Review of ECT Practice at Riverview Hospital - Preparation and Aftercare of ECT

Written by Riverview Hospital Report

Patients and families are also encouraged to view a video about ECT as well as visit the ECT suite prior to beginning ECT to meet the Staff, see the facilities and address any concerns they may have about the process.

A pre-ECT nursing checklist is completed prior to the patient leaving the ward (for inpatients) and checked by the waiting room nurse. For outpatients, the waiting room nurse completes the pre-ECT nursing checklist.

The PARR nurses manage the patient's airway, administer oxygen at 6-8L per minute, and monitor the heart rhythm by ECG. They also assess and score the following every five minutes until the patient meets discharge criteria: blood pressure, pulse, respiratory rate, oxygen saturation, level of consciousness and muscle strength. When the patient has met the criteria for discharge from the PARR they are transferred from the stretcher to a wheel chair and returned to the waiting room. The waiting room nurse receives a verbal report from the recovery room nurse of any significant information. This is in turn passed on to the escort nurse or to the person returning the patient to a facility or home. The patient is offered cookies and juice in the waiting room prior to discharge from the ECT suite. Patients returning to their wards will have their vitals assessed and recorded within 30 minutes.

Outpatients are discharged home in the care of a responsible adult.

Concern was raised about the length of time some patients were required to fast prior to receiving their treatment, despite requesting an earlier time slot. The ECT Treatment Team are aware of this and have responded by suggesting methods of keeping patients hydrated (e.g. with intravenous fluids) prior to their treatment. They have also attempted to accommodate these patients as best as possible.

Recommendations: a) Improved communication is necessary to facilitate the issue surrounding fasting patients (i.e. personal contact rather than an answering machine). Without increased resources such as a registered nurse (on site five days per week), this will be difficult to accomplish. b) Riverview needs to expand their discharge information for outpatients and identify staff responsible for providing this information. A checklist would ensure this information has been disseminated (as is already established for inpatients).

5. Patient Selection

PATIENT SELECTION Assessment: There was a lack of pertinent statistics pertaining to ECT at Riverview. Moreover, due to time constraints it was not possible to conduct a systematic chart review to address issues pertaining to patient selection. There is however, no doubt that the number of ECT procedures at Riverview has increased over the last few years and that this increase in ECT procedures is primarily due to an increase in ECT procedures for geriatric patients. There is insufficient information available to draw any firm conclusions regarding the rate of ECT across age and diagnostic groups or the number of treatments per patient. For the same reason, it is not possible to draw any conclusions whether patient selection and utilization are in agreement or at variance with other provincial, national and international data.

Efforts are being made by an internal subcommittee at Riverview to address questions related to appropriate utilization of ECT, and we were pleased to be informed of changes of the composition of said committee to better accommodate the concerns of the Medical Staff for a more objective assessment.

Recommendation: The committee, due to inadequate data, is unable to draw any conclusions regarding ECT patient selection and utilization at Riverview. The committee strongly supports the internal review currently underway under the auspices of the Riverview Medical advisory Committee and cannot underscore enough the need for an independent and objective review process. Although this Review Team cannot speak to Riverview's numbers, nor the appropriateness of patient selection, the Ministry of Health and Ministry Responsible for Seniors needs to extend effort to refine ECT data collection and examine ECT use Province-wide.

SECOND OPINION FOR TREATMENT Assessment: Several staff aired concerns about the process of a second psychiatric opinion. It was pointed out that the bulk of the ECT at Riverview is carried out by Geriatric Psychiatrists for Geriatric patients.

Recommendation: We recommend that second opinions should be done in a more objective manner i.e.: by Adult psychiatrists for geriatric patients. The Geriatric Psychiatrists have agreed with this in principle and have added that it is also crucial for the second opinion to be done by psychiatrist well versed in ECT. They have expressed a desire for Adult Psychiatrists to join the ECT delivery team in the future.

6. Patient Education / Consent

PATIENT EDUCATION Assessment: Patients and families are invited to view a video regarding ECT and are provided with written brochures (appended). They are further referred to Riverview's library for additional information. Attending physicians also spend time preparing patients and their families for ECT. Despite this, at the open forum, some patients, as well as the Patient Advocacy group representative, expressed a concern that often, patients do not fully understand ECT and are scared during their initial treatment.

The family representatives that spoke at the open forum, as well as those interviewed on the second review day, all expressed a sense that they had been given ample relevant information prior to the treatments. They also felt strongly that their input had been valued in the initial decision to proceed with treatment.

Recommendation: While fear of medical procedures and or anesthesia is common, Riverview Staff need to remain sensitive to patients' reactions during a course of ECT and encourage education and support. CONSENT Assessment: We did not witness any consent interviews during our visit. Therefore, our data comes from chart review and discussion with the above-mentioned parties.