Annexure-I

 

Minimum Standards for Deaddiction centres in Tamil Nadu

 

 

Introduction

 

Two types of treatment and two types of deaddiction centres are necessary for the management of a person addicted to alcohol or other substances. The two types of treatment are.

 

1) Detoxification treatment

2) Rehabilitation.

 

Detoxification treatment is “a medical intervention that manages an individual safely through the process of acute withdrawal. The first week of acute withdrawal may require emergency medical management of life-threatening intoxication and related medical problems. This phase can have medical complications like, injuries, infections, reduced blood sugar levels, blood electrolyte imbalances, acute confusional states, psychotic symptoms, even commonly delirium in which patients can be extremely fearful, restless, sleepless, agitated, confused, can lose touch with reality, disoriented (not aware of oneself and the surroundings), can act upon their false beliefs (Delusions) and voices heard unusually (Hallucinations), and can lead to impaired judgemental capacity. The patient can develop convulsions during this phase and can be acutely violent too. The acute withdrawal and its medical complications can be life threatening in severe cases and can result in death of the patient. Detoxification represents a point of first contact with the treatment system and the first step to recovery. Supervised detoxification can prevent potentially life-threatening complications.

 

Rehabilitation treatment on the other hand, involves a constellation of ongoing therapeutic services intended to promote recovery for substance abuse patients designed to resolve the longstanding psychological, social, and behavioural problems associated with alcohol and drug abuse. A rehabilitation centre for addictive disorders will be managing patients addicted to alcohol and other substances after the period of acute withdrawal state, which usually lasts for one week to ten days. A rehabilitation centre will be employing psychological methods of treatment like cognitive behavioural therapy, motivational interviewing, education, family therapy, and group therapy, apart from pharmacotherapy (medications).

 

The minimum standards for the Deaddiction centres involved in detoxification treatment should be different from the minimum standards for the deaddiction centres involved in the rehabilitation treatment. The minimum standards are prescribed for the following categories of Deaddiction centres.

 

Deaddiction Centres (Categories)

1) Detoxification centres

2) Rehabilitation centres

 

Minimum standards for Deaddiction centres

 

The following are the common minimum standards for both Detoxification centres and Rehabilitation centres.

 

Standard One

All admissions in a Deaddiction centre should be preferably with the consent of the patient as independent admissions. When the dependence to the substance is very severe to the level of impairing the capacity of the patient to take decisions regarding treatment, such patients can be admitted under section 89 of the Mental Health Care Act 2017, meticulously following the procedures laid down in the Act, with intimation to the Mental health Review board. Such admissions without the consent of the patient shall not extend beyond thirty days. Once the patient regains the capacity to take treatment decisions, admission can be continued only with the consent of the patient.

 

Standard Two. The premises shall –

 

a) be concrete structure, strong enough to withstand heavy rains and moderate natural calamities.

b) be equipped with functional windows and doors with strong and intact vertical grills and wire meshes to avoid attempts for suicide or self-harm.

c) have lift with generator or power backup for areas having more than four floors.

d) have sufficient ventilation and natural light.

e) have sufficient illumination after sunset for reading without causing strain to the eyes.

f) have illuminated passages leading to toilets and emergency exits during the night.

g) have inverters or power back-up or emergency lights during power failures.

 

h) have periodic maintenance of the infrastructure and equipments / appliances in the De-addiction centre; and

i) have heaters and coolers subject to safety and health of residents, according to seasons.

Standard Three. The living conditions shall be comfortable with –

 

a) separate cots, mattresses, pillow, and blanket (with due regard to the season) for each patient placed in a manner that there is sufficient space between each (1 meter).

b) residents must not be made to sleep on the floor.

c) adequate fans in running condition.

 

Standard Four. Hygiene, cleanliness, and sanitation shall be maintained by

 

a) daily sweeping, swabbing, and dusting of the entire premises.

b) sanitation maintained in all the areas including toilets and bathrooms using disinfectants.

c) One toilet for seven patients and one bathing room for seven patients with non-slip floors, separate toilets and bathrooms for male and female inpatients, and disposal facilities for sanitary napkins.

d) adequate availability of water in wash basins, bathrooms, and toilets.

e) fumigation, pest control and fixing of wire meshes on all doors and windows to keep out pests.

f) cleaning and changing the linen daily.

g) providing in every Institution automated laundry service, or a separate area for washing and drying clothes, with adequate workforce, so that the laundry is collected, washed, dried, and returned to the residents the same day or by outsourcing the laundry service, and adequate arrangements for safe disposal of biomedical waste.

 

Standard Five. Wholesome, sumptuous, and nutritive food and potable drinking water shall be provided in comfortable settings and –

 

a. food shall be served in a respectable and comfortable manner.

b. hygienic and nutritious food shall be served.

c. cooks and persons involved in preparation and serving of food must undergo mandatory health check-ups periodically; aprons, masks and headgears must be provided to all.

d. food must be served at frequent intervals at least 3 meals a day under the supervision of sufficient number of attendants so that there shall be no long gap between mealtimes.

e. the food served to each patient must meet their unique dietary requirements, Meal plans by a dietician should be done by preparing charts; and

f. special diet based on special nutritional requirements must be given to women who are elderly, pregnant, lactating, or have recently undergone abortion or miscarriage.

g. Same food should not be given daily and needs to be of variety and in rotation.

 

Standard Six. Facilities shall be provided for social, cultural, leisure and recreational activities including –

 

a. entertainment programs, socials, and excursions for inpatients; and

b. furnished visitors’ room for families coming to meet the inpatients.

c. Family members should be allowed to see the inpatients in person in the specified visitors time (at least for two hours) both in the morning and evening.

 

Standard Seven. Adequate number of health professionals shall be employed to provide proper treatment and –

 

a. the inpatients should be seen on a regular basis by the psychiatrist / a mental health professional.

b. a medical officer shall be available on call twenty-four hours to meet the emergencies. Daily rounds of the patient’s medical condition by a medical officer should be done and documented in the case sheet.

c. the trained human resources in mental health shall be made available to provide mental health services:

d. provisions must be made for emergency treatment; ambulances equipped with necessary medical equipment must be always kept ready in the Deaddiction centre.

 

Standard Eight. Medical and para-medical staff shall be engaged in accordance with the specified requirements and –

 

a. there shall be daily visits by a qualified medical practitioner,

b. nurses engaged for shift duty shall be in conformity with the norms made by the Indian Nursing Council from time to time. 24 hours qualified nurse should be available.

c. multipurpose workers, one for every ten beds or part thereof shall be employed; and

d. multipurpose workers shall be engaged after an adequate induction training programme.

 

Standard Nine. The premises shall have adequate floor space having –

 

a. separate wards for female inpatients and male inpatients.

b. adequate space between beds (1 meter).

c. adequate dimension to ensure comfortable passage and safe evacuation in case of emergencies fire safety license is mandatory.

d. ward bed and surrounding space not less than one metre on all sides.

e. common room, where possible, which has television, newspapers, magazines, and indoor games and the chairs provided is 1:4 ratio; and

f. outpatient department and inpatient facilities shall have sitting arrangements for patients and accompanying family members, registration, help and cash counters, drinking water facilities and separate toilets for males and females.

 

Standard Ten. Equipment and articles shall be procured and used for inpatients in accordance with the requirements in Deaddiction centre having –

 

a. medical equipment and instruments, commensurate with the scope of services and the number of beds.

b. equipment and inventory kept in a good usable condition.

c. sufficient sets of basic equipment such as blood pressure apparatus, stethoscope, weighing machine, thermometer and like other equipment, with backup.

d. sufficient stock of drugs, medical devices, and consumables.

e. first aid box with standard contents; a daily check done for replenishments; and

f. an examination table with footstep.

g. Emergency medical tray should be available.

 

Standard Eleven. There shall be no torture, cruelty, inhuman and degrading treatment, punishment, exploitation, violence, negligence, and abuse of patients.

Criteria

a. No verbal, physical, sexual, or mental abuse.

b. Reasonable remuneration shall be paid for work given with consent.  

c. No regimentation about sleeping hours.

d. Safe injection practices shall be followed.

e. Patients should not be engaged involuntarily or forced from doing any form of work in the rehabilitation centre.

 

Standard Twelve. Alternate methods shall be used in place of restraint to de-escalate crises situations and

 

a. physical restraints to be used only to prevent inpatients from hurting themselves or others, with the permission of the medical practitioner on duty or consultant psychiatrist and the circumstances, duration of restraint, shall be recorded in a separate register kept for this purpose.

b. nursing staff shall be trained to use de-escalation techniques to prevent patients from harming themselves and others; and

c. adequate number of security staff must be hired, with an equal number of female guards.

d. female patients to be manned only by female attendants

 

Standard Thirteen. There shall be protection of privacy, dignity, safety, and security of patients especially of women and their confidentiality and –

 

a. no discrimination on the grounds of religion, race, caste, sex, creed, place of birth and economic condition or on any other ground in the matter of admission or treatment of patients.

b. reasonable freedom and facility for pursuing religious beliefs.

c. physical examination or treatment of female patients done shall be in the presence of a female attendant or female nursing staff, if conducted by male medical staff inside the hospital and vice versa.

d. independent lockers provided to patients to keep their personal belongings.

e. necessary procedures exist to meet fire and non-fire emergencies and safe exit of inpatients and others.

f. appropriate display of directional fire exit signage, at least in two languages, one of which is local.

g. all fire safety measures taken including fire prevention, detection, mitigation, evacuation, containment, and mock drills.

h. firefighting equipment to be periodically inspected, chemicals replenished and shall be kept in usable condition.

i. residents must be provided with adequate number of clean undergarments and disposable sanitary napkins that are marked for personal use in public mental health establishments; and

j. each individual resident must be provided with basic hygiene articles such as slippers, towels and combs, bathing and washing soap on a fortnightly basis, and at least two shampoo sachets every week; basic cosmetics such as powder, cream, bindis and kumkum and other items should be provided in sufficient quantity.

 

Standard Fourteen. The minimum qualification for the personnel engaged in the Deaddiction centre will be the minimum qualifications as laid down in the Act. For those personnel for whom the minimum qualifications are not laid down in the Act, shall be governed by the recruitment rules applicable to the respective cadre like security personnel, ministerial staff, and driver.

 

Standard Fifteen

 

a. Maintenance of records and reporting. -The Deaddiction centre under the regulation of SMHA shall keep the medical records in the manner specified in Form-A annexed.

b. The Authority may call for any medical record on receipt of any complaint.

c. The medical records shall be kept for the period in accordance with the extant Government instructions or any other law for the time being in force.

d. A discharge summary shall be given to the patient at the time of discharge in the manner specified in Form-B annexed.

Standard Sixteen.

 

a) CCTV cameras should be installed in entrance, exit, shared areas, dining hall, and wards.

b) Digital video recordings of CCTV cameras should be preserved and retrievable for a minimum period of 3 months.

 

Standard Seventeen – Registers to be maintained

a) Admission Register

b) Discharge Register

c) Inventory of all the facilities (Stock Registers)

d) Establishment Register

e) Census / Nominal Register

f) Treatment Register (case sheet).

g) Injury Register

h) Death Register

i) Patient weight Register

j) Dangerously ill / seriously ill patient chart

 

k) Physical Restraint Register

l) Absconded patients register

m) Emergency call register attended by Psychiatrist

n) Attendance Register for Staffs

o) Social Worker’s Register

p) Drug register

q) Nominal roll of patients

 

Minimum Standards specific for Detoxification Centres

 

Standard Eighteen.

 

a) For each Detoxification centre, One Psychiatrists shall be visiting the centre every day and should review the patients and document the findings and treatment in the case record. Shall be available on call round the clock for emergencies and should be able to visit the centre anytime for emergency calls. One psychiatrist shall oversee not more than two detoxification centres situated within a radius of ten kms from the residence of the Psychiatrist.

b) A medical practitioner with MBBS qualification shall be on duty round the clock in three shifts, shall be attending to the patients.

c) One Nurse should be available for every five patients round the clock.

d) Two multipurpose health workers for every five patients round the clock.

e) Facilities should be available for giving intensive medical care. Intensive care unit cots, Oxygen, suction apparatus, ventilators, emergency medicines, should be available. Laboratories for doing blood investigations should be available.

 

Minimum Standards specific for Rehabilitation Centres

 

Standard Nineteen

 

a. One psychiatrist for every fifty patients (part time psychiatrist)

b. The psychiatrist shall visit the centre at a frequency of three half day sessions in a week and will be available on-call at emergencies. One Psychiatrist shall oversee not more than four Rehabilitation centres (If a Psychiatrist is in charge of two acute care psychiatric hospitals or two Detoxification centres, Such Psychiatrist can oversee not more than two Rehabilitation centres) situated within a radius of thirty kms from the residence of the psychiatrist.

c. One medical Practitioner for every fifty patients, who should visit daily and be present from 09:00 am to 02:00 pm and examine the general health of all the patients daily and document in the same in the case sheet.  After 02:00 pm the medical practitioner should be available round the clock for any emergencies.

d. One Social Worker for every fifty patients.

e. One nurse for every ten patients.

f. One Psychologist for every fifty patients

g. One Nurse shall be available in the ward round the clock.

h. One attender for every ten patients.

 

Standard Twenty

 

Prior to admission into a Rehabilitation centre, it is to be ensured that the patient does not suffer from any major medical problem requiring intensive medical care. The Rehabilitation centre shall not admit the patient for detoxification process. In such case, the rehabilitation centre can admit the patient for after care treatment, after Detoxification treatment having been conducted in a Detoxification centre or elsewhere in a medical facility where intensive medical care facilities are available. The acute physical complications occur during detoxification period (during the first ten days after the last dose of alcohol or substance), intense monitoring is to be ensured and appropriate medical facilities to manage medical emergencies shall be made available in Such detoxification centre.

 

In case, any acute medical emergency requiring intensive medical care develops, the patient shall be shifted immediately to nearby medical facility where intensive medical care facility is available.

 

 

 

Form-A.

 

Basic Medical Record

a) Name of the mental health establishment/doctor:

b) Date:

c) Hospital registration number:

d) Patient’s Name:  

e) Age: Sex:  

f) Father’s/Mother’s name:

Address:

 

Mobile No:

g) Patient accompanied by (Name, age and nature of relationship):  

h) Identification marks:  

i) Nominated representative:  

 

j) Advanced Directive – Yes or No, If yes salient features of the content:

 

k) Date of admission:          Date of discharge:  

l) Mode of admission (section under Mental Healthcare Act, 2017): Independent/ Supported

m) Chief complaints:

 

 

 

n) Summary of Medical Examination

 

 

 

 

 

 

 

o) Salient behavioral observations:

 

 

 

 

 

p) Psychological Assessment Report:

 

 

 

 

q)    Laboratory investigations:

 

 

q) Provisional/differential/final diagnosis:

 

 

 

r) Course in the hospital (Treatment and Progress):

 

 

s) Condition at discharge or discharge at request or leave against medical advice or person with mental illness absconding or others:

 

 

 

t) Treatment advice at discharge:

 

 

 

u) Follow-up recommendations:

 

 

 

 

v) Signature and seal of the Doctor:

Form B

DISCHARGE SUMMARY

 

Name of Patient:

 

Tel No.

 

Mobile No.

 

IPD No.

 

Admission No.

 

Treating Consultant/s Name, contact numbers

and Deaddiction Centre Name and address

 

 

 

Date of Admission

 

Time of Admission

 

Date of Discharge

 

Time of Discharge

 

 

MLC No. / FIR No.

 

Provisional Diagnosis at the time of Admission

 

Final Diagnosis at the time of Discharge

 

ICD-11 code(s) or any other codes, as recommended

by the Authority, for Final diagnosis

 

Presenting Complaints with Duration and Reason

for Admission

 

 

 

 

 

 

Summary of Presenting Illness

 

 

 

 

 

 

Key findings, on physical examination at the time of Admission

 

 

 

 

 

 

History of alcoholism, tobacco or substance abuse

 

 

 

 

 

Significant Past Medical and Surgical History, if any

 

 

 

 

 

 

 

Family History if significant/relevant to diagnosis or Treatment

 

 

 

 

 

 

Summary of key investigations during

Hospitalization

 

 

 

 

 

Treatment given and course in the Hospital including complications, if Any

 

 

 

 

 

 

Advice on Discharge

 

 

 

 

 

 

 

Name of treating Consultant/ Authorized

Team Doctor

 

 

 

Signature of treating Consultant / Authorized

Team Doctor

 

Name of Patient /

Attendant

 

 

Signature of Patient /

Attendant

 

 

 

 

 

 

 

 

Chief Executive Officer

Tamil Nadu State Mental Health Authority,

Institute of Mental Health Campus,

Chennai-10