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Guideline The Administration of Electroconvulsive Therapy July 2017 The Adminis

Guideline The Administration of Electroconvulsive Therapy July 2017 The Administration of Electroconvulsive Therapy - ii - Guideline for the Administration of Electroconvulsive Therapy Published by the State of Queensland (Queensland Health), March 2017 This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au © State of Queensland (Queensland Health) 2017 You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health). For more information contact: Mental Health Alcohol and Other Drugs Branch, Department of Health, GPO Box 48, Brisbane QLD 4001, email OCP-MHAODB@health.qld.gov.au, phone (07) 332 89374. An electronic version of this document is available at https://www.health.qld.gov.au/qhpolicy/html/index-m.asp Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information. The Administration of Electroconvulsive Therapy - iii - Contents 1. Purpose ..................................................................................................... 1 2. Background ................................................................................................ 1 3. Scope ......................................................................................................... 1 4. Related documents .................................................................................... 1 4.1 Authorising Policies and Standards ............................................................ 1 4.2 Procedures, Guidelines and Protocols ........................................................ 2 4.3 Forms and templates .................................................................................. 2 4.4 Terminology used in guiding documents ........................................................ 2 5. Governance of the ECT service ................................................................. 4 5.1 Role and membership of the ECT Management Committee ....................... 4 5.2 Maintenance of equipment and supplies ..................................................... 5 6. Staff training ............................................................................................... 6 6.1 Consultant psychiatrists .............................................................................. 6 6.2 Registrars ................................................................................................... 6 6.3 Other medical officers ................................................................................. 6 6.4 Nursing staff ............................................................................................... 7 7. Granting clinical privileges to perform ECT (credentialing) ........................ 8 7.1 Responsibility for clinical privileging ............................................................ 8 7.2 Initial clinical privileging process ................................................................. 9 7.3 Ongoing clinical privileging ......................................................................... 9 7.4 Privileging of psychiatry registrars and other medical officers ..................... 9 8. Consent and legal issues ........................................................................... 9 8.1 ECT is a Regulated Treatment under the Mental Health Act 2016 ............ 10 8.2 Mental Health Review Tribunal Approval .................................................. 11 8.3 Emergency ECT ....................................................................................... 12 9. Indications for ECT .................................................................................. 13 10. Risks of ECT ............................................................................................ 13 10.1 Non-cognitive risks of ECT ....................................................................... 13 10.2 Cognitive risks of ECT .............................................................................. 15 10.3 Adverse incident or critical event ................................................................ 16 11. ECT in special populations ...................................................................... 16 11.1 Children and adolescents ......................................................................... 16 11.2 Pregnancy ................................................................................................ 17 11.3 The elderly ................................................................................................ 17 12. Cultural considerations ............................................................................ 17 13. Medical considerations prior to ECT—history, physical examination and baseline cognitive testing .......................................................................... 18 13.1 Psychiatric examination ............................................................................ 18 13.2 Extended assessment .............................................................................. 18 The Administration of Electroconvulsive Therapy - iv - 13.3 Investigations............................................................................................ 18 13.4 Consultation with other specialists ............................................................ 18 13.5 Medications and ECT ............................................................................... 19 13.6 Cardiac pacemakers ................................................................................. 19 13.7 Implanted cardiac defibrillators ................................................................. 19 13.8 Cochlear implants ..................................................................................... 20 14. Equipment and staffing ............................................................................ 20 14.1 Location of ECT administration ................................................................. 20 14.2 ECT equipment ......................................................................................... 20 14.3 Anaesthetic and resuscitation equipment .................................................. 21 14.4 Staffing of the ECT suite ........................................................................... 21 15. The ECT procedure ................................................................................. 22 15.1 Patient identification and procedure matching........................................... 22 15.2 During the procedure ................................................................................ 23 15.3 Sign out—before the patient leaves the ECT suite ..................................... 23 16. Post ECT care .......................................................................................... 24 16.1 Recovery .................................................................................................. 24 16.2 Management of adverse effects ................................................................ 24 16.3 Post-ECT delirium .................................................................................... 24 17. Treating electrodes .................................................................................. 24 17.1 Electrode placement options ..................................................................... 25 17.2 Electrode placement recommendations .................................................... 26 17.3 Electrode placement—positions................................................................ 27 18. Dosage .................................................................................................... 28 18.1 Dosage increases during treatment .......................................................... 28 19. Pulse width............................................................................................... 29 20. Frequency and spacing of treatments ...................................................... 29 21. Number of treatments .............................................................................. 30 22. Determination of an adequate seizure ..................................................... 30 22.1 Criteria for re-stimulation .......................................................................... 31 22.2 Prolonged seizures ................................................................................... 31 23. Titration technique ................................................................................... 32 24. Documentation ......................................................................................... 32 24.1 Clinical monitoring over the treatment course ........................................... 33 24.2 ECT treatment record ............................................................................... 33 24.3 Clinical record ........................................................................................... 34 24.4 Post-ECT follow up and monitoring ........................................................... 34 24.5 ECT register ............................................................................................. 34 25. Continuation (C–ECT) and maintenance ECT (M–ECT) defined and explained .......................................................................................................... 35 26. Outpatient ECT ........................................................................................ 35 26.1 Indications for outpatient ECT ................................................................... 35 The Administration of Electroconvulsive Therapy - v - 26.2 Care after outpatient ECT ......................................................................... 35 Approval and Implementation ........................................................................... 37 Policy Custodian: ............................................................................................... 37 Responsible Executive Team Member: .............................................................. 37 Approving Officer: .............................................................................................. 37 Appendix 1 ....................................................................................................... 38 ECT Credentialing – Practical Technique Guide ................................................ 38 Appendix 2 ....................................................................................................... 40 Medications by class: Considerations/advice relevant to ECT practice .............. 40 Appendix 3 ....................................................................................................... 43 Clinically significant drug interactions37,38 ........................................................... 43 Appendix 4 ....................................................................................................... 44 Glossary ............................................................................................................ 44 Appendix 5 ....................................................................................................... 46 References ........................................................................................................ 46 Appendix 6 ....................................................................................................... 49 Suggested reading ............................................................................................. 49 Figures Figure 1 Bilateral and unilateral placement ............................................................. 26 Figure 2 Bi-frontal placement .................................................................................. 26 The Administration of Electroconvulsive Therapy - 1 - 1. Purpose This Guideline provides recommendations regarding best practice for the administration of electroconvulsive therapy (ECT). 2. Background ECT has been an important treatment in psychiatry since the 1930s. There has been increasing evidence demonstrating the effectiveness of ECT in the treatment of severe depressive illness. There is also evidence to support the use of ECT in the treatment of acute mania, catatonia and schizophrenia and as a long term maintenance treatment (M–ECT) for the same indications as for acute treatment. It is an available treatment option at many specialist mental health facilities in Australia. A number of organisations in Australia and internationally have produced guidelines to promote best practice and optimal outcomes in terms of efficacy and safety. This Guideline includes material from some of these, and in particular those from New South Wales,1 Victoria2 and South Australia3 are acknowledged. This Guideline has been developed by the Queensland ECT Committee under the auspices of the Chief Psychiatrist, Department of Health. It is intended as a reference document to inform services undertaking the development or amendment of their own practices, procedures and work instructions. 3. Scope In Queensland, ECT is performed at a range of facilities and settings. These include public and private hospitals in metropolitan and regional centres. A significant proportion of patients receive day procedure ECT as outpatients. However, ECT may only be performed in an authorised mental health service, declared under the Mental Health Act 2016. This Guideline provides information for all Hospital and Health Service (HHS) employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including visiting medical officers (VMOs) and other partners, contractors, consultants and volunteers) involved in the delivery of ECT. It is also relevant to all staff of private sector authorised mental health services which are declared as an authorised mental health service for the purpose of providing ECT. 4. Related documents 4.1 Authorising Policies and Standards  Mental Health Act 2016  Guide to the Mental Health Act 2016  Hospital and Health Boards Act 2011  Guardianship and Administration Act 2000 The Administration of Electroconvulsive Therapy - 2 -  Powers of Attorney Act 1998  National Safety Priorities in Mental Health 2005  National Safety and Quality Health Service Standards 2012  National Standards for Mental Health Services 2010  Mental Health Statement of Rights and Responsibilities 2012  Australian Commission on Quality Health Care Accreditation Standards 2011  Australian and New Zealand College of Anaesthesia (ANZCA) Policy on Supervision of Clinical Experience for Vocational Trainees in Anaesthesia 2011  Royal Australian and New Zealand College of Psychiatrists (RANZCP) Training and Assessment Regulations 2012  Credentialing and Defining the Scope of Clinical Practice Health Service Directive 2014  Patient Safety Health Service Directive 2014  National Framework for Recovery-Oriented Mental Health Services 2013  Australian Charter of Health Care Rights 2008  National Practice Standards for the Mental Health Workforce 2013. 4.2 Procedures, Guidelines and Protocols  Royal Australian and New Zealand College of Psychiatrists’ Position Statement 74 Electroconvulsive Therapy (ECT)  Guideline for Clinical Incident Management 2013  Australia and New Zealand College of Anaesthetists’ (ANZCA) Handbook for Training and Accreditation 2014  ANZCA Recommendations on Essential Training for Rural General Practitioners in Australia proposing to Administer Anaesthesia 2010. 4.3 Forms and templates  ECT consent form  ECT consumer information form  Certificate to Perform Emergency Electroconvulsive Therapy  Treatment Application (Electroconvulsive Therapy)—available from the Mental Health Act Delegate or Mental Health Review Tribunal. 4.4 Terminology used in guiding documents  The Royal Australian and New Zealand College of Psychiatrists’ Position Statement 74 Electroconvulsive Therapy (ECT) states that ‘ECT should be administered by a medical practitioner (usually a psychiatrist) who has received specialized training in ECT treatment techniques, and is of an adequate standard to have received clinical privileges to perform the procedure.’ The Administration of Electroconvulsive Therapy - 3 -  The uploads/s1/ ect-guide.pdf