ECT Manual

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ECT ManualLicensing, Legal Requirementsand Clinical Practice Guidelines

Aged, Community and Mental Health

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AcknowledgmentsPublished by the Aged, Community and MentalHealth Division, Victorian Government Departmentof Human Services.

Melbourne, Victoria

January 2000(1460599)

Copyright State of Victoria 2000

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Foreword

Guidelines for the practice of electroconvulsive therapy (ECT) in Victoria were first published in June 1991.Since that time there has been significant growth in our knowledge about ECT, advances in the availabletechnology and major changes to the environment in which mental health services are delivered.

Most importantly, changes to the legislation in 1995 required that all services performing ECT must now belicensed. Licensing provides a uniform mechanism by which the Department can establish minimumstandards for the provision of ECT and enhance consumer and public confidence in its administration. Thischange has led service providers to seek guidance from the Department about its requirements.

At a broader level, the National Mental Health Strategy has encouraged the mainstreaming of mental healthservices with the general health system, a shift in the balance towards greater community-based treatment,an increasing emphasis on standards and a renewed focus on patient rights. These major changes have allhad an impact on the prescription and practice of ECT.

These revised guidelines reflect all these changes and are intended to be a primary reference document forthe performance of ECT. They set the requirements for the licensing of premises for the performance of ECT,outline the minimum standards for resources and equipment and provide practical clinical guidelines forstaff who prescribe or are involved in the administration of ECT.

I would like to thank the members of the ECT reference group and other senior clinicians from both thepublic and private sectors who contributed their time, knowledge and advice to the development of theseguidelines.

I am confident these guidelines will be a valuable resource for both clinicians and administrators to guidethe development of local practices to ensure that ECT is used effectively and safely to optimise the best

possible treatment outcome for people with a mental disorder.

Associate Professor Norman JamesChief Psychiatrist

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Contents

Foreword iiiPart AIntroduction 1

Background 1Purpose 1Definitions 2

Part BLicensing 3Administration 3Application for a Licence [section 75] 3Cancelling a Licence [section 76(2)] 4Renewal of Licence [section 77] 4Amendment of Licence [section 78] 5Review of Decisions [section 79] 5

Part CResources and Equipment 7Building Design 7

Equipment 8Staffing 8Training and Education 10Quality Improvement 10Record Keeping 11

Part DClinical Practice Guidelines 13Decision to Prescribe ECT 13Legislation 13Preparation for ECT 13Informed Consent 14Passive Consent 14Consent by Other People 15Consent by the Authorised Psychiatrist 15

Urgently Needed ECT 16Penalties for Performing ECT Without Informed Consent 16Confidentiality 16Prescription of ECT 16Administration of Anaesthetic 17Stimulus Parameters and Seizures 17Recovery 18Monitoring Clinical Response 18Privacy 18ECT on an Outpatient Basis 18

Part ECriteria for Licensing ECT Premises 21Suitability of the Applicant to Hold a Licence [section 75(5)(a)] 21The Suitability of the Premises [section 75(5)(b)] 21

Suitability of Equipment to be Used in the Performance of ECT [75(5)(c)] 21Suitability of Qualifications of Persons Performing ECT [75(5)(d)] 22

Part FAppendices 23Appendix 1: Sample Information SheetAdditional Information for Patients Receiving ECT as Outpatients 23Appendix 2: Schedule 17Application for Licence to Permit the Performance of Electroconvulsive Therapy 24Appendix 3: Schedule 18Licence Authorising Performance of Electroconvulsive Therapy 25Appendix 4: Schedule 19Application for Renewal of an Electroconvulsive Therapy Licence 26Appendix 5: Schedule 20Application for Amendment of an Electroconvulsive Therapy Licence 27Appendix 6: Schedule 21Electroconvulsive Therapy Return 28Appendix 7: Informed Consent to Electroconvulsive Therapy ECT) (PSY 16) 29Appendix 8: Authority to Perform Electroconvulsive Therapy (ECT) Where Informed Consent Not Obtained (PSY 17) 30Appendix 9: Royal Australian and New Zealand College of PsychiatristsElectroconvulsive Therapy Explained 31Appendix 10: Royal Australian and New Zealand College of PsychiatristsClinical Memorandum #12: 34

Electroconvulsive TherapyReferences 51

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Part AIntroduction

Background

Electroconvulsive therapy (ECT) is a procedureperformed under general anaesthesia and musclerelaxation in which modified seizures induced bythe selective passage of an electrical current throughthe brain are used for therapeutic purposes. ECT ismost commonly prescribed for the treatment ofsevere depression, but may also be used for othertypes of serious mental illness such as mania,schizophrenia, catatonia and other neuropsychiatricconditions. It is most often prescribed as part of atreatment regime in combination with othertherapies.

Convulsive therapy was first administered early thiscentury following studies by Ladislaus von Medunaas a method of relieving the symptoms of mentalillness. In 1938 the first machine was developed byCerletti and Bini to produce electrically inducedseizures. This replaced chemically induced seizuresand the treatment first came to be calledelectroshock therapy.

Representations of ECT in popular culture have been frightening and have had a negative publicimpact. However, there have been significantadvances in the technology and knowledge aboutECT over recent years and studies support its use asa safe and effective psychiatric treatment. Guidelinesto clinical practice published by organisations suchas the Royal Australian and New Zealand College ofPsychiatrists and the Australian and New ZealandCollege of Anaesthetists (ANZCA) have contributedto the high standards now associated with thetreatment.

Government regulation has also played a major rolein setting standards for the performance of ECT. The Mental Health Act 1986 contains detailed legislativeprovisions regulating consent to treatment. The Actdefines the elements of informed consent andstrictly prescribes the circumstances and therequirements when ECT may be performed withoutinformed consent. The Act also establishes aframework for licensing of premises.

Licensing provides a tool by which standards can beset and monitored while providing a readymechanism for responding to concerns, for example,

by placing a specific condition on a licence.Licensing also acts to enhance consumer confidencein ECT. The nature of ECT and the historyassociated with it means that some patients mayexperience distress or fear when it is proposed as anappropriate treatment. In making an informedchoice, patients are limited in their ability to obtaininformation about the quality of available services.Licensing provides assurance to patients that aservice and the practitioners performing ECT meetestablished standards.

Legislation, licensing, guidelines, new technology

and advances in clinical knowledge all act to ensurethat ECT is used in a safe and effective manner andin a way that is respectful of the persons rights,privacy, dignity and self-respect.

PurposeECT is an important treatment in modernpsychiatric practice. It is essential that it isadministered properly at premises which have beenlicensed to perform ECT.

The purpose of this document is to: Provide guidelines, minimum standards and

information about the prescription, practice andprocedures relating to the performance of ECT.

Set minimum standards for staffing, facilities andequipment relating to the performance of ECT.

Prescribe key criteria by which premises will beassessed for a licence.

As such it is intended to assist service planning byhospital management, guide the clinical practice ofmedical and nursing staff and provide informationfor Department of Human Services staffadministering the licensing procedure. Thedocument may also have a broader educative rolefor consumers, carers and other members of thecommunity about the performance of ECT.

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Definitions

Approved Course in ECTThis is a training course in the contemporary use ofECT approved from time to time by the ChiefPsychiatrist.

Approved Mental Health Service

An approved mental health service is premises or aservice proclaimed to be an Approved MentalHealth Service under section 94 of the MentalHealth Act.

Authorised PsychiatristAn authorised psychiatrist is a qualified psychiatristappointed as the Authorised Psychiatrist undersection 96 of the Mental Health Act. For the purposeof this document the term Authorised Psychiatristincludes their delegate.

Clinical Director (ECT)

Clinical Director (ECT) means a qualifiedpsychiatrist appointed to have overall clinicalresponsibility for ECT at the licensed premises, andwho has undertaken an approved course in ECT.

Course of ECT

A course of ECT is up to six treatments given over aperiod with not more than seven days elapsing between any two treatments. The course is deemedto be finished if more than seven days elapses between any two treatments. Further treatment willneed a new consent. One course may immediatelyfollow another.

Key Licensing Criteria

Key licensing criteria means the criteria developed by the Department of Human Services by whichpremises will be assessed for a licence (see part E).

Occupier

The Occupier of any premises means the bodycorporate of the health service.

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Premises

Premises means an individual hospital or a campusof a hospital group or network. The premises mayencompass one or more treatment suites at eachhospital or campus.

Registered Medical Practitioner

Registered medical practitioner means a registeredmedical practitioner within the meaning of the Medical Practice Act 1994.

Registered Nurse

Registered nurse means a nurse whose name isincluded in Division 1 or 3 of the register of nurseskept under Part 2 of the Nurses Act 1993.

Senior Clinical Nurse (ECT)

Senior Clinical Nurse (ECT) means a registerednurse appointed to have ongoing managementresponsibility for coordination of nursing staff anddirect management of the ECT suite and who hasundertaken an approved ECT course.

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Part BLicensing

Licensing of ECT premises is fundamental to theregulation of standards under the Mental HealthAct. ECT may only be performed at premiseslicensed for the performance of ECT. Thisrequirement applies to both public and privateservices.

The Mental Health Act provides for inspection ofpremises and regulates the suitability of the licenceholder, the standards and conditions of premisesand equipment, and the qualifications of the personspermitted to perform ECT. The Mental Health Actdefines the elements of informed consent and

strictly prescribes the circumstances and therequirements when ECT may be performed withoutinformed consent. The Mental Health Act alsoprovides penalties in the case of poor practice,including the revocation of a licence.

The Mental Health Regulations 1998 accompany theMental Health Act and their role is to operationalisethe Act. In particular they prescribe the variousforms and fees associated with the licensing of ECT.

AdministrationUnder the Mental Health Act all the powers, dutiesand functions relating to licensing of premises areassigned to the Secretary to the Department ofHuman Services. In practice, all such duties areperformed by the Chief Psychiatrist, under adelegation made by the Secretary.

All enquires about licensing of premises to performECT should be directed to the Chief Psychiatrist.

Application for a Licence [section 75]The occupier of any premises may apply to theChief Psychiatrist for a licence to perform ECT. Inmost cases the Chief Executive of the premises willmake the application on behalf of the Occupier. Theapplication is to be made in the form of Schedule17 Application for Licence to Permit the Performance of Electroconvulsive Therapy(see appendix 2) and a floorplan of the premises indicating all suites/areaswhere ECT is to be performed must be attached. The

floor plan will be incorporated to become part of theECT licence. The premises may encompass one ormore treatment suites at each hospital or campus.For example, a hospital may have a dedicated ECT

suite and an operating suite at which ECT will beoccasionally performed. In such a case, both suitesshould be included in the floor plan.

In circumstances where an occupier operatesservices from a number of different campuses, anapplication for a licence must be made for eachcampus.

Enclosed with the application must be theprescribed application fee. The fee is anadministration fee and will not be refunded if alicence is not approved.

InspectionEach service must be inspected before a licence can be approved. A qualified psychiatrist, a registerednurse and other staff nominated by the ChiefPsychiatrist will conduct the inspection.

Personnel representing the occupier at theinspection should be familiar with the premises and be able to provide information to address the keylicensing criteria. The personnel could include the

Medical Director, the Clinical Director (ECT) and theSenior Clinical Nurse (ECT).

Inspection Report and Recommendation

Following inspection, a nominated member of theinspection team will prepare a report for the ChiefPsychiatrist, addressing the key licensing criteriaand making a recommendation. Options are: Recommended.or Qualified recommendation, subject to specific

conditions being met. It must propose such termsand conditions as are necessary to ensure theservice meets the key licensing criteria.

or Not recommended. Where an application is not

recommended, a statement of reasons will beprovided.

Licence Approval

The Chief Psychiatrist determines the application.

The decision will be based on the inspection reportand the key licensing criteria. The Chief Psychiatristmay seek further information as necessary.

Licence Documentation3

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The licence is prepared in the form of Schedule 18Licence Authorising Performance of ECT (see appendix3) and details the following information: The licence holder. The name of the service. The address of the premises. The period of the licence which may be for a

period of up to five years. The licence number. A plan of the premises showing all areas/suites

where ECT can be performed, contained inAttachment A.

The terms and conditions to be attached to thelicence, contained in Attachment B.

Attachment B to the licence lists the terms andconditions of the licence. Standard conditions of thelicence that the licence holder must observe are to: Allow the Chief Psychiatrist or nominee to visit

and inspect any part of the licensed premises. Allow the Chief Psychiatrist or nominee to

inspect and make copies of any documents keptat the premises relating to the regulation and

performance of ECT. Provide the Chief Psychiatrist or nominee with

any reasonable assistance in the performance ofany duties or functions relating to the regulationand performance of ECT.

Cancelling a Licence [section 76(2)]The Chief Psychiatrist may cancel a licence ifsatisfied that: There has been a breach of any of the terms or

conditions attached to the licence.or An offence under section 73 of the Mental Health

Act (relating to the requirement to obtaininformed consent) has been committed.

or The premises are no longer suitable.or Equipment on the premises does not comply

with the prescribed standards and conditions.or

An unqualified or insufficiently qualified personhas been performing ECT on the premises.

Cancellation must be in writing and will give

reasons. As a general principle, consultation withthe licence holder will occur before a licence iscancelled. Other options such as imposing a specificcondition or limitation will be considered.

In accordance with section 79 of the Mental HealthAct, any person who disagrees with any decision ofthe Chief Psychiatrist may apply to the VictorianCivil and Administrative Tribunal for a review ofthe decision.

Renewal of Licence [section 77]The Mental Health Act places the onus on the holderof a licence to apply to the Secretary to theDepartment of Human Services for the renewal of alicence. To assist licence holders, a notice of renewalwill be sent to the licence holder about two months before the licence expires.

An application for renewal must be made in theform of Schedule 19 Application for Renewal of anECT Licence(see appendix 4). Enclosed with theapplication must be the prescribed application feewhich is an administration fee and will not berefunded if the licence is not renewed.

The Chief Psychiatrist must renew the licence unlessany of the grounds for cancelling a licence in section76 of the Mental Health Act apply.

Renewal Procedures

On receipt of the application for renewal and theprescribed fee, the procedure for renewal will beimplemented. This parallels the procedure formaking a new licence. A service will be inspectedand a report will be prepared in accordance with theprocedures set out in the earlier part of theseguidelines. However, the Chief Psychiatrist mayrenew a licence without an inspection of premises ifsatisfied that the relevant criteria have been met.

Licence Approval

The Chief Psychiatrist will determine the application based on the key licensing criteria. The renewedlicence is issued in the form of Schedule 18 Licence

Authorising Performance of ECT (see appendix 3).

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Licence Not Approved

Where an application for renewal is not approved,the Chief Psychiatrist will notify the applicant inwriting and enclose a statement of reasons.

Amendment of Licence [section 78]The Chief Psychiatrist may amend a licence byrevoking or varying any of the conditions or byinserting a new condition or conditions.

The holder of a licence may also apply to theSecretary for the licence to be amended in the form

of Schedule 20 Application for Amendment of anElectroconvulsive Therapy Licence(see appendix 5).There is no fee to have a licence amended.

An amendment will be considered in accordancewith the key licensing criteria. An inspection of thepremises may be necessary at the discretion of theChief Psychiatrist. If an amendment is made, a newlicence in the form of Schedule 18 Licence Authorising Performance of ECT , incorporating theamendment(s), will be prepared.

If an application for amendment is not approved,the Chief Psychiatrist will notify the applicant inwriting and enclose a statement of reasons.

Review of Decisions [section 79]Fundamental to the application of these guidelinesare the principles of communication andcooperation. Any person who feels aggrieved aboutany decision is encouraged to resolve the problem by communicating with the Chief Psychiatrist. In

accordance with section 79 of the Mental Health Act,any person who disagrees with any decision of theChief Psychiatrist may apply to the Victorian Civiland Administrative Tribunal for a review of thedecision.

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Part CResources and Equipment

Building Design

Section 75(5)(b) of the Mental Health Act requiresthat the Secretary to the Department of HumanServices consider the suitability of the premises atwhich ECT is to be performed before issuing alicence. The Chief Psychiatrist or a nominee willinspect the premises to determine the suitability.

Licences may be issued for dedicated ECT suites,theatre suites or multi-purpose treatment suites.

Dedicated ECT Suite

A dedicated ECT suite requires three separaterooms: a waiting room, a treatment room and arecovery room. A fourth room or area, to serve as arecovery lounge where food and beverages areprovided, is desirable, particularly at services whichprovide ECT as a day procedure.

All rooms will be linked internally by doors andeach room will preferably have a door opening ontoa corridor. Tipping trolleys, not beds, must be usedin both the treatment and recovery rooms. Internal

and external doorways must be wide enough toallow trolleys to pass through.

All rooms should be of sufficient size toaccommodate the rate and number of patientstreated per session at the licensed premises. As ageneral guide, the minimum space required for eachroom is: Waiting Room.......................12m 2

Treatment Room...................18m 2

Recovery Room....................12m 2

Recovery Lounge.................12m 2

In services where the number of patients receivingECT is small, the requirement for a separate waitingroom may be waived. Services may consult with theChief Psychiatrist to determine specificrequirements.

The treatment room should contain a stainless steelsink and drainer and scrub-up basin. A set-up benchand cupboards for the storage of sterile supplies,

linen, instruments and equipment should also beprovided in or adjacent to the treatment room.

The treatment room must have provision for a

separate, lockable but accessible area for the storageand preparation of medication, including theemergency trolley. Adequate reserves of oxygenmust be available in both the treatment andrecovery rooms. An emergency cylinder supply ofoxygen must be available.

The treatment room and the recovery room musthave appropriate lighting for the clinical observationof patients. Emergency lighting must be available.

There must be a telephone/intercom tocommunicate with persons outside the suite in an

emergency.There must be access to adequate toilet facilities.

While the treatment room will generally only beused for the performance of ECT, to ensure a betteruse of resources the other rooms may at other times be used for other purposes. For example, thewaiting room may be used as an interview roomand the recovery area as a group room.

Multi-Purpose Treatment/Recovery Suite

ECT may be performed in a multi-purposetreatment/recovery suite, for example, a dayprocedures unit. The suite should preferably bewithin reasonable proximity to the psychiatric unitto ensure access to appropriate equipment and staffexpertise.

The requirements for a multi-purposetreatment/recovery suite are the same as for adedicated suite.

Operating SuiteECT may be performed in an operating theatre suiteif the patients privacy, confidentiality and safetyneeds can be assured and ECT is scheduled atregular and appropriate times that meet patientsneeds. The use of an operating suite may beindicated when the anaesthetist believes that apatient with a serious medical condition requiresimmediate access to superior resuscitation andemergency treatment options.

Services which have operating suites and whichmay wish to have them licensed should submit floorplans of these suites to be included in the licence.

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Checking, Cleaning, Infection Control andServicing Equipment

Regular checking, cleaning, sterilising, andhousekeeping routines for the care of equipmentshould be established. A documented infectioncontrol policy must be implemented and subjectedto periodic evaluation. Emergency resuscitationequipment should be tested and checked weekly.

Complete and comprehensive registers must be keptof: Six-monthly maintenance and servicing checks of

anaesthetic and emergency equipment. Regular monthly checks and replacement of out-of-date anaesthetic and emergency drugs.

A review of anaesthetic and emergency drugs keptin the ECT suite should be conducted by a SpecialistAnaesthetist every 12 months.

ECT machines must be kept in working order and be serviced at least once a year. The ECT electrodesshould be visually checked weekly.

A service register must be kept. The register mustinclude details of the date, the name of the servicecompany and technician, the result of the check andany action taken.

StaffingThe significant advances in technology and theknowledge about ECT over recent years have madeit a very effective treatment for some forms ofmental illness. It is therefore imperative that this

knowledge informs the practice of ECT to ensurethat it is delivered in a safe and effective manner.The Chief Psychiatrist therefore requires that eachlicensed premises appoint a qualified psychiatrist asClinical Director (ECT) and a senior registered nurseas Senior Clinical Nurse (ECT). This will facilitateimprovements in ECT practice and patientoutcomes.

Clinical Director ECT

This person will be thoroughly familiar with current

scientific literature on ECT and will have completedan approved ECT course. The Clinical Director ECTwill have overall clinical responsibility for the ECTsuite including:

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Privacy

Patients should be protected from unnecessaryobservation by other people while ECT is beingperformed and during the recovery period. Thelayout of the recovery room should facilitateprivacy; in particular, to prevent observation ofpatients by other patients.

Internal partitions or curtains in the recovery roommust not, however, prevent observation andsupervision of the recovery of patients.

EquipmentSection 75(5)(c) of the Mental Health Act requiresthat the Secretary to the Department of HumanServices, in considering an application for a licence,must consider whether the equipment to be used inthe performance of ECT complies with theprescribed standards and conditions.

Equipment means all equipment used during theperformance of and recovery from ECT, however,primary emphasis is placed on the following:

The ECT machine. Anaesthetics equipment. Resuscitation equipment. Emergency drug supplies.

ECT Machine

The ECT machine must: Be listed with the Therapeutic Goods

Administration. Provide electroencephalogram (EEG) monitoring

and recording of the duration of the seizure. Permit a charge of up to 1000 mC to be given. Be able to give stimulus dose titrated ECT.

Anaesthetic and Resuscitation Equipment

Anaesthetics equipment, resuscitation equipmentand emergency drug supplies must meet thestandards articulated in ANZCAs policy documentRecommended Minimum Facilities for Safe AnaestheticPractice for Electroconvulsive Therapy (ECT)(revised1994).

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Development, implementation and evaluation ofpolicies, procedures and standards in relation tothe performance of ECT.

Training and privileging medical staff whoprescribe and/or administer ECT. To maintain anappropriate level of skill in the performance ofECT, the Clinical Director (ECT) might considerlimiting the number of practitioners accordedprivileges in ECT at the licensed premises. Thiswill enable these practitioners to have regularexperience and develop expertise.

Maintaining a register of medical staff privilegedto perform ECT at the licensed premises. Theregister should keep a record of the number oftreatments performed by individual practitionersin each year.

Ensuring all psychiatrists, psychiatric registrarsand medical officers are adequately supervised inthe administration of ECT.

Conducting quality improvement programs.

ECT Administration

Two registered medical practitioners must be

present at all times when ECT is administered.One registered medical practitioner must be trainedand experienced in the administration of ECT. Thismay be achieved either by the practitioner attendingan approved ECT course or by being personallytrained by a medical practitioner who has done so.The practitioner must be familiar with theindications and side effects of the treatment, theprocedures and equipment required and anaestheticemergencies and resuscitation procedures. The

practitioner must maintain their level of skills in theadministration of ECT. To demonstrate this it isexpected that practitioners will be administering atleast 25 treatments per year. The practitioner mustalso be proficient in cardiopulmonary resuscitationtechniques.

The other registered medical practitioner must be aSpecialist Anaesthetist or, in the absence of aSpecialist Anaesthetist, a registered medicalpractitioner accorded privileges in anaesthesia at the

licensed premises in accordance with the ANZCAspolicy document Privileges in Anaesthesia.

The anaesthetist should have training and

experience in anaesthesia for ECT. Whereanaesthetic registrars are administering theanaesthetic, adequate supervision and support must be provided by a specialist anaesthetist.

Senior Clinical Nurse ECT

This person will be thoroughly familiar with currentscientific literature on ECT and will have completedan approved ECT course and a cardiopulmonaryresuscitation course. The Senior Clinical Nurse(ECT) will be responsible for the management of theECT suite including:

Development, implementation and evaluation ofnursing standards, policy, practices andprocedures for ECT.

Coordination and training of nursing staffincluding student nurse training.

Liaison with anaesthetic services. Ensuring that appropriate staffing, equipment

and supplies are available. Establishing regular checking, cleaning,

sterilising and housekeeping routines for the careof equipment.

Ensuring that the recording and reportingrequirements for ECT are met.

Quality improvement activities. Maintenance of a CPR Training Register.

Nursing Staff

All nursing staff must have the necessary trainingand experience to enable them to perform thevarious roles required in the ECT suite. Thereshould be a core team of nurses who work in theECT suite on a regular basis for the purpose ofcontinuity. One registered nurse with recent trainingin providing assistance to an anaesthetist is to beresponsible for coordinating the delivery of nursingcare at each session.

Nursing staff numbers required to ensure adequatestandards of practice will depend on the number ofpatients to receive treatment. As a minimumrequirement there must be : A nurse, on Division 1, 2 or 3 of the register of

nurses kept under Part 2 of the Nurses Act 1993,in constant attendance on patients in the waitingarea. This nurse will provide appropriatephysical and psychological preparation of

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patients for ECT and ensure that alldocumentation is in order. It may also be helpfulfor a patients individual case manager to bepresent throughout the procedure.

A registered nurse competent in resuscitationmethods available wholly and exclusively toassist the anaesthetist in accordance withANZCAs policy document Minimum AssistanceRequired for the Safe Conduct of Anaesthesia, exceptfor the Course of Instruction requirementsstated in 3.2 of the document.

A registered nurse with recent training inresuscitation and CPR procedures must be inconstant attendance on patients in the recoveryarea after the administration of ECT.

Training and EducationPolicies and Procedures

The Clinical Director (ECT) must ensure that thereare written policies, procedures and standards forthe performance of ECT at the premises. Thepolicies must be implemented and subjected to

periodic evaluation. All clinical staff should haveaccess to and be familiar with the policies andprocedures.

Training Programs

All medical staff involved in the administration ofECT are expected to have theoretical and practicaltraining before administering ECT. The ClinicalDirector (ECT) is responsible for the ongoing clinicalsupervision of medical staff administering ECT. TheClinical Director should provide or make provision

for an educational program for all staff concerned inthe administration of ECT. Training programs should be regularly updated to provide the best possibletreatment in the light of current research evidenceand new technologies and techniques. ECT referencematerial should be available and regularly updated.

A record of medical and nursing staff trained in thepractice of ECT should be maintained and regularlyupdated as part of a quality improvement program.

ECT MachineThe Clinical Director (ECT) must have completed anapproved course in the use of the ECT machine.This expertise may be taught to other medical staff

at the licensed premises who prescribe and/oradminister ECT. The Senior Clinical Nurse (ECT)must also complete the course and may train othernurses. However, medical and nursing staff who aretrained by persons who have completed anapproved course cannot in turn train others.

CPR Training

All nursing staff must have undertaken an approvedcourse in cardiopulmonary resuscitation techniquesand must update their training at 12-monthlyintervals. A register of training must be maintained.All medical staff must also update theircardiopulmonary training annually.

Emergency Plan

Plans must exist for the transfer of a patient in anemergency from the ECT suite under adequatemedical supervision. All clinical staff should befamiliar with the plan.

Communication

All staff associated with the treatment suite should

be trained and supervised to communicate withpatients and families in a sensitive manner. Somepatients and their families have found ECT to be adistressing experience or have a sense of shame because of the social stigma they associate with ECT.For these reasons, special skill and care is needed intalking to patients and their families about ECT.

Training in communication is particularly importantfor staff working in multi-purpose treatment suitesand operating suites who may not have regular

experience in the administration of ECT.In providing information to family and carers, issuesof confidentiality must always be considered. Thelicence holder should ensure that training andprocedures are in place to enable staff to respondappropriately to requests for information aboutpatients. If staff have queries about their duty tomaintain the confidentiality of a patient, the licenceholder should obtain independent legal advice.

Quality ImprovementEach service must include various aspects of theiruse of ECT in their ongoing quality improvementprogram.

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The licence holder must provide procedures andguidelines for responding to complaints aboutstandards of treatment and care. Information must beavailable to patients and their families and advocatesabout the procedures. The mechanisms must be readilyaccessible, easily understood and the response timely.

Record KeepingECT Register

Schedule 21 Electroconvulsive Therapy Return (seeappendix 6) sets out the minimum informationwhich must be recorded for statutory purposes andmay be used as the ECT register. This includes: The date, name, UR number, sex and age of each

patient. The names of the doctors giving the anaesthetic

and the ECT. Whether the treatment was bilateral or unilateral. The nature of the consent given for treatment. Country of birth. Principal diagnostic code relating to treatment.

Individual services should determine otherinformation which is required for local purposes, forexample, quality improvement programs.

A designated person, preferably the Senior ClinicalNurse (ECT), is to have management responsibilityfor ensuring the register is maintained.

Reporting

The Authorised Psychiatrist or occupier of licensedpremises must send the Chief Psychiatrist a reportof ECT performed at the licensed premises as soonas practicable after the end of each month.

The report must contain the information asdescribed in Schedule 21 Electroconvulsive TherapyReturn . If no ECT has been performed in thepreceding month a nil return is still required. TheChief Psychiatrist reviews and compiles these datato: Monitor trends in the use of ECT. Inform the development of recommendations

and guidelines for the improvement of services. Identify potential problems and/or areas forimprovement in clinical service delivery atspecific services.

Clinical Record

Various aspects of the performance of ECT should be recorded in the patients clinical file by theresponsible clinical staff.

Information which must be documented in theclinical file for each ECT given includes: Doses of anaesthetic and relaxant drugs given. The stimulus level and the duration of seizure. The complete print-out from the EEG.

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Part DClinical Practice Guidelines

Decision to Prescribe ECT

The decision to recommend ECT should be based ona thorough physical and psychological evaluation ofthe individual patient, taking into account theillness, the past history of illness and treatmentresponse, the degree of suffering of the patient, thepreferences of the patient and their family orguardian and the prognosis if ECT is withheld.

The decision that ECT be prescribed for a particularpatient is the responsibility of a psychiatrist whoshould record the reasons for this decision in the

case notes. ECT may not be prescribed by aregistered medical practitioner who is not aqualified psychiatrist.

LegislationThe objects of the Mental Health Act require thatpeople with a mental disorder are to be given the best possible care and treatment appropriate to theirneeds in the least possible restrictive environmentand least possible intrusive manner. The objects alsoseek to protect the rights, privacy, dignity and self-respect of people receiving care and treatment for amental disorder.

Section 6A of the Mental Health Act establishescertain principles which are to apply to theprovision of treatment and care to people with amental disorder. These include the requirement thatpeople with a mental disorder should be providedwith timely and high quality treatment and thatthey should have comprehensive information abouttheir mental disorder, proposed and alternativetreatments and services available to meet theirneeds.

Preparation for ECTCommunication

While clinicians see ECT as a valued and effectivetreatment for some forms of mental illness, there aresome patients and/or their carers who have doubtsabout whether it is a humane form of treatment.Some patients and their families experience a senseof shame because of the social stigma they associatewith ECT. For these reasons, special care is neededin talking to patients and their families about ECT.

Frequent consultation between patient, family anddoctor is essential before and during a course ofECT. It is recommended that a printed informationsheet be available which describes the nature of thetreatment, the procedures involved and the expected benefits, discomforts and risks. This ensures that asmuch as possible the patient and family understandthe nature of the treatment and its likely effects sothat any personal distress associated with thetreatment is minimised. For example, some patientswho are severely ill may have difficulty recallingpre-ECT consultations.

Medical AssessmentAn appropriate medical history and physicalexamination is necessary. Any physical illness that islikely to compromise the procedure should beinvestigated and an appropriate medical history andphysical examination must be conducted prior totreatment.

A decision to proceed with ECT will always dependon consideration of the risks versus the benefits.Liaison between psychiatric and anaesthetic staff iscritical and it may be necessary to arrange furtherinvestigations before treatment. Consideration may be given to administering ECT in a theatre or dayprocedure suite licensed to perform ECT wheremore sophisticated medical treatment andresuscitation facilities may be available.

Medication Review

All medication that either raises or lowers theseizure threshold should be reviewed prior to ECT

being administered.A Course of ECT

A course of ECT is defined in section 72(2) of theMental Health Act as a course of electroconvulsivetherapy consisting of not more than six treatmentsgiven over a period with not more than seven dayselapsing between any two treatments. If more thanseven days elapse between any two treatments andfurther treatment is recommended then a newconsent must be obtained for either singletreatments or a course of up to six treatments. Inpractice the average number of treatments in anepisode of care is eight. One course may

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immediately follow another provided the variousclinical and consent provisions are met.

Patient Rights Brochure

Every person, whether voluntary or involuntary forwhom ECT is proposed must be given a copy of theprescribed brochure Electroconvulsive TherapyAboutYour Rights. This applies whether the person is in aprivate or public mental health service. Basic rightslisted in the brochure, which patients should know,include the right: To obtain legal and medical advice (including a

second psychiatric opinion). To be represented by a person of their choosing before giving consent.

To have someone of their choice with them whendiscussing ECT with their psychiatrist or doctor.

It is the responsibility of the Authorised Psychiatristin an approved mental health service and the licenceholder in other services (private hospitals) to ensurethat patients are advised about their rights.

Informed ConsentA person is able to give informed consent to ECT ifthey are able to consent to the treatment in writingafter they have been given an explanation andunderstand the matters set out in section 53B of theMental Health Act as follows: The person has been given a clear explanation

containing sufficient information to enable themto make a balanced judgement.

The person has been given an adequatedescription of benefits, discomforts and riskswithout exaggeration or concealment.

The person has been advised of any beneficialalternative treatments.

Any relevant questions asked by the person have been answered and the answers have beenunderstood by the person.

A full disclosure has been made of any financialrelationship between the person seekinginformed consent or the registered medicalpractitioner who proposes to perform the

treatment, or both, and the service, hospital orclinic in which it is proposed to perform thetreatment.

The person on whom the treatment is to be

performed has been given the prescribed brochure Electroconvulsive TherapyAbout Your

Rights.

In addition to the brochure, the person must begiven an oral explanation of the informationcontained in the brochure. If the person appears notto understand, or to be incapable of understandingthe information contained in the brochure,arrangements must be made to convey theinformation to the person in the language, mode ofcommunication or terms which they are mostfamiliar with. The brochure is available in 12

community languages.

Documentation

If the person does provide informed consent to theperformance of ECT, the form Informed Consent toElectroconvulsive Therapy (ECT)(PSY 16) (seeappendix 7) must be completed and signed by theperson and a witness. The person may consent toone treatment or to a course of treatment which may be up to six treatments.

Right to Withdraw ConsentDespite signing a consent to one or more treatments,a person has the right to withdraw consent at anystage before or during the course of treatment.

Consent to Anaesthetic

A person who gives informed consent to havingECT is also taken to have consented to theadministration of an anaesthetic to enable the ECTto be performed.

Passive ConsentThe passively consenting patient presents a difficultclinical situation which is a matter for individualassessment. Generally, the consent can be accepted,even though the person does not believe the ECTwill work, if the person when giving consent is ableto fulfil the criteria for providing informed consentas specified in section 53B of the Mental Health Act.However, if consent is given on the basis ofdelusional thinkingfor example, the person believes that ECT might kill them, which would be just reward for some perceived transgression, thenthe person should not provide consent. In situations

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Consent by the Authorised

PsychiatristIn accordance with section 73(3) of the MentalHealth Act, if an involuntary, forensic or securitypatient is incapable of giving informed consent, theAuthorised Psychiatrist may authorise theperformance of ECT after being satisfied that: The ECT has clinical merit and is appropriate. Having regard to any benefits, discomforts or

risks the ECT should be performed. Any beneficial alternative treatments have been

considered. Unless the ECT is performed, the patient is likelyto suffer a significant deterioration in theirphysical or mental condition (section 73(3) of theMental Health Act).

It is important to note that the AuthorisedPsychiatrist may only consent for a patient who isincapable of giving consent, not a patient who isunwilling to give consent. The only exception iswhere the nature of the mental disorder is such that

the performance of the ECT is urgently needed(section 73(4) of the Mental Health Act).

Notification to Patients Guardian or Primary Carer

If the Authorised Psychiatrist proposes to authoriseECT for a patient, they must also ensure that allreasonable efforts have been made to notify thepatients guardian or primary carer of the proposedperformance of the ECT (section 73(3)(b) of theMental Health Act). Special care should be taken toensure that as much as possible the patients familyunderstand the nature of the treatment, why it isrequired and its likely benefits so that the personaldistress often associated with the treatment isminimised.

If the primary carer or guardian opposes theperformance of ECT, the Authorised Psychiatristmust wherever possible obtain a second psychiatricopinion and do everything possible to inform andrelieve the anxiety of those concerned.

In all cases the final decision to give ECT, in thesecircumstances, rests with the AuthorisedPsychiatrist.

15

like this and subject to the criteria in section 73(3) ofthe Mental Health Act, only the AuthorisedPsychiatrist can provide consent, and the patientwould need to be an involuntary patient undersection 12 of the Mental Health Act.

Consent by Other PeopleAdults

While it is good practice to involve families in thedecision to prescribe ECT, no relative, carer orguardian may consent to ECT on behalf of anotherperson. It is the patients personal capacity only thatis considered when determining whether the personcan give informed consent.

If the person cannot consent and the ECT isnecessary, then consideration should be given tomaking the person an involuntary patient and,subject to section 73 of the Mental Health Act,consent will be provided by the AuthorisedPsychiatrist.

If the person is a patient in a private hospital, the

person should be recommended for involuntaryadmission to an Approved Mental Health Serviceso that the ECT may be performed with theauthorisation of the Authorised Psychiatrist.

People under 18 Years

If a person under 18 years of age does not have theemotional or intellectual maturity to consent totreatment, and in the usual course of events consentis provided by a parent, then the parent may giveconsent to the performance of the ECT.

If the parent refuses to give consent and the ECT isnecessary, then consideration should be given tomaking the young person an involuntary patientand consent provided by the AuthorisedPsychiatrist.

If a person is under 18 years of age and wouldusually be considered able to give consent on theirown behalf, then it is that persons consent totreatment which must be considered. The usual

requirements for informed consent will then apply.

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Second Opinion

If the Authorised Psychiatrist proposes to authoriseECT for an involuntary, security or forensic patient,a second psychiatric opinion should be obtained.This opinion should be recorded in writing in thecase notes before the ECT is given. In remote areaswhere it may not be possible or practical to have asecond psychiatrist examine the patient, otheroptions including telepsychiatry or telephoneconsultation should be considered.

Documentation

If the Authorised Psychiatrist authorises the ECT on behalf of the patient, the Authorised Psychiatristmust complete and sign the form Authority toPerform Electroconvulsive Therapy (ECT) WhereInformed Consent Not Obtained (PSY 17) (seeappendix 8).

Urgently Needed ECTInformed consent is not required where ECT isurgently needed because of the nature of thepersons mental illness (section 73(4) of the MentalHealth Act). The Authorised Psychiatrist willconsent on behalf of the person. While the usualrequirements for substituted consent contained insection 73(3) of the Mental Health Act do not apply because of the urgency of the situation, they should be met wherever possible.

Penalties for Performing ECT withoutInformed ConsentA registered medical practitioner who performs ECTwithout informed consent is guilty of professionalmisconduct unless the medical practitioner cansatisfy the Medical Practitioners Board of Victoriathat there were valid reasons for not obtainingconsent.

The exceptions are: The person is either an involuntary, security or

forensic patient and incapable of giving informedconsentin which case the Authorised

Psychiatrist may consent on behalf of the personif the relevant criteria are met (section 73(3) of theMental Health Act).

or

ECT is urgently needed (section 73(4) of theMental Health Act).

Further, a person (including a licence holder) whopermits ECT to be performed without informedconsent is guilty of an offence against the MentalHealth Act.

The Secretary may cancel a licence if an offenceunder section 73 has been committed on the licensedpremises.

Confidentiality

Section 120A of the Mental Health Act prohibits anystaff member of a psychiatric service from providinginformation about people who are or have been inreceipt of psychiatric services. A psychiatric serviceincludes any premises licensed to perform ECT.However, section 120A(3) provides certainexceptions to these strict requirements ofconfidentiality. These include the giving ofinformation: With the prior consent of the person. In general terms. To a guardian, family member or primary carer, if

the information is reasonably required for theongoing care of the person, and the guardian,family member or primary carer will be activelyinvolved in providing that care.

In connection with the further treatment of theperson.

While the patients family should be involved in thedecision to perform ECT and discussions during acourse of ECT, clinical staff should ensureconfidentiality requirements are met.

Prescription of ECTBilateral versus Unilateral ECT

This is a clinical decision guided on an individual,case-management basis. There is a continuingdebate about the merits of bilateral versus unilateralECT. No clear recommendations can be made,however, current practice with stimulus dose

titration favours unilateral ECT.

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Frequency of Treatment

Both unilateral and bilateral ECT should be given ata rate of two or three treatments per week. Twice-weekly ECT is likely to reduce the occurrence oftransient cognitive side effects. Increasing thefrequency of treatment beyond three times weeklymay increase the degree of cognitive impairmentand does not increase the speed of clinical response.

Number of Treatments

The number of treatments to be prescribed should be determined by clinical need on a case by case

basis and reviewed on a continuing basis dependingon the clinical response. Single treatments may beprescribed, however, the Mental Health Act permitsa course of up to six treatments may be prescribed ata time. One course may immediately follow anotherif clinically indicated and the necessary consent isobtained. On average, patients with a diagnosis ofdepression usually require 6 to 12 treatments andthe psychotic disorders, such as schizoaffectivedisorders usually require 1020.

Administration of AnaestheticInduction agents and anaesthetic agents will bedetermined by the specialist anaesthetist ifnecessary in conjunction with the psychiatrist.

Documentation

A record must be kept of anaesthetic and relaxantagents given and of any problems and complicationswhich occur.

Oxygen

Pre-stimulus ventilation with oxygen will reduce therisk of cardiovascular complications and may alsoreduce adverse effects. Hyperventilation withoxygen is a useful technique which augmentsseizure activity.

Stimulus Parameters and SeizuresIt is important to test for adequate contact betweenthe electrodes and the scalp prior to each treatment.The self-test function on the ECT machine should beused for this.

Seizure Threshold

Seizure threshold depends on the type of stimulusused and on other factors including age, sex,concomitant medication and recent ECT. Clinicalstaff are advised to keep abreast of the currentliterature and training on the topic. At present thereare three methods to determine the adequate chargeor dose for an individual patient. They are: Dose Titrationthis is the most accurate method

and is therefore preferred. The clinician should be aware that the higher the stimulus the greaterthe likelihood of transient cognitive disturbance.

Age Dosing Half Age Dosing

Determining an Adequate Seizure

The minimum requirements for a therapeuticseizure have not been universally agreed upon.However, current literature indicates that adequateseizures are determined by a compilation of: The clinical response. An EEG seizure duration>25 seconds.

A motor seizure>20 seconds. Good post-ictal suppression>87 per cent. The quality and amplitude of the EEG recording.

Review of the Stimulus Dose

The dose should be reviewed after each treatmenton the basis of the patients clinical response. Anincrease in dose may be indicated: If the treatment response is poor.or If generalised seizures of sufficient duration, 25

seconds on EEG, are not achieved.or When a reduction in the length of the seizure

occurs. Seizure threshold rises by an average of80 per cent during a course of treatment (range25200 per cent), thus seizure duration shortens.

A decrease in dose may be indicated: If the patient is experiencing adverse cognitive

side effects. In instances like this it may be beneficial to consider less frequent treatments, forexample, twice weekly.

or Where prolonged seizures occur.

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Monitoring Seizure Activity

Licensing in Victoria requires that the ECT machineused for the procedure must be capable of providingEEG monitoring of the seizure. This is currently bestpractice in determining the adequacy of the type andduration of the seizure. Further, it is recommendedthat the factors outlined in Determining anAdequate Seizure are monitored, for instance: An adequate seizure would generally be a

bilateral muscular (tonic/clonic) seizure lasting20 seconds or more, and/or 25 seconds or moreon an EEG recording.

The duration of cerebral seizure activity mayexceed that of the peripheral manifestations ofthe seizure (muscle twitching) by 1015 seconds.

Prolonged seizures, lasting longer than 120 seconds,should be terminated. Options include a further bolus of general anaesthetic used or midazolam. Theanaesthetist should be advised after 90 seconds offitting.

Restimulation

Patients having inadequate seizures, for example,unilateral ECT, may be restimulated after 90 secondswith increased charges provided satisfactoryanaesthesia and muscle relaxation are maintained.A maximum of 3 stimuli in the one session isadvised as marked amnesia may result.

RecoveryWhile the patient is recovering from the anaesthetic,ensure that there is an adequate airway. Monitor the

patients pulse and blood pressure until stable.There should be continuous nursing presence andobservation until the patient is fully orientated.

Memory impairment should be monitored andtreatment reassessed if cognitive impairment is aproblem (consider the stimulus, electrodeplacement, frequency, and so on).

There may be a small minority of patients who become acutely agitated immediately after emergingfrom the general anaesthetic. Immediate actionshould be taken by the intravenous administrationof additional anaesthetic agent or midazolam.

Monitoring Clinical Response

Clinical response should be recorded at least weeklywith respect to symptomatic response and adverseeffects. If a patients clinical condition is failing toimprove, then all aspects of the ECT treatment must be reconsidered.

Two-way communication between the ECT staff andthe treating clinical team is essential. This willdepend on local circumstances, but clear local policyand procedures should be developed so that: Before each treatment, the ECT staff know about :

The charge required to achieve the previoussatisfactory seizure.

The clinical response so far. Changes in physical status. Changes in medication. Changes in legal status. Cognitive and other side effects the most com-

mon being headache, which may be managed by the prescription of a suitable analgesicagent such as paracetamol with codeine.

The treating clinical team knows the stimuliused, the seizure parameters and any problemsafter each treatment.

PrivacyECT must at all times be performed in such a wayas to respect the privacy, dignity and confidentialityof the patient. Under no circumstances must thenature of the treatment be disclosed to patients orothers at shared facilities, such as multi-purposetreatment suites.

The patients consent is required for nursing andmedical students or clinical staff to be presentexclusively for the purpose of training during theadministration of ECT.

ECT on an Outpatient BasisClinical Issues

Prescription of ECT on an outpatient basis is aclinical decision. Matters which must be considered

when selecting a patient for outpatient ECT include: That the nature and seriousness of the patients

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present a contra-indication to management on anoutpatient basis. The treating psychiatrist isresponsible for ensuring the continuingsuitability of the patient for such treatment.

That the anticipated risks associated with theECT course are detectable and manageable bothduring the ECT session and in an outpatientsetting.

The same indications, contra-indications, consentrequirements and pre-ECT evaluations apply.

The use of outpatient ECT poses some specialpractical problems which need to be considered

and resolved. For example: The patient must be willing and able to

comply with the behavioural limitations thatare necessary prior to and following ECT, suchas fasting (see sample document AdditionalInformation for Patients Receiving ECT asOutpatients ; appendix 1).

The patient must have a responsible adult asescort to and from the ECT suite and to staywith them on returning home for 24 hours oruntil full recovery.

The patient must have access to a telephone athome and must be given a contact name andnumber in the event of any problems.

Procedural Matters

The case manager or consultant psychiatrist mustensure that the patients clinical file is in the ECTsuite prior to the treatment being administered.

Food and drink must be made available tooutpatients recovering from ECT while awaitingpermission to leave. A private area must beprovided which also allows appropriate monitoringof the persons condition.

The Clinical Director (ECT), Specialist Anaesthetistor Senior Clinical Nurse (ECT) will make thedecision about when the patient is able to leave theECT suite. It is recommended that the patientremains under observation for a minimum of fourhours post-ECT.

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Part ECriteria For Licensing ECT Premises

21

The following information establishes theDepartments criteria by which services will beassessed for an ECT licence based on the fourcriteria specified in section 75(5) of the MentalHealth Act. These criteria should be seen as settingthe minimum acceptable standard for premises atwhich ECT is to be performed and are known as theKey Licensing Criteria. These criteria are madeavailable to licence holders or applicants to assist inunderstanding the licensing process and to ensurethe procedures are open and accountable.

Suitability of the Applicant to Hold aLicence [section 75(5)(a)]The requirements are: Private Hospitals: A private hospital must be

registered in accordance with Division 3 of Part 4of the Health Services Act 1988 and the registrationmust specify that psychiatric health services may be carried out on the premises of the privatehospital. Psychiatric health services are definedin Schedule 8Health Services (Private Hospitals

and Day Procedure Centre) Regulations 1991. Public, Denominational and Metropolitan Hospitals:A public, denominational or metropolitanhospital must be listed in the schedules to theHealth Services Act.

Approved Mental Health Services: An ApprovedMental Health Service is a service proclaimed bythe Governor in Council and published in theGovernment Gazette to provide treatment topatients. A Public, Denominational orMetropolitan Hospital may be an Approved

Mental Health Service.

The Suitability of the Premises[section 75(5)(b)]Suitability of the premises will be assessed againstthe following principles: The premises facilitate the safe administration of

ECT. Privacy needs of patients receiving ECT are

maximised. ECT is able to be scheduled at a time that meets

patient care needs.

All areas/suites where ECT may be performed areto be inspected. This includes operating suites inservices which use them. The minimum requirementfor a dedicated ECT Suite is three rooms: Waiting room, with access to toilet facilities. Treatment room, including scrub-up basin/sink,

oxygen supply, emergency oxygen supply,adequate lighting, emergency lighting andtelephone/intercom.

Recovery room of sufficient size to accommodaterate and number of patients treated per session,including scrub-up basin/sink, oxygen supply,

emergency oxygen supply, adequate lighting,emergency lighting and telephone/intercom.

Suitability of Equipment to be Used in the Performance of ECT [75(5)(c)]The minimum requirements are: ECT machine must be listed with the Therapeutic

Goods Administration, must provide EEGmonitoring and recording of the duration of theseizure and permit a charge of up to 1000 mC to

be given, and be capable of delivering stimulusdose titration.

Documented servicing of the ECT machine mustoccur at least once a year.

Anaesthetics equipment, resuscitation equipmentand emergency drug supplies to be in accordancewith ANZCAs policy document Recommended Minimum Facilities for Safe Anaesthetic Practice forElectroconvulsive Therapy (ECT).

Existence of demonstrated systems for themaintenance and servicing of anaesthetic andresuscitation equipment.

Existence of demonstrated systems for regularreplacement of out-of-date and missinganaesthetic and emergency drugs.

Existence of demonstrated infection controlpolicy.

Annual review of anaesthetic and emergencydrugs kept in the ECT suite by a specialistanaesthetist.

Designated person, such as the Senior Clinical

Nurse (ECT), is to be responsible for these duties.

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Suitability of Qualifications of

Persons Performing ECT [75(5)(d)]The minimum requirements are: Each licensed premises must have a qualified

psychiatrist and a registered nurse with training,experience and an interest in ECT, designated asClinical Director (ECT) and Senior Clinical Nurse(ECT).

Only a registered medical practitioner ispermitted to perform ECT. The practitioner musthave demonstrated theoretical and practical

training in the performance of ECT or be directlysupervised by a practitioner with experience intraining medical staff in the performance of ECT.

A register of practitioners and theirqualifications, with privileges in ECT, is to bemaintained by the Clinical Director (ECT).

Anaesthesia used for performing ECT must beadministered by a Specialist Anaesthetist or, inthe absence of a Specialist Anaesthetist, aregistered medical practitioner accordedprivileges in anaesthesia at the licensed premisesin accordance with ANZCAs policy documentPrivileges in Anaesthesia.

A registered nurse with recent training inassisting an anaesthetist is to have managementresponsibility for coordinating the delivery ofnursing care at each ECT session.

Nursing staff numbers at each session are to be inaccordance with these guidelines.

Documented training programs should be inaccordance with these guidelines, and include: Clinical Director (ECT) and Senior Clinical

Nurse (ECT) must have completed anapproved ECT administration course.

Nursing and medical staff must undergo CPRtraining every 12 months.

Psychiatric and medical emergency plan. Each service must include various aspects of

their use of ECT in their ongoing qualityimprovement program.

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Part FAppendices

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Appendix 1: Sample Information Sheet

This information sheet is a sample only. Services that wish to provide additional information for patientsreceiving ECT as an outpatient may use this as a model to develop information brochures that best meetparticular service needs.

Additional Information for Patients Receiving ECT as Outpatients

This information should be read along with your patient information booklet.If you are having ECT as an outpatient, there are some rules which must be followed because you will

be given a brief anaesthetic by injection into a vein in your arm.1. Your psychiatrist has prescribed ECT to treat your condition and has recommended that you

receive this treatment on an outpatient basis. They would also have arranged for you to be seen by

an anaesthetist to see if you are medically fit to receive a brief general anaesthetic. Once theanaesthetist has declared that you are well enough for a general anaesthetic, you will be given aday to come in for the treatment.

2. ECT will be administered --------- times a week on the following morning/s --------------------------------------------- commencing on ---------------------------------------- until -----------.

3. You must not have anything to eat or drink from midnight on the day before each treatment. Ifyou are taking tablets in the morning dont take them on the morning of your treatment; bringthem with you and give them to the nurse who will give them to you with a drink after yourtreatment.

4. On the day of the ECT treatment you will need to :

Dress in loose clothing. Ensure that your hair is clean and dry. Remove any nail polish. Ensure that your bowel and bladder are empty before the treatment.5. If you develop any infection such as a severe cold during the time that you are having ECT this

may mean that you are not able to have an anaesthetic while your cold is bad. If this happens, youshould contact your doctor or case manager who will advise you what to do.

6. You must not drive a car on the day on which you have treatment or travel unaccompanied. Afamily member or friend should bring you for treatment and take you home.

7. You should not be alone when you return home for 24 hours or until you have fully recovered fromthe anaesthetic; and you should have a telephone available in case you have problems and need tocontact the hospital.

ECT is usually not an unpleasant treatment. You will wake up within a few minutes of the treatmentand not remember anything of it. You may feel a little disorientated initially on waking and have aslight fuzzy feeling or headache. However, these feelings will soon pass. You may also have difficultyremembering events which occurred around the treatment time, but this almost always clears up veryquickly.When you have woken sufficiently the staff will assist you from the trolley bed and give yousomething to eat and drink.The ECT generally does not have an immediate effect on your mood so dont be worried if you do notfeel better after the first few treatments. If you wish to discuss your progress or you have anyquestions about the ECT please feel free to discuss this with the nursing staff or your doctor.

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Appendix 2: Schedule 17Application for Licence to Permit the Performanceof Electroconvulsive Therapy

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SCHEDULE 17

Regulation 9Mental Health Act 1986 (section 75)

Mental Health Regulations 1998

APPLICATION FOR LICENCE TO PERMIT THEPERFORMANCE OF ELECTROCONVULSIVE THERAPY

To the Secretary,

..............................................................................................................................................................................................(Name of Occupier eg. Body Corporate, Partnership)

is the occupier of premises known as ............................................................................................................................

..............................................................................................................................................................................................(Name of premises eg. Private Hospital, Approved Mental Health Service, Public Hospital)

located at ............................................................................................................................................................................

..............................................................................................................................................................................................(Address of premises)

I apply for a licence to perform electroconvulsive therapy at the above premises.

In attachment A, I have enclosed a plan of the above premises indicating all areas/suites where electrocon-vulsive therapy is to be performed.

Signature:....................................................................................

......................................................................................................GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)of person authorised to sign for and on behalf of the occupier.

Title: ............................................................................................

Date: ............................................................................................

Attachment A

A plan of the premises indicating all areas/suites where electroconvulsive therapy is to be performed.

S A M P L E O N L Y

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SCHEDULE 18

Regulation 10Mental Health Act 1986 (section 76)


LICENCE AUTHORISING PERFORMANCE OFELECTROCONVULSIVE THERAPY

Licence Number

..............................................................................................................................................................................................(Name of Occupier)



located at ............................................................................................................................................................................


This licence authorises the performance of electroconvulsive therapy at the above premises in theareas/suites shown in Attachment A.

This licence is in force from to , and is subject to the terms andconditions contained in Attachment B.

Signature: ................................................................................

Title: ........................................................................................(Secretary or delegate)

Date: ........................................................................................

Attachment A

A plan of the premises where electroconvulsive therapy is to be performed.

Attachment B

The terms and conditions to which the licence is subject.

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Appendix 3: Schedule 18Licence Authorising Performance ofElectroconvulsive Therapy

S A M P L E O N L Y

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SCHEDULE 19

Regulation 11Mental Health Act 1986 (section 77 (2))


APPLICATION FOR RENEWAL OF ANELECTROCONVULSIVE THERAPY LICENCE

Licence Number

To the Secretary,




located at ............................................................................................................................................................................


The abovenamed premises are licensed to permit the performance of electroconvulsive therapy.

The licence expires on ......................................................................................................................................................

I apply for the renewal of this licence on the same terms and conditions.

Signature: ..............................................................................

................................................................................................GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)

of person authorised to sign for and on behalf of the Occupier.

Title: ........................................................................................

Date:........................................................................................

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Appendix 4: Schedule 19Application for Renewal of ElectroconvulsiveTherapy Licence

S A M P L E O N L Y

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SCHEDULE 20

Regulation 12Mental Health Act 1986 (section 78 (2))


APPLICATION FOR AMENDMENT OF ANELECTROCONVULSIVE THERAPY LICENCE

Licence Number

To the Secretary,




located at ............................................................................................................................................................................


The abovenamed premises are licensed to permit the performance of electroconvulsive therapy.

The licence expires on ......................................................................................................................................................

I apply for the amendment of this licence as follows:

Present term or condition: ..............................................................................................................................................

Proposed amendment: ....................................................................................................................................................

Reasons for proposed amendment: ................................................................................................................................

Signature: ..............................................................................

................................................................................................GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)

of person authorised to sign for and on behalf of the Occupier.

Title: ........................................................................................

Date:........................................................................................

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Appendix 5: Schedule 20Application for Amendment of anElectroconvulsive Therapy Licence

S A M P L E O N L Y

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Appendix 6: Schedule 21Electroconvulsive Therapy Return

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Appendix 7: Informed Consent to Electroconvulsive Therapy (ECT) (PSY 16)

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Appendix 8: Authority to Perform Electroconvulsive Therapy (ECT) WhereInformed Consent Not Obtained (PSY 17)

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Appendix 9: Royal Australian and New Zealand College of PsychiatristsElectroconvulsive Therapy Explained

Electroconvulsive Therapy Explained

This document has been prepared to provide some general information about theadministration of ECT in contemporary psychiatric practice in Australia and New Zealand.

It is intended to accompany theRANZCP Clinical Memorandum #12, Electroconvulsive Therapy (1999).

What is ECT?Electroconvulsive therapy, more commonly known as ECT, is a medical treatmentperformed only by highly skilled health professionals under the direct supervision ofa psychiatrist, who is a medical doctor trained in diagnosing and treating mentalillnesses. Its effectiveness in treating severe mental illnesses is recognised by theRoyal Australian and New Zealand College of Psychiatrists and similar organisationsin the United States, Canada, Great Britain and many other countries.

A course of treatment with ECT usually consists of six to twelve treatments giventhree times a week for a month or less. The patient is given general anaesthesia anda muscle relaxant. When these have taken full effect, the patient's brain isstimulated, using electrodes placed at precise locations on the patient's head, with abrief, controlled series of electrical pulses. This stimulus causes a seizure within thebrain which lasts for approximately a minute. Because of the muscle relaxants andanaesthesia, the patient's body does not convulse and the patient feels no pain. Thepatient awakens after five to ten minutes, much as he or she would from minorsurgery.

How does it work?The brain is an organ that functions through complex electrochemical processes,which may be impaired by certain types of mental illnesses. Scientists believe ECTacts by temporarily altering some of these processes, thereby returning function tonormal.

When is it used?The decision to administer ECT is based upon a thorough physical and psychiatricevaluation of the patient, taking into account the illness, the degree of suffering, theexpected result and the prognosis for the patient if the treatment is not given. Whenthe risk of suicide is high, or when seriously ill patients are unable to eat or drink,ECT can be life-saving.

Electroconvulsive therapy is generally used in patients with severe depressive illnesswhen other forms of therapy, such as medications or psychotherapy, have not been

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effective, cannot be tolerated or, in life-threatening cases, will not help the patientquickly enough. ECT also helps patients who suffer with most forms of mania (a mooddisorder which is associated with grandiose, hyperactive, irrational and destructivebehaviour), some forms of schizophrenia, and a few other mental and neurologicaldisorders. ECT is also useful in treating these mental illnesses in older patients forwhom a particular medication may be inadvisable.

How effective is it?Electroconvulsive therapy has been an important and effective treatment in psychiatryfor over half a century. Its effectiveness in a variety of psychiatric conditions has beenwell established. Clinical evidence indicates that for uncomplicated cases of severemajor depression, ECT will produce a substantial improvement in at least 80 percentof patients. 1 ECT has also been shown to be effective in depressed patients who donot respond to other forms of treatment. 2 Medication is usually the treatment ofchoice for mania, but here too certain patients don't respond. Many of these patientshave been successfully treated with ECT. 3

Are there any risks?Any medical procedure entails a certain amount of risk. However, ECT is no moredangerous than minor surgery under general anaesthesia, and may at times be lessdangerous than treatment with antidepressant medications. This is in spite of itsfrequent use with the elderly and those with coexisting medical illnesses. 4 A smallnumber of other medical disorders increase the risk associated with ECT, and patientsare carefully screened for these conditions before a psychiatrist will recommend themfor the ECT treatment.

Are there any side effects?Immediate side effects from ECT are rare. Some people will experience headaches,muscle ache or soreness, nausea and confusion, usually during the first few hoursfollowing the procedure. Over the course of ECT, it may be more difficult for patients toremember newly learned information, though this difficulty disappears over the daysand weeks following completion of the ECT course. Some patients also report apartial loss of memory for events that occurred during the days, weeks, and monthspreceding ECT. While most of these memories typically return over a period of days tomonths following ECT, some patients have reported longer-lasting problems with recallof these memories. However, other individuals actually report improved memory ability

following ECT, because of its ability to remove the amnesia that is sometimesassociated with severe depression. The amount and duration of memory problemswith ECT vary with the type of ECT that is used and are less a concern with unilateralECT (where one side of the head is stimulated electrically) than with bilateral ECT.

Can ECT cause brain damage?There is no evidence that ECT causes any structural cerebral damage. 5 There aremedical conditions (such as epilepsy) that cause spontaneous seizures which, unlessprolonged or otherwise complicated, do not harm the brain. ECT artificially stimulatesa seizure; but ECT-induced seizures occur under much more controlled conditionsthan those that are "naturally occurring" and are safe. A recent study 6 found nochanges in brain anatomy with ECT, as measured by very sensitive scans of the brainusing magnetic resonance imaging (MRI) equipment. Other research has establishedthat the amount of electricity which actually enters the brain (only a small fraction of

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what is applied to the scalp) is much lower in intensity and shorter in duration thanthat which would be necessary to damage brain tissue. 7

What about pregnancy?The decision whether or not to treat pregnant women with ECT needs to take intoaccount the risks associated with alternative treatments, the risks to the mother andfoetus of withholding ECT and any complications of the pregnancy which mayincrease the risks of ECT or the anaesthetic. ECT may be used with confidenceduring the second and third trimesters. 8 Little information is available for its use in thefirst trimester, so until further data are available, caution is advisable during this stage.ECT does not produce abnormal uterine contractions and it appears to be safe evenin complicated pregnancies. 9 Foetal monitoring during ECT has not revealed anyuntoward effects on the foetus.

What about patient consent?All patients selected for ECT should receive a careful explanation of the procedure,including the side effects, by the medical and nursing staff involved in their care, andtheir permission for treatment obtained. It should be made clear to the patient thatregardless of whether permission is given for each separate occasion of treatment orfor a course of treatment of unspecified length, consent may be withdrawn at any time.Occasionally, when a patient is too severely impaired to be able to give properconsent, permission to proceed with ECT without the patients consent can bearranged through the relevant Mental Health Act. This would happen only inemergency situations when the illness is causing serious risk to the patient or others.

1 Weiner RD, Coffey CE: Indications for use of electroconvulsive therapy, in Review ofPsychiatry, Vol 7. Edited by Frances AJ, Hales RE. Washington, DC: American PsychiatricPress Inc., pp 45881, 1988

2 Sackheim, HA, Prudic J, Devanand DP: Treatment of medication resistant depression withelectroconvulsive therapy, in Review of Psychiatry , Vol. 9. Edited by Tasman A, GoldfingerSM, Kaufman CA, Washington, DC: American Psychiatric Press, Inc., pp 91115, 1990

3 Small JG, Klapper MH, Kellams JJ, Miller MJ, Milstein V, Sharpley PH, Small IF:Electroconvulsive treatment compared with lithium in the management of manic states. ArchGen Psychiatry 45:72732, 1988

4 Weiner RD, Coffey CE: Electroconvulsive therapy in the medical and neurological patient, inPsychiatric Care of the Medical Patient. Edited by Stoudemire

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ECT Manual