POLICY FOR ECT CLINICAL GUIDELINES

DOCUMENT CONTROL: Version: Ratified by: Date ratified: Name of originator/author:

Name of responsible committee/individual: Date issued: Review date: Target Audience

4 Clinical Effectiveness Group 9 February 2015 Lead ECT Consultant/ ECT Lead Clinician/Associate/ Lead ECT Consultant/ Lead ECT Anaesthetist/ Lead ECT Recovery Nurse/ Lead ECT Operating Department Practitioner Clinical Effectiveness Group 12 March 2015 February 2018 Clinical staff who work within the ECT department, including staff from the Rotherham Older Peoples Services who provide cover through a service level agreement and any staff responsible for escorting patients to receive ECT treatment.

CONTENTS SECTION

PAGE NO

1.

INTRODUCTION

4

2.

PURPOSE

4

3.

SCOPE

4

4.

RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

5

4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5.

Lead Consultant for the ECT Department Lead Nurse for ECT Department Lead Anaesthetist Operating Department Practitioner Recovery Nurse Consultant Psychiatrist Qualified Ward Staff Escorting Nurse ECT Link Nurse PROCEDURE/IMPLEMENTATION

5 5 5 5 6 6 6 7 8 8

5.1 5.2 5.2.1 5.2.2 5.3 5.4 5.5 5.5.1 5.6 5.7 5.8 5.8.1 5.8.2 5.8.3 5.9 5.10

Implications of the Mental Capacity ACT ECT Department Staff Requirements Students in the Department Volunteers Relatives/Carers in the Department Equipment and Medical Physics Drug requirements within the Department Drugs used and stored on the ECT Unit Ward Preparation for Treatment Patient Transport arrangements Treatment and Recovery Pre treatment Treatment Post ECT Post treatment care Action in event of emergency

8 9 9 9 9 10 10 10 11 11 12 12 12 13 14 14

6.

TRAINING IMPLICATIONS

15

7

MONITORING ARRANGEMENTS

16

8. 8.1 8.2

EQUALITY IMPACT ASSESSMENT SCREENING Privacy, Dignity and Respect Mental Capacity Act

17 17 17

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9.

LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS

18

10

REFERENCES

18

11

APPENDICES

20

Protocol 1 – Maintenance/Continuation of ECT

21

Protocol 2 – Nursing Protocols for running the ECT suite

22

Protocol 3 – ECT Protocol for choice of laterality of treatment

26

Protocol 4 – Reference to ECT and consent

27

Protocol 5 – Preparation of patient for treatment

29

Protocol 6 – Patient’s medication during and after treatment

31

Protocol 7 – Dealing with potentially violent or very disturbed/agitated patients and patients who are deemed high risk

32

Protocol 8 – Stimulus dosing for Thymatron machine

33

Protocol 9 – Management of a prolonged or Tardive seizure

37

Protocol 10 – Monitoring patients immediately after ECT and discharge Criteria

38

Protocol 11 – Day/Outpatient ECT

39

Protocol 12 – Discontinuation of ECT and follow-up arrangements

41

Protocol 13 – Treatment of elderly patients

42

Protocol 14 – Treatment of children and young people

43

Protocol 15 – Consultation between the ECT Consultant and the referring psychiatrist in situations where ECT is prescribed outside of NICE Guidelines

44

Protocol 16 – Storage of Dantrolene

45

Protocol 17 – Equipment List

46

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1.

INTRODUCTION For the Rotherham, Doncaster and Scunthorpe localities there is one centralised Electro Convulsive Therapy (ECT) Department which is located in Rotherham. This department provides ECT treatment to patients across these three areas. It is a purpose built treatment suite, and is staffed by a dedicated team that has received training to work within the department. NICE guidelines (2003; 2009) recommend that electro convulsive therapy (ECT) is used only to achieve rapid and short term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life threatening in individuals with:   

Severe depressive illness Catatonia A prolonged or severe manic episode

The decision as to whether ECT is clinically indicated should be based on a documented assessment of risks and potential benefits to the individual including: 

The risks associated with the anaesthetic, current co-morbidities, anticipated adverse events particularly cognitive impairment and the risk of not having treatment.

See protocol for maintenance/continuation (ECT PROTOCOL 1) 2.

PURPOSE These guidelines have been written to reflect the NICE recommendations (2003; 2009) and aims to provide a framework for giving the highest possible quality of clinical care to any patients who are prescribed this course of treatment.

3.

SCOPE The contents of this policy apply to: 

All staff who are employed to work within the ECT department, including staff from the Rotherham Older Peoples Services who provide cover through a service level agreement.



Any staff who are responsible for escorting patients to the department for treatment.

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4.

RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES

4.1

Lead Consultant for the ECT Department Dr Avevor Dr Rabee The Lead Consultant is responsible for:     

4.2

The development of the protocols for the department; Training the Junior Doctors in relation to the safe administration of ECT; Keeping their own practise in relation to ECT updated by attendance at relevant training, and conferences; Reporting any concerns in relation to safe practise within the ECT department; and Participating in audit work.

Lead Nurse for ECT Department Tracy Houghton Shona Nicholson The Lead Nurse is responsible for:      

4.3

The day-to-day running and management of the department; Checking that all equipment is maintained and in safe working order; The care of any patients whilst they are in the department; Keeping their own practice in relation to ECT updated by attendance at relevant training, and conferences; Reporting any concerns in relation to safe practise within the ECT department; Participating in audit work; and Training other members of the Nursing team to assist within the department.

Lead Anaesthetist Dr Nanayakkara The Lead Anaesthetist is responsible for:    

4.4

Assessing patient suitability to receive an anaesthetic; Advising in relation to anaesthetic practice and equipment within the department; Assisting in audit work within the department; and Attending training to keep themselves up to-date with ECT practice.

Operating Department Practitioner The Operating Department Practitioner will work with the Anaesthetist to prepare the drugs and equipment needed for the safe delivery of an anaesthetic to the patients.

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4.5

Recovery Nurse The Recovery Nurse is responsible for the post-anaesthetic care of the patients in the department until he/she is satisfied that the patient is fit to be transferred to the post recovery room.

4.6

Consultant Psychiatrist The Consultant Psychiatrist in charge of the patient’s care must make the initial decision to give a patient ECT; this must involve an assessment of the risks and benefits and document alternative treatments which have failed. The Consultant Psychiatrist should also decide the initial frequency and laterality of ECT; this will depend on previous response to ECT, cognitive difficulties and urgency of treatment. The choice of electrode placement should be a part of the consent process and discussed with the patient where possible. See ECT PROTOCOL 3 The Consultant Psychiatrist in charge of the patient’s care must also assess the patient’s capacity to consent and follow the appropriate procedures to obtain consent/Mental Health Act documentation. All detained patients should be given the Mental Health Act Commission leaflet No. 3. The Consultant should document all of the above on the ECT Care Record (Page 3). The Consultant should ensure that copies of the Mental Health Act (1983) documentation is filed in the case notes (they may also be stapled to the drug kardex; this should be in addition to the copy in the case notes to avoid accidental loss). The Consultant, nominated deputy or ward staff may refer the patient to the ECT team. See ECT PROTOCOL 4

4.7

Qualified Ward Staff Qualified staff on the ward should complete the care record, ensuring that the theatre checklist is completed and the physical observations have been written on the treatment sheet. Ward nursing staff should also make sure that all the relevant documentation is available and completed, to avoid delay in the ECT suite; this may include Mental Health Act papers, the ECT care record, the Drug kardex, VTE assessment, patient notes (Mental health and general, if appropriate), blood results and ECGs. The patient should also be wearing an identity bracelet with their allergy status identified as necessary (see protocol 5). Page 6 of 46

See ECT PROTOCOL 5 Ward staff also need to make sure that the escort policy is adhered to, to avoid the team refusing treatment of a patient. If there are staffing difficulties, the wards can contact the ECT suite to discuss staggering the patients from that area to allow staff to return. There may also be issues with patient who may become violent or aggressive attending ECT, they can be accommodated but this may need some planning prior to the treatment day, please discuss with ECT staff. See ECT PROTOCOL 7 The ECT staff are available to talk to patients and offer reassurance if required (if logistically possible); as link nurses undergo training they will take up this responsibility in the Doncaster and Scunthorpe area. To arrange a visit from ECT staff or to show a patient around the department contact the ECT office (01709 447013). Ward staff should also ensure that the patient has been given the information booklet about ECT during preparation for treatment (and if detained under the Mental Health Act (1983) leaflet number 3). 4.8

Escorting Nurse In accordance with the Royal College of Psychiatrists ECT Handbook (2006), the escort nurse must be a qualified registered nurse whom the patient knows reasonably well and who can act as an advocate, assessing concerns and informing the team, as well as giving reassurance to the patient both before and after treatment. The escort should be aware of the patient’s legal and consent status and have an understanding of ECT. The escort nurse should have at least basic resuscitation training and remain with the patient during all stages of treatment in the case of in-patients the ideal escort is the patient’s named nurse, while in the case of outpatients; the patient’s community nurse/key worker should perform this function. If a driver is required this person must be independent to the escort nurse. Please refer to section 5.7. On arrival to the unit, the escort should report to the ECT nursing staff and have in their possession the necessary documentation required for ECT to be given. They should report to the ECT staff any relevant information regarding the patient and their treatment. The escort nurse is responsible for the patient’s possessions and valuables whilst on the ECT unit but can sign them into the lockers provided if they wish to do so. The escort nurse must remain with the patient throughout their treatment, including in the treatment room in order to provide reassurance to the patient and answer any questions from the ECT team should they arise. The escort should also monitor the patient closely following treatment (in post recovery/discharge lounge) ensuring they Page 7 of 46

continue to appear physically stable and report any concerns regarding this or the patients mental/cognitive functioning to the ECT team. The escort nurse must obtain permission from the ECT nurse/recovery nurse before the patient can leave the ECT unit. It is the responsibility of the escort nurse to ensure that all relevant documentation is returned with the patient. 4.9

ECT Link Nurses Link nurses are to be trained in all the Trust’s Mental Health Units, to act as a liaison between the unit and the ECT department. It is envisaged that these nurses will have the knowledge to be able to ensure that preparation for ECT is properly carried out and be able to relay information to the patient and their relatives. They will also be able to pass this information on to other staff. The ECT staff are available to answer any queries or problems that may arise.

5.

PROCEDURE/IMPLEMENTATION

5.1

Implications of the Mental Capacity Act The Principles of the 2005 Act:      

A presumption of capacity - Every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise. The right for individuals to be supported to make their own decisions People must be given all appropriate help before anyone concludes that they cannot make their own decisions. Those individuals must retain the right to make what might be seen as eccentric or unwise decisions. Best interests - Anything done for or on behalf of people without capacity must be in their best interest. Least restrictive intervention - Anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedom.

Capacity must now be documented and reviewed as identified in the care record, it is required as the consent forms may not be valid without documented capacity or lack of, and this may include the completion of form 4 (Department of Health). Please note that for a form T6 to be valid, the patient must be lacking in capacity and for a form T4 to be valid a patient must have capacity.

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5.2

ECT Department Staff Requirements The minimum staffing requirements, which will allow ECT treatment to proceed, are as follows: 1. Anaesthetist x1. 2. Operating Department Practitioner (ODP) x1. 3. Psychiatric Doctor to give the ECT treatment x1. This doctor must have achieved the required level of competency in the administration of ECT under the supervision of the lead consultant prior to independent practice. 4. At a minimum, one registered psychiatric nurse who has received additional training to work in the ECT Department. 5. If only one ECT nurse, an ECT support nurse who has also received additional training to work in the ECT department. 6. Where possible a member of nursing staff should accompany each patient who is having ECT treatment. (See nurse escort section). On no occasion will a patient be left un-chaperoned. Two staff (gender to be considered) will be in attendance at each stage of the treatment.

5.2.1

Students in the Department There are often nursing students and medical students who wish to see ECT treatment; they must be in appropriate training (e.g. medical, nursing, recovery, O/T). Any arrangements made, need to ensure that there is only one student in the room where the ECT treatment is given. For training purposes it would seem sensible that half the time is spent in the ECT treatment room and half the time can be spent in the ECT recovery room. This will make it possible that up to two students can attend, one in the treatment room, one in the recovery room, who can then swap halfway through. For the purposes of nursing or medical student training, there is little if any benefit to seeing any more than two ECT treatments being given. The time spent in the recovery room can be used to observe issues relating to recovery, but can also be spent in informal discussion with one of the trained ECT psychiatric nurses. Students are present only to observe and will not participate in any way with the ECT treatment.

5.2.2

Volunteers If volunteers are working in the ECT Suite, they cannot be involved in direct clinical care of patients and should not be present in the rooms where the ECT treatment is given or in the room where recovery takes place.

5.3

Relatives/carers in the Department Relatives may be permitted to wait on the inpatient wards or in outpatient reception however, this needs to be prearranged with ward managers and the ECT staff. It is not appropriate for relatives to sit in the ECT suite as there are other patients receiving treatment present. Page 9 of 46

5.4

Equipment and Medical Physics There is a standard list of equipment which is used to enable ECT to be given safely.

5.5

It must be regularly serviced and maintained by a recognised authority, namely the Biomedical Engineering Department at RDGH in accordance with the Trusts Medical Devices Management Policy .The list of equipment in the department can be found in protocol 17. Drug requirements within the Department Drugs used on the ECT Unit are requested by the Consultant Anaesthetist and monitored by the operating department assistants. The Nurse in charge of the ECT Suite is responsible for ordering and safe and appropriate storage of the drugs. Nursing staff must not be involved in the preparation of anaesthetic drugs. The drugs used in the ECT Suite are ordered by the ECT nurse from the Brambles Ward pharmacy file on a Monday morning or after treatment Friday. ECT nurse to collect medication when it arrives and erase the order in the file or it will automatically order the following week.

5.5.1

Drugs used and stored on the ECT Unit Routine Stock                    

Suxamethonium Chloride Injection 100mg in 2ml Thiopentone 500mg Fresenius Propofol 1% Lignocaine Injection 1% Cyclizine Lactate 50mg Atropine Sulphate Injection 600mcg in 1 ml Diazepam Injection 5mg Ranitidine 50mg Water for injections, 10ml ampoules Sodium Chloride 0.9% 1 litre for IV infusion Plus one vial of alternative anaesthetic and muscle relaxants (to order more if a case occurs) – Etomidate 2mg/ml and Atracurium Besilate 10mg/ml. Emergency (less routine) stock Hydralazine Hydrochloride Ampules 20mg Hydrocortisone as the sodium succinate 100mg Disopyramide 50mg in 5ml Glycopyprolate USP 600mcg in 3ml Aminophylline Injection BP 250mg in 10ml Verconium Bromide 10mg Glyceryl Trinitrate spray Salbutamol Inhaler.

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5.6

Ward Preparation for Treatment The medical team need to ensure that a patient is fully assessed prior to ECT. If there are physical complications with a patient, this may mean requesting an anaesthetic assessment or discussing the patient with the ECT staff. If unsure, advice should always be sought from the ECT team to avoid unnecessary delay to the beginning of treatment. The standard tests are clearly outlined in the care record (U&E, FBC, ECG, X-ray if indicated and a physical examination), however if there are contraindications to either ECT or anaesthesia, further tests may be required. See ECT PROTOCOLS 5 and 7 The medical team must also ensure that the care record for the treatment is also completed, this includes ticking the Mental Health Act status, consent type, prescription required (weekly/twice weekly, unilateral/bilateral) and signing the treatment sheet. The clinical team should also assess the patient before each treatment to monitor for any sign of adverse side effects and that further treatment is required (this is in addition to the interim reviews identified in the care record). Medications may also need to be reviewed or withheld or given prior to treatment. It is the medical team’s responsibility to ensure the ward nurses are clearly informed which medications to give and withhold prior to ECT. If there is doubt contact the ECT team for advice. See ECT PROTOCOL 6 In the interim review (at least weekly) the patient’s capacity to consent to ECT, clinical status, and cognitive side effects, including orientation and memory, should be assessed at least weekly and documented in the care record. The patient’s subjective experience of side effects and objective cognitive side effects should also be recorded, e.g. through the use of a memory diary.

5.7

Patient Transport Arrangements Patients travelling from inpatient facilities with escort (see escort section of policy 4.8) must be transported in a suitable vehicle. This will usually be a taxi or a trust vehicle where available. The driver should always be in addition to the escorts. There may be cases where due to mobility or increased risk an ambulance may be required, these should be arranged by ward staff in each area. Any issues with this can be discussed with the ECT team.

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5.8

Treatment and Recovery

5.8.1

Pre-Treatment Patients will arrive in the department at their agreed time and be asked to sit in the waiting room. The ECT pre-treatment staff will take the notes and drug kardex and must be told any issues by the escort at that point. Delivering same sex accommodation within the ECT Department. In order to meet the Department of Health requirements, the following is in place: 

All patients attend the department wearing their own loose fitting clothing.



Treatment is planned for there to only ever be one patient in the treatment room, and recovery room.



Patient flow through the department is controlled by the lead clinician to enable all patients to receive their treatment, and recovery with patients of the same sex. This covers any emergency situation where there may need to be more than one patient in recovery.

See ECT PROTOCOL 2 

The patient will be introduced to the team (and permission obtained for observers to be present) in the pre-treatment/treatment room as appropriate, the ECT nurse will explain the procedure again and any further explanations required.



The ECT nurse will fill in the pre-treatment checks before the treatment is given (see care record), including checking documentation, preparation and consent.



The pre-treatment ECT staff will also complete the ECT register. The Consultant Psychiatrist will also explain what is happening as appropriate.



The patient will then be taken into the treatment room where the staff will explain what they are doing while they place the monitoring equipment on the patient and prepare them for treatment.



The Consultant Psychiatrist will decide and set the appropriate settings for the Thymatron, depending on the prescription (in care record), previous response and side effects.

See ECT PROTOCOL 8 5.8.2

Treatment 

If during treatment the seizure continues for longer than 2 minutes, steps must be taken to terminate it. See ECT PROTOCOL 9.



Following the ECT treatment being given, the Psychiatrist needs to complete the treatment section of the ECT care record. Page 12 of 46



The anaesthetist to complete anaesthetic record and pass on any concerns or requests for alterations to treatment to the recovery nurse and escort nurse.



The patient will then be monitored and observed in both recovery and in the post-treatment room until ready to go into the discharge lounge for a drink and some toast.



The recovery nurse will complete the care record and hand over any difficulties to the escort. The escort must remain with the patient at all times to monitor for any signs of difficulty or distress and offer reassurance or assistance during this time.

See ECT PROTOCOL 10  Escorts must ensure that the discharge criteria are met and that ECT/ recovery staff make the decision to discharge the patient from the ECT suite to their ward/transport. 

If there was an untoward event however minor, this should be recorded in both the ECT record pack and the patient’s clinical notes, and an IR1 completed as per Trust policy for untoward events.



Patients may attend for ECT as outpatients so long as it has been arranged in advance between the prescribing Consultant Psychiatrist and the ECT team. There should be an assessment of risk before, during and after treatment, and supervision protocols must be adhered to.

See ECT PROTOCOL 11 Also note there may be differences to treatment of the elderly and young people, as deemed appropriate. See ECT PROTOCOLS 14 & 15 5.8.3

Post ECT The ECT department recommends that all patients remain at the department for at least one hour following treatment. This time may need to be extended for outpatients receiving treatment. (See outpatient guidelines). Before leaving the department, each patient must have their physical observations recorded (usually in recovery), as per discharge criteria. See ECT PROTOCOL 10 On return to the inpatient unit, the department advise that physical observations, i.e. blood pressure, pulse and respirations are checked regularly and the patient is monitored for any side-effects, e.g. nausea, vomiting, headache, confusion, postictal seizures, muscular aches and stiffness, and memory loss. Please note: The patient’s level of risk and motivation to self harm is to be continuously Page 13 of 46

assessed. Following every treatment, staff are to be aware of possible raised level of motivation which can lead to potential risk of the person acting upon thoughts of self harm/suicide. 5.9

Post Treatment Care Patients must be fully assessed at least weekly during a course of ECT, this will include assessing any side effects, improvement, and an interim physical. (See care record). The cognitive assessment should take place at least 24 hours after ECT and should include a MMSE, retrograde amnesia and an assessment of subjective memory impairment. The Consultant Psychiatrist or a Section 12 Approved Doctor must assess the patient’s capacity to consent to ECT and complete the appropriate part of the care record (at least weekly on the interim review). The care record must be completed fully or treatment may be refused. The patient’s clinical status/symptomatic response should be assessed and documented between each treatment session by their prescribing team. See ECT PROTOCOL 4 Any decision to end treatment must also follow the appropriate guidelines. See ECT PROTOCOL 12 Patients will be further assessed by their Consultant Psychiatrist at 3, 6 and 12 months post ECT, to monitor and address any side effects, and assess the patient’s mental state.

5.10

Action in the Event of an Emergency In the event of an adverse healthcare event the ECT team must be informed immediately (if not already present). The doctors will then decide the course of action in line with local policies. See ECT ANAESTHETIC COPY Protocols for the management of anaesthetic emergencies are on laminated sheets located in the treatment room. These include Malignant Hyperthermia, Anaphylaxis, Local anaesthetic toxicity, Difficult Airway Society Guidelines, Resuscitation Council Guidelines and Advanced life support Guidelines. The resuscitation trolley is located in the recovery room, with an emergency oxygen cylinder, a drip stand and the defibrillator. Any staff may be asked to collect one of these items. There is also further emergency medication in the ECT drug cupboard. See ECT PROTOCOL 15

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In the event of a cardiac arrest, the Anaesthetist and ODP will manage the situation. An ambulance will be called by 9 999. Give the exact location ECT Suite The Woodlands Oakwood Hall Drive Rotherham S60 5UD Until the ambulance arrives follow local resuscitation policy or early warning score guidelines as appropriate. Any adverse event must be fully documented in the patient notes and using the IR1 system. It is also good practice to contact the patient’s Consultant Psychiatrist and the Modern Matron and inform them verbally of the incident as soon as possible. 6. TRAINING IMPLICATIONS

Staff groups requiring training

How often should this be undertaken

2 Sessions During attachment Medical Staff

Plus on going supervision

Length of training

Every four months, or until required level of competence. Decided by Consultant

Each ECT Session until required level of competence is achieved Nursing Staff

Each member of nursing staff is assessed individually on competence

Delivery method

Observation, Discussion, Practical, Research, Reflection

Training delivered by whom

Lead Consultant Associate ECT Consultant

Policy & Protocol Observe practical & Discussion. Mandatory Training, ILS, MVA

Where are the records of attendance held?

Electronic Staff Record system (ESR) Medical Education Coordinators

ECT Nurses

ECT Lead Nurse

ECT Lead Nurse

Student Mentor

Policy & Procedure

Student Nurses

No formal placement within the ECT Department

N/A

Observation Only

ECT Nurse

Attends on Request Each Session Until Level of competence Link Nurses

After Initial Training Nurses will receive yearly Refresher

Page 15 of 46

Observe, Practical, Discussion Mandatory Training, ILS, MVA Policy & Procedure

ECT Lead Nurse ECT Nurse

Ward Manager

Once in a Six Week Placement Students

7.

Once in a Six Week Placement

Observe discussion Policy & Procedure

ECT Lead Consultant Associate Consultant

Electronic Staff Record Medical Education Coordinator

MONITORING ARRANGEMENTS

Area for Monitoring Compliance with the standards set out within this policy

How

Audit

Who by

Reported to

Lead The Adult Consultant and Business Lead Nurse for ECT Divisions Leadership and Quality Group

Frequency

Yearly

Number and Incident type investigation of any adverse health care incidents which occur within the department

Lead Nurse for ECT in conjunction with the Trust Patient Safety Lead

Trust Health As and when and Safety an Committee and incident occurs the Adult Business Divisions Leadership and Quality Group

Staff compliance with the training requirements of this policy

Modern matron for the Rotherham Older Peoples Service

The Adult Business Divisions Leadership and Quality Group

Audit of training records

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Yearly

8.

EQUALITY IMPACT ASSESSMENT SCREENING

The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1

Privacy, Dignity and Respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.2

Indicate how this will be met In order to maintain the privacy and dignity of patients who are receiving treatment within the department the following is in place: • All patients attend the department wearing their own loose fitting clothing. • Treatment is planned for there to only ever be one patient in the treatment room, and recovery room at any given time. • Patient flow through the department is controlled by the lead clinician to enable all patients to receive their treatment, and recovery with patients of the same sex. This covers any emergency situation where there may need to be more than one patient in recovery. • In the post recovery room there are curtains in place which screen each of the patient bays.

Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.

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Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1)

9.

LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Good practice in consent – Clinical Policies. Resuscitation policy – Clinical Policies. Clinical Risk Assessment and Management Policy – Clinical Policies. Medical Devices Management Policy – Clinical Policies. Mental Capacity Act Policy – Clinical Policies. Infection Control Policy for the Prevention and Management of Infections – Clinical Policies. Hand Hygiene Policy – Clinical Policies Guidelines for Clinical Staff on the use of Section 62 – Clinical Policies. Policy and Procedure relating to the Handling of Formal Complaints – General Policies. Policy for the Investigation of Untoward and Serious Untoward Incidents – General Policies. Accident and Incident reporting Policy – Health and Safety Policies. COSHH Policy and Procedure – Health and Safety Policies.

10.

REFERENCES This policy is a local implementation of the: The ECT Handbook: The Third Report of the Royal College of Psychiatrists' Special Committee on ECT (2005), Ed. Allan Scott; Gaskell. The handbook has a full list of references. Cheller A. 2000 Resuscitation. A Guide for Nurses. Dept of Health and Welsh Office. Mental Health Act 1983 – Code of Practice. Department of Health, (2008). Code of Practice: Mental Health Act 1983. Stationary Office. Dimond B C, Barker F H (1996) Mental Health Law for Nurses. Blackwell Science. Duffett R & Lelliott P (1997) Junior Doctors Training in the Theory & Practice of Electroconvulsive Therapy. Psychiatric Bulletin 21, 563 – 565.

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Duffett R & Lelliott P (1998) Auditing Electroconvulsive Therapy. British Journal of Psychiatry. 172, 401 – 405. Duffy, Grosz & Beatson (1999) A Guide to the Human Rights Act 1998. Sweet & Maxwell. Jones R (2009) Mental Health Act Manual 12th Edition Sweet & Maxwell Heller T, Reynolds J, Gomm R, Huston R, Pattison S (1996) Mental Health Matters. Open University publication. Lester & Pannick (1999) Human Rights Law and Practice. Butterworths Pippard J & Ellam L (1981) Electroconvulsive Therapy in Great Britain. British Journal of Psychiatry 139, 563 – 568. NICE (2003), Guidance on the use of electroconvulsive therapy – Technology appraisal 59. DoH; London. NICE (2009). Depression in Adults (Update). Depression: The Treatment and Management of Depression in Adults. National Clinical Practice Guideline 90. DoH; London. Pippard J (1992) Audit of ECT in Two NHS Service Regions. British Journal of Psychiatry 160, 621 – 637. Robertson C & Ferguson G (1996) Electroconvulsive Therapy Machines. Advances in Psychiatry Treatment 2, 24 – 31. Royal College of Psychiatrists (1977). The Royal College of Psychiatrists Memorandum on the use of Electroconvulsive Therapy. British Journal of Psychiatry 131, 261 – 272. Royal College of Psychiatrists (1989). The Practical Administration of Electroconvulsive Therapy. London: Gaskell Royal College of Psychiatrists (1994) Electroconvulsive Therapy: The Official Training Video. Royal College of Psychiatrists (1995). The ECT Handbook: The second report of the Royal College of Psychiatrists Special Committee on ECT. Council Report CR39. Swage. Thoreya (2001) Clinical Governance in Health Care Practice. Butterworth. Heinemann. Websites The Home Office: http://www.Homeoffice.gov.uk/hrat The Royal College of Psychiatrists: http://www/rcpsych.ac.uk.. Royal College of Nursing: http://www.RCN.org.uk. NICE: http://www.nice.org Page 19 of 46

11.

APPENDICES Protocol 1 – Maintenance/Continuation of ECT Protocol 2 – Nursing Protocols for running the ECT suite Protocol 3 – ECT Protocol for choice of laterality of treatment Protocol 4 – Reference to ECT and consent Protocol 5 – Preparation of patient for treatment Protocol 6 – Patient’s medication during and after treatment Protocol 7 – Dealing with potentially violent or very disturbed/agitated patients and patients who are deemed high risk Protocol 8 – Stimulus dosing for Thymatron machine Protocol 9 – Management of a prolonged or Tardive seizure Protocol 10 – Monitoring patients immediately after ECT and discharge Criteria Protocol 11 – Day/Outpatient ECT Protocol 12 – Discontinuation of ECT and follow-up arrangements Protocol 13 – Treatment of elderly patients Protocol 14 – Treatment of children and young people Protocol 15 – Consultation between the ECT Consultant and the referring psychiatrist in situations where ECT is prescribed outside of NICE Guidelines Protocol 16 – Storage of Dantrolene Protocol 17 – Equipment List

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ECT PROTOCOL 1

ECT PROTOCOL FOR MAINTENANCE/CONTINUATION ECT Maintenance ECT NICE (2003; 2009) recommend that ECT should not be used as a long-term treatment to prevent recurrence of depressive illness, apart from in exceptional circumstances as the evidence of its efficacy is limited and that it should not be used in the general management of schizophrenia. Maintenance ECT may be prescribed if the patient has capacity is consenting and is in agreement with the Consultant Psychiatrist to go ahead. The above must be clearly documented in the patients’ notes. Continuation ECT NICE (2003; 2009) recommended that more than one course of ECT should only be considered for someone who is experiencing an episode of severe depressive illness, catatonia or mania and who has not responded to a course of ECT but has responded well previously to ECT. The appropriate consent/Mental Health Act paper work must be obtained. Patients receiving either continuation or maintenance ECT should be reviewed by their Consultant Psychiatrist on a regular basis, the frequency of this will depend on the frequency of treatment. The clinical status of the patient, cognitive functioning (including MMSE, retrograde amnesia and assessment of subjective memory impairment) and side effects should be taken into account when deciding whether it is appropriate to continue with such treatment.

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ECT PROTOCOL 2 NURSING PROTOCOLS FOR RUNNING THE ECT SUITE THURSDAY 3pm BEFORE FRIDAY TREATMENT AND MONDAY PM BEFORE TUESDAY TREATMENT. Contact all wards by telephone, if faxes have not already been sent through: Doncaster Wards (Coniston, Brodsworth, Cusworth and PICU) Scunthorpe Wards (Tennyson) Ring the Acute Wards at Swallownest Court. All telephone numbers are in the ECT information on the ECT desk. If Scunthorpe or Doncaster have not faxed the ECT Suite, ring and ask for their referrals. If both sites are requiring treatment on the same day, then Scunthorpe staff need to be informed that their patients have to be a the Suite by 8:30am in order to allow pre-treatment checks to be completed before the team arrives. Doncaster should arrive after Scunthorpe patients, and may wait in the Woodlands seating area until the first patient has gone into the pre-treatment area, to protect confidentially. Swallownest Court Acute Wards will be informed the day before treatment of what time they are to arrive. The Brambles, Ferns and Glade Wards should be telephoned on the day of treatment, and are to arrive at the Suite when the last outpatient is in treatment. TREATMENT DAY- PREPARATION 8.00AM- Collect any supplies from The Brambles e.g. bread, milk margarine, any medications that have been ordered (2 pints of milk and 2 loaves of bread are ordered to arrive on the breakfast trolley every Tuesday and Friday) the keys for the ECT suite are kept in The Brambles safe Unlock the entire ECT suite and turn on all the lights. Set up the ECT suite firstly by placing the required medications on the tray ready for the anaesthetist; ensure there is adequate stock and that the medications are in date. The medication to place on the tray is thiopentone, diazepam injection, atropine, cyclizine, lidocaine, atropine, ranitidine, water for injections and sodium chloride. You will also need to unlock the ECT fridge to allow access to the suxamethonium by the anaesthetist (it must remain in the fridge until it is required).Place the tray on the work surface ready for the anaesthetist to use. Get 2ml and 10 ml syringes out and place next to a brown injection tray. Get the ECG electrodes out of the cupboard under the Thymatron for the EEG reading and ECG monitoring. Check the emergency equipment is in working order including the suction machine (X4) and the defibrillator, and that there is adequate oxygen in the emergency tank. Make the four bed chairs ready for treatment by putting a continence sheet on the chair bed and covering them with a folded sheet and putting a pillow and blanket in place. Ensure there are alcohol wipes and electrode gel out for treatment and the Thymatron has been switched on, and has completed its self test, also check there is enough paper in the EEG box. To check the settings on the Thymatron press the flexidial, then turn the dial till Page 22 of 46

PROGRAMMES is shown press the flexidial again; the last set programme should be flashing, if this is not DGX then turn the dial until DGX shows. Press the start/stop button on the ECG to fix the settings, a print out will confirm the DGX setting with a pulse width of 1.00ms.The Tyhmatron is now ready. Tape an orange bag to the unit and get the gags out and place on the side ready for the anaesthetist to use. 8.30 patients may be arriving from Doncaster, ask them to take a seat in the waiting area. Ensure the wards have followed the escort policy, there should be one escort per patient this does not include irregular bank staff or students. If the ward area is transporting more than one patient for treatment then there should be one qualified staff patient. It is not safe to treat patients without this level of support and the anaesthetist may refuse treatment. Check that all appropriate documentation has been brought, The ECT prescription including mental state, cognitive functioning and capacity, the drug card Mental Heath Act documentation Section papers and the relevant consent form T4 or T6 or a 62; general health notes and the ECT care record is completed including the blood results. Ensure they are wearing a patient identification wrist band and they have been starved. Also ensure that they have taken the appropriate medications prior to treatment, inform the anaesthetist if they have not been given. 9am- If the junior doctor on the ECT rota has not arrived telephone them to inform them of their need to attend treatment if they are unable to attend write in on the duty rota. Treatment must not commence till all the following have arrived; consultant psychiatrist, junior doctor, Anaesthetist ODA/ODP, recovery nurse and 2 ECT STAFF (including you). Prioritise all patients due to physical health (e.g. Diabetes or potential anaesthetic risk). TREATMENT There will be 2 ECT staff present one should complete the patients checklists and help in both waiting rooms and post recovery, the other member of staff (Must be qualified ) should assist in the treatment room. Once the last person from Doncaster is waiting for treatment any patients from Swallownest court should be arriving, give them as much notice as possible of the amount of patients you are treating, preferably the day before so they can organise transport. The same escort and treatment protocols apply. In the pre- treatment room make the patient comfortable on a chair bed and ensure the patient is wearing their wrist band on. Introduce yourself to the patient and make sure they have adequate understanding of the treatment, answer any questions the patient may have. Complete the check list in the care record ensuring the patient has had nothing to eat or drink, has taken all their appropriate medications, they have removed or taped jewellery and items are removed from their pockets, At this stage dentures need to be removed and given to the escort nurse with the patients name written on the denture pot. If the patient does not have dentures then ask them of any dental problems, loose teeth caps or crowns the anaesthetist must be informed of this prior to treatment starting. The escort for each patient should remain with the patient throughout the process and offer reassurance, they may also be required to answer any questions the anaesthetists has in the treatment room and report what is normal behaviour when in recovery ( e.g. mute /speaking agitation, confusion.

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The ECT nurse not in the treatment room should also check on the pose recovery and waiting areas that there are no problems. This would also include changing the chair beds and moving them into the pre-treatment room for the next patient. The staff in treatment should receive a handover from the checking staff (if not the same person- one staff could follow a patient through the process) and discuss any issues with the anaesthetist or Consultant Psychiatrist. The patient should be introduced to all of the team. Place a hair net on the patient to keep hair out of the way, explain what is happening then begin to place the monitoring EEGelectrodes on the forehead and behind the ears on the mastoid bone (red on the forehead and green in the middle).Place a small amount of contact gel on to the area of the patient where the paddles will be placed (this improves contact ). Meanwhile the ODA and the anaesthetist will be applying monitoring, oxygen, and sighting an intravenous cannula. Ask the patient to lie still and close their eyes while you test the EEG this is done by pressing start/stop on the thymatron. Check with the consultant that the reading is okay. The anaesthetist will check everyone is ready and induce anaesthesia; the staff should be quiet at this point as hearing is heightened as they fall asleep. The patient will also be given the muscle relaxant suxamethonium, staff should observe for this taking effect, it will produce fasciculation (a twitching of the muscles).This should have stopped before treatment begins. The anaesthetist should also place either a gag or an airway in the patient’s mouth before treatment commences. The Consultant psychiatrist may also be teaching the SHO, in which case they may ask you to press the treatment button whilst the SHO observes the Consultant holding the Thymatron electrode paddles, you should only press the treatment button if the Consultant has set and checked the Thymatron, has given you clear instructions and that you are directly supervised. If you are performing this role you should verbally confirm the treatment dose after checking the impedance before pressing the treatment button. In a normal treatment session the SHO will hold the Thymatron electrode paddles and the Consultant Psychiatrist will press the treatment button. Ensure the person holding the Thymatron paddles has placed gel onto each side of the head to ensure good contact. The impedance will be checked once the paddles are in contact with the patient by pressing the button on the thymatron, it will flash