Electroconvulsive Therapy (ECT) - Adults and Children …health.act.gov.au/sites/default/files/new_policy_and_plan... · Web viewSchizophrenia and related disorders (schizophreniform

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Canberra Hospital and Health ServicesClinical Procedure Electroconvulsive Therapy (ECT) - Adults and Children over 12 years of ageContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Clinical Indications for ECT......................................................................................4

Section 2 – Legislative Requirements under the Mental Health Act 2015................................4

2.1 Decision Making Capacity...............................................................................................5

2.2 ECT Orders...................................................................................................................... 6

2.3 Emergency ECT Orders....................................................................................................7

2.4 Records of ECT................................................................................................................ 8

Section 3 – Consent and Prescription of ECT............................................................................9

Section 4 – Preparation for ECT and Documentation..............................................................10

Section 5 – Administration, Monitoring and Post ECT Follow Up...........................................14

Section 6 – Staff Training Requirements.................................................................................17

Section 7 – Clinical Supervision...............................................................................................18

Implementation...................................................................................................................... 18

Related Policies, Procedures, Guidelines and Legislation.......................................................18

Definition of Terms................................................................................................................. 19

References.............................................................................................................................. 20

Search Terms.......................................................................................................................... 20

Attachments............................................................................................................................20

Attachment 1: ECT Flow Chart for a Consumer with Decision Making Capacity 18 + years old....................................................................................................................................... 22

Attachment 2: ECT Flow Chart for a Consumer NO Decision Making Capacity 18 + years old............................................................................................................................................ 23

Attachment 3: ECT Flow Chart for a Consumer with Decision Making Capacity 12—15 years old..............................................................................................................................24

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Attachment 4: ECT Flow Chart for a Consumer with Decision Making Capacity 16—17 years old..............................................................................................................................25

Attachment 5: ECT Flow Chart for a Consumer NO Decision Making Capacity 12—15 years old....................................................................................................................................... 26

Attachment 6: ECT Flow Chart for a Consumer NO Decision Making Capacity 16 - 17 years old....................................................................................................................................... 27

Attachment 7: Titration Chart - A method for ECT Dose Titration......................................28

Attachment 8: Titration and Treatment Schedule for Thymatron Series IV........................29



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Purpose

The purpose of this procedure is to provide staff with information on safe and effective administration of Electroconvulsive Therapy, in line with legislative and best practice requirements.

Electroconvulsive therapy (ECT) is a therapeutic medical procedure for the treatment of severe psychiatric disorders. It has efficacy in treating clinical depression, mania and psychosis, and it is occasionally used to treat other neuropsychiatric conditions. Its primary purpose is to quickly and significantly alleviate psychiatric symptoms. (RANZCP, 2014, page 1)

Alerts

Staff should always refer to the Mental Health Act 2015 for the most definitive understanding, interpretation and explanation of the Act itself, particularly when making any decisions in relation to the Act.

ECT CANNOT be given to children under the age of 12.

An Emergency ECT order may only be made for a young person who is at least 16 years old.

A person commits an offence if they are not a doctor and they administer ECT to a person. A doctor commits an offence if they administer ECT to a person without meeting the requirements.

Guardians and Attorneys are not entitled to give consent to electroconvulsive therapy.

Scope

This procedure pertains to Adults and Children over 12 years of age.

This document applies to: All staff working with people who are being treated with ECT, including: Medical Officers involved in the prescription, preparation and administration of ECT Registered Nurses involved in the preparation and administration of ECT Student Nurses under direct supervision Wards persons and other staff involved in the transportation of people undergoing ECT

from the ward to the ECT procedure room Anaesthetic nursing staff.

Section 1 – Clinical Indications for ECT



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ECT is clinically indicated for: Major depressive episode / severe melancholic depression +/- psychotic features Mania / manic episode Schizophrenia and related disorders (schizophreniform disorder, schizoaffective disorder)

- especially with short duration of positive symptoms Psychosis Catatonia.

ECT is more commonly used when other treatments have proven to be unsuccessful. However, ECT should not be seen as a treatment of last resort and can be used even as a primary treatment in situations such as: Delusional depression (especially in the elderly where there is up to a 95 percent efficacy

rate in some studies) Catatonia Depressed people who are not eating or drinking adequately Depressed people who are actively suicidal and need the quickest response People with a previous good response to ECT for the same condition Personal preference (if ECT is clinically indicated).

In the case of special populations such as adolescents or pregnant women, the seeking of a psychiatric second opinion (even in people with voluntary legal status) may prove to be a useful strategy but should be at the discretion of the treating psychiatrist (except where involuntary legal status occurs and it is mandatory).

Rarely ECT may have a role (due to its dopaminergic and change in seizure threshold effects) in treating certain medical conditions when standard management practices have failed. These include: Neuroleptic Malignant Syndrome (provided antipsychotics are ceased before hand) Intractable Seizure Disorder (due to its anticonvulsant properties ECT may be effective in

status epilepticus or intractable complex partial seizures for which pharmacological measures have proven unsuccessful)

Parkinson’s Disease (benefit to motor symptoms independent of effects of ECT on psychiatric symptoms)

Back to Table of Contents

Section 2 – Legislative Requirements under the Mental Health Act 2015

ECT has strict legislative requirements for adults and children over 12 with decision making capacity, without decision making capacity and the rare occurrence of emergency ECT. The strict criteria are detailed below.

2.1 Decision Making CapacityAdults with decision-making capacityECT can be administered to an adult with decision-making capacity if the person: has given consent to the administration of ECT, and



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has not withdrawn their consent, either orally or in writing, and ECT has not been administered:

o more than nine times since the consent was given, oro if the consent was for the administration of ECT for a stated number of times less

than nine, that number of times.

Refer to Attachment 1: ECT Flow Chart for a Consumer with Decision Making Capacity 18 + years old.

Adults without decision-making capacityECT can be administered to an adult without decision-making capacity if the person: has an Advance Consent Direction consenting to the administration of ECT, and ECT is administered in accordance with the Advance Consent Direction, and the person does not refuse or resist.

ECT can also be administered to an adult without decision-making capacity in accordance with an emergency ECT order that is in force in relation to the person, and

o the person does not refuse or resist ECT; or o a Psychiatric Treatment Order (PTO) or Forensic Psychiatric Treatment Order (FTPO) is

in force in relation to the person.

Refer to Attachment 2: ECT Flow Chart for a Consumer NO Decision Making Capacity 18 + years old.

Ideal clinical practice would encourage a Consultant Psychiatrist second opinion even though this is not formally required under the Mental Health Act 2015.

Young people with decision-making capacityThis section applies to children at least 12 years old and less than 18 years of age who have decision-making capacity to consent to ECT.

ECT can be administered to a person aged: between 12 and 15 years old if an ECT order is in force in relation to the person, or between 16 and 17 years old if an ECT order or an Emergency ECT order is in force in

relation to the person, and the person has given consent to the administration of ECT, and the person has not withdrawn their consent, either orally or in writing.Also refer to Attachment 3: ECT Flow Chart for a Consumer with Decision Making Capacity 12—15 years old and Attachment 4: ECT Flow Chart for a Consumer with Decision Making Capacity 16—17 years old.

Young people without decision-making capacityThis section permits the administration of ECT to a young person who lacks decision-making capacity to consent, so long as: for a 12 to 15 year old, the ECT is administered in accordance with an ECT order, or



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for a 16 or 17 year old, the ECT is administered in accordance with an ECT order or emergency ECT order, and eithero the person does not refuse or resist, or o the person is subject to a psychiatric treatment order or a forensic psychiatric

treatment order.

Also refer to Attachment 5: ECT Flow Chart for a Consumer NO Decision Making Capacity 12—15 years old and Attachment 6: ECT Flow Chart for a Consumer NO Decision Making Capacity 16—17 years old

2.2 ECT OrdersThe Chief Psychiatrist or a doctor can apply to the ACT Civil and Administrative Tribunal (ACAT) for an ECT order.

If the person is under 18 years old, the application must be supported by another doctor. And at least one of the doctors must be a Child and Adolescent Psychiatrist.

Who must ACAT consult with about ECT orders?Before making an ECT order ACAT must, as far as practicable, consult with the following people if they are involved in the person’s care: those who have parental responsibility, if the person is a child the Guardian the Attorney the Nominated Person and the Health Attorney.

ACAT must hold a hearing before making an ECT order in relation to a person.

What must ACAT take into account in making an ECT order?In making an ECT order ACAT must take the following into account: whether the person consents, refuses to consent or has the decision-making capacity to

consent to ECT the person’s views as set out in an Advance Agreement or Advance Consent Direction the views of the person responsible for the person’s day-to-day care the views of people appearing at proceedings the views of people listed above under ‘who must ACAT consult’ any alternate treatment, care or support available including:

o the purpose of the treatment, care or support;o the benefits likely to be received by the person by the treatment, care or support, ando the distress, discomfort, risk, side effects or other disadvantages associated with the

treatment, care or support, and any relevant medical history of the person.



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Making an ECT OrderACAT may make an ECT order in relation to a person, if the person is at least 12 years old, if they are satisfied that the person has a mental illness and: the person does not have decision-making capacity to consent to the administration of

ECT and the person does not have an Advance Consent Direction refusing consent to ECT the administration of ECT is likely to result in substantial benefit to the person and either:

o all other reasonable forms of treatment available have been tried but have not been successful or

o the treatment is the most appropriate treatment reasonably available.

ACAT may make an ECT order in relation to a person if the person is at least 12 years old but under 18 years of age if they are satisfied that the person has a mental illness and: the person has decision-making capacity to consent to the administration of ECT and the person consents to the administration of ECT, and the administration of ECT is likely to result in substantial benefit to the person.

As soon as possible after making an ECT order under this section ACAT must give a copy of the order to: the person in relation to who the order is made the person who applied for the order, and the people consulted about the order.

What will the ECT order include?The ECT order must state: The matters that ACAT is satisfied of (i.e. as described above in section ‘Making an ECT

Order’) the maximum number of times ECT may be administered under the Order.

The person in charge of the facility where ECT is to be administered must ensure that the person receiving ECT is told about the ECT and how it is administered, in a language and way of communicating that the person is most likely to understand.

2.3 Emergency ECT OrdersACAT may make an emergency ECT order if an application is made by the Chief Psychiatrist and another doctor. The emergency ECT order must be accompanied by an application for an ECT order.

What must ACAT take into account in making an emergency ECT order?In making an emergency ECT order ACAT must take the following into account: whether the person consents, refuses to consent or has the decision-making capacity to

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the views of the person responsible for the person’s day-to-day care if the person is under 18 years of age, the views of each person with parental

responsibility the views of the Guardian, the Attorney, the Health Attorney, and the Nominated

person where these people are in place.

Making an emergency ECT OrderACAT may make an emergency ECT order in relation to a person, if the person is at least 16 years old, if they are satisfied that the person: has a mental illness, and the person does not have decision-making capacity to consent to the administration of

ECT, and the person does not have an Advance Consent Direction refusing consent to ECT, and the administration of ECT is necessary to:

o save the person’s life, oro prevent the likely onset of a risk to the person’s life within three days.

either:o all other reasonable forms of treatment available have been tried but have not been

successful, oro the treatment is the most appropriate treatment reasonably available.

ACAT may make an emergency ECT order in relation to a person, if the person is at least 16 years old, if they are satisfied that the person has a mental illness and: the person has decision-making capacity to consent to the administration of ECT and

consents to the administration and the administration of ECT is necessary to:o save the person’s life, oro prevent the likely onset of a risk to the person’s life within three days.

either:o all other reasonable forms of treatment available have been tried but have not been

successful, oro the treatment is the most appropriate treatment reasonably available.

What will the emergency ECT order include?The emergency ECT order must state that: ECT may be administered to the person a stated number of times (not more than three),

and the order expires in a stated number of days (not more than seven).

2.4 Records of ECTA doctor administering ECT must record the administration, including whether administration: was in accordance with an ACAT order, and was with the person’s consent.

The Doctor must give the record to the person in charge of the facility.



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Records of ECT must be kept for five years.


Section 3 – Consent and Prescription of ECT

ConsentConsent for ECT is mandatory (see exceptions above relating to ECT Orders) and is to be documented on the Electroconvulsive Therapy Consent and Prescription form located on the CHHS Clinical Forms Register.

Both verbal and written information should be provided to the person, in a language and way of communicating that the person is most likely to understand. It is recommended that the treating team consider involvement of the family or significant others (if this is the person’s wish) in the discussion about potentially administering a course of ECT.

Advice provided should include the risks of ECT and precautions that need to be adhered to 24 hours post procedure such as not driving a motor vehicle, using heavy machinery, making major life decisions, entering into business arrangements or signing a contract. It is also important to suggest that the person make provision for the possibility that they may be unable to recall important information such as PIN details or phone numbers. The treating team is to inform the person that consent can be withdrawn at any time, except if it is given under a PTO with approval for involuntary ECT. Refer to section 2 for further information about ECT orders and Emergency ECT orders.

Although the responsibility of obtaining and documenting consent rests with the treating team, signed consent forms (or valid involuntary treatment orders) need to be checked prior to each ECT treatment. This is performed by nursing staff, psychiatrist and/or delegate in preparation for the person receiving ECT on the day of the procedure.

A new consent form is required if the course of ECT goes beyond nine treatments as specified within the Mental Health Act 2015. In the event of involuntary legal status further ACAT authorisation is required if more than nine treatments are required.

Involuntary ECT needs to be applied for through ACAT and is required to have a current psychiatric treatment order in place (or applied for concurrently).

Documentation in the clinical record should include the following information regarding the consent process for people with decision making capacity: the reasons for the course of ECT treatment. reference that the person (and carer/nominated person if relevant) was provided with

relevant information regarding ECT including, verbal information from the treating doctor and written material about the treatment, its reasons for use, its course and possible side effects.

reference to the assessment of Decision-making capacity.



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reference to the properly signed and witnessed consent that must also be obtained using the ECT Consent and Prescription form. The form must be witnessed by a person who has no financial interest in the affected person’s affairs.

reference to any Advance Consent Directions where applicable

PrescriptionThe decision to recommend and implement ECT lies with the treating team for the person (including the psychiatrist responsible for the care of that person) and should be based on a careful assessment of the risks to and potential benefits for that individual. There should be a clear documentation in the person’s clinical record of the decision to embark on ECT and this should include the treating team’s recommendation in terms of bilateral versus right unilateral (RUL) or other (e.g. bifrontal) electrode placement, DGX or ultrabrief stimulus and frequency of treatments (usually two or three times a week except for ‘continuation‘ or ’maintenance‘ ECT).

The ECT Consent and Prescription Form is to be completed by the Psychiatry Registrar (or Consultant) of the treating team and containing the following information:1. Psychiatric diagnosis and indication for ECT2. Significant medical conditions 3. Current medication4. Cerebral dominance 5. Legal status (i.e. voluntary vs. involuntary)6. Consent / Decision Making capacity status7. Preferred electrode placement8. Recommended frequency of treatments9. Previous ECT (and if known seizure threshold / dose charge used with most recent course

of ECT + any special precautions), and 10. Anaesthetic agents used and any complications or reasons for changing from the usual

agents.

This form should be placed within the ECT section of the person’s notes with a coloured cardboard marker to notify this section / folder.


Section 4 – Preparation for ECT and Documentation

Preparation of a person for ECTThe responsibility for the preparation of a person for ECT lies with the treating team. An awareness of and vigilance for high risk co morbidities is vital. These include: bradycardia and bradyarrhythmias, poorly controlled hypertension, myocardial ischaemia especially recent myocardial infarction, CVA (depression associated with severe stroke may respond to ECT), raised intracranial pressure, epilepsy, Addison’s disease, phaeochromocytoma, thyroid disease, diabetes, electrolyte abnormalities, severe osteoporosis, obstructive airways



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disease and asthma, unmanaged urinary retention, skull defect, pregnancy, aneurysm, glaucoma and severe oesophageal reflux.

An appropriate appraisal of the person’s medical status and current medications (including noting whether the person is charted for benzodiazepines or anticonvulsant mood stabilizers) is an integral part of preparing a person for ECT. It is essential to be aware that benzodiazepines are potent anticonvulsants and increase seizure threshold, inhibit seizure propagation and alter the neurobehavioural effects of ECT and as such should be avoided if at all possible during a course of ECT. Even the so-called non-benzodiazepine hypnotics, zopiclone and zolpidem, act on benzodiazepine receptors and although short acting are also powerful anticonvulsants. The use of such medications and associated risks should be clinically assessed for each individual case.

The responsibility for making sure that a clinician (preferably both a Psychiatry Registrar and Consultant Psychiatrist but at times there may only be one of these present) is available for the carrying out of each ECT treatment on the person rests with the treating team (in liaison with the ECT nurse / coordinator). This might be facilitated by the creation of a weekly or monthly roster by the treating registrar in conjunction with other registrars. For the initial ECT treatment session using the titration method the attendance of a psychiatrist or experienced registrar is required.

Adult Mental Health Unit (AMHU) and Dhulwa Mental Health Unit (DMHU) ProcedureThere are a number of documentation and procedural requirements that AMHU/DMHU staff need to be aware of in preparation for the administration of ECT and subsequent to the person’s return to AMHU/DMHU.

1. It is the role of the ECT Nurse (AMHU) or primary nurse (DMHU) to liaise with the Psychiatry Registrar or Consultant regarding the plan for course of treatment and to arrange bookings for the ECT Procedure Room.

2. The use of medications should be discussed with the person’s treating Psychiatry Registrar or Consultant Psychiatrist. Some medications can be given prior to treatment, e.g. antihypertensives. However, all medications that may affect the quality of the seizure are to be withheld ten hours prior to treatment, e.g. benzodiazepines.

3. The person is to fast 12 hours prior to the treatment. Refer also to the Clinical Guideline Fasting Guidelines—Elective Surgery Patients on the Policy Register.



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4. The ECT or primary Nurse provides the following documentation for each ECT procedure:

General DocumentationCopy of ECT Order and Psychiatric Treatment Order (PTO)/Forensic Psychiatric Treatment Order (FPTO)ECT Consent and PrescriptionProgress NotesMedication ChartPatient Care and Accountability PlanPatient StickersProcedure DocumentationPre Operative ChecklistAnaesthetic Assessment—Pre Admission and Anaesthetic RecordECT Treatment RecordAnaesthetic Nurse Procedure ReportRecovery DocumentationPost Anaesthetic Observation ChartProgress NotesTransfer (if required)Request for Transport of a Mental Health Consumer under an Order

5. The treatment is to be recorded in the ECT Register (that is stored in the AMHU/DMHU safe) and in the person’s Electronic Clinical Record.

6. A proper record of recovery must be maintained after each treatment and throughout the course of the treatment, including the recording of side effects and complications. The forms listed above must be used for ECT procedures to document the person’s treatment and recovery.

7. The person will be escorted back to the High Dependency Unit at AMHU (HDU), Low Dependency Unit at AMHU (LDU) or DMHU, post recovery.

8. Post-treatment observations of blood pressure and pulse are to be taken once the person returns to HDU/LDU/DMHU unless otherwise directed by the anaesthetist, or the person is clinically compromised.

9. The ECT Stimulator will be kept in the ECT Procedure room and will be included in the routine maintenance schedule for equipment in that area. The ECT Nurse is responsible for restocking and reordering necessary equipment used in the ECT procedure, e.g. monitoring and treatment electrodes, gel, mouthguards, paper.

10. If a person is transferred from AMHU to Canberra Hospital Operating Theatres for the procedure the AMHU Transport Van is to be used and the MHJHADS Transport of Admitted Persons Procedure should be followed.

11. If a person is transferred from DMHU to Canberra Hospital Operating Theatres for the procedure the DMHU Transport Van is to be used and the DMHU Transport of Admitted Persons, Vehicle Management Safety Procedure should be followed.



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Section 5 – Administration, Monitoring and Post ECT Follow Up

Electrode placementAlthough strong consideration of a preference for right unilateral electrode placement is recommended in most cases (to minimise cognitive side affects) the choice of electrode placement lies with the treating team (and discussion with the person). There may be some circumstances, however, where bilateral (or bifrontal) electrode placement is indicated. This may be due to psychiatric, medical or anaesthetic issues in the person’s presentation. In addition, the treating Consultant Psychiatrist’s preference needs to be respected. If there is disagreement between the treating team Consultant Psychiatrist and the clinician performing the ECT with regard to this issue, informed discussions should follow in an attempt to reach a decision which is in the best interests of the person.

Stimulus titration method versus age or age hybrid methods. It is recommended that strong consideration be given to the stimulus titration method (as described in ’A method of ECT Dose Titration’—Attachment 7) for most people. This consists of titrating the charge up from recommended starting levels (based on age and gender) until the stimulus threshold is reached and then to increase by three levels for unilateral and one level for bilateral. The other methods may result in an appreciable number of people either being inadequately (especially with RUL electrode placement) or excessively treated (especially with bilateral treatment). Inadequate treatment may result in no clinical benefit for that session and excessive treatments may be associated with increased cognitive adverse effects. The rationale for this recommendation is that evidence suggests that the treatment seizure needs to be 50 percent above seizure threshold for bilateral and at least 150 percent above seizure threshold for unilateral to achieve optimal clinical efficacy. The stimulus delivered may need to be increased during the course of ECT based on EEG tracing characteristics / parameters, clinical progress and occasionally anaesthetic issues. The ultimate decision regarding these matters however lies with the treating team and there will be occasions where the age or age hybrid methods are indicated (e.g. where due to a cardiac condition the risks associated with the autonomic response to ECT render the titration method unacceptable).

Refer to Attachment 7: A method of ECT Dose Titration and Attachment 8: Titration and Treatment Schedule for Thymatron Series IV.

Administration of ECTECT is to be delivered by a Consultant Psychiatrist or Psychiatry Registrar. This registrar may administer ECT unsupervised if sufficiently experienced (as assessed by a Consultant Psychiatrist) but in the case of more junior staff adequate supervision (either by a Consultant or a more senior registrar) must be provided. In accordance with the mandatory 5 step policy for procedures the following are necessary:1. Verification that consent has been provided or in the circumstances of involuntary legal

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of written consent or ECT order by ward staff prior to the person being transferred to theatres or procedures suite, theatre staff, the ECT coordinator and the Consultant Psychiatrist / Psychiatry Registrar involved

2. Checking the indicated electrode placement (and charge dose)for the person3. Verification of the correct identity of the person who has been prescribed ECT is to take

place in the ward prior to transport to theatre / procedures suite and in the anaesthetic bay or operating theatre / procedures suite prior to the commencement of the anaesthetic

4. After the person has been anaesthetised all members of the ECT team are to stop and conduct a final verification of the correct person identity, electrode placement and the charge dose.

Venue for ECTECT is to be administered in a designated site that provides a suitable environment (including the availability of resuscitation equipment). Preferably there is to be a minimum of three areas—a waiting room, treatment room and a recovery room. The treatment room may be an operating theatre or other approved site (e.g. a procedures suite). Equipment, medications and current protocols for the management of cardiac arrest, anaphylaxis and malignant hyperthermia are present. The local storage of dantrolene (treatment for malignant hyperthermia) or proximal availability of dantrolene also needs to be considered.

Maintenance of ECT equipmentRegular maintenance of the Thymatron (or alternative machine) by the Biomedical department is indicated. Consumables such as ECT paper and other items should be ordered in advance by the ECT coordinator / nurse and always are available on the ECT trolley.

The role of ECT nurseThere should be a nominated / designated ECT nurse at all times who also attends ECT training sessions to continually update knowledge. The ECT Nurse is responsible for ensuring maintenance of ECT equipment, stocking of necessary items for the delivery of ECT and for the nursing care / management of the person in aspects that pertain to the preparation for and the delivery of ECT and the immediate after care (including ensuring that the person’s medical file and medication chart accompany him / her to theatre or procedures room). The ECT Nurse is to play a coordinating role and maintain close and timely communication with other members of both ECT team, the treating team and ward, theatre and recovery room clinical staff.

Anaesthetic issues1. Administration of anaesthesia for ECT follows best practice recommendations2. Choice of inducing agent (e.g. thiopentone vs. propofol) is the prerogative of the

anaesthetist. It is recommended that if possible for a given person the same agent be used all the way through a given course of ECT as this is less likely to cause variability in seizure properties (e.g. threshold and duration). Remifentanyl is usually given to reduce the dose of Propofol required in order to maximise the quality of the treatment seizure. A muscle relaxant must be given to the person before a stimulus can be given,



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3. The preparation and management of a person who is behaving in a highly agitated or aggressive manner may need to be discussed with the anaesthetic staff, especially in terms of what pharmacological agents are to be used in this situation that minimise interference with either the seizure or the administration of the anaesthesia.

4. In the event of a prolonged seizure (i.e. a seizure lasting more than 120 seconds) the anaesthetist is to be involved in terminating this with the agent of his / her choice (e.g. Propofol or a benzodiazepine)

5. The use of mouth guards is mandatory and is the responsibility of both the anaesthetic and psychiatric staff present. Staff should be vigilant to ensure that this is not overlooked.

6. A pre anaesthetic assessment should always occur prior to the commencement of a course of ECT. If during the preparation of a person for the next ECT treatment there is a question about the ongoing fitness for anaesthesia of a given individual, a further anaesthetic consult should be requested

7. If the titration method is being used there may be several charge deliveries on the first ECT treatment which do not result in a seizure. Therefore the anaesthetist needs to be communicated with and alerted to this possibility prior to the commencement of the anaesthetic as a higher dose of Propofol, Remifentanyl or Suxamethonium or a second dose of same may be required.

8. Non-depolarising muscle relaxants are relevant in pseudocholinesterase deficiency, hyperkalaemia and diffuse muscle membrane dysfunction e.g. NMS and Malignant Hyperthermia.

9. For interested mental health staff, especially those involved in the delivery of ECT, perusal of current literature (refer to Reference list in the procedure) reviewing anaesthetic issues pertaining to ECT is encouraged as it may help liaison and interfacing with anaesthetic staff.

MonitoringThe monitoring process should include clinical appraisal and documentation in the progress notes of any side effects present after any ECT treatment (this is the responsibility of the treating team) with special emphasis given to neurocognitive side effects. Also recommended is a regular review of EEG tracings by a Consultant or Psychiatry Registrar with some degree of expertise in ECT. If good prognostic EEG parameters are not present consideration should be given to increasing the size of the charge (or possibly alternative electrode placement) for the ensuing ECT treatments. The person’s clinical notes should also reflect the general clinical trajectory of the person in terms of the symptoms or mental state examination findings which constituted the original indication for ECT.

EEG tracings are to be cut into sections, mounted in sequence on a page (similar to what is done to ECG tracings) and then entered into the person’s file in the ECT folder section so that they may be scanned into the CRIS electronic record for future reference. If paper clinical records are kept the mounted tracings may need to be photocopied as the originals are likely to fade with time.

Post ECT Follow Up



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People having ECT should be reviewed clinically by the treating Psychiatry Registrar and/or Consultant prior to each treatment. Bedside cognitive testing should be done in between treatments. This should include a Folstein Mini Mental Examination (MMSE).


Section 6 – Staff Training Requirements

Psychiatrist training requirementsThere should be a designated Psychiatrist who leads ECT and this psychiatrist is to have dedicated sessional time for ECT. The Consultant Psychiatrist will have mandatory training (externally-delivered ECT-training) and experience in the delivery of ECT and possess a degree of technical mindedness. This Consultant Psychiatrist has responsibility for regular attendance at ECT treatments, the development of treatment protocols, training, supervision and support of clinical staff. Provision of advice to other health professional may include giving second opinions in the case of involuntary legal status and special populations such as pregnant women or adolescents, audit and quality assurance programmes to ensure ongoing optimal practice of ECT and continuing professional development (including keeping abreast of advances and controversies in the field).

Nursing training requirementsThere should be a nominated / designated ECT nurse at all times who also attends internally-delivered ECT training sessions to continually update their knowledge and skills. External professional development and accredited training courses are also encouraged.In the DMHU the primary nurse for a consumer prescribed ECT will be provided with this training and will liaise with the ECT nurse from theatres.




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Section 7 – Clinical Supervision

Clinical SupervisionSupervision is a very important aspect of best practice for delivery of ECT, both to maximise the care of and optimise results for the person and also to provide support and training for the Registrar and other staff involved. It is the Royal Australian and New Zealand College of Psychiatrists requirement for psychiatric trainees to receive supervision in ECT. In addition to practical ‘hands-on’ supervision during service delivery, seminar teaching sessions as part of training are seen as extremely useful in addition to a regular annual workshop by experts in the field (again including both theory and practical aspects).

Note: A psychiatrist should be credentialed by the Medical Dental Advisory & Appointments Committee (MDAAC) as qualified to administer ECT.


Implementation

The contents of this procedure will be communicated through in—service training provided to relevant teams where the procedure applies.


Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health Consent and Treatment Policy

Procedures ACT Health Incident Management Procedure ACT Health Inter-hospital Transfer: Non Critical Patients Procedure Advance Agreements, Advance Consent Directions, and Nominated Persons Assessment of Decision-making Capacity and Supported Decision-making CHHS Clinical Handover Procedure Clinical Handover within MHJHADS Procedure BHRC Clinical Risk Assessment and Observation Procedure Clinical Risk Assessment Procedure for AMHU and MHAU Clinical Risk Assessment and Management Procedure for DMHU MHJHADS Operational Management of the Adult Mental Health Unit (AMHU) High

Dependency Unit (HDU) MHJHADS Confidentiality and Privacy and access to MHJHADS Clinical Records Procedure MHJHADS Significant Incidents Reporting Procedure Second Opinion Reviews in Mental Health Services Transport of Consumers within the Canberra Hospital Campus Procedure



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Memorandum of understanding between MHJHADS, the ACT Ambulance Service, the Australian Federal Police, the Canberra Hospital, Calvary Health Care ACT for People Requiring Mental Health Care.

SMHU Vehicle Management and Safely using a vehicle to Transfer Admitted People

Guidelines ACT Charter of Rights for people who experience mental health issues Mental Health Statement of Rights and Responsibilities 2012 Australian Charter of Healthcare Rights 2008

Legislation Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Carers Recognition Act 2010 ACT Human Rights Act 2004 Children and Young Persons Act 2008 Privacy Act 1988 Information Privacy Act 2014 (ACT) Health Records (Privacy and Access) Act 1997 (ACT) Human Rights Act 2004

Definition of Terms

Decision-making Capacity: The term capacity is used in this document to mean a person is capable of: Understanding the nature and effect of decisions about consent and communicating the

understanding verbally or non-verbally Freely and voluntarily making decisions about consent Communicating the decisions verbally or non-verbally, and Retaining the information, their decision and their consent.The type of assessment required to determine someone’s capacity will vary depending on the type of decision being made.

Nominated person: A person with a mental disorder or mental illness, who has decision-making capacity, may, in writing nominate someone else to be their nominated person. The NP cannot consent on the person’s behalf (unless they have that power in another role such as Power of Attorney).

Person: In this document, the term ‘person’ refers to patients, consumers and people or individuals under the care of ACT Health.

Treating Team includes the Medical Officer, Consultant Psychologist, Senior Nurse, nursing staff, Emergency Medicine Specialist, interdisciplinary team and other relevant healthcare providers



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References

Malhi G.S., Bassett D., Boyce P., Bryant R., Fitzgerald P.B., Fritz, K., Hopwood, M., Lyndon, B., Mulder, G., Murray G. Porter, R. and Singh A.B., (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry, 49(12), pp. 1087-1206.

National Institute for Health and Care Excellence (2003). Guidance on the use of electroconvulsive therapy. NICE, United Kingdom (Changes after publication occurred in January 2014 and March 2012)

The Royal Australian & New Zealand College of Psychiatrists (2014). Position Statement 74 - Electroconvulsive Therapy (ECT). RANZCP, Melbourne.

Royal College of Psychiatrists (2015) ECT Accreditation Service (ECTAS) Standards for administration of ECT. 12th Edition, Royal College of Psychiatrists Centre for Quality Improvement, London UK.


Search Terms

Electroconvulsive Therapy, ECT, Emergency ECT, ECT Order, Decision-making, Advance Consent Direction, Mental Health Act 2015


Attachments

Attachment 1: Titration Chart—A method for ECT Dose TitrationAttachment 2: Titration and Treatment Schedule for Thymatron Series IVAttachment 3: ECT Flow Chart for a Consumer with Decision Making Capacity 12—15 years oldAttachment 4: ECT Flow Chart for a Consumer with Decision Making Capacity 16—17 years oldAttachment 5: ECT Flow Chart for a Consumer with Decision Making Capacity 18 + years oldAttachment 6: ECT Flow Chart for a Consumer NO Decision Making Capacity 12—15 years oldAttachment 7: ECT Flow Chart for a Consumer NO Decision Making Capacity 16—17 years oldAttachment 8: ECT Flow Chart for a Consumer NO Decision Making Capacity 18 + years old

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.



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Date Amended Section Amended Approved By26 Aug 2016 Information pertaining to the

Dhulwa Mental Health Unit added to procedure

Clinical Safety and Quality Unit Policy Manager



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Attachment 1: ECT Flow Chart for a Consumer with Decision Making Capacity 18 + years old



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Attachment 2: ECT Flow Chart for a Consumer NO Decision Making Capacity 18 + years old



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Attachment 3: ECT Flow Chart for a Consumer with Decision Making Capacity 12—15 years old



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Attachment 4: ECT Flow Chart for a Consumer with Decision Making Capacity 16—17 years old



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Attachment 5: ECT Flow Chart for a Consumer NO Decision Making Capacity 12—15 years old



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Attachment 6: ECT Flow Chart for a Consumer NO Decision Making Capacity 16 - 17 years old



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Attachment 7: Titration Chart - A method for ECT Dose Titration



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Attachment 8: Titration and Treatment Schedule for Thymatron Series IV



Documents

Electroconvulsive Therapy (ECT) - Adults and Children …health.act.gov.au/sites/default/files/new_policy_and_plan... · Web viewSchizophrenia and related disorders (schizophreniform