NATIONAL

GUIDELINES FOR
‘NEW NORM’ IN Psychiatry And
Mental Health

PSYCHIATRIC AND
Services, MOH
Malaysia

MENTAL HEALTH
SERVICES
TABLE OF CONTENTS

PAGE

Guideline development group 2

Introduction 4

Inpatient Service 6

Electroconvulsive Therapy 17

Outpatient Service 24

Community Psychiatry Service 43

Institutions of Psychiatry 55

Forensic Psychiatry Service 63

Clinical Psychology Service 75

1
 GUIDELINE DEVELOPMENT GROUP

Chairperson

Dr Hjh Salina Abdul Aziz

Technical Head of Psychiatric Services
Consultant Psychiatrist and Clinical Epidemiologist
Hospital Kuala Lumpur
Kuala Lumpur

Members (alphabetical order)

Dr. Ahmad Qabil Bin Khalib Dr Arlina Nuruddin

Hospital Director and Consultant Consultant Psychiatrist
Psychiatrist, Hospital Kajang
Hospital Mesra Bukit Padang Kajang
Kota Kinabalu Selangor
Sabah

Dr Chee Kok Yoon Dr Cheah Yee Chuang

Consultant Neuropsychiatrist
Hospital Kuala Lumpur
Kuala Lumpur
Consultant Psychiatrist (Community
and Rehabilitation Psychiatry)
Hospital Bahagia Ulu Kinta
Tanjung Rambutan
Perak

Dr Deepa Darshini A/P Amarnath Dr Husni Zaim Ab Latiff

Clinical Psychiatrist Clinical Psychiatrist
Hospital Kuala Lumpur Hospital Kuala Lumpur
Kuala Lumpur Kuala Lumpur

Dr Ian Lloyd Anthony Dr Johari Khamis

Consultant Forensic Psychiatrist Consultant Forensic Psychiatrist
Hospital Bahagia Ulu Kinta Hospital Permai
Tanjung Rambutan Johor Bharu
Perak Johor

Dr Kenny Ong Kheng Yee Dr Melisa Binti Abdul Aziz

Consultant Neuropsychiatrist Psychiatrist
Hospital Kuala Lumpur Hospital Ampang
Kuala Lumpur Selangor

2
Dr Nooraini Binti Darus
Head Profession and Head of
Clinical Psychology Unit
Hospital Kuala Lumpur
Kuala Lumpur
Dr Peter Low Kuan Hoe
Psychiatrist and Fellow in Community
and Rehabilitation Psychiatry
Hospital Bahagia Ulu Kinta
Tanjung Rambutan
Perak
Dr Saramah Mohd Isa
Psychiatrist and Fellow in Forensic
Psychiatry
Hospital Bahagia Ulu Kinta
Tanjung Rambutan
Perak
Dr Sharifah Suziah Syed Mokhtar
Consultant Psychiatrist
Hospital Kajang
Kajang
Selangor
Dr. Sivenanthini A/P Purana
Visvanathan
Clinical Psychiatrist
Hospital Mesra Bukit Padang
Kota Kinabalu
Sabah
Dr Norhayati Binti Nordin
Hospital Director and Consultant
Psychiatrist (Child and Adolescent
Psychiatry)
Hospital Bahagia Ulu Kinta
Tanjung Rambutan
Perak
Dr Riana Binti Abdul Rahim
Consultant Psychiatrist (Community
and Rehabilitation Psychiatry)
Hospital Kuala Lumpur
Kuala Lumpur
Dr Selva Ratnasingam
Consultant Psychiatrist (Child and
Adolescent Psychiatry)
Head of Department of Psychiatry
and Mental Health
Hospital Umum Sarawak
Kuching
Sarawak
Dr Siti Zubaidah Binti Ismail
Psychiatrist and Fellow in Community
and Rehabilitation Psychiatry
Hospital Bahagia Ulu Kinta
Tanjung Rambutan
Perak
Umi Izzati Binti Saedon
Clinical Psychologist and Head of
Service Development Bureau for
Clinical Psychologist Profession
Hospital Raja Perempuan Zainab II
Kota Bharu
Kelantan
3
INTRODUCTION

GENERAL PRINCIPLE:

1. Limit entry point into hospital to facilitate the control of movement of the health
worker / patient. Provide separate routes for patients and health workers.

2. Body temperature or thermal scanner check must be done at entry. Screening for
cough symptoms, sore throat, or shortness of breath is mandatory.

3. If body temperature readings are 37.5 ° C or higher, or symptoms are present, the
healthcare worker/patient should be isolated / referred to the Fever Clinic/
Designated Clinic.

4. Provide hand sanitizer / disinfection kits at the entrance of the hospital and at all
common areas.

5. It is mandatory to practice social distancing at all locations in the hospital

including staff rest rooms, meeting rooms, pantries, prayer rooms, etc.

6. Hospitals should ensure that social distancing and other MOH protocols pertaining
to the Covid-19 pandemic are clearly displayed using signage/posters. This is
especially applicable in areas such as:
a. Psychiatric ward/other clinical areas
b. All patient waiting rooms in all locations
c. Meeting / seminar rooms at all locations
d. Dining room / lounge
e. Elevator
f. Surau
g. Cafeteria

7. Limit the number of patients and visitors to hospital to reduce congestion.

4
8. Encourage virtual meetings.

9. The hospital should appoint a coordinator to manage Covid-19 outbreaks in the

hospital. The Occupational Safety and Health Committee should play their role as
outlined.

10. Hospitals should carry out sanitation processes in the relevant areas each time
before the shift or operation begins.

11. The sanitation and cleaning process should be carried out three (3) times per day
or when necessary especially in common spaces such as:
a. Hospital lobby
b. Elevators
c. The cafeteria
d. Meeting rooms
e. Surau
f. The lounge / pantry
g. All toilets
h. The garbage disposal areas

12. Ensure that the hospital's ventilation system is effective and efficient.

13. The cafeteria / cafeteria in the hospital is only allowed to operate for the purpose
of providing packaged food. Food operators should wear face masks, gloves and
always ensure social distancing at all time. Buffet meals should not be allowed.

5
NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – INPATIENT SERVICE

1.0 OBJECTIVES:

• The objective of this standard operating procedure is to set out the specific
standards for managing the inpatient psychiatric service post MCO upliftment.
• To focus on safeguarding Health Care Workers (HCW), patients and caregivers
against Covid-19 transmission.

2.0 STANDARDS OF PRACTICE (THE NEW NORMs):

• Social distancing.
• Stringent hand hygiene.
• Rational and appropriate use of Personal Protective Equipment (PPE).
• Fostering creative use of digital platform.

3.0 INFRASTRUCTURE:

• Psychiatry Ward
• Isolation unit
• Visiting area
• Pantry
• Dining hall

In general, inpatient admission should be restricted to only those that are absolutely
necessary, based on the clinical judgement of the clinician, to avoid congestion in
the psychiatry ward.

Pre-admission

• Referral for psychiatric assessment should be made by a medical officer.

• COVID-19/PUI status of all referred patients to be ascertained upon receiving
the referral.

6
 • Social distancing, hand hygiene, rational and appropriate use of PPE should
be exercised at all times by the attending HCW.

Documentation to be completed
• Covid-19 screening should be conducted prior to admission to the psychiatry
ward. ‘BORANG DEKLARASI SARINGAN COVID-19’ is used for COVID-19
screening. Refer APPENDIX I.
• If a Person Under Investigation (PUI) with mental health issues requires a
medical admission, psychiatric service shall be made available through the
psychiatry consultation-liaison service. Refer “FLOWCHART FOR ADMISSION
PROCESS”.

Action on Patient’s Arrival at the Psychiatry Ward

• Screen for body temperature and symptoms of acute respiratory infection.

INFECTION CONTROL ON THE WARD:

• Screening should be done on all persons prior to ward entry.

• Hand sanitiser made available at every entrance/exit point of psychiatry ward.
For diligent hand sanitisation prior to access into ward/exit from ward.
• All HCWs must wear facemasks in clinical area.
• Wards should exercise the principles of social distancing across the ward
community especially at common areas (e.g. pantry, prayer room, dining hall,
visitors room etc). This means minimal contact and an advised physical
distance of at least 1 metre.
• The need to limit contact between individuals should be clearly
communicated to HCWs, patients and visitors.
• Strong emphasis must be placed on regular disinfection of high-touch surfaces
(e.g. door handles, workstation, conference table, bed rails, lift buttons,
telephones etc).
• Windows should be open for natural ventilation in ward.

7
 • Patient in Isolation Unit should be placed in negative pressure rooms. If not
available, adequately ventilated single room with natural ventilation and
closed doors will suffice.
• Rational and appropriate use of Personal Protective Equipment (PPE)
according to type of activity/job scope, refer Appendix II.
• Avoid involving HCWs with chronic medical comorbidities (e.g. DM/HPT) in high
risk procedures (e.g. Aerosol Generating Procedures such as manual bagging
and oral suctioning during ECT).
• In cases when a HCW had close contact with a patient who later turns out to
be Covid-19 positive, referral to Occupational Safety and Health (OSH) Unit
of the respective health facility is to be made for further investigations and
management of the HCW to be carried out.

FEBRILE PATIENTS WITH OR WITHOUT INFLUENZA-LIKE ILLNESS:

• Careful and sensitive management of patients who experience symptoms of

COVID-19 while on the ward is essential.
• While it will not be possible to turn mental health wards into full isolation units, it
will be necessary to take appropriate steps to isolate patients with respiratory
infection symptoms in the ward.
• If isolation is warranted but not possible for any reason whatsoever, this should
be reported immediately to senior management and be treated as an
emergency.
• As far as possible, psychiatric services should be continued when patients are
in isolation.
• HCWs in-charge of isolation units to be restricted to the same person/team –
shift rotation basis.
• HCW in-charge of isolation units to maintain social distancing and to minimise
interactions with other HCW/patients.
• Rational and appropriate use of Personal Protective Equipment (PPE)
according to type of activity/job scope, refer Appendix II.
8
 • Hospitals/Mental Health facilities should develop their respective local
agreements on the management of suspected COVID-19 cases which would
include referral to Medical/Infectious Disease disciplines for co-management
or transfer to a medical ward. Refer “FLOWCHART FOR MANAGEMENT OF THE
FEBRILE PATIENT +/- INFLUENZA-LIKE ILLNESS (ILI) IN THE PSYCHIATRIC WARD".
• Review the psychiatric treatment plan, consider postponement of any
therapies (e.g. ECT) and a re-evaluation of any medications in line with advice
from pharmacy departments.
• For patients who display symptoms suggestive of COVID-19 and require
Isolation or transfer to a Medical/Infectious Disease ward, their family/carers
should be informed as soon as possible. Any person who has visited the patient
should also be informed and advised to self-isolate in keeping with national
recommendations.

WARD ACTIVITIES:

• Wards should try and maintain some group activities (with social distancing in
mind) with adjustments to maintain morale, communication and provide
reassurance to patients.
• Mealtimes and small group-based activities such as exercise/dancing,
mindfulness/relaxation groups, karaoke and other occupational therapy
activities should be carried out in areas large enough to adhere to the
recommended minimum 1-metre social distancing.
• Materials, objects and tools that can be wiped clean and disinfected or
disposable should be used during ward activities.
• Patients in Isolation Unit who are able to carry out activities may be provided
single use activity packs.
• Ward rounds, pass over, family sessions can be carried out provided adequate
distancing is maintained and physical contact is avoided. Alternatively,
creative use of digital platforms for should be encouraged with extra care
taken to eliminate risk of data breach and maintain patient’s confidentiality.
9
 • In cases when next of kin’s presence required (e.g. consent taking for ECT/
procedures/ hospital transfer), treating doctor to meet family member in the
allocated visitor’s area. Next of kin access restricted to the person who will be
giving consent.

HOSPITAL TRANSFER:

• Should a patient require hospital transfer for further psychiatric care, safety
measures are of paramount importance. This includes social distancing of
HCWs and patient during transport, diligent practice of hand hygiene and
wearing a face mask.
• Before transfer, temperature and vital signs of the patient should be taken and
recorded. If a patient develops fever, plan for hospital transfer should be
aborted/postponed and the plan promptly reassessed.
• A copy of the patient’s completed Covid-19 screening questionnaire should
be provided for the receiving hospital.
• To ensure that there is no non-essential stop during travel.

DEALING WITH VISITING TIMES AND VISITORS:

• Families to limit visiting and to consider other ways of keeping in touch, such as
via phone calls.
• All visitors should undergo screening for COVID-19 before entry to the ward.
• They should not be allowed to visit if they are unwell, especially if they have a
fever or ILI.
• Only immediate family members or carers are allowed to visit.
• All visitors must wear masks during visits.
• Only 30 minutes of visiting duration allowed per patient during visiting hours.
• To restrict visiting to designated visiting area.

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MONITORING:

• As this is an unprecedented challenge, it will be important to appoint an

individual or a team i.e. Pegawai Pemantau Pencegahan Covid-19 at the
departmental level to oversee the wellbeing of HCWs, patients and visitors by
anticipating, responding and managing challenges as they arise.
• This representative shall work on optimising communication between HCW,
patients and their families at an optimal level through written communications,
smaller group or individual meetings and texts and digital messaging within the
ward.
• Government and national guidance should be easily available to all and the
entire ward should stay informed of any latest developments.
• HCWs should be clear about rules that are recommended nationally. HCWs
should always model this advice.

11
REFERENCES

1. The Infection Prevention and Control (IPC) Measures in Managing Patient Under
Investigation (PUI) or Confirmed Corona Virus Disease (COVID-19), Ministry of Health,
Malaysia, 2020. Accessed at :
http://www.moh.gov.my/moh/resources/Penerbitan/Garis%20Panduan/COVID19/A
nnex_8_IPC_21032020.pdf
2. COVID-19 : Inpatient Services, The Royal College of Psychiatrists, United Kingdom.
Accessed at : https://www.rcpsych.ac.uk/about-us/responding-to-covid-
19/responding-to-covid-19-guidance-for-clinicians/community-and-inpatient-
services/inpatient-services
3. Zhu, Y., Chen, L., Ji, H. et al. The Risk and Prevention of Novel Coronavirus
Pneumonia Infections Among Inpatients in Psychiatric Hospitals. Neurosci.
Bull. 36, 299–302 (2020).
4. Management of Healthcare Worker (HCW) during COVID-19 Pandemic, Ministry of
Health Malaysia, 2020.
5. Policies and Procedures on Infection Prevention and Control, Ministry of Health
Malaysia, 2018.
6. Personal Protective Equipment (PPE) for Severe Acute Respiratory Infections (SARI)
Wards in Hospital Kuala Lumpur, Infection Control Unit, Hospital Kuala Lumpur, 2020.
7. HKL Psychiatry & Mental Health Inpatient Interim Guidance Plan in Response to
COVID-19 & Movement Control Order 2020 Ver. 2.0, Department of Psychiatry &
Mental Health, Hospital Kuala Lumpur, 2020.

12
Appendix I

13
Appendix II

14
 FLOWCHART FOR ADMISSION PROCESS

MO received referral
from A&E

COVID-19 No For COVID-19

No done?
Screening screening

Yes

Assessment by
MO

No Yes
To discuss with
PUI
psychiatrist on-call
?

N
Psychiatry Patient admits to
Admission?
required? dedicated PUI ward,
psychiatric review as
Ye
liaison case
s

Fever
No Discuss with
> 37.5 ̊C + ILI
symptom?
Psychiatrist On-call

Yes

Discuss with
Psychiatrist On-
Discharge call

Admit Psychiatry
Admit Isolation
Ward
Unit Psychiatry

15
FLOWCHART FOR MANAGEMENT OF THE FEBRILE PATIENT +/- INFLEUNZA-LIKE ILLNESS
(ILI) IN THE PSYCHIATRIC WARD

Febrile Patient
Temp > 37.5 ◦C

No Investigate
Influenza-like
illness? other causes
of fever

Yes

Discuss with Psychiatrist On-

Treat
Call
accordingly

Transfer Isolation Unit

Refer medical/ ID Team

N.B. : Anosmia and conjuctivitis are amongst the less common and milder presenting
symptoms of COVID-19.

16
NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – ELECTROCONVULSIVE
THERAPY (ECT)

The modified ECT with the use of general anaesthesia is an aerosol generating
procedure as it involves manual bagging and oral suctioning for non-complicated
cases. The risk for viral infection during the COVID-19 pandemic is significant with the
high potential for aerosolization of respiratory droplets. Although proper screening is
done prior to ECT, some patients could be asymptomatic carriers. Precautionary
measures therefore are to be undertaken at the patient, healthcare personnel & ECT
suite (or designated operating theatre) levels to further minimise the risk of viral
transmission and cross-contamination.

Patient level

(1) Prioritise the indication for ECT

• First and foremost, prioritise cases for both acute and maintenance ECT after
considering the risks and benefits.
• When considering ECT for patients, ECT prescribers need to decide whether the
cases are elective, urgent/essential, or emergency ones.(1)

Elective cases: Patients who have a chronic Recommendation: All

or treatment resistant depression without
active suicidal ideation or dangerousness.
Others include the more stable long-term
maintenance ECT patients.
maintenance ECT cases
should be delayed for a
number of days or weeks, or
withheld if possible, based
on clinical judgement of the
ECT prescriber.

17
Urgent or Essential cases: Patients who are Recommendation: To
at risk for rapid decline leading to continue ECT treatment as
hospitalization, suicidal tendency, poor oral usual.
intake or neglected self-care. Often these
are the acutely ill index outpatient or
inpatient cases, or the maintenance ECT
outpatient cases in whom the illness is
expected to relapse rapidly if ECT is not
continued. Furthermore, these patients may
require Emergency Department visits and
hospitalizations that would increase
infection exposures for the patient and
others if not treated with ECT.
Emergency cases: Patients who are at high
risk of harm to self or others due to severity
of the illness. These patients will likely be
inpatient cases with e.g. severe psychotic
depression, medical frailty, catatonia or
neuroleptic malignant syndrome.

• Regarding the course for acute cases (if ECT is indicated), ECT prescribers may
continue the typical 3 sessions per week schedule to stabilize patients and plan
for discharge at the soonest possible. Alternatively, the course could switch to a
2 sessions per week schedule to reduce the number of ECT sessions i.e.
➢ For depression, a 2 sessions per week schedule is feasible but the electrode
placement would be bitemporal. Unilateral placement would still require the
3 sessions per week schedule.(2)
➢ For other illnesses such as schizophrenia and bipolar mania, the current
recommendation is still a 3 sessions per week schedule with bitemporal
electrode placement.(3)

18
(2) Prior to obtaining consent for ECT, do ask the screening questions
• To further increase surveillance and reduce exposure risk of any potential
COVID-19 cases, screening for the symptoms prior to obtaining ECT consent is
required (refer to Appendix).(1)
• ECT is to be avoided for any COVID-19 positive patient or patient under
investigation (PUI) for COVID-19 unless there is imminent risk for the patient (e.g.
in life-threatening cases of suicide or severe malnutrition due to psychiatric
illness). If a COVID-19 positive or PUI patient requires ECT, the issue of intubation
may be raised by the anaesthetic team and risks/benefits should be reviewed.(1)

Healthcare personnel level

(3) Only essential healthcare personnel are to be involved for the ECT procedure
Depending on the availability, it is recommended to only incorporate essential
and dedicated healthcare staff for the procedure in the suite or designated
operating theatre (OT) i.e.
• Only 1 ECT Medical Officer at a time (may have 2 Medical Officers for ECT
schedule)
• Maximum 2 ECT Co-ordinators at a time (may have 3 Co-ordinators for ECT
schedule)
• Only 1 Anaesthetic Medical Officer
• Only 1 Anaesthetic Assistant

(4) Donning of appropriate Personal Protective Equipment (PPE)

• For the anaesthetic team, a full PPE would be required i.e. N95 mask, head
cover, face shield, long-sleeved fluid repellent isolation gown, gloves and plastic
sleeveless apron.
• For ECT team, at least 4 items i.e. N95 or KN95 mask (with a possible risk of less
than 8% leakage), face shield, plastic sleeveless apron & gloves (optional: head
cover & long-sleeved fluid repellent gown).

19
(5) Use of aerosol box for further protection against aerosolization
• In uncomplicated cases that do not require intubation of patients, an aerosol
box is recommended during ECT procedure with manual bagging and oral
suctioning, particularly in situations with limited PPE supply. Without the box,
contamination could be detected more than 2 meters away from the patient.(4)
• Aerosol box: a box made of acrylic sheets with an opening on one side and 2
pre-cut holes on the opposite side (refer Figures 1 to 3 below).(5)
• This aerosol box is possible only when administering the bilateral electrode
placement using the headband. It is to be disinfected with alcohol wipes after
completion of each case.

Figure 1: Aerosol box Figure 2: Manual bagging by Anaesthetic Medical

Officer / Assistant

Figure 3: A semi-circular hole

on right-sided lower edge of
box to accommodate
oxygen tubing’s & ECT
electrode cables

(6) Practice of physical distance in the ECT suite or designated OT

• For ECT personnel, after placing the electrodes, to step away at least 1 meter
from the area of manual bagging.

20
 • Ensure positioning of the ECT machine is of at least 1 meter from the area of
manual bagging.

ECT suite or designated operating theatre level

(7) Disinfection regime to be implemented

• It is recommended to disinfect the ECT suite or OT before commencement of
the ECT procedure for the day, and re-disinfect after cases are done for each
different ward (e.g. male and female wards) so as to reduce risk of cross-
contamination.
• For terminal cleaning of ECT suite or OT after completion of ECT procedure for
the day.

21
References

1. Letter on COVID-19 and ECT by International Society for ECT and

Neurostimulation (ISEN) Executive Committee on April 2, 2020.
2. Semkovska M, Landau S, Dunne R, et al. Bitemporal Versus High-Dose Unilateral
Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A
Pragmatic, Randomized, Non-Inferiority Trial. Am J Psychiatry. 2016;173(4):408-
417.
3. Chanpattana W, Chakrabhand ML, Buppanharun W, Sackeim HA. Effects of
stimulus intensity on the efficacy of bilateral ECT in schizophrenia: a preliminary
study. Biol Psychiatry. 2000;48(3):222-228.
4. R. Canelli, C.W. Connor, M. Gonzalez, A. Nozari, R. Ortega. Barrier Enclosure
during Endotracheal Intubation. N. Engl. J. Med. 2020. DOI:
10.1056/NEJMc2007589
5. Everington K. Taiwanese doctor invents device to protect US doctors against
coronavirus. Taiwan News. March 23, 2020.
(https://www.taiwannews.com.tw/en/news/3902435).

22
Appendix III

Screening questions prior to obtaining ECT consent (adapted from International

Society for ECT and Neurostimulation or ISEN)

Screening Questions

1 Have you been tested for COVID-19 within ☐ Yes; If yes, have you been
the past month? advised the outcome of the
test result? ☐ Yes ☐ No
☐ No

2 Have you travelled overseas or out of state ☐ Yes

in the last 21 days? ☐ No

3 Have you had contact with someone with ☐ Yes

COVID-19, in the last 14 days? ☐ No

4 Have you been advised by a health ☐ Yes

professional (Public Health / Infectious ☐ No
Diseases) to self-quarantine for 14 days due
to contact with someone who has COVID-
19?

5 Have you been in a group of more than 10 ☐ Yes

individuals in the last 14 days? ☐ No

6 Have you experienced any flu-like / ☐ Yes

respiratory symptoms over the past 2 weeks? ☐ No

7 Does anyone in your immediate household ☐ Yes

have cough, fever, difficulty breathing, sore ☐ No
throat, or muscle aches, over the past 2
weeks?

Informant: Patient / Relative / Guardian

Screening performed by:

___________________________________________________
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(Signature & Name of Prescribing Psychiatrist / Medical Officer)

Date & Stamp:

NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – OUTPATIENT SERVICE

INTRODUCTION

Despite movement control order (MCO), all healthcare services have been ongoing
with appropriate restrictions in place in order to reduce the spread of infection i.e. to
flatten the curve. However, even after the MCO has been lifted, measures to prevent
another ‘wave’ should be continued diligently whereas services that have been ‘put
on hold’ should gradually resumed.

OUTPATIENT SERVICES

• Specialist/ subspecialty clinics.

• Visiting clinics – health clinics (KK), prison.
• Day care.

OBJECTIVES

• To outline risk reduction measures that will be taken to prevent outbreak during
outpatient service delivery.
• To maintain good quality of care despite the changes imposed as a result of
the recent pandemic.

STANDARDS OF PRACTICE

• To adhere social distancing.

• To emphasize on hand and respiratory hygiene and other infection prevention
techniques.
• To ensure the use of appropriate Personal Protective Equipment (PPE).
• Fostering creative use of digital platform.

RECOMMENDATIONS

• Limit entry and exit points (preferably 1 each) and label them clearly
o Develop patient movement plans if applicable (Appendix I).
o Maximize the usage of space.

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 o Healthcare workers in charge of screening counter will also become the
gate keepers of the clinic who will limit the number of people in the clinic
at any particular point of time.

• Determine location for screening process – before entering the clinic

o Screening should be done for staff and patients.
o Screening procedure – temperature check and record/ tag,
questionnaire (Appendix II).
o Example of flowchart (Appendix III).

• Social distancing measures

o Limit number of patients waiting in the waiting area. Limit only 1 carer
per patient (if needed):
▪ Staggered appointment system must be adhered to strictly.
▪ Minimize consultation time.
▪ Longer follow-up dates.
▪ Referral to nearest health clinics (KK) for stable cases.
▪ Consider extending clinic sessions e.g. increasing clinic days or
sessions.
▪ Consider ‘virtual clinic’ for selective cases decided by specialists/
senior medical officers – via phone (Appendix IV), virtual
consultation (Appendix V) [refer to MMC advisory on virtual
consultation]
• Prepare requirements in terms of infrastructure e.g. video
teleconsultation sets, stable internet lines, proper standard
operating procedures (SOPs) are available and in place
before starting virtual clinic.
• Need to determine how the appointments, registration and
billing should be done.
• Determine how to facilitate or ‘fast track’ collection of
medication e.g. fast lane to collect prescription slips outside
25
 clinic, encourage the usage of value added services (VAS)
provided by the pharmacy department.
• Make sure all sessions are documented in patients’ files.
▪ Encourage the usage of value added services (VAS) offered by
the pharmacy department e.g. ‘Ubat Melalui Pos’ (UMP), drive
through, ‘sistem pembekalan ubat berkala’ (SPUB) etc.
o Other measures:
▪ Distance marking (‘tanda jarak’) – queue (at least 1 meter apart),
seating (1 meter apart or alternate chair seating) and distance
marking in front of counter.
▪ To rearrange the consultation room layout (Appendix VI).

• Other preventive measures

o All patients and carers must wear face masks during clinic visits.
o All staff are required to wear appropriate PPE as per Ministry of Health
(MOH) guideline (appendix VII).
o Encourage regular hand sanitization/ washing in between procedures
e.g. blood taking, vital signs checking, depot administration.
o Provide hand sanitizer at entry point, at clinic counters and in
consultation rooms.
o Regular sanitization activities esp. for high-touch surfaces at work e.g.
clinic counters, door knobs, stairs, consultation tables, lift buttons etc. At
least 2-3x a day – before clinic, in the afternoon, before closing.
o Minimise items/fomites to reduce the risk for cross infection. Laminate
any posters to facilitate the ease of sanitization processes.
o Display posters or videos about preventive measures e.g. hand washing,
correct usage of gloves and mental health awareness e.g. deep
breathing techniques, stress management.

26
• Establish an isolation area
o To determine how and where suspected cases will be isolated from
other patients in the clinic space.
o To facilitate needs during isolation e.g. collecting/ administering
medicine such as depot injection for them (if necessary).
o To identify hospital’s flow chart on follow up actions e.g. referral to
screening tent or discussion with Emergency Physician / Infectious
Disease physician.
o To perform terminal cleaning and disinfection activities once the
suspected case leaves the area.

• Risk reduction measures amongst healthcare workers (HCWs)

o Staggered time in pantry, rest area and surau.
o If need to do face to face meetings, must adhere to social distancing
(not more than 10 people at one time) and all wearing mask.
o Strict adherence to hand washing/ sanitizing.

• Visiting clinics
o Limit cases and minimize consultation time.
o Adhere to other safety measures as described above.
o Empower the existing medical unit available at the area to continue the
care of those patients with support and external supervisions from the
specialists.

• Day care
o Education about safety and preventive measures to all patients prior to
starting the activities.
o Limit cases (social distancing) and minimize contact time (reduce risk of
exposure).
o Adhere to other safety measures mentioned above.

27
 o After the sessions are over, make sure all the equipments used are
sanitized.

• Addressing issues
o Longer waiting time for appointment dates:
▪ Staggered or re-scheduling appointment based on triaging/
urgency.
▪ Virtual clinic – teleconsultation or phone consultation.
o Overcrowding and limited facility spaces:
▪ Collection of medicines via VAS offered by pharmacy as above.
▪ Wait for turn in other areas e.g. outside the hospital or in the car
until nearer to appointment time.
▪ Adhere to staggered appointment system strictly.

• Monitoring
o Head of departments and specialists shall be the reference point for
decision making and monitoring.

28
REFERENCES:

• Cadangan SOP sektor perkhidmatan kesihatan pasca perintah kawalan

pergerakan (PKP) – perkhidmatan hospital
• Covid-19 healthcare planning checklist - U.S. Department of Health and
Human Services (HHS) Office of the Assistant Secretary for Preparedness and
Response
• HKL Psychiatry & Mental Health Clinic interim guidance plan in response to
covid-19 and movement control order 2020
• Hospital Ampang – Borang Saringan Risiko Covid-19
• Malaysian Medical Council Advisory on Virtual Consultation (during the Covid-
19 pandemic)
• Pelan Tindakan Pasca PKP, Jabatan Psikiatri Hospital Kajang
• Recommended PPE to be used when managing PUI/ confirmed covid-19 in
healthcare facilities – MOH, 21.4.2020
• Revised Policy and Practice Updates in Response to Covid-19, Department of
Psychiatry, Hospital Miri

LIST OF APPENDICES:
1. Example of patient movement plan
2. Example of screening questionnaire (Hospital Ampang)
3. Example flowchart of screening and triaging
4. Example procedure for teleconsultations (Hospital Kuala Lumpur)
5. Malaysian Medical Council Advisory on Virtual Consultation (during the
Covid-19 pandemic)
6. Example of consultation room layout (Hospital Miri)
7. Recommended PPE to be used when managing PUI/ confirmed Covid-19 in
healthcare facilities – MOH, 21.4.2020

29
APPENDIX I

EXAMPLE OF PATIENT MOVEMENT PLAN

30
APPENDIX II

EXAMPLE OF SCREENING QUESTIONNAIRE (HOSPITAL AMPANG)

31
APPENDIX III

EXAMPLE OF FLOWCHART OF SCREENING AND TRIAGING

32
APPENDIX IV

EXAMPLE OF PROCEDURE FOR TELECONSULTATIONS (HKL)

33
APPENDIX V

Reference: https://mmc.gov.my/wp-
content/uploads/2020/04/MMC_virtualconsultationADVISORY.pdf

34
APPENDIX VI

EXAMPLE OF CONSULTATION ROOM LAYOUT

35
APPENDIX VII

36
EXAMPLE OF POSTERS TO BE DISPLAYED

37
38
39
40
41
42
NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – COMMUNITY PSYCHIATRY
SERVICE

World Health Organization suggested six factors that are to be considered on easing
Movement Control Order (MCO):

1. The transmission of virus is controlled

2. Health system capacities are in place to detect, test, isolate, and treat every
COVID-19 case and trace every contact
3. Outbreak risks are minimized in special settings like health facilities and nursing
homes (Mental facilities/Nursing homes)
4. Preventive measures are in place in workplace, schools, other places where it
is essential for people to go to
5. Importation risks can be managed
6. Communities are fully educated, engaged and empowered to adjust to the
“New Norms” and to put the new normal into practice

I. COMMUNITY MENTAL HEALTH TEAM (CMHT)

Home visit is carried out for people with serious mental illness who will benefit from
CMHT services. CMHT is provided for under Regulation 16, Mental Health
Regulations (2010) and Mental Health Act (2001). Garispanduan Perkhidmatan
Pasukan Kesihatan Mental Masyarakat with its inclusion & exclusion criteria was
prepared by the Ministry of Health in 2016.

The new normal in Community Mental Health Team: (The following strategies are
adopted from Royal College of Psychiatrists (RCPsych) COVID-19 Guidance for
Psychiatrists in Community Mental Health Settings 2020).

1. We need to look at the potential susceptibility to COVID-19 for certain patients

(Ref: COVID-19 – Working in community mental health setting, Royal College
of Psychiatrists, 2020) such as:
• older adults (particularly those over 70 years)

43
 • people with enduring mental illness who smoke, use alcohol and are in
poorer physical health
• people with existing respiratory disease e.g. COPD and asthma, and
people at risk of chest infection
• people who are malnourished for any reason (including metabolic
disorder) often have a reduced immune response and it may contribute
to poor outcome
• patients who do not adhere to self-isolation advice, such as delusional
beliefs, behavioural problems, chaotic life styles, etc.

2. Review caseload at least weekly for community mental health team.

3. Keeping patients and families informed: health professionals to update

patients and families on the new normal i.e. physical distancing and frequent
sanitization. All case managers to explain to the patients and families about
the need to maintain up-to-date risk stratification by carrying out telephone
screening prior to home visit, and that staff may wear personal protective
equipment (e.g. mask, gloves, apron, etc.) during visit.

4. Plan and organize visits: ensure/confirm availability of patient and families at

home.

5. Consideration should be given to whether a face-to-face interaction is

needed or whether known contact (exclude new patient) can be safely
managed over the telephone or other visual technologies (should comply with
the 2020 Malaysian Medical Council Advisory on Virtual Consultation during
the Covid19 pandemic, and may involve mobile telephone claim of staff).
Categorize need rating of every old case (exclude new patient) into:
• Red: Vulnerable, high risk (include patient on depot injection who have
issue of adherence to oral medications or are unable to go to clinic)
o Preferably face-to-face contact
44
 • Yellow: Moderate risks/ concerns
o Require monitoring via phone with option to step up to face to
face if required
• Green: Generally stable presentation
o Require telephone contact – need telephone review in place of
face-to-face. Option to escalate depends on patient’s mental
state.

Consideration should be given to older people, person who is less likely to

access or no access to technology, or person who is unable to hear well over
the phone.

6. Prior to home visit, the case manager is to make telephone contact with the
patient and families to establish the physical health status of patients and
families as follows:
• Do you have high fever/temperature?
• Do you have a new continuous cough?
• Does anyone in your home address have these symptoms?

If the answer is yes to any of above, this will be considered as “symptomatic”,

and patient and families are advised to seek treatment at the nearest clinic or
hospital.

If the team is unable to make successful telephone contact with a patient prior
to their visit, attempts should be made to telephone the patient’s family. If
contact cannot be established, do not visit, but continue to try to make
contact.

In special circumstances where the patient does not have a telephone and
families are not living nearby/with the patient, and families do not know the
patient’s progress, the psychiatrist in charge will discuss with the
45
 multidisciplinary team and make a conjoint decision on the need for the case
manager to do a home visit, balancing all risk and benefit factors.

7. Social distancing must be practiced in the car if case manager goes for home
visit with an accompanying person.

8. All case managers should be alert and screen the health status of the patient
and patient’s family members upon arrival to a patient’s house. If there is any
concern that the patient or the patient’s family members are having
symptoms, do not enter the house. Advise the patient and the patient’s family
members to seek treatment at the nearest clinic or hospital.

9. Before entering the house, the case manager is to wear a mask. The case
manager must keep the visit duration less than 15 minutes per session and
practice physical distancing (at least 1 meter apart). Hand sanitization is
required after touching all objects or surfaces in the patient’s house and
sanitize again before entering the car. The case manager must wear
mask/face shield/gloves before giving depot injection to the patient.

10. In relevant cases, case managers may educate the patient and families to
optimize the use of “Ubat Melalui Pos” (UMP) services and case managers
should improve collaborative efforts with Klinik Kesihatan (KK) for stepdown
care of stable patient.

II. COMMUNITY MENTAL HEALTH CENTRE (CMHC)

A community mental health centre (CMHC) is a centre for community care

treatment which includes the screening, diagnosis, treatment and rehabilitation of
any person suffering from any mental disorder (Section 32, Mental Health Act 2001).

46
In response to the Covid-19 pandemic, the Movement Control Order (MCO) has
been imposed and enforced by the government to control the rapid spread of
infection in the community. Upon the gradual lifting of the MCO, various measures
need to be in place to ensure continuous adherence to high standards of personal
hygiene and physical distancing in healthcare facilities. As people with mental
disorders are a vulnerable group in the community, it is imperative that such
measures are implemented in the daily operations of the CMHC post-MCO.

While the CMHC continues to function in providing services to clients in the

community, such preventive measures need to be adapted as the new normal in its
day-to-day functions and operations so as to protect the health and safety of clients
as well as staff members in the CMHC.

General measures in the new normal

1. Front door screening: All clients who wish to access services at the CMHC need
to complete a health screening questionnaire and temperature check at the
front counter before entering the CMHC premises.
2. Physical distancing: All clients and staff members of the CMHC need to
maintain a minimum distance of at least one meter (or three feet) apart from
one another while in the premises of the CMHC.
3. Hand hygiene: Facilities for hand-washing must be available in the premises
of the CMHC including washing basin with soap, or hand sanitizers made
available for use by clients and CMHC staff members at all times.
4. Cleanliness of premises : The CMHC and its vicinity must be kept clean at all
times, and staff members need to ensure that regular daily cleaning by
cleaning services are carried out at the CMHC premises and its vicinity.
5. Crowd control: The number of clients attending the CMHC at any one time
must be staggered so as to avoid overcrowding or breach of physical
distancing; CMHC managers may need to adjust their centre’s service/activity

47
 schedule into separate sessions in a day if necessary, and plan and organize
the number of clients per session.
6. General health/contingency measures : All other general health/contingency
measures are to be in place in the event a client develops sudden health
signs/symptoms (e.g. ILI or SARI signs/symptoms) while accessing services in the
CMHC.
7. Education of clients & families: All the general measures mentioned here
should be adequately taught and explained to all clients and their families
prior to them accessing the services at any CMHC.

Measures in relation to specific CMHC service components (CMHC Implementation

Guidelines 2013; Draft of Second Edition CMHC Implementation Guidelines 2020)

1. Consultation Clinic: (refer to subsection on Psychiatry Clinic/Outpatient

Services).

2. Community Psychiatry Services: (refer to subsection on Community Mental

Health Team / Home Visit).

3. Psychiatric rehabilitation: Due to prolonged confinement at home during the

MCO, many existing clients attending the CMHC rehabilitation programmes
may long for an immediate return to such services; the gradual resumption of
such services at the CMHC may be necessary to reduce negative interactions
at home, and also provide respite to some families. However, it is imperative
that careful planning is prepared ahead so that such services may be resumed
in a gradual manner. CMHC managers are to ensure that strict adherence to
the general measures mentioned above are followed at all times when such
services are being resumed at their respective CMHCs. In order to avoid
overcrowding of premises with limited space, assessment of client needs may
be required in order to identify potential clients attending, as numbers may
48
 need to be limited per session (may refer to RCPsych Covid-19: Guidance for
Psychiatrists in Community Mental Health Settings 2020).

4. Supported employment: One of the key service components is the supported

employment programme, which is a measured Key Performance Indicator
(KPI) of CMHCs. In view of changes in environmental circumstances post-MCO,
methods of implementation of the activities of supported employment may
need to be adapted to suit the new normal practices. The designated job
coach may need to explore new innovations in job search and job coaching
processes to ensure all general measures are complied with, for example using
online resources and online/tele- monitoring of clients in the supported
employment programme. Depending on circumstances of
employment availability, clients may spend a longer duration in
transitional employment programmes instead.

5. Social Enterprise: Where rehabilitative activities of social enterprise are carried

out in CMHC premises, for example bakery, all measures in relation to physical
distancing and hand hygiene must be complied with at all times. All activities
will limit the number of patients to about eight to ten patients. Alternative
methods to previous practices such as marketing of products/services may be
considered (for example online sale, telephone order and drive in collection,
etc.) to limit unnecessary movement and external contact of clients and staff.

6. Community Out-reach: Where programmes involving the community are

concerned, all general measures pertaining to physical distancing, hand
hygiene, crowd control and capping the number of participants are to be
followed. Alternative methods are preferred over in-person meetings, for
example using social media or visual conferences.

7. Lodging < 24hours (where available) : For CMHCs where services are available
for lodging of clients not exceeding 24 hours (as per Section 37 of the Mental
49
 Health Act 2001), all measures must comply with recommendations of the SOP
for Hospital Services post-MCO (refer Cadangan SOP Perkhidmatan Kesihatan
Pasca PKP-Perkhidmatan Hospital).

Review of Individual Care Plan for CMHC clients

In view of the potential challenges that may be faced by clients with mental disorders
in the community, especially in adjusting to changes in practices and new norms, it
is important that each client’s individual care plan in the CMHC be reviewed. This is
to enable the incorporation of general measures of the new normal as mentioned
above into their treatment and rehabilitation care plans. For existing clients, such
measures (e.g. physical distancing, hand hygiene) may need to be incorporated
into part of their social skills training in rehabilitation for example. The education on
the need to comply with such measures is emphasized as part of their
psychoeducation programme. For new clients, screening and education may be
done at the intake assessment and be incorporated into their individual care plan as
part of their treatment and rehabilitation in the CMHC.

Anticipating issue of space-limitation / crowd control in CMHC premises

In view of its accessibility in the community and fear of contact with hospital services,
it is anticipated that the number of clients seeking services of the CMHCs may
increase. Furthermore, there may be increase in mental health problems associated
with the pandemic and MCOs. In the event of such circumstances, it may be
necessary to define client groups according to needs. The COVID-19 Guidance for
Psychiatrists in Community Mental Health Settings by the Royal College of Psychiatrists
(RCPsych) UK may be referred to in identifying clients with high needs; among some
of the criteria mentioned by the RCPsych include risk, acuity of mental & physical
health, environment at home and network of support, as well as other lifestyle
concerns. Individual CMHCs may adapt such criteria in defining/identifying potential
clients and tailoring the CMHC services to suit their treatment and rehabilitation
needs.

50
III. GOVERNMENT PSYCHIATRIC NURSING HOME (GPNH)

A Government Psychiatric Nursing Home (GPNH) is a psychiatric facility provided for

under the provision of the Mental Health Act (MHA) 2001 and Mental Health
Regulations 2010. The appointment of a Government Psychiatric Nursing Home is by
the Health Minister (Sec 27, MHA 2001).

A psychiatric nursing home is a home for accommodation and provision of nursing

and rehabilitative care for persons suffering or convalescing from mental disorders.
(Sec 26 MHA 2001)

The following strategies are adopted from the US National Council for Behavioural
Health: COVID-19 Guidance for Behavioural Health Residential Facilities 2020, and
applied in the context of the operations and functions of GPNHs at the local level.

Accepting new patients

Where possible, GPNHs should continue to accept new patient referrals, through
proper work place planning and organization. It is essential to implement a
comprehensive physical distancing programme, which include the physical
arrangement of beds, sitting arrangement, bathroom facilities, etc. and adequate
hand washing facilities. The patients and their families should be educated and
informed of their rights and responsibilities in the horizon of the new normal with the
addition of infection control and prevention measures.

The following measures are to be followed when accepting new patients:

• The same screening procedures should be employed in accordance with

existing guidelines and SOPs.
• To obtain detailed information from the referring team with regards to the
patient’s health status, history and symptoms, and to be alerted to any changes
in the current status of the patient.

51
 • It may be necessary to place all new patients (who are unsure of their contacts
or exposure) in a separate designated area for the first 14 days upon arrival to
the GPNH facilities, and for them to wear a facemask.

Screening

Screening for COVID-19 symptoms should be done on all individuals who access
GPNH facilities including staff members, patients or other visitors.

Staff members are to self-monitor daily for signs and symptoms of COVID-19, and to
inform their immediate supervisor if they fall ill. Staff members who are ill should be
educated and understand that it is vital to look after themselves, stay at home and
not pass on the illness to others at work.

Programme modification

GPNHs are encouraged to take additional infection control and prevention

measures in their facilities. The general measures such as physical distancing, hand
hygiene and crowd control should be practised.

Telemedicine consultation may be arranged by GPNH managers with the health

care providers of the patients if relevant.

Supported employment is one of several service components of the rehabilitation

programme in the GPNH. The new normal practices shall be similar to those as
mentioned above in the CMHC section, whereby innovations in job search and job-
coaching processes may be adopted, and patients may be placed longer in
transitional employment programmes instead.

52
Facility access

Only patients, staff members and vendors should have access to GPNH facilities,
while limited access to visitors may be considered in certain situations. Where limited
access is granted to visitors, strict adherence to SOPs and policies on visitation to
healthcare facilities must be ensured by GPNH managers.

Visits should be restricted to a dedicated visiting area, the location of which should
preferably be near the entrance of the facility, and kept sanitized and disinfected
after each visit.

How to respond if patient develops COVID-19 symptoms

• If a patient develops symptoms that could indicate a COVID-19 infection, the

response depends on the patient’s condition and involves either transfer to a
dedicated hospital or management within the GPNH facility (after consultation
with the Physician of the dedicated hospital).

• If a patient meets criteria for remaining at the GPNH facility:

• Facemasks should be worn by the patient and staff members.

• A physical distance of at least two metres (or six feet) should be kept
between the affected patient and staff members or other patients in the
facility. In situations whereby nursing care requires staff to be closer to the
affected patient, then appropriate PPE should be worn by the attending
staff member and other harm reduction measures taken.

• The frequency of hand hygiene practices by the patient and staff should
be increased.

• A designated isolation room/area or single room (if available) should be

prepared for the patient, where the patient remains in and where meals
and medications are taken by the patient.

53
• Other inmates of the GPNH who were exposed to the affected patient
should also be kept in their own rooms for 14 days, after which they may be
allowed back to share common areas if they remain symptom-free.

• Common areas such as kitchens and lounges should not be used by the
affected patient while in self-isolation, and changes to existing routines
need to be arranged.

• Frequent sanitization should be done for surfaces that come into frequent
hand contact such as knobs, handles and other items.

• Patients who are categorised as PUIs should be allocated their own

bathrooms.

• GPNH managers should ensure that all other surfaces (such as tables, light
switches, desks, toilets, sinks, etc.) are disinfected daily.

• Adequate hand sanitizer should be made available throughout the facility.

54
References

1. Mental Health Act 2001.

2. Mental Health Regulations 2010.
3. Garispanduan Perkhidmatan Pasukan Kesihatan Mental Masyarakat,
Bahagian Perkembangan Perubatan, Kementerian Kesihatan Malaysia, 2016.
4. Community Mental Health Centre Implementation Guideline 2013.
5. Draft of Second Edition of Community Mental Health Centre Implementation
Guidelines 2020.
6. Cadangan SOP Perkhidmatan Kesihatan Pasca Perintah Kawalan Pergerakan
(PKP) – Perkhidmatan Hospital 2020.
7. Royal College of Psychiatrists (RCPsych) COVID-19 Guidance for Psychiatrists in
Community Mental Health Settings 2020.
8. US National Council for Behavioural Health: COVID-19 Guidance for
Behavioural Health Residential Facilities 2020.
9. Malaysian Medical Council Advisory on Virtual Consultation (during the
Covid19 pandemic) 2020.

55
56
Appendix 2

57
NATIONAL GUIDELINE FOR ‘NEW NORMS’ – INSTITUTIONS OF PSYCHIATRY

1.0 Objectives
• To ensure patients, staff members and service users are adequately protected
from the risk of COVID infection
• To ensure the smooth delivery of full range of services in the institutions of
psychiatry within the ‘new normal’

2.0 Centralized Approach To Prevention And Control Of COVID Infection

• COVID Management Committee

The committee oversees the management of all aspects of prevention and
control of COVID infection in the hospital. The committee is comprised of:

Hospital Director

Hospital Deputy Director

Psychiatrist in-charge of the Committee

Head of Nursing

Head of Assistant Medical Officer

Infection Control Unit

Occupational Safety and Health Unit

Public Health Unit

Head of Pharmacy

Security officer

Asset and Logistics officer

58
 • Triage Centre
- screens everyone who enters the hospital compound through temperature
checking and declaration form
- comprises medical officers and paramedics who perform screening around
the clock, with adequate numbers of personnel to cater to clinic patients and
during the changing of shifts
- Infection Control Nurse work according to the duty roster with after office hours
on-call
- there are designated areas for PPE donning and doffing, PUI assessment, and
high-risk patient review
- an established SOP for appropriate PPE use is followed
- an established SOP for referral to COVID centre is followed (Refer Appendix)
- high risk patients are reviewed by the medical officer at the designated area
in the triage centre, hence avoiding the need for the patient to enter the
outpatient clinic or other facilities

3.0 Outpatient Services – as per the outpatient services section

4.0 Inpatient Services – as per the inpatient services section

- Transfer of involuntary patient to an approved psychiatric hospital

• When an order has been made to transfer a patient from a psychiatry

hospital to an approved psychiatric hospital, the receiving hospital
should prepare an isolation ward and do necessary preparation to swab
the patient on arrival.
• The room should be adequately lit, ventilated, of a minimum dimension
of 10 square meters with closed doors and furnishing in such room shall
be made of material that will not endanger patient.

59
 • A copy of patient’s completed Covid-19 screening questionnaire and
temperature with vital signs prior to transfer should be provided to the
receiving hospital.
• The psychiatric management should be continued and appropriate use
of Personal Protective Equipment (PPE) according to type of activity and
job scope as mentioned in Appendix II of inpatient services section.
• Patient can be transferred to designated ward once the swab result is
negative.

5.0 Psychosocial Rehabilitation Services

- Selected psychosocial rehabilitation services which can be conducted with

adherence to social distancing and hand hygiene include:

- Inpatient

• Psychoeducation: this could be done on a one-to-one basis or in group

of maximum 10 patients with strict adherence to social distancing. The
session would include providing information on illness and management,
early warning signs detection and crisis intervention and management.
• ADL training, grooming, personal hygiene and communication training,
preferably to be done on a one-to-one basis or in group of maximum 5
patients.
• Family intervention: This can be performed via phone consultation in
order to comply to social distancing and to minimize movement of
family members.
- Outpatient:

• Stress management/relaxation techniques are recommended to be

done on a one-to-one basis or in small group with proper social
distancing

60
 - Social Enterprise (Carwash/Minimarket/Bakery/Cafeteria/others)
• Strict hand hygiene and social distancing.
• For food handling services, staffs or patients should be more diligent in
practicing frequent hand hygiene.
• Digital wallet services are encouraged in order to enable contactless
payments.
- Agricultural Rehabilitation
• Strict hand hygiene and social distancing.
- Supported Employment
• Strict hand hygiene and social distancing.
• Patients who are employed outside the institution are required to
undergo thorough screening processes daily when they return to the
institution.

6.0 Training and Educational Activities

• Strict hand hygiene and social distancing shall be maintained for all the
activities concerned. All activities are required to be performed in accordance
with the current guidelines issued by the Ministry of Health.
- Courses/workshops/seminars
- Attachments/practicum
- Educational visits
- Other related activities

• Board of visitors (BOV)

- Strict hand hygiene and social distancing during the monthly BOV visits to
the facility. No physical contact with patients and staff members.
- The meetings can be held with strict arrangement of physical distancing. To
limit the number of members in the meeting room accordingly and meet
via virtual for other members.

61
Appendix

62
NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – FORENSIC PSYCHIATRY
SERVICES

Forensic psychiatry service in Malaysia is exclusively provided by the four mental

institutions which have been designated as approved psychiatric hospitals in
accordance with Section 22 of the Mental Health Act 2001.

The four institutions are:

a) Hospital Bahagia Ulu Kinta, Perak

b) Hospital Permai, Johor
c) Hospital Sentosa, Sarawak
d) Hospital Mesra, Sabah

These four forensic facilities receive referrals from the courts under Sections 342, 344
and 348 of the Criminal Procedure Code (CPC). Referrals for mental assessment
under Section 342 CPC account for nearly 1000 cases every year. 90% of these cases
are referred to Hospital Bahagia and Hospital Permai. In addition, mental health
services for prisoners are also provided in accordance with the Prisons Act 1995.
However, the facilities, manpower and number of beds available are limited.

Secure hospital services will be able to draw upon general and mental health
specific guidance in terms of how it responds to COVID-19 by the Ministry of Health.
However, forensic hospitals receiving cases from the courts and prisons need to
adopt different approaches to prevent and limit the threat posed by COVID-19.
Restrictions, which in the past were non-existent, may now have to be imposed in the
light of this pandemic. The forensic units of these hospitals cannot afford to be shut
down in the event of a positive COVID-19 case within its walls.

This guideline aims to address the modified working process of the forensic psychiatry
service following the COVID-19 pandemic.

63
1. Forensic Units in Approved Hospitals

Forensic services in all hospitals shall remain open. The services must pay due regard
to legal duties and be cognizant of the impact of decisions on patient-care against
the risks associated with COVID-19.

The background of accused persons and prisoners are largely undetermined or

unknown with regards to the risks of COVID-19. Due to the limited resources in all four
forensic hospitals, concerted effort must be taken by the judiciary and the police in
staggering the referrals in order to prevent overcrowding in the wards. Overcrowding
will invariably potentiate the risk of spread of COVID-19.

a) The Judiciary
Prior to the onset of this pandemic, cases are sent to the forensic hospitals
without prior notice or arrangements. This, together with the delayed discharge
of cases upon completion of the forensic psychiatric reports have resulted in
overcrowding of the wards, frequently exceeding the capacities of the
forensic units. This practice is no longer tenable.
Courts must make appointments with the respective forensic units before
sending the cases.
While waiting for a forensic bed, the accused persons shall be remanded in
prison or offered bail.
Emergency assessments shall be discussed directly with the psychiatrist in-
charge of the respective forensic units.
Upon receiving notice of completion of the forensic psychiatric report, the
courts must issue the Order To Produce (OTP) without delay and instruct the
police to discharge the accused from the hospital with immediate effect.
The courts shall practice the recommendations by the Ministry of Health to
prevent the spread of infection at all times when handling accused persons
prior to sending the case to the hospital.

64
 (Courts in this document refers to the Magistrates Court, Sessions Court and the
High Court).

b) The Police
Upon receiving the OTP and instructions from the courts, the police must
discharge the accused person from the hospital at the soonest possible. Delays
in discharging accused persons will lead to overcrowding in the wards.
The police shall practice the recommendations by the Ministry of Health to
prevent the spread of infection at all times when handling accused persons to
and from the hospital.

(Refer to Appendix 1 for the flow chart on the procedure of admission and
discharge)

2. Admission Procedures

a) Triage

All new cases referred from the courts and prisons must be triaged at the
emergency departments or the triaging centres of the respective hospitals. The
escorting police officers are to remain until this process is completed.

Symptom screening, history of contact and recent travel as well as a physical

examination will be conducted.

If the accused person is suspected to be COVID-positive, an urgent referral to

the nearest general hospital must be done immediately. The local Crisis
Preparedness & Response Centre (CPRC) shall be notified.

A brief assessment of psychiatric symptoms compromising immediate health

and safety such as active suicidal intent and actions, serious self-injury and risk
of harm to others must be done prior to making the referral.

65
The escorting police officers will be advised send the case to the general
hospital’s emergency department for admission as the accused person is still
under police custody. The police are only allowed to return once the patient
is under the care of the general hospital.

In suspected COVID-positive cases, police escorts will not be expected to

continue escorting the accused person at the general hospital’s COVID or
isolation wards. A letter of notification will be sent to the nearest Ibu Pejabat
Polis Daerah (IPD) to inform the police about the admission of the accused
person to the general hospital.

If the accused person is certified COVID-negative and has been admitted to

the general medical ward, only then the police from the nearest IPD will be
notified to escort the accused in the ward.

Upon triage, if the accused person is physically well and has no risk factors for
COVID-19, the police will then send the case for admission to the Forensic Unit.
The Forensic Unit shall only take over legal custody of the accused person once
this process has been cleared.

Scenario

A case under Section 342 CPC is sent to Hospital Bahagia for mental
assessment from Mahkamah Majistret Besut, Terengganu, escorted by police
officers from IPD Besut. Upon arrival at Hospital Bahagia’s triage counter, the
accused person is suspected to be COVID-positive. A referral is made to
Hospital Raja Permaisuri Bainun (HRPB) Ipoh. The accused will be sent to HRPB
for admission by the police officers from IPD Besut. A letter will be sent by the
Forensic Unit of Hospital Bahagia to IPD Ipoh to notify the police about the
admission of the accused to HRPB Ipoh. The police from IPD Ipoh will only be
expected to escort the accused once he/she has been certified COVID-
negative and transferred to the general medical ward.

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 (Refer to Appendix 2 for the flow chart on the referral of accused persons to
the general hospital while still under police custody)

b) Admission to the Forensic Unit

The standard screening and admission procedures of the respective forensic

units will apply.

Medical staff must be cognizant of changes in the patient’s physical condition

especially with regards to emergent COVID-19 symptoms after admission to
the forensic unit. If the patient develops ILI/SARI or other acute medical
conditions after admission to the forensic unit, pre-existing SOP’s of the
respective forensic units on referring cases to the general hospital shall apply.

Every forensic unit should have a simple social distancing policy in place that
is compliant with the Ministry of Health Guidelines. Patients must be orientated
about social distancing with other patients and to observe strict personal
hygiene.

Psychiatrists and medical officers should ensure that there is a review of each
patient’s pre-existing physical health vulnerability and consider any particular
vulnerabilities for the circumstances as a result of their mental disorder.

c) Cases of suspected/confirmed COVID-19 returning from general hospitals to

the forensic unit.

Patients returning from the general hospital after a period of admission there
shall preferably be nursed separately or isolated from the other patients in the
forensic unit.

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 The patient is expected to wear a face mask at all times.

d) Medical staff

All medical staff working in the forensic unit must maintain a high level of
alertness and observe a standard level of precaution and personal protection.

Standard social distancing measures must be observed between staff and

patients whenever possible.

Doctors and paramedics are expected to wear a face mask at all times
especially while conducting interviews, physical examination and serving
medications.

Staffing needs in secure forensic services needs to be high-priority and be able

to call on staff from outside their own services if there are significant workforce
pressures.

Management of violent patients eg. control and restraint, may need to be

adapted to include social distancing where possible.

Frequent ward sanitisation is to be performed, preferably at the beginning of

each shift.

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3. Discharge Procedure
Once the forensic psychiatric report is ready, the court will be notified via fax and
telephone.
The courts must issue the OTP and instruct the police to discharge the accused
immediately without delay.

4. Inpatient Service

All the forensic units of the four approved psychiatric hospitals provide inpatient
services for remand (s342 CPC) as well as long-stay forensic patients (s344/s348
CPC).

Every ward represents a community of people – staff, patients and the support
services of the hospital. This community should work together to best ensure the
safety of everyone.

Physical safety and infection control must be the main priority.

Key to managing this will be ward cohesion, communication and adapting as a

community within the forensic psychiatric services.

a) Conventional treatment of patients mental health needs will not be

compromised during this period.
b) The present situation gives an added dimension to the decision-making of the
multidisciplinary forensic teams.
c) Patients and families will need to work together to best protect the ward from
COVID-19 infection.
d) Most if not all of the familiar routines associated with ward care must be
reviewed. All activities that bring patients and staff into close contact will need
to stop altogether or be adjusted to meet the national guidelines. Ward
rounds, mealtimes and visiting times should all be reviewed to allow for as little
contact as possible. Much of this routine may be postponed for the
foreseeable future.
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 e) However, removing all ward activities is likely to be counterproductive. Patients
can become bored and agitated and may require restraint or other restrictive
practices. Occupational therapy activities must be adapted to reduce
duration, unnecessary attendance and increase personal space whilst
maintaining the social distancing recommendations.
f) Patients are the main service users in the wards and should be included as
much as possible in assisting in the restructuring of activities and ward routines.
This is to maintain harmony amongst patients and staff.
g) Each ward community should work on keeping communication between staff
and patients as good as possible. Ward meetings can still be carried out while
maintaining adequate social distancing.

5. Visitors

Relatives are encouraged to limit visiting and to consider other ways of keeping in
touch, like phone calls, especially for long-stay forensic patients. Only immediate
relatives are allowed to visit. Prior arrangements must be made with the respective
wards before visitation is granted.

Relatives may be required to attend interviews in the hospital with the psychiatrist-
in-charge for important cases under Section 342 CPC. Telephone interviews shall
preferably be conducted whenever possible.

All visitors to the forensic unit must declare if they have a fever or cough and must
allow the staff to carry out temperature checks.

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6. Leave of Absence

Leave of absence for patients under Form 1 MHA 2001 (s350 CPC) has been
temporarily frozen in accordance with the Movement Control Order. Once the
MCO is lifted, it is recommended that leave be given only in exceptional
circumstances eg. family emergencies.

7. Mental Wellbeing of Staff

It is anticipated that there will be high levels of anxiety in the present situation.
Good mental healthcare of staff who are skilled in the management of anxiety,
both their own and of the patients cannot be overstated. It is important that staff
remain confident in their ability and ensure that principles of mutual support and
team cohesion remain a cornerstone of the forensic services.

It is essential to recognise that forensic staff are likely to be under significant

pressure and to experience stress related to issues both at work and home and will
therefore require support. Staff shall be made aware of where they can access
support services i.e the Mental Health Psychosocial Support (MPHSS).

8. Legal Matters

All provisions of the Mental Health Act 2001 and the Criminal Procedure Code shall
be adhered to.
Any use of restraint or seclusion must be proportionate to the risks involved and
end as soon as possible.

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References

1. Mental Health Act 2001.

2. Criminal Procedure Code.
3. The Royal College of Psychiatrists UK: Responding to COVID-19 Guideline.
4. Cadangan SOP Sektor Perkhidmatan Kesihatan Pasca Perintah Kawalan
Pergerakan (PKP)- Perkhidmatan Hospital.
5. Guidelines COVID-19 Management in Malaysia No 05/2020.

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Appendix I

73
Appendix II

74
NATIONAL GUIDELINE FOR ‘NEW NORMS’ IN PSYCHIATRY – CLINICAL PSYCHOLOGY
SERVICES

PRINCIPLE OF SERVICE OPERATIONS

The principle of service operations is to ensure the risk of Covid-19 infection is at its
minimum level. All clinical psychology services will be continued as usual, based on
the new norms as follows:

• Applying social distancing* at all times.

• Maintaining optimum levels of hygiene such as wearing face masks, washing
hands using soap or hand sanitizer, sanitation of evaluation tools and
treatment rooms.
• Alternating between clinical tasks and tasks assigned at the Mental Health &
Psychosocial Support Services (MHPSS).

A. NEW CASES / FOLLOW UP CASES

• New referrals will be scheduled to the closest available date whereas follow
up cases will be lengthened accordingly.
• Priority will be given to cases that need immediate treatment/assessment, with
first appointment scheduled within 1 to 3 months.
• Non-urgent cases and cases with Influenza-like Illness (ILI) symptoms will be
scheduled at a later date, ideally a gap of 3 to 6 months should be given
before the first session.

B. ASSESSMENT CASES

• Psychological assessment methods and procedures are carried out as usual.

• To ensure minimal risk of infection and optimal practice of hygiene, patients
are not allowed to fill in any hardcopy screening sheets / questionnaires at
home.
• Test substitutions are only allowed in compliance to the following conditions:
• No significant deviation in test reliability and validity.

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 • It is allowed by the tool’s manual, using specific substituted tests suggested in
the manual.
• For screening purposes, not for diagnostic and comprehensive assessment.
• Priority will be given to cases that need immediate assessment results, with first
appointment scheduled within 1 to 3 months.
• Multiple sessions for certain test administrations are not allowed in order to
reduce patients’ exposure to environmental risk. However, multiple breaks in
between test administration are encouraged in order to reduce contact
exposure between assessor and patient.
• Room and assessment table are arranged according to the Social Distancing
Guidelines*.
• Patients are allowed to be accompanied only by 1 parent/ guardian.
• During the registration process, patients have been screened using Covid-19
Screening Declaration Form (Borang Deklarasi Saringan Penyakit COVID-19).
• For child assessment cases, only 1 parent / guardian is allowed to be in the
assessment room.
• Practice social distancing and wear face masks at all times.
• Wash hands using soap or hand sanitizer before and after assessment sessions.
If access to hand washing facilities are limited, then the use of medical gloves
are encouraged.
• Ensure that sanitation processes are carried out in the treatment room and on
assessment tools after the session has ended.
• Assessment results are to be informed to the patients via telephone.

C. INTERVENTION CASES

• Intervention sessions are reduced to 30-40 minutes per patient.

• Priority will be given to cases that need urgent treatment sessions, with first
appointment scheduled within 1 to 3 months.
• Non-urgent cases will be given a longer duration, a gap of 3 to 6 months
duration before the first session.

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 • Non-urgent follow up cases are offered brief sessions using telepsychology /
online platforms.
• To ensure minimal risk of infection and optimal practice of hygiene, patients
are not allowed to fill in any intervention / homework sheets at home.
• Patients are allowed to be accompanied by only 1 parent/ guardian.
• During the registration process, patients have been screened using Covid-19
Screening Declaration Form (Borang Deklarasi Saringan Penyakit COVID-19).
• For child intervention cases, only 1 parent / guardian is allowed to be in the
assessment room.
• Practice social distancing and wear facial masks at all times.
• Wash hands using soap or hand sanitizer before and after assessment sessions.
If access to hand washing facilities are limited, then the use of use medical
gloves are encouraged.
• Ensure that sanitation processes are carried out in the treatment room and on
assessment tools after the session has ended.

D. GROUP BASED INTERVENTION

• Sessions will be carried out in smaller groups, a maximum of 6 people (including

therapist) in a single session.
• Room and chairs are arranged according to the Social Distancing Guidelines*.
• During the registration process, patients have to be screened using the Covid-
19 Screening Declaration Form (Borang Deklarasi Saringan Penyakit COVID-
19).
• Practice social distancing and wear face masks at all times.
• Intervention will be carried out by combining a few modules in one session.
• The room be spacious and have good ventilation.
• It is advisable to maintain the same room at all times for group based
intervention.

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E. BRIEF INTERVENTION SESSION USING TELEPSYCHOLOGY / ONLINE PLATFORM

• Brief intervention for follow-up cases via telepsychology or any online platform
can be continued in compliance to the following conditions:
• Obtain permission from the head of department.
• Obtain patient’s consent.
• Ensure that the registration process, treatment fees, treatment records are
completed in accordance to the standard operating procedures of the
respective hospital.
• Therapist and patient’s privacy and confidentiality are preserved.
• Patients have the facilities and access (such as internet access) to use the
online platform.
• Follow the available standard guidelines for telepsychology;
https://www.apa.org/practice/guidelines/telepsychology

Any further enquiries regarding these guidelines, kindly contact the Head of Service
Development Bureau, Clinical Psychologist Profession; umiizzatti@gmail.com
attention to Umi Izzatti binti Saedon.

Reference:

*Covid-19: Social Distancing Guidelines For Workplaces, Homes & Individuals.

Guidelines COVID-19 Management No. 5/2020 Updated on 24 March 2020.

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GUIDELINES ON CLINICAL PSYCHOLOGY SERVICES DURING COVID-19
REHABILITATION PHASE AND POST OUT-BREAK

79