Review of ECT Practice at Riverview Hospital - Review of ECT

Written by Riverview Hospital Report

The process being followed for informed consent is well outlined in documents appended here. In addition, the Coordinator of ECT Services stated that ECT was not given without the consent of family, even though that may not formally be required under the Mental Health Act.

In charts reviewed by the team, appropriate consent documents were found in 100% of cases.

The facility has a clear understanding of the effect of the new Guardianship Legislation on consent and has built in new steps to accommodate this.

Involuntary patients may sign consent forms for themselves if their physician considers them to be mentally capable; however, if they are incapable of signing, the Vice President of Medical and Academic Affairs must sign as "Deemed Consent".

Although this consent process is outlined in the ECT Policies and Procedure Manual on all wards, some staff indicated that they are unaware of the VP's decision-making "checklist" in signing "Deemed Consent" for Involuntary patients.

Recommendation: The VP of Medical and Academic Affairs' role in consent for Involuntary patients should be clearly delineated and communicated to staff.

NUMBER OF TREATMENTS IN CONSENT Assessment: Some concern was expressed by a number of physicians that the consent form, being designed for up to fifteen treatments, might influence the number of treatments given. Certain physicians recommended reducing the number of treatments in a course per consent.

Recommendation: The average number of treatments for an index course is normally between six and twelve, however more may be needed. It is advisable that a new informed consent form is signed after a course of twelve treatments or a period of six months.

7. Staff Training

PHYSICIANS Assessment: Since the last review in 1996, the prerequisite training for psychiatrists wishing to carry out ECT has increased significantly. Attendance at the Duke University Course in ECT is recommended, and most of the psychiatrists currently performing ECT have attended this course. All of them endorse it as an outstanding experience which has prepared them well to carry out ECT. Currently, the hospital pays for missed sessional time while the individual pays for their airfare, accommodation, and course registration.

Some psychiatrists have expressed concern that the hospital should fully compensate physicians for attending this course if it is a prerequisite to practising ECT. According to the Coordinator of ECT Services, while the course is strongly recommended, equivalent experiences can be arranged within British Columbia for those who do not wish to attend. The Coordinator of ECT Services is insistent that psychiatrists practising ECT require sophisticated skills, as the patient population at RVH frequently suffers from co-morbid medical conditions.

Consideration is being given to having a separate credentialing process for psychiatrists wishing to practise ECT in order to maintain high standards of practice.

Currently, exposure to the ECT suite and the practice of ECT is not part of the orientation for Physicians.

Ongoing ECT grand rounds are offered annually. However, in our discussions with physicians and nursing staff, questions were raised about the increasing numbers of geriatric patients with dementia who were receiving ECT. There seemed to be limited understanding of the current changing indications for ECT in people with Dementia. Recommendations: a) The criteria for joining the ECT treatment team, as a Psychiatrist, need to be clarified (i.e. what constitutes an adequate "specific training course/lecture" as specified in the Medical Staff Policy and Procedure Manual, 1997). b) All physicians hired at Riverview Hospital should receive an orientation to the ECT suite and the practice of ECT. This should become a formal part of their orientation to aid in their understanding and decision-making about ECT. c) ECT Grand Rounds should continue to occur on an annual basis and should reflect the educational needs voiced by staff. This would be an excellent opportunity to relay new research findings related to ECT.

NURSING Assessment: In-services about ECT have been held and ECT information and procedure binders have been created for each ward. There appears however, to be a lack of ongoing education for Riverview nurses. This concern was voiced by The Coordinator of ECT Services and the nurses from the ECT Treatment Suite. In particular, staff who are rarely involved with patients undergoing ECT should nevertheless be kept abreast of ECT practices at RVH. Recommendation: All nurses at RVH should be required to spend time in the ECT suite to develop thorough knowledge of the indications for and the practice of ECT. In additions, they should be oriented to the current indications for ECT to enhance their ability to participate in team ECT decisions.

8. Monitoring and Evaluation Assessments: a) The ECT program lacks a detailed database. Statistics currently kept are collected manually by staff in the ECT suite. This deficit makes examination of the RV practice of ECT with respect to patient selection and outcome virtually impossible.

We have been made aware by the administration at RVH that a database is not likely forthcoming for at least another year and a half. This hampers both monitoring of clinical practice and research initiatives.

b) While an outcome tool was included in our pre-reading package, it was not found on any of the charts reviewed.

d) Similarly to the Inpatient population, there is little data regarding the use of outpatient ECT at Riverview. Monitoring of the progress of these patients occurs partially in the community, and partially by ECT physicians. There are no dedicated resources for Outpatient ECT.