SH CP 46
Electro Convulsive Therapy Policy
Version: 4
Summary:
This policy is for all teams who prescribe ECT and
which is administered by Southern Health ECT
Departments (including patients who we have a
service level agreement with), to ensure the safe
appropriate and effective use of ECT and should be
read in conjunction with The ECT Handbook Version 3
2013
Keywords (minimum of 5):
(To assist policy search engine)
ECT, Electro Convulsive Therapy Policy
Target Audience:
All teams prescribing Electro Convulsive Therapy
(ECT)
Next Review Date:
May 2020
Approved & Ratified by:
ECT Forum Meeting
Date issued:
May 2017
Authors:
Lead ECT Doctor & Lead ECT Nurse
Sponsor:
Karen Guy Professional Lead for Mental Health
Date of meeting:
15 May 2017
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Electro Convulsive Therapy Policy
Version 4
May 2017
Version Control
Change Record
Date
August
2012
March
2014
June
2015
March
2017
Author
Version
Page
Reason for Change
Lead ECT Doctor
& Lead ECT
Nurse
Lead ECT Doctor
& Lead ECT
Nurse
V1- SHFT
Lead ECT Doctor
& Lead ECT
Nurse
Lead ECT Doctor
& Lead ECT
Nurse
V3
Policy review
V4
Review of policy re ECTAS standards- Updated
driving advice, updated patient information from
Royal college leaflet .Updated forms number CTO12
on legal status
V2
New layout for policies and Bi annual review
SHFT Format
5, 11,
13,14,
15,17
18,19,
Policy review
Reviewers/contributors
Name
Megan Roberts
Karen Osola
Megan Roberts and Karen
Osola
Megan Roberts and Karen
Osola
Position
Version Reviewed & Date
Trust ECT Lead Doctor
Trust ECT Lead Nurse
Trust ECT Lead Doctor
Version 1 August 2012
Version 2 August 2012
Version 3 March 2014
Trust ECT Lead Doctor and Trust Lead
Nurse
Version 4 March 2017
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Electro Convulsive Therapy Policy
Version 4
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Contents
Page
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Introduction
Scope
Definitions
Duties/ responsibilities
Indications for ECT
Consent to Treatment
Special Provisions
Side-Effects
Pre-Treatment Protocol
Medication Guidance
Prescription of ECT
Anaesthetic Practice
Delivery of ECT
Equipment
Stimulus Dosing and Electrode Placement
Continuation and Maintenance ECT
Record Keeping & Audit
Training requirements
Monitoring compliance
Policy review
Associated documents
Supporting references
4
4
4
5
5
6
9
10
10
10
12
12
13
14
15
15
16
16
17
18
18
18
Appendices
A1
A2
Training Needs Analysis (TNA)
Equality Impact Assessment (EqIA)
19
20
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Electro Convulsive Therapy Policy
1
Introduction
1.1
Electro Convulsive Therapy (ECT) is one of the therapeutic options available to
patients within Southern Health Foundation Trust ECT remains an essential tool in
the treatment of mental disorders.
1.2
Southern Health Foundation Trust is dedicated to providing a high quality service
which all patients rightly expect. All patients who have been prescribed ECT as a
treatment option can be assured that:
 Their illness has been properly assessed
 Other treatment options have been considered including no treatment and
discussed and recorded with them
 They are properly advised about the process of ECT and its possible side effects
 The consent policy is fully explained
 The treatment is delivered by Practitioners competent to do so
 There is full recording of the process for each client
 There is periodic review of the treatment via the audit process
1.3
This Policy reflects current standards in the practice of ECT and is liable to be up
dated as standards and practice change. It will provide the basis of a programme of
audit of local ECT Administration and practice and be reviewed every 2 years (or
sooner in light of any new guidance issued by the Royal College of Psychiatrists or
National Institute of clinical Excellence)
2
Scope
2.1
This policy is for all teams who prescribe ECT and which is administered by Southern
Health ECT Departments (including patients who we have a service level agreement
with), to ensure the safe appropriate and effective use of ECT and should be read in
conjunction with The ECT Handbook. The second report of the Royal College of
Psychiatrists Special committee on ECT and NICE Guidance on the use of
Electroconvulsive Therapy (April2003) it is also supported by relevant clinical practice
guidelines produced by the different professions involved in ECT.
3
Definitions
ECT
NICE
ECTAS
SOAD
CTO
MHA
ASA
CGI
Electro Convulsive Therapy
National Institute of Clinical Excellence
ECT Accreditation Service
Second Opinion Approved Doctor
Community Treatment Order
Mental Health Act
American Society of Anaesthesiologists
Clinical Global Impression Tool
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Duties / Responsibilities
4.1
These are defined within the policy and associated documents
5
Indications for ECT
5.1
ECT may be administered for the relief of conditions contained in:
 the NICE Guidelines Technology Appraisal 59, Guidance on the Use of Electro
Convulsive Therapy published April 2003 or
 the ECT Handbook 3rd edition published 2013
5.2
Consent Process
5.2.1
It is recommended that the consent process for ECT is undertaken by the most
senior doctor available. This ideally should be the consultant for that patient but if not
it is the consultant’s responsibility to ensure they are happy that the doctor obtaining
consent is qualified to do so.
5.2.2
The referring consultant needs to determine whether the patient has capacity and
can give valid consent and the Mental Health Act is used when appropriate.
5.2.3
Patients for ECT are provided with appropriate written and verbal information to allow
them to give consent. This needs to include treatment alternatives (including no
treatment) and the patient’s rights including the right to withdraw consent at any time.
Also to include:-
5.2.3.1 The relative risks of the possible impact of ECT on cognition.
5.2.3.2 The likely consequences of not having ECT.
5.2.3.3 Treatment alternatives and confirmation that these will be available if patient decides
not to have ECT.
5.2.3.4 The patient’s rights in relation to ECT.
5.2.4
Except in urgent situations, patients should be given at least 24 hours to consider
their options and discuss with anyone they wish.
5.2.5
Clinic staff will check for original and valid on-going consent before each treatment.
Any concerns will be communicated to the referring team but if the clinic staff do not
believe valid consent and/or relevant Mental Health Act paperwork is in place then
ECT will not take place.
5.3
Clinicians who wish to prescribe ECT for conditions not included in the NICE
Guidelines or the ECT Handbook from the Royal College of Psychiatrists must obtain
a second Consultant opinion which must confirm that the proposed treatment is in the
best interest of the patient, notwithstanding any consent the patient may give.
5.3.1
For a new course of ECT, except in an emergency, the patient is given at least 24
hours to reflect on information about ECT and discuss with relatives, friends or
advisors before making a decision regarding consent.
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5.4
Legal Status, Consent & Capacity
5.5
The following is a visual overview of consent, capacity and legal status:
Legal
status of
patient
Informal
Informal
Informal
Capacity to
consent to ECT
Consents to ECT
Action by ECT
department
Yes
Yes
No
Yes
No
Not actively refusing
Informal
No
Sections 2
or 3
Sections 2
or 3
Yes
Actively refusing, or
advance decision, or
deputy or attorney
refusing
Yes
Yes
No
Sections 2
or 3
No
Sections 2
or 3
No
CTO
Yes
No advance
decision, or deputy
or attorney refusing
Advance decision, or
deputy or attorney
refusing
Yes
Give ECT with consent
Do not give ECT
Assess for Mental Health
Act
Refer to parent team –
may need to use Mental
Health Act to override if it
is an emergency.
Give ECT if form T4 in
place
ECT cannot be given
unless it is an
emergency (s 62)
Give ECT if form T6 in
place
CTO
CTO
Yes
No
CTO
No
No
No advance
decision, or deputy
or attorney refusing
Advance decision, or
deputy or attorney
refusing
ECT can only be given if
it is an emergency (s 62).
Give once CTO12 is in
place.
Cannot give ECT.
Recall to hospital treat
under MHA
Do not give ECT
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Consent to Treatment and Provision under the Mental Health Act (MHA
Section 6.1 applies to Informal Adult Patients.
Section 6.2 to 6.6 applies to Detained Adult Patients.
Special provisions apply to young persons under the age of 18, whether detained or
informal. These are given in Section 6.7
6.1
Informal Patients
6.1.1 Informal patients must give consent to treatment and this must only be done on the
current consenting documentation within the ECT Care Pathway, (see Pathway
Document). Consent shall be given without duress and the patient shall be advised
6.1.2 that consent can be withdrawn by them at any time. Although documentation will be
used to initiate the consent process prior to commencing ECT the patient will be
asked to confirm consent at the time of each application.
6.1.3
Consent procedures will take into account the provisions of the Mental Capacity Act
2005 where these apply.
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6.1.4
Informal patients may make an Advance Decision refusing treatment. It is the
responsibility of the patient or their representative to notify the clinician of this.
6.1.5
Patients who have a DNACPR established and who require ECT need reviewing in
light of the procedure, it may be appropriate to temporarily suspend a decision not to
attempt CPR. DNACPR decisions should be reviewed in advance of the procedure
and discussed with the patient and their carers if they lack capacity, as part of the
consent process .Some patients may wish a DNACPR decision remain valid despite
the increased risk of cardio respiratory arrest and the presence of potentially
reversible causes: others will request that the DNAR is suspended temporarily.
6.1.6
The time the DNR decision is reinstated should also be discussed and agreed. This
should be clearly documented by the person who has made the temporarily
suspension decision and also the person carrying out the procedure if different.
6.1.7
Informal patients who do not have capacity and for whom ECT is recommended are
unable, by definition, to give consent. Consideration should be given to such patients
being assessed under the Mental Health Act, and if detained, treated under sec
6.2.3.
6.2
Patients Detained in Hospital under the MHA 1983
6.2.1
ECT is covered under section 58A of the MHA 1983 (as amended). This section also
includes medication administered as part of ECT. Chapter 24 of the MHA Code of
Practice refers to treatment under the MHA.
6.2.2
Patients with Capacity to Consent
6.2.2.1 ECT may not be given to a capacious patient unless they do give consent, except in
urgent cases (see paragraph 6.5 below).
6.2.2.2 Before ECT is given to a capacious patient (except in an urgent case) the Approved
Clinician in charge of the patients’ treatment or a SOAD must provide a certificate
under Part 4 of the Act on a Form T4 confirming:
 That the patient has capacity to give consent
 That the patient has given their consent
6.2.3
Patients without the Capacity to Consent
6.2.3.1 In order that an incapacitated patient may be legally given ECT, (except in an urgent
case), a SOAD must, after appropriate consultation, provide a certificate under Part 4
of the Act on a Form T6 confirming:
 That the patient lacks capacity to consent to ECT
 That no valid and applicable Advance Decision has been made under the Mental
Capacity Act 2005 refusing treatment
 No suitably authorised attorney or deputy objects to the treatment on the patient’s
behalf
 That treatment would not conflict with a decision of the Court of Protection which
prevents the treatment being given.
6.2.4
An attorney or deputy may not give consent on the patient’s behalf if that patient is
detained under the MHA.
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6.2.5
Patients on Community Treatment Orders (CTOs) ECT treatment and CTO
patients
For CTO patients who are aged 18 years or over, the new form CTO12 can be used
to certify consent to ECT treatment in the rare circumstances where this might be
considered.
However, the new regulations do not alter the previous position that ECT treatment
cannot be given to any patient who is not yet 18 (regardless of whether or not the
patient is detained or subject to a CTO), unless a second opinion appointed doctor
has certified that the patient consents to ECT and that the treatment is appropriate
(using form T5).
6.3
CTO Patients Recalled to Hospital
6.3.1
ECT may be given to a patient where a CTO has been revoked when:
 A Part 4A Certificate explicitly approves continued treatment in the circumstances,
or;
 Treatment already being given on the basis of a Part 4A Certificate may be
continued, even though it is not authorised for administration on recall, if the
approved clinician in charge of the treatment considers that discontinuing such
treatment would cause the patient serious suffering. Treatment may however only
be administered pending a new certificate being provided by a SOAD.
6.4
Urgent Cases Where Certificates are Not Required (Sec.62 Treatment)
6.4.1
Section 58A does not apply in urgent cases where treatment is immediately
necessary. Similarly a Part 4A certificate is not required in cases where treatment is
immediately necessary. However Approved and/or Responsible Clinicians
authorising treatment under Sec 62 must be aware that the circumstances under
which Sec 62 treatment can be given have been amended, (and are different from
the circumstances allowing medical treatment under Sec 62), and are given in 6.5.2.
6.4.2
ECT under Sec 62 may only be given if the treatment is immediately necessary to:
 Save the patient’s life, or;
 Prevent a serious deterioration of the patient’s condition and the treatment does
not have unfavourable physical or psychological consequences which cannot be
reversed.
6.4.3
Treatment may only be given for as long as immediately necessary. When treatment
ceases to be immediately necessary, the usual requirements for certificates apply.
6.5
Circumstances Where a Certificate Ceases to Authorise Treatment
6.5.1
A certificate provided under Part 4 or Part 4A will cease to authorise treatment when:
 The clinician who provided the certificate stops being the approved clinician in
charge of the patient’s treatment
 The patient stops being detained in hospital or liable to a CTO (even if only
temporarily) (except for patients under the age of 18)
 The patient regains capacity where they previously lacked capacity or the patient
loses capacity.
 The patient consented to treatment but is now refusing.
 A clinician treating the patient becomes aware that treatment would conflict with
an advance decision to refuse treatment.
 A clinician treating the patient becomes aware that the Court of Protection or an
attorney or deputy makes (or has previously made) a decision that treatment
should not be given.
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 The SOAD has specified a time limit and that time expires, or limits the number of
treatments and the number is reached.
6.5.2
Unless in an urgent case (see section 6.5 above) treatment may not be continued
whilst a new certificate is obtained.
6.5.3
All expired or ended certificates must be clearly marked as expired and copies kept
with the ECT Pathway with the patient’s Health Records.
6.6
Special Provisions applicable to young persons under the age of 18
6.6.1
Section 58A of the MHA 1983 (as amended) applies to all patients under the age 18
regardless of their legal status.
6.6.2
Detained Patients and Informal Patients under 18 with capacity
6.6.3
No person under the age of 18 may be given ECT unless all the following 3
requirements are met.
1 If the patient is competent consent must be given.
2 A SOAD must certify the patient is capable of understanding and consents.
3 A SOAD must agree the treatment is appropriate
4 A competent child refusing consent cannot be given ECT
6.6.4
Detained Patients under the age of 18 without capacity
6.6.5
The process applied to adult incapacitated patients (6.2.3) applies, except that no
one under 18 can make an Advance Decision to refuse medical treatment.
6.6.6
Informal Patients under the age of 18 without capacity.
6.6.7
Additional authority is required for patients under the age of 18 without capacity.
Authority under the Mental Capacity Act is required for patients aged 16-17. For
patients aged under 16, to whom the Mental Capacity Act does not apply, Parental
Authority or Court Authority is required. (Sec 58A(7)
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Special Provisions applicable to the Elderly (over 65 years)
7.1
The ECT department ensures equal rights for all patients, regardless of age, gender,
faith and ethnicity. The main indication for ECT in older people is severe depressive
illness. It may be regarded as a first line treatment for patients with previous
episodes that have responded to ECT but not to antidepressants, those with
psychotic symptoms, those with severe agitation or catatonia and those with high
suicidal risk or poor food and fluid intake.
7.2
We do recognise that in the elderly there are potentially greater anaesthetic risks and
also greater chance of cognitive side effects. Cognitive side effects are more
common in this group.
7.3
Patients over age 65 often have a higher seizure threshold. Therefore allowance is
made for this in the stimulus dosing protocol. This may mean that an initial higher
energy setting is required for effective treatment. Caution will be used when
determining seizure threshold as patients may also be on multiple other medications.
7.4
The monitoring of the patient’s cognitive function is particularly important during a
course of treatment for an older person. The ECT technique should be modified as
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necessary usually from bilateral to unilateral treatment to minimize any cognitive
adverse effects during treatment should any evidence of decreased functioning
occur.
7.5
The anaesthetic induction agent in this age group is Propofol unless other indications
exist. The agent used is prescribed by the anaesthetist for each session, again on a
case by case basis.
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Side-Effects
8.1
All patients for whom ECT is considered must be warned of adverse effects both
short term and potentially long term, and this must be done within the consenting
process. All patients will be offered both written and verbal information.
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Pre-Treatment Protocol
9.1
All patients must enter the ECT treatment process via the current ECT Pathway
which is in use at all Trust sites delivering ECT. The Pathway includes a mandatory
physical examination and other investigations determined by age and physical health
together with a baseline mental state examination.
9.2
The Pathway has an anaesthetic checklist which takes note of the anaesthetic risk
and quantifies that risk using the American Society of Anaesthesiologists
classification. ASA categories 1 and 2 need not be reported to the Anaesthetist
before the patient presents for treatment, subject to the results of other investigations
being in place. Patients with ASA classification 3, 4, or 5, or with a significant
concurrent medical disorder, will always require notification to the Anaesthetist before
the treatment session. Such patients will not be treated in remote sites without prior
discussion with the Anaesthetist.
9.2.1
Any variation in the ASA grade of the patient is recorded before the treatment
session.
9.2.2
A physical examination is recorded which includes the cardiovascular, respiratory
and neurological systems, a VTE assessment and a pregnancy test where
applicable.
9.2.3
The patient’s Mental Health Act status is recorded.
9.2.4
An assessment of the risk/benefit balance of having ECT is considered and recorded.
9.2.5
A clear statement is included on why ECT has been prescribed.
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Medication Guidance for Prescribers
10.1
A number of medications can affect an individual’s seizure threshold and their
prescription therefore should be reviewed prior to ECT
10.2
Benzodiazepines
Whenever clinically possible the concomitant prescription of benzodiazepine drugs
should be avoided during a course of ECT. If a hypnotic drug is clinically indicated at
night then it would be good practice to consider the use of a non-benzodiazepine
drug. Long established benzodiazepine drug use should not be stopped suddenly
just before few days before a course of ECT because there is the risk of a dramatic
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lowering of seizure threshold. If the dose cannot be gradually reduced and stopped
before the administration of ECT, it may be better to continue the drug during ECT,
perhaps in reduced dosage.
10.3
Antidepressants Drugs
An anti-depressant drug should not be abruptly discontinued before ECT, particularly
one with a short half-life or one of the SSRIs. Monoamine oxidase inhibitors do not
need to be discontinued before ECT but the anaesthetist should be informed in
advance that the patient is taking one. It is probably better to prescribe an effective
antidepressant drug at least before the end of a course of treatment, if only to provide
adequate early prophylaxis. In elderly patients or patients with pre-existing cardiac
disease potential cardio toxicity should influence the choice of drug.
10.4
Lithium
The co-administration of the lithium ion is not a contraindication to ECT. Preliminary
evidence suggests that the early introduction of the lithium ion reduces the likelihood
of early relapse of depressive illness after ECT. The co-administration of the lithium
ion with ECT may be one risk factor amongst several for adverse effects such as
prolonged cerebral seizure activity.
10.5
Antipsychotic drugs
A small dose of a sedative antipsychotic drug may be preferred to a benzodiazepine
drug if a hypnotic drug is indicated. Clozaril patients should have their medication
withheld for 12 hours prior to ECT (Clozapine may lower the seizure threshold).
10.6
Patients on Continuation/Maintenance treatment after ECT
It has been established that there is a high risk of relapse in the first few weeks after
successful ECT if a patient is left untreated. Continuation treatment with doses of
medicine known to be therapeutic is essential for at least 6 months after successful
ECT. Many patients who have suffered from recurrent episodes of illness will be
candidates for longer-term prophylactic or maintenance treatment to reduce the
likelihood of new episodes of illness.
10.7
Special Preparations prior to ECT
 History of reflux prophylactic measures: Ranitidine and Metoclopramide on the
morning before ECT
 Diabetes: blood sugar to be requested prior to ECT course and then repeated as
per care plan during treatment. Test to be done by ward staff on morning of
treatment.
 Lithium Patients: must have recent level prior to ECT and then routinely during
treatment.
 Patients receiving diuretics are to have weekly blood tests for U & Es.
 History of Chest and Cardiac Problems: patients with a history or new symptoms
respiratory conditions to have a chest x-ray prior to treatment.
 All patients over 45 and any patients with cardiac problems, hypertension or
diabetes should have an ECG recording completed prior to treatment. Consult the
Anaesthetist whether to have further tests e.g. Echo/chest x-ray.
 An anaesthetic referral to be requested before ECT course commences if cardiac
or respiratory conditions are considered an anaesthetic risk, ASA grade 3 and
above.
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10.8
Medication Immediately Prior to ECT
Patients who are prescribed proton pump inhibitors (e.g. omeprazole, lansoprazole,
etc.) or H2 antagonists (e.g. ranitidine) for gastro-oesophageal reflux, hiatus hernia or
other gastric disorder MUST be given this medication in the morning prior to ECT.
Patients with hypertension MUST receive their prescribed medication in the morning
prior to ECT. Their blood pressure must be recorded prior to leaving the ward to
attend the ECT suite and should be clearly documented in the patient case notes.
Individuals with a history of asthma, chronic obstructive pulmonary disease or
smoking related airways disease should receive routinely prescribed inhalers
immediately prior to leaving the ward to come down to ECT.
Patients with diabetes mellitus should NOT receive their usual insulin prior to ECT.
The senior ECT nurse should be notified of any diabetic patient due to commence
ECT. They will then be placed first on the ECT list. They will be able to have their
insulin with their breakfast upon return to the ward after ECT.
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Prescription of ECT
11.1
ECT will be prescribed on the care pathway. A maximum of two applications may be
prescribed at any one time. The total number of treatments in any one course would
not normally be expected to exceed twelve applications. Should it be considered
necessary to give more than twelve applications, then a second opinion is advised
from the local ECT Consultant and recorded. The patient’s Consultant is responsible
for the prescription of ECT.
11.2
Electrode placement will be decided by the prescribing clinician. In making that
decision he or she will be aware of the urgency to achieve a therapeutic result, the
potential for adverse effects and any previous history.
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Anaesthetic Practice – this must include the following:-
12.1
‘Recommendations for standards of monitoring during anaesthesia and recovery’,
Association of Anaesthetists of Great Britain and Ireland (AAGBI, 2007) are followed.
12.2
The anaesthetist checks the anaesthetic and suction equipment and prepares the
anaesthetic agents.
12.2.1 There is consistent use of anaesthetic agents and dosing.
12.2.2 Any reason for a change of anaesthetic induction agent is discussed with the ECT
team and documented.
12.3
Oxygen is normally administered before ECT
12.4
Before induction, the anaesthetist or assistant checks that any dentures have been
removed or are secure.
12.5
The anaesthetist explains what he/she is doing and why.
12.6
When the patient is induced, the anaesthetist or assistant inserts a bite block.
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Delivery of ECT
13.1
ECT will be administered in clinical areas suitable for the purpose. All sites will
match standards of the Electro Convulsive Therapy Accreditation Service (ECTAS) of
The Royal College of Psychiatrists. The Reception/Waiting area will be supervised by
a Receptionist or ECT Nurse. The treatment area will have an ECT Nurse fully
trained in the administration of ECT and a Doctor fully trained in its application. The
Recovery area will have a Recovery Nurse plus a nurse for every unconscious
patient. The Anaesthetist will ideally have a special interest with sessions dedicated
to anaesthesia for ECT and will be supported by a Theatre Practitioner. High risk
patients (ASA 3 or greater or pregnant or with significant concurrent medical
disorders) will not be treated in remote sites without prior discussion with the
Anaesthetist and a risk analysis being done. Inpatients attending for ECT should be
accompanied throughout the treatment process by a Nurse escort. The number of
escorts and grade of staff accompanying patients shall be decided according to
individual patient need and consideration of their physical and mental health risks.
Individual needs shall be determined by the multidisciplinary team before a course of
ECT starts and be reviewed prior to each session by the Nurse in charge of the
Ward. The escorting Nurse will know the patient and have knowledge of the ECT
procedure and suite layout so that they are able to provide informed support for the
patient. Ideally all patients should have their own escort and under no circumstances
should one person escort any more than two patients. Escorts should be available to
respond to patients’ needs during the journey so should not be driving and fulfilling
the role of escort at the same time.
ECT Clinic & Facilities
13.1.1 The clinic is able to demonstrate that it adheres to the Trust’s infection control policy.
13.1.2 The clinic has access and facilities for disabled people.
13.1.3 The clinic has a post-ECT waiting area.
13.1.4 The clinic has an office for ECT staff
13.1.5 It has a work surface and sink with hot and cold water.
13.1.6 It has a secure drug storage cupboard.
13.1.7 It has a small fridge with a lock.
13.1.8 Speech from the treatment room cannot be heard in the waiting area, e.g. staff keep
their voices low, music is played in the waiting area to mask sound.
13.1.9 There is one trolley or bed per patient which can comfortably accommodate a
reclining adult, has braked wheels and can rapidly be tipped into a head-down
position.
13.1.10 There is a means of establishing an emergency surgical airway e.g. an emergency
cricothyroidotomy kit (and the anaesthetist is familiar with the use of the particular
skit stored in the clinic).
13.2
Some patients will require their ECT treatment to be performed at a General Hospital
– usually for either medical or anaesthetic reasons. In the event of this being
necessary, the referring psychiatrist responsible for the patient should liaise with both
the ECT Team and also one of the regular consultant anaesthetists in ECT (usually
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the lead anaesthetist). The lead anaesthetist will then make the necessary
arrangements at the local General Hospital.
13.3
Outpatients receiving ECT as day cases will need transport to and from the ECT
suite following their treatment. The transport will be organised by the referring team
who will ensure that any escort is made aware of the requirements of the Guidance
for Day Patients Receiving ECT which includes the following for the next 24hours






Will be accompanied by a responsible adult.
Will not operate machinery
Will not drink alcohol
Will not sign any legal document
Will not be solely responsible for children until the following morning
And in addition will not drive for the duration of the full course of ECT or until
advised that they are fit to drive by the Consultant Psychiatrist, and in agreement
with DVLA medical standards of fitness to drive.
13.3.1 The patient is escorted through the treatment journey by an escort.
13.3.2 The named responsible adult and/or the patient signs to say they will observe the
limitations on drinking alcohol, operating machinery, (including electrical equipment)
and signing legal documents for 48 hours following discharge.
13.3.3 The patient is escorted both to and from the ECT clinic by a named responsible adult.
Post ECT & Recovery
13.4
Both first and second stage recovery will be monitored using the paperwork of the
current Care Pathway.
13.5
A Recovery Nurse/ theatre practitioner who have been trained / recognised
competence will supervise post Anaesthetic Management - Patients recovering from
anaesthesia for ECT where regular and appropriate observations will be documented
in both first stage and second stage recovery. The Anaesthetist must be satisfied that
patients are fully recovered before the Anaesthetist leaves the Department.
13.6
After anaesthetic recovery patients should have a supervised sitting area where
appropriate refreshments can be obtained.
13.6.1 The patient is offered something to eat and drink before they are discharged from the
ECT suite.
13.7
Following treatment and recovery the patient will be discharged from the ECT
Treatment Suite. Patients must fulfil the criteria on the Recovery Record Sheet
(Discharge) within the Care Pathway. Responsibility for discharge will rest with the
ECT team. Different criteria apply to the discharge of inpatients returning to the Ward
and outpatients returning to their own home.
14
Equipment
14.1
The ECT machine will be of sufficient standard to meet the current requirements of
The Royal College of Psychiatrists’ recommendations. Machines will be replaced in
a planned schedule at regular intervals by the Trust. All machines will comply with
ECTAS standards.
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14.2
Anaesthetic standards when ECT is performed on “remote sites” will always conform
to the standard set in the Interim Statement from The Royal College of Anaesthetists
on “Electro Convulsive Therapy provided in Remote Sites”.
14.3
All equipment will be checked and recorded in the service manual before ECT
commences by the ECT team.
15
Stimulus Dosing and Electrode Placement
15.1
The threshold of convulsive stimulation will be determined by stimulus dosing. This
should be routinely measured by an empirical titration method and this should ideally
be determined at the first or second treatment in a course of ECT. The purpose of
stimulus dosing is two-fold, first, to achieve sufficient electrical discharge to cause a
therapeutic fit and second, to avoid excessive dosage which has a proportionate
impact on the side-effects experienced.
15.2
Electrode placement is a clinical decision made by the prescribing consultant and the
patient. The one foreseen exception to this procedure will be those clients for whom
ECT is viewed as an emergency or life-saving situation in which case, bilateral ECT
without the full regime of stimulus dosing may be employed to achieve a therapeutic
fit at first application. It is not expected that all patients treated under Section 62
would necessarily or routinely fall into this category.
16
Continuation and Maintenance ECT
16.1
Although not recommended by the NICE Guidelines, Southern Health Foundation
Trust recognise that it is likely that all Consultant Psychiatrists will have experience of
patients whose illnesses relapse, who are not controlled by medication or cannot
tolerate medication or are poorly compliant with medication. Some of these patients
will benefit from continuation / maintenance ECT treatment.
16.2
Continuation/ Maintenance ECT is a term that has been used to describe the use of
the treatment to prevent the early relapse of an index episode of illness. It is
generally used over the first few months of remission. Maintenance ECT is used to
prevent further episodes of recurrences of illness in general
Continuation/Maintenance ECT should be considered when –
 The index episode of illness responded well to ECT.
 There is early relapse despite adequate continuation of medication or an inability
to tolerate drug treatment.
 The patient’s attitude and circumstances are conducive to safe administration.
16.3
Whenever Continuation/Maintenance ECT is considered a full documented
assessment of the potential risks and benefits of treatment is required and a new
maintenance treatment record and consent is documented and recorded in the ECT
pathway. This must be renewed with new consent and new care pathway including
new anaesthetic assessment every 6 months or 12 treatments whichever is sooner.
16.4
It is strongly recommended the Consultant undergo the following process:



Carefully document a risk/benefit analysis for ECT in the circumstances.
Refer the patient for an independent second opinion from another Consultant.
This may be the ECT Consultant but not necessarily so.
Involve the patient at each stage during the decision making process and obtain
consent as appropriate.
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

Consent must be obtained by a Consultant level doctor for any use of ECT
outside of NICE guidelines, it is not acceptable for this to be delegated to a junior
team member and ECT will not be given in these circumstances. Patients who do
not consent and are subject to the Mental Health Act will need a T6, T4 or
Section 62 form as usual.
The referring Consultant should discuss and document the use of ECT with the
ECT Consultant prior to the first treatment session.
(Reference; The third Edition ECT Handbook 2014)
17
Record Keeping and Audit
17.1
The standards determined by the Trust for record keeping should be regarded as a
minimum when prescribing and administering a potentially controversial treatment.
The process of consent must fall within the Trust’s Consent to Examination or
Treatment Policy, and take into account the provisions of the Mental Capacity Act
(2005) where these apply.
17.2
Information must be recorded in an accessible and auditable manner.
17.3
The Trust ECT Committee will regularly audit its service as per ECTAS standards
and requirements to ensure that Clinical Governance and standards are maintained.
It will publish its findings and recommendations to the Trust Integrated Clinical
Governance Committee as required.
18
Training Requirements [see Appendix 1]
18.1
All personnel in the ECT Treatment Team must have received appropriate training
which ensures they are competent to carry out their particular role within the
procedure. Patients will only be taken through the consent process by Doctors who
have been specifically trained and are competent to fully answer questions posed by
patients. The Doctor delivering the treatment will have received both theoretical and
practical training and be supervised when he or she first begins to administer ECT.
Only when the Consultant Psychiatrist responsible for the Department is satisfied in
the competence of the Doctor will they be allowed to administer the treatment
unsupervised. All junior doctors will be expected to attend Core Skills Group and
Medical Device training as well as training and observation by local ECT Lead.
18.1.1 Direct supervision by the ECT Consultant or appropriately trained deputy until they
are assessed as competent to administer ECT unsupervised.
18.2
Nursing members of the ECT Team will receive specialist training before being given
responsibility for a treatment session. All ECT staff will have specialist training in
appropriate procedures which will be evidenced at appraisal.
18.2.1 ECT nurses undergo an induction programme covering ECT policies and procedures,
medical equipment safety and clinic management.
18.3
This may include Consenting the patient, Stimulus Dosing, the physical monitoring
requirements in anaesthesia and recovery and medical device training.
18.4
It is recommended that the Lead Nurse attends the South of England Special Interest
Group for ECT and The Royal College of Psychiatrists ECT training events on a
regular basis.
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18.5
ECT teams have regular development meetings, chaired by a member of the Senior
Management Team or a Deputy.
18.6
ECT anaesthetists undergo a course of specific training from a consultant
Anaesthetist with an interest in ECT, and have been assessed as competent.
18.6.1 ECT clinic staff attend appropriate training and conference events, e.g. Royal College
of Psychiatrists’ ECT training course, at least once every three years.
19
Monitoring Compliance
19.1
It is recommended that the patient’s mental state be monitored and recorded by the
prescribing team. It is expected that the prescribing Psychiatrist or a nominated
deputy shall review the patient’s progress, including capacity, side effects, cognitive
and non-cognitive function on a weekly basis, and record this on Rio. The patient’s
mental state must be evaluated at the beginning and at the end of a course of
treatment by the ECT team using CGI tool in accordance with the standards
determined by the Care Pathway and ECTAS.
Element to be
monitored
Lead
Tool
Frequency
Capacity
Prescribing
team/ECT
team
CGI
Each
application
Reporting
arrangements
Rio and care
pathway
Clinical
On
prescribing
Rio
Progress
19.2
Prescribing
Team
Depression
Prescribing
team
Cognitive and Non
Cognitive
Prescribing
team
Orientation
ECT Team
On
Hamilton
prescribing
Depression and after
Rating
treatments
Scale
4, 8 & 12
(HDRS)
On
Clinical
prescribing
MMSE
Orientation Each
Tool
application
Rio
Rio
Care Pathway
Clinical response is monitored and recorded using appropriate validated
scales. CGI weekly .HDRS at baseline treatments 4, 8 and 12 or as clinically
indicated
Patients receiving maintenance ECT. Require the same monitoring
19.3
The patient’s orientation and memory is assessed before and after the first ECT, and
re-assessed at intervals throughout the treatment course, using tools embedded in
the care pathway
19.3.1 The patient’s cognitive side effects/memory are assessed using for example, the
MMSE, and HDRS or similar, and subjective questioning in a clinical interview 3 or 4
working days after the end of the treatment course, and at 1 or 2 months follow-up.
19.4
Issues of non-compliance with assessments and monitoring are addressed with the
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Referring team on each occasion. Sustained non-compliance issues are addressed
through established risk-reporting systems.
19.5
Patients and their carer’s are offered the opportunity to formally feedback on their
experiences of care and treatment. This feedback is documented and regularly
appraised by the ECT Team.
20
Policy Review
20.1
This policy shall be reviewed every three years or when national or ECTAS standards
and practice changes.
21
Associated Documents
21.1
All ECT departments will display local procedures for:
 Storage of Dantrolene
 Cardiac arrest
 Anaphylaxis
 Malignant hypothermia
 ECT Care Pathway
22
Supporting References
 National Institute for Clinical Excellence, Guidance on the use of Electro
Convulsive Therapy. Technology Appraisal 59 April 2003.
 The ECT Handbook, Second Edition, The Royal College of Psychiatrists Council
Report CR128 2005.
 Electro Convulsive Therapy (ECT) for Depressive Illness, Schizophrenia,
Catatonia and Mania, The School of Health & Related Research (ScHARR)
University of Sheffield, Nuffield Institute of Health University of Leeds, May 2002.
 Interim Statement from The Royal College of Anaesthetists on Electro Convulsive
Therapy provided in remote sites (http://www.rcoa.ac.uk/index.asp?PageID=402)
 Southern Health Foundation Trust, Trust Consent to Examination or Treatment
Policy
 Health Record Policy and Procedures
 Mental Health Act 1983 (as amended)
 Mental Health Act Code of Practice (2008)
 Mental Capacity Act 2005
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APPENDIX 1: LEaD (Leadership, Education & Development) Training Needs Analysis
If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Louise Hartland, Strategic Education Lead or
Sharon Gomez, Essential Training Lead on 02380 774091) before the policy goes through the Trust policy approval process.
Training
Programme
Title and Level (if
appropriate) of
your training
programme
Frequency
How often will the target
audience need to attend this
course?
Directorate
Learning Disability Services
Older Persons Mental
Health
Specialised Services
TQtwentyone
Adults
ICS
Children’s Services
Specialist Services
Corporate
Services
How long will the
programme run (April –
April?) and how long will
each course take (3
hours?)
All (Workforce &
Development, Finance &
Estates, Commercial)
Delivery Method
Trainer(s)
How and where do you
intend delivering this
programme (face to face,
e-learning, Essential
Training Days)?
Who will be delivering
this programme if
delivery method is face
to face?
Recording
Attendance
Who do you
anticipate
recording
attendance?
Strategic &
Operational
Responsibility
Who is accountable
for this training
strategically and who
is operationally
accountable?
Target Audience
Division
Adult Mental Health
MH/LD
Course Length
All clinical staff who work in ECT departments should attend The Royal College of Psychiatrists ECT training day appropriate to
their grade All nurses attend the Lead Nurses Training run by ECTAS
Not relevant
All clinical staff who work in ECT departments should attend The Royal College of Psychiatrists ECT training day appropriate to
their grade All nurses attend the Lead Nurses Training run by ECTAS
Not relevant
Not relevant
Not relevant
Not relevant
Not relevant
Not relevant
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APPENDIX 2: Southern Health NHS Foundation Trust:
Equality Impact Analysis Screening Tool
Equality Impact Assessment (or ‘Equality Analysis’) is a process of systematically analysing a new
or existing policy/practice or service to identify what impact or likely impact it will have on protected
groups.
It involves using equality information, and the results of engagement with protected groups and
others, to understand the actual effect or the potential effect of your functions, policies or
decisions. The form is a written record that demonstrates that you have shown due regard to the
need to eliminate unlawful discrimination, advance equality of opportunity and foster good
relations with respect to the characteristics protected by equality law.
For guidance and support in completing this form please contact a member of the Equality
and Diversity team.
Name of policy/service/project/plan:
Policy Number:
Electro Convulsive Therapy Policy and
Procedures including:
 Anaphylaxis
 Anaesthetic Fact Sheet
 ECT Choice of Laterality of Treatment
 Protocol for ECT in the Elderly (over
65years)
 Emergency ECT at Antelope House
 Escorting a service user undergoing ECT
from an onsite ward
 Legal status, Consent and Capacity
 Malignant Hyperthermia Crisis
 The management of Cardiac Arrest
 Medication Guidance for Prescribers
 Protocol for outpatient ECT
 Suxamethonium Apnoea
 The storage of Dantrolene for use in ECT at
Antelope House Southampton
 The Use of ECT Outside NICE Guidance
 ECT Protocol for Stimulus Dosing
SH CP 46
Department:
ECT Departments across the Trust
Lead officer for assessment:
Karen Osola: Trust ECT Lead Nurse
Ricky Somal: Equality and Diversity Lead
August 2012
Date Assessment Carried Out:
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1. Identify the aims of the policy and how it is implemented.
Key questions
Answers / Notes
Briefly describe purpose of the policy
including
 How the policy is delivered and by
whom
 Intended outcomes
Electro Convulsive Therapy (ECT) is one of the
therapeutic options available to patients within
Southern Health Foundation Trust. ECT remains
an essential tool in the treatment of mental
disorders.
ECT may be administered for the relief of
conditions contained in:
(i) the NICE Guidelines Technology Appraisal 59,
Guidance on the Use of Electro Convulsive
Therapy published April 2003 or
(ii) the ECT Handbook Council Report CR128
published by the Royal College of Psychiatrists
2005
2. Consideration of available data, research and information
Monitoring data and other information involves using equality information, and the results of
engagement with protected groups and others, to understand the actual effect or the potential
effect of your functions, policies or decisions. It can help you to identify practical steps to tackle
any negative effects or discrimination, to advance equality and to foster good relations.
Please consider the availability of the following as potential sources:







Demographic data and other statistics, including census findings
Recent research findings (local and national)
Results from consultation or engagement you have undertaken
Service user monitoring data
Information from relevant groups or agencies, for example trade unions and
voluntary/community organisations
Analysis of records of enquiries about your service, or complaints or compliments about
them
Recommendations of external inspections or audit reports
Key questions
2.1
What is the equalities profile of the team delivering the
service/policy?
2.2
What equalities training have staff received?
Data, research and
information that you can
refer to
The Equality and Diversity
team will report on
Workforce data on an
annual basis.
All Trust staff have a
requirement to undertake
Equality and Diversity
training as part of
Organisational Induction
(Respect and Values) and
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2.3
2.4
2.5
2.6
E-Assessment
The Trust Equality and
Diversity team report on
Trust patient equality data
profiling on an annual
basis
What other data do you have in terms of service users or
The Trust is preparing to
staff? (E.g. results of customer satisfaction surveys,
implement the Equality
consultation findings). Are there any gaps?
Delivery System which will
allow a robust examination
 National Institute for Clinical Excellence, Guidance of Trust performance on
on the use of Electro Convulsive Therapy. Equality, Diversity and
Human Rights. This will be
Technology Appraisal 59 April 2003.
based on 4 key objectives
that include:
 The ECT Handbook, Third Edition, The Royal
College of Psychiatrists Council Report CR128
1. Better health
2005. Electro Convulsive Therapy (ECT) for
outcomes for all
Depressive Illness, Schizophrenia, Catatonia and
2. Improved patient
Mania, The School of Health & Related Research
access and
(ScHARR)
experience
3.
Empowered,
 Interim Statement from The Royal College of
engaged and
Anaesthetists on Electro Convulsive Therapy
included staff
provided in remote sites
4.
Inclusive
http://www.rcoa.ac.uk/index.asp?PageID=402
leadership
What is the equalities profile of service users?

Health Record Policy and Procedures NCP 8 and
CP 21.

Mental Health Act 1983 (as amended)

Mental Health Act Code of Practice (2008)

Mental Capacity Act 2005
What internal engagement or consultation has been
undertaken as part of this EIA and with whom?
What were the results? Service users/carers/Staff
What external engagement or consultation has been
undertaken as part of this EIA and with whom?
What were the results? General
Public/Commissioners/Local Authority/Voluntary
Organisations
ECT Committee consult
with all service providers
ECTAS accreditation for
all clinics
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In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any
potential negative impact on equality of opportunity for the target:
In the case of negative impact, please indicate any measures planned to mitigate against this:
Positive impact
Negative Impact
Action Plan to address negative impact
(including examples of what
the policy/service has done to
promote equality)
Actions to
overcome
problem/barrier
Age
Section 6.7
Special Provisions
applicable to young
persons under the
age of 18
Section 1.2
The Trust will provide
information that is
clear and precise
without the possibility
for error in
interpretation to all
age groups. With the
possibility of young
carers, the Trust will
ensure information
provided is accessible
Resources
required
Responsibility
Target
date
No adverse impacts
identified at this stage
of screening but any
negative impacts will
be addressed through
policy
review/compliance
Protocol for ECT in
the Elderly (over
65years): The Trust
identifies potential
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risks with certain
groups and has
developed protocols
to safeguard service
users
Disability
The Trust will
respond positively to
requests of
reasonable
adjustments and
provide information in
alternative formats as
requested. This
includes, audio, easy
read, Braille, large
font and BSL
Gender
Reassignment
Marriage and
Civil Partnership
Pregnancy and
Maternity
Section 10.1
High risk patients
(ASA 3 or greater or
Lack of ability to retain
information about their
treatment and fulfil the
safety requirements
before and after
treatment
Patients may
require ECT
appointment
cards/information
to be available in
easy read format
for those with
learning and
sensory disabilitycommunication to
be made with
engagement team
and Equality and
Diversity Lead
No adverse impacts
identified at this stage
of screening but any
negative impacts will
be addressed through
policy
review/compliance
No adverse impacts
identified at this stage
of screening but any
negative impacts will
be addressed through
policy
review/compliance
No adverse impacts
identified at this stage
of screening but any
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Race
Religion or
Belief
pregnant or with
significant concurrent
medical disorders)
will not be treated in
remote sites without
prior discussion with
the Anaesthetist and
a risk analysis being
done.
The Trust will
respond positively to
requests of
information in
alternative formats
and provide
interpreters via
Access to
Communications
negative impacts will
be addressed through
policy
review/compliance
A Diversity Calendar
is available to all
Trust staff via the
Website that
highlights key events
and festivals
throughout the year
The service may
require access to the
forehead; discussions
will be taken with
service users who
may wear turbans or
head scarves and will
be treated with dignity
and respect. This
ECT treatments may
be carried out on a
Friday morning. This
may potentially have
an impact on Muslim
patients that Pray on a
Friday.
Lack of ability to retain
information about their
treatment and fulfil the
safety requirements
before and after
treatment
Patients may
require ECT
appointment
cards/information
to be available in
alternative
languagescommunication to
be made with
engagement team
and Equality and
Diversity Lead
The service will
engage with
patients to identify
appropriate clinic
times days for the
treatment to be
undertaken. The
service provides
treatments on
Tuesdays also
Religion or Belief:
A Practical Guide
for the
NHS (2009)
states that
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“Research
suggests that
attention to the
religious and
cultural needs of
patients and
service users can
contribute to their
wellbeing and, for
instance, reduce
their length of
stay in hospital.”
includes same sex
practitioners in regard
to upholding dignity
and respect
Sex
Sexual
Orientation
No adverse impacts
identified at this stage
of screening but any
negative impacts will
be addressed through
policy
review/compliance
Research undertaken
by CSIP: Mental
disorders, suicide, and
deliberate self-harm in
lesbian,
gay and bisexual
people 2007 (a
systematic review)
found that LGB people
are at greater risk of
mental disorders and
suicidal behaviour than
heterosexual people.
They are also at
greater risk of
deliberate self-harm.
Although most LGBT
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people do not
experience poor mental
health, research
suggests that some are
at higher risk of mental
health disorder,
suicidal behaviour and
substance misuse.
National Health
Inequalities data shows
that lesbian, gay,
bisexual and
transgender (LGBT)
people are significantly
more likely to smoke,
to have higher levels of
alcohol use and to
have used a range of
recreational drugs than
heterosexual
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