues - like suicide.

A handbook for journalists and editors has recently been published with the help of mental health professionals, journalists and people with mental health problems that provides further guidance and research on mental health reporting in Sri Lanka.

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We would be happy to send you copies and speak to your reporters given the opportunity. If you have any questions, please don't hesitate to contact us. We appreciate your time.

Sincerely, XXXXXX Contact (the) reporter yourself if you have a relationship .

Building relationships with journalists and news editors is extremely important, and can be a big help when an unethical mental health news item appears.

By developing a strong relationship, the chances are far greater of being listened to when you request action.

Contact the Press Complaints Commission of Sri Lanka'(online and print media newspapers only) The Press Complaints Commission of Sri Lanka is an independent body that accepts complaints on editorial content from members of the public and seeks to resolve the dispute through conciliation, mediation or arbitration. There is no fee involved for this service, and the PCCSL will strive to resolve the matter within 30 working days of receiving a complaint.

The PCCSL only deals with newspapers and online articles. For further details, including the process of making a complaint, visit www.pccsl.lk Contact the National Institute of Mental Health‘s Media Coordination Unit While research shows that a protest is most effective when it comes directly from the individual negatively impacted, it may not always be possible or comfortable to make a complaint as an individual.

To help with those cases, the National Institute of Mental Health's (NIMH) Media Coordination Unit will respond to the media outlet on your behalf.

Simply email all the details of your protest, including a copy of the news item and how it adversely impacted you, to info@nimh.health.gov.lk The Media Unit will then draft a response and send it out under the signature of NIMH to the media outlet in question as quickly as possible.

Don‘t just criticize!

The best way to build relationships with your local media is to thank them for positive articles/programs about mental health that they publish or broadcast.

By recognizing their good work, media outlets will be more likely to listen when you present them with a complaint.

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Donations and Sponsoring of Meals to Patients 1. Donations and sponsoring of meals to patients at NIMH is welcomed.

2. Donations are to be given in material form, 3. All donors must fill the stipulated donation declaration form available at the reception.

4. This form then will be approved by the Director and accountability of donations will be strictly maintained.

5. All material donations will be accounted for by the Accounting Department and all drugs and surgical items that are donated will be accounted for by the Chief Pharmacist.

6. All meal sponsorships or sharing of meal based gifts should be pre-approved by the Director by filling the relevant form at the reception. If not or should be booked via email.

7. Section C should also follow the same procedures.

8. During the receiving process of donations or sponsored meals the dignity of the patients must be upheld at all times.

9. Acknowledgement letters will be issued to all donors/ sponsors.

10. Meals that are sponsored are encouraged to be given as raw material to be cooked at NIMH kitchen.

Further they can also be given as cooked food however the place of supply of food should be acceptable to the NIMH administration.

11. If monetary donations are considered they should be made to the Mano Mithuro Organization which is the linked patient welfare association to NIMH.

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Medical Boards 1. NIMH holds medical boards for those with psychiatric and mental health conditions.

2. Medical Boards will be be appointed as per the Establishment Code and the appointing will be mainly done by the Ministry of Health 3. There shall be a relevant Subject Officer from the Establishment Branch of the General Office to coordinate the medical boards.

4. The Boards will be held at the earliest possible date for the board members and the service recipient.

5. The service recipients can check on the status of medical boards by contacting the General Administration Office.

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Housing and Accommodation NIMH Housing and accommodation is governed under the provisions of the Establishment Code and relevant government circulars and laws.

The relevant Subject Officer in the Establishment Section of the General Office shall be the central coordinating point. Shared houses shall have House Wardens for supervision where necessary.

Following are available 1. .Male Post Graduate Trainee Medical Officers Shared Quarters - for trainee only up to 03 trainees 2. Female Post Graduate Trainee Medical Officers Shared Quarters - for trainee only up to 03 trainees 3. Male Nurses Shared Bachelor Quarters 4. Female Nurses Shared Bachelor Quarters 5. PL1-2006 category : 65 Bachelor Quarters ; 46 Family Quarters 6. PL2-2006 category : 19 Family Quarters 7. PL3-2006/MN1-2006 category : 04 Family Quarters 8. MN2-2006/MT1-2006 category : 06 Family Quarters 9. MN4-2006/ MT4-2006/ MT 5- 2006 category : 02 Family Quarters 10. MN5-2006/ MT6 - 2006/ MT 7- 2006 category : 14 Family Quarters for Nurses ; 05 for others 11. MN7-2006/ MT8-2006 : Designated Quarters to AO, Designated Quarters to C/SGNO, Family Quarter to SGNO 12. SL1-20016/ SL2 - 2006/ SL3- 2006 : 07 Family Quarters for Deputy Director, Medical Officers, Dental Surgeons, Accountant, 01 for Specialist Medical Officers, 01 designated quarters for Director 13. As a form of temporary accommodation for training 05 ―Sada Niwasa‖ are available. These are issued on a bachelor usage basis on a payment calculated per day. Trainees who are sent for training to the NIMH Training Unit can reserve these for usage with the permission of the Director. They are not allocated for use by PGIM trainees. A training unit Bungalow is available for usage by Director/ Deputy Director/ Consultants of NIMH and Visiting Lecturers/ Consultants to NIMH for short stay or as on call room basis.

14. Mulleriyawa Nursing Training School (NTS) shall have its own housing governed under the Principal of the NTS.

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Damage to Property by Patients Patients admitted to NIMH may from time to time behave in a manner, that results in damage to property.

It is of paramount importance to identify the behaviour of these patients early and to take steps to avoid such damage as much as possible by the medical and nursing staff.

Damages to moveable to or immovable property incur costs on the state and it is a fiduciary duty of all public servants to ensure that loss to the state is minimised.

If damage occurs to state property by a patient it must be documented on the BHT by the Medical Officer and reported to the Director. Such a patient should be reviewed by a senior clinician within 24 hours of the incident.

The Nursing in Charge of the Ward/ Unit must report this damage to the Director via the communication book as well as inform the Special Grade Nursing Officer.

Special Grade Nursing Officers should keep a summary of the damages happening within the section and report to the Director periodically.

The Director will direct the Accountant and the relevant officers to act in accordance with the Financial Regulations with regard to the damaged property.

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Maintenance Services NIMH Maintenance Services are supervised under the Administrative Officer.

There is a specific subject officer to look after the maintenance services at the Establishment Section of the General Office.

Any request to attend for maintenance by the relevant services should be first approved by the Director/ Deputy Director/ Administrative Officer. This request should come in the duplicate book of the unit.

Regularly needed items for maintenance should be made available as bulk stocks in the stores.

Following Maintenance Sections are available at NIMH. 1.

2.

3.

4.

5.

Carpentry Section Welding Section Plumbing Section Sewage Maintenance Section General masonry and maintenance section

Following maintenance activities are done as outsourced services.

1. Electrical Maintenance 2. Electrical Items Repairs and Maintenance 3. Air Conditioning Machine Maintenance

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Information Communication Technology Maintenance Unit Founded as the Computer Maintenance Unit as per the Ministry of Health directives it was renamed as Information Communication Technology Maintenance Unit (ICTMU) in 2019 and is still located on the 3rd floor of Research and Training Building near the Research Department.

1. The ICT Maintenance Unit (ICTMU) is running under the guidance of the Health Informatics Section of Planning & Development Unit and the Administrative Officer.

2. The ICTMU will oversee all computer hardware & software issues as well as issues arising from communication tools such as CCTV & Audio Systems.

3. Any section having any computer issue may contact the ICTMU by directly calling the relevant officers/Assistants via the exchange.

4. Duplicate Book should be ordered about the ICTMU maintenance required.

5. ICTMU will review the work and put a worksheet at the beginning and work completion sheet after fixing.

6. The ICTMU has no authority to request any supplier to come and fix any item. All official requests to fix computer items externally should be sent to the relevant subject as per routine procedure.

ICTMU will put a required recommendation for the said work through a worksheet.

7. You may contact ICTMU before sending an official request to relevant subjects in the Accounts Department / Other to improve efficiency.

8. ICTMU will be doing routine maintenance of Computers on an annual planned system basis.

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CCTV Maintenance and Access CCTV Equipment installed throughout NIMH provides a valuable service in ensuring security and patient safety in the hospital.

Please note the following with regard to CCTV usage and maintenance.

1. These Equipment and their recordings are public property under the custody of the Department of Health.

2. The recordings in these are governed under the Evidence Special (provisions) Act No 14 of 1995 and considered as admissible evidence for both civil and criminal procedures.

3. As such the safety of the CCTV system & Recordings must be always ensured by all staff and any fault/damage or sabotage must be reported to the Director immediately.

4. CCTV footage access for day to day purposes can be done by the Consultant /Medical Officers, Nursing Officers of Ward using a given password. The relevant in-charge of the unit must ensure that no attempt of tampering is done on CCTV hardware or recordings.

5. Administrative Access to CCTV footage is restricted & requires approval from the Director/Deputy Director.

6. CCTV Maintenance will be under the supervision of the following. a. MO-Health Informatics=> Information Communication Technology Maintenance unit b. Administrative Officer =>Relevant Subject PHMA 7. The subject officer must keep the relevant unit/ ward in-charge informed about access to CCTV footage when retrieving evidence & the in-charge must ensure access freely. Retrieval will be done by the ICTMU staff under the guidance of the Subject Officer.

8. CCTV equipment routine maintenance will be done on once a month basis.

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Subsistence and Transport Expenses for Discharged Patients 1. In accordance with the Mental Diseases Ordinance and Establishment Code patients can be given subsistence and transport expenses to return home after discharge.

2. To grant subsistence the Medical Officer of the Ward/ Unit should get the approval from the Director for discharge and sending home 3. The Medical Officer should also document on the BHT to the Office to issue the subsistence.

4. The relevant form should be filled by the ward requesting the amount.

5. The amount requested should be shown as a breakdown of cost for the relevant traveling path and traveling means 6. The amount will be issued by the Shroff after approval from Director/ Deputy Director/ Administrative Officer/Chief PHMA.

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Security Services 1. Security Services for NIMH will be provided by a private security company selected by tender process by the Ministry of Health 2. The required security points and coverage will be decided by the NIMH Administration.

3. Security Service providers will abide by the tender awarding document and the signed agreement with the Ministry of Health.

4. The Officer In Charge on Duty should be contacted immediately via telephone if any section of ward in charge needs security assistance to prevent any wrongdoing, 5. Any absconding of a patient should be informed to security so that they can search the hospital premises.

6. Security personnel are not allowed to be placed inside wards; their duties are always beyond ward gates and they should not be asked to attend to direct inward patient care issues without the approval of the Director.

7. While security services will be reviewing the designated parking areas of the hospital, Parking will be at the risk of the owner and NIMH will not be held legally liable for any damages occurring to private vehicles.

8. Parking of vehicles in undesignated areas is discouraged and parking in designated ambulance bays are strictly prohibited.

9. Security Services have the right to check the ID of any person entering NIMH 10. As NIMH houses judicial patients, security will be kept at a higher alert level than other hospitals.

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Section F – Annexures

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Mental Diseases Ordinance

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Patient Care Service Units Distribution updated in January 2022

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