Clinical Electroconvulsive Therapy (ECT): Standard Operating Procedure Document Control Summary Status: Version: Author/Title: Owner/Title:
Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures
Replacement. Replaces: ECT Policy v1.1
Date:
09/03/2016
Martin Bassett – Consultant Psychiatrist (ECT lead consultant Shropshire) Kenny Laing – Deputy Director of Nursing Policy and Procedures Committee
Date:
18/02/2016
Policy and Procedures Committee
Date:
18/02/2016
Clinical Strategy February 2016 January 2018 Treatment, Therapy, ECT Policy Mental Health Act Policy Mental Capacity Act Policy Consent to Examination or Treatment SOP
Contents 1.
Introduction .............................................................................................................. 2
2.
Purpose ..................................................................................................................... 2
3.
Scope ........................................................................................................................ 2
4.
Procedure ................................................................................................................. 2
5.
Process for Monitoring Compliance and Effectiveness ........................................ 6
6.
References ................................................................................................................ 6
Electroconvulsive Therapy (ECT) SOP/January 2016
Change Control – Amendment History
Version
Dates
Amendments
1.0
January 2016
SOP written
1.1
09/03/2016
Short review time given. Additional information added and MH Act forms amended
1. Introduction South Staffordshire & Shropshire Healthcare NHS Foundation Trust ‘The Trust’ provides Electroconvulsive Therapy (ECT) to patients in our care as there is substantial evidence to support its effective treatment for a severe depressive illness, a prolonged or severe manic episode and catatonia (NICE - Guidance on the use of ECT (2003) & NICE CG90 Depression in Adults Recognition and Management (2009). The policy and SOP incorporates recommendations from the current ECT Handbook Royal College of Psychiatrists, January 2004, NICE Guidelines for ECT (2003 & 2009) and The Royal College of Psychiatrist ECT Accreditation Scheme (ECTAS), December 2013. Anaesthetic and recovery policies incorporate recommendations from the Royal College of Anaesthetists’ Guidance on the provision of anaesthetic care in the non-theatre environment (2011).
2. Purpose This SOP should be read in conjunction with the ECT Policy which provides the details of the national standards which the Trust ECT service will adhere to in order that the provision of ECT to our patients is of the highest quality possible. This SOP provides the procedural detail of the steps to be taken by those staff involved in the administration of ECT to ensure consistent delivery of ECT.
3. Scope This SOP applies to all staff who are involved in the process of caring for patients who receive ECT.
4. Procedure Roles of the patient’s medical team / ward nursing staff. Patients should not eat or drink from midnight on the day before ECT and for a minimum of 6 hours prior to ECT. Consideration should be given to flexibility on the timing of starvation and treatment with respect to disability or religious practise. Non-psychiatric medicines should be given routinely with a sip of water up to an hour before ECT. Omit hypoglycaemic agents in patients with diabetes until after treatment.
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Electroconvulsive Therapy (ECT) SOP/January 2016
Depending on patient’s choice, dentures could be removed at ward level or immediately before treatment. Dentures removed in the treatment room, should be placed in a marked container clearly identifying the patient. Head and neck jewellery including studs and hair clips must not be worn and all rings should be secured with adhesive tape if loose. Prior to leaving the ward the patient’s identity is checked and an identity bracelet is placed on the patient. The patient should be requested to pass urine before leaving the ward, prior to treatment. The patient’s daily allocated nurse should be available to answer questions, offer reassurance and explain the procedure. If possible, the patient should be offered the opportunity to talk to someone else who has benefited from the treatment. Prior to treatment commencing all physical investigations, mental state examinations and assessments of cognitive functioning should be reviewed and repeated as necessary The doctor obtaining consent asks the patient if there is any additional information they might need. If possible (except in an emergency) the patient is given at least 24 hours to consider and reflect on the information about ECT, and should (if desired) discuss with relative, friends or advocates before making a decision regarding consent. When considering ECT for patients the NICE guidelines on the use of ECT should form part of the consultation process. The referring psychiatrist informs the patient that consent can be withdrawn at any time. If the patient wishes to talk with staff within the ECT department or visit the treatment area prior to receiving the first treatment, this should be arranged through the nurse in charge of the relevant ward in liaison with the ECT lead nurse or consultant The patient will be given the latest RCPsych ECT information leaflet, which explains ECT, and if necessary the named nurse should guide the patient through this step by step. This can be found here http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx Prior to the patient leaving the ward the nursing staff will complete the pre- ECT checklist. (appendix A) The patient should be escorted to the ECT department waiting room by a nurse who knows the patient and is familiar with the procedure. The accompanying nurse should be someone who can identify the patient and preferably knows them well. The patient will be escorted back to the ward by a member of staff who is known to the patient, trained in BLS, and has knowledge of the ECT process. Nurse in charge of ECT session The nurse in charge will ensure that: Page 3 of 6
Electroconvulsive Therapy (ECT) SOP/January 2016
emergency resuscitation equipment is tested and checked before each ECT clinic session
emergency drugs tray is checked before each ECT clinic session for out of date drugs and missing items
the ECT electrodes are checked visually before each ECT clinic session
If the machine does not self-check, the nurse ensures that the output and electrical safety of the ECT machine is checked and recorded prior to each ECT session, including the testing of delivery dose
the ECT department is properly, organised, stocked and maintained
each patient has been examined by a doctor
all necessary parts of the ECT documentation are complete
all relevant legal documents are in place in the notes prior to bringing the patient into the treatment room for treatment, as below:
For informal patients with capacity to consent to the treatment, the consent ((see associated documents - Electro-Convulsive Therapy (ECT) Pathway Documents – part 4) should be signed.
For informal patients who lack capacity to consent to the treatment, the Mental Capacity Assessment Form and Best Interest Decision Making Form must be completed within the RiO patient record.
For patients detained under the Mental Health Act 1983 (MHA) the following legal documentation will be completed: 1. Section 58A 3 (Certificate of consent to treatment – form T4) or 2. Section 58A 3 (Certificate of second opinion – form T6) or 3. Section 62 (Urgent treatment/Authority for ECT)
The Nurse in charge of the ECT session will telephone the appropriate ward to request the transportation of the patient and nurse escorts, to ensure that the waiting time in the pretreatment waiting room is kept to a minimum, and no longer than 30 minutes unless an emergency occurs. Responsibilities of the treating Psychiatrist The administering doctor ensures that the stimulus dose and administration technique are optimal – this may involve clarification/ presence of lead ECT consultant as necessary at first treatment There is adequate contact between the electrodes and the scalp of the patient The administering doctor ensures that an appropriate seizure is induced Page 4 of 6
Electroconvulsive Therapy (ECT) SOP/January 2016
The seizure induced is a typical generalised tonic clonic convulsion The seizure duration is monitored by the direct observation of the resulting motor effects and two channel EEG monitoring Responsibilities of the Anaesthetist “Recommendations for standards of monitoring during anaesthesia and recovery”, Association of Anaesthetists of Great Britain and Ireland (AAGBI, 2007) are followed The anaesthetist checks the anaesthetic and suction equipment and prepares the anaesthetic agents There is consistent use of anaesthetic agents and dosing Any reason for a change in anaesthetic induction agent is discussed with the ECT team and documented Oxygen is normally administered before ECT Before induction, the anaesthetist or assistant checks that any dentures have been removed or are secure The anaesthetist explains what he/she is doing and why When the patient is induced, the anaesthetist or assistant inserts a bite block Responsibilities of the ECT Team The doctor and nurse giving the ECT treatment should ensure that the relevant consent and / or second opinion documents are present and that, where necessary, consent is ongoing before the treatment is administered. The ECT team should introduce themselves to the patient, and the nurse in charge explains the procedure to the patient, and if necessary secures the patient valuables. Before ECT is administered, the patient is given any further information they may need. The nurse checks that the patient has been asked when he or she last drank and this should concord with the length of required fasting time. The doctor should ensure that the treatment is administered according to the relevant local ECT protocol which should be displayed in each ECT treatment room. (see associated documents - Electro-Convulsive Therapy (ECT) Pathway Documents) The doctor should ensure that the treatment administration record ((see associated documents - ElectroConvulsive Therapy (ECT) Pathway Documents) is complete. Anaesthetic administration record (see associated documents - Electro-Convulsive Therapy (ECT) Pathway Documents) will be completed by anaesthetist.
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Electroconvulsive Therapy (ECT) SOP/January 2016
Recovery Period and Recovery Room On arrival in the recovery room the patient will be cared for by a nurse who is appropriately trained in recovery techniques and basic life support (BLS). Oxygen saturation, blood pressure, respiration and pulse will be measured and documented (see associated documents - Electro-Convulsive Therapy (ECT) Pathway Documents) until the patient responds verbally to the recovery nurse in a coordinated and coherent way. The patient should remain on the trolley until conscious. Once conscious the patient can sit up with assistance and have a period of rest. The Nurse in charge of ECT will have the final decision about discharging patients from ECT recovery and deciding when the patient should be escorted back to his / her ward by the escorting nurse. Patients from other parts of the hospital, who are unable to walk or sit in a wheel chair, should be transported to and from ECT department by ambulance or designated hospital transport with emergency equipment on board. One of the staff escorting patients back to their ward must be trained in BLS and have knowledge of the ECT process. The Anaesthetist must remain in the ECT department until the last patient has recovered sufficiently to return to the ward. When the patient returns to the ward a designated nurse will monitor the patient’s progress and complete the ECT post treatment ward nursing observations (see associated documents - Electro-Convulsive Therapy (ECT) Pathway Documents)
5. Process for Monitoring Compliance and Effectiveness The process for monitoring compliance with this SOP will be undertaken in the following ways:
Operationally the lead consultant and lead nurse of each ECT suite will ensure that there are regular audits undertaken to address compliance with standards set out in the policy and SOP
The Trust is committed to maintaining its registration and participation with the Royal College of Psychiatry ECT Accreditation Scheme (ECTAS), which includes annual self-audit and three yearly external audit of facilities and practice.
6. References Royal College of Psychiatry (2013) ECT Accreditation Service (ECTAS) Standards for the administration of ECT Eleventh Edition: December 2013 NICE - Guidance on the use of ECT (2003) & NICE CG90 Depression in Adults Recognition and Management (2009) Association of Anaesthetists of Great Britain and Ireland (AAGBI) (2007) Recommendations for standards of monitoring during anaesthesia and recovery. Page 6 of 6
