Review of ECT Practice at Riverview Hospital

February 21, 2001
Riverview Hospital Report

Carried out by:

* Dr. Caroline Gosselin (Head, Dept. of Geriatric Psychiatry, VHHSC) - Chair
* Dr. Elisabeth Drance (Geriatric Psychiatrist, Providence Health Care) - Member
* Ms. Jeanette Eyre (RN and ECT Coordinator, UBC Hospital) - Member
* Dr. Norman Wale (Anesthesiologist, Dept. of Anesthesia, Royal Jubilee Hospital, Capital Health Region) - Member
* Dr. Athanasios Zis (Professor and Head, Dept. of Psychiatry, UBC and VHHSC) -Member
* Mr. Noam Butterfield (PhD candidate, Pharmacology & Therapeutics, UBC) - Secretary and Principle Facilitator
* Mr. Wayne Jones (MHECCU, St. Paul's Hospital) - Statistical Consult

February 21, 2001

Review of ECT Practice at Riverview Hospital February 21, 2001

PURPOSE: The Ministry of Health, Division of Mental Health Services, has appointed a committee to review the current practice of electroconvulsive therapy (ECT) at Riverview Hospital (RVH). The mandate of this review was to determine if patients at RVH are provided with ECT services that are appropriate and safe, and to make Recommendations to improve ECT service.

COMMITTEE COMPOSITION: * Dr. Caroline Gosselin (Head, Dept. of Geriatric Psychiatry, VHHSC) - Chair
* Dr. Elisabeth Drance (Geriatric Psychiatrist, Providence Health Care) - Member
* Ms. Jeanette Eyre (RN and ECT Coordinator, UBC Hospital) - Member
* Dr. Norman Wale (Anesthesiologist, Dept. of Anesthesia, Royal Jubilee Hospital, Capital Health Region) - Member
* Dr. Athanasios Zis (Professor and Head, Dept. of Psychiatry, UBC and VHHSC) - Member

ADDITIONAL CONTRIBUTORS: * Mr. Noam Butterfield (PhD candidate, Pharmacology & Therapeutics, UBC) - Secretary and Principle Facilitator * Mr. Wayne Jones (MHECCU, St. Paul's Hospital) - Statistical Consult

TERMS OF REFERENCE (as outlined by the Ministry of Health): Purpose: To determine if patients at RVH are provided with ECT (electroconvulsive therapy) services that are appropriate and safe, and to make recommendations to improve service.

Issue: ECT practice at RVH has been questioned by Dr. Jaime Paredes, Medical Staff President, in a letter to Honourable Corky Evans, Minister of Health and Minister Responsible for Seniors. Media coverage reflects concern for safety of clients.

Deliverables: The review will determine practices for both in- and outpatient ECT in the following areas and compare with accepted medical practice:

1. Equipment of Physical Design - specifications of the ECT machine (e.g. waves, voltage, monitoring heart rate, e.e.g.s etc) design of the ECT and recovery rooms, safety and anesthetic and ancillary equipment issues.

2. ECT Technique and Anesthesia - issues of technical competence (unilateral versus bilateral; timing of current, wave forms, etc) that are designed to have the therapeutic effect and reduce memory disturbance. Medications including type and dosage of anesthetics used during ECT and physiological monitoring during ECT.

3. Care Plan and Documentation - protocols and guidelines in place for ECT. Clear documentation of Assessment and treatment plan.

4. Preparation and Aftercare - preparation of the patient for the procedure and aftercare including instructions to caregivers.

5. Patient Selection - exclusions for other medical conditions, characteristics of psychiatric conditions including non-responsiveness, urgency, etc. and indications for second opinions and other consultations are addressed. Indications for maintenance ECT.

6. Patient Education/Consent - process for informed consent; consent forms; completed methods of presenting material to patients and families.

7. Staff Training - level of skill and knowledge of staff involved in any aspect of providing ECT.

8. Monitoring and Evaluation - RVH practice of monitoring important aspects of ECT. Trends and comparisons in the use of inpatient and outpatient and maintenance ECT. Monitoring, on a periodic basis the type of equipment, techniques, staff training and patient outcomes.

NOTE: The review is to address system issues as opposed to professional practice of individuals. Individual practice concerns are not the purview of this report and, therefore the review team will refer such issues to appropriate RVH professional bodies and/or provincial practice bodies.

REVIEW PROCESS: Discussions were held over three days with management, medical staff, nursing staff, patients and their families and patient advocacy groups.

The first site visit was conducted on January 16, 2001, during which the review team members, the terms of reference and the review process were introduced to President/CEO of RVH, Chair of the Board of Trustees, the Clinical Executive Team and ECT staff representatives. Following introductions, meetings were held separately with the following groups:

* ECT physicians (psychiatrists and anesthesiologists) and ECT Nursing Staff
* Coordinator of the ECT program and Manager of the ECT Program
* Vice President, Medicine and Research and Vice President of Clinical Services
* President, Medical Staff Association
* Medical Director and Patients Services Director of the Geriatric
Psychiatry Program and five Medical Staff
* Medical Director and Patient Services Director of the Adult Residential Transfer Program
* Medical Director and Patient Services Director of the Adult tertiary Redevelopment Program
* An open forum was also held for any other Riverview Hospital Staff, patients, families or advocacy groups, to voice any concerns and provide feedback.

During the second site visit on January 17, 2001, time was spent observing patients in the pre-ECT room, in the treatment room, and in the post-anesthetic recovery room, as well as being transferred back to the ward. A discussion was held with families of some of the patients who received ECT treatment this day. A chart review was initiated and additional discussions were held with the following:

* Union of Psychiatric Nurses (UPN, Local 102) Nurse, Aggressive Stabilization Ward and Vice President, UPN
* Five members of Medical Staff Organisation

On January 22, 2001, discussions were held with the following:

* Ten Geriatric physicians * Vice President of Clinical Services

In addition to the three site visits, materials provided by Riverview Medical Staff and Administration were reviewed. Substantial correspondence received by the Minister from a variety of individuals and organisations was forwarded to the team as well.

ASSESSMENT AND RECOMMENDATIONS:

1. Equipment and Physical Design

Assessments: PHYSICAL DESIGN Riverview Hospital houses a newly built ECT suite on the ground floor of Valleyview Pavilion with formal operation underway since December, 2000. This current location was found to be well located with respect to the patient population served. It encompasses a waiting area for patients and families, a treatment room and a recovery room capable of managing 4 post-ECT patients. It is clean, spacious, well lit, and provides a comfortable environment for both recipient and providers of ECT.

ECT EQUIPMENT The ECT suite is equipped with the newest ECT devices available. A Spectrum 5000Q is used for daily ECT. A Thymatron and an older model of MECTA (the JRI) are also in the treatment room for backup in the event of equipment failure.

ANESTHESIA EQUIPMENT a) Stretchers - The stretchers are of current design, safe and sturdy. b) Monitoring Equipment - Blood pressure, heart rate, electrocardiogram, haemoglobin saturation and neuromuscular transmission monitors are all of current design and good quality. c) Suction Equipment - Suction availability, although not through a central system, is adequate. Three such suctioning units were tested and all well functioning.

2. ECT Technique and Anesthesia

ECT TECHNIQUE Assessment: ECT Technique was uniformly praised by all those interviewed, including by those who raised concerns in other domains.

Patients are prepared for ECT in accordance with APA standards i.e.: skin cleansing with alcohol, application of abrasive and non-abrasive conductant gels. Bilateral lead placement is routinely used with the Titration Method dosing strategy according to the protocol devised by Duke University. A standard rubber mouth guard is inserted into the patient's mouth prior to ECT and the anesthesiologist provides jaw support during the delivery of the stimulus itself. The ECT device creates an EEG recording of the convulsion, which is documented on a flow sheet.

It is presumed, given the training the treating psychiatrists have, that EEG morphology is used as an adjunct to the progress report of the patient's physician to determine electrical dosage used for each treatment. We observed the Coordinator of ECT Services deliver ECT for several patients. The remaining five psychiatrists who deliver ECT declined to allow us to observe them - stating that we did not have the authority to do so. They cited receiving advice from the College of Physicians and Surgeons of B.C for their decision. The Coordinator of ECT Services informed us that they have all received ECT training at either Canadian or American programs and practice accordingly.

Recommendation: Although the choice of electrode placement is a subject of continuous research and discussion, recent evidence suggests that the therapeutic outcome of unilateral electrode placement of sufficient electrical intensity is comparable to bilateral ECT, but with reduced cognitive side effects. The choice of electrode placement should be reviewed and updated.

ANESTHESIA Assessment: Oxygen Supply: The provision of oxygen was adequate, although the addition of a pressure gauge to provide "real time" monitoring of supply/pressure would be desirable. Absent also was any conspicuous visual or auditory alarm to be deployed if there should occur a failure in oxygen supply. A large K-cylinder of oxygen as back up supply was readily at hand.

Drug Supply: Sufficient and appropriate drugs are readily available. Drugs and equipment required for resuscitation are also appropriately stored, labelled, and immediately available. Surveillance and replenishment of dated drugs is an ongoing commitment of Riverview Pharmacy.

Practice: The current practice in the provision of anesthesia for ECT at Riverview Hospital conforms to the "Guidelines to the Practice of Anesthesia, revised edition 2000" as recommended by the Canadian Anesthesiologists' Society. The safe and courteous conduct of anesthesia was apparent, as was the cooperative compassionate approach to patient care.

Recommendations: a) "Real time" monitoring of oxygen supply pressure should be provided. b) Auditory and visual alarms to notify personnel of failure of oxygen supply are also recommended. c) Consideration should be given to the use of "needle-less" supplies for the administration of drugs and/or intravenous fluids. There is no doubt that patients receiving therapy later in the day do benefit from intravenous fluid administration, and such fluids may be given utilizing one of the several "needle-less" products which are currently available. The principle advantage of using "needle-less" supplies continues to be the reduced risk of "needle-poke" injuries.

3. Care Plan and Documentation

Assessment: We reviewed the following documents and guidelines:
* ECT Consent Process (Flow sheet)
* Consent for ECT Treatment (Guidelines)
* Consent for Treatment, Involuntary Patient
* Consent for Treatment, Informal Patient and Outpatient
* ECT - Information for Patients and Families (1997)
* Preparing for ECT - Information for Inpatients (1997)
* Preparing for ECT - Information for Outpatients (1997)
* ECT Information For Students (1996)
* Pre-ECT Nursing Checklist
* ECT Ward Nursing Guidelines
* Request for Consultation (form)
* ECT Service Procedure Manual: Pre-ECT/Pre-Anaesthesia Consultations
* Pre-ECT Medical Checklist
* Medications Used In ECT - A Brief Compendium for Ward Nursing Staff
* ECT Service Procedure Manual: Duties of the Escort Nurse
* ECT Service Procedure Manual: Duties of the Waiting Room Nurse
* ECT Service Procedure Manual: Description of the ECT Treatment Process
* ECT Service Procedure Manual: Clinical Nursing Procedures in the ECT Room
* ECT Service Procedure Manual: Description of the ECT Treatment Process
* Medical Staff Policy & Procedure Manual: ECT (1997)
* ECT Service Procedure Manual: Anaesthesia Procedures in the ECT Treatment Room
* ECT Treatment Room Drug List (1996)
* Communication In the ECT Suite
* ECT Treatment Record
* ECT Nursing Record
* Methicillin Resistant Staphylococcus Aureus Guidelines (MRSA) (1997)
* Management of Patients Infected or Colonized with MRSA and other Multiple Drug-Resistant (MRO) Microorganisms
* ECT Service Procedure Manual: PARR Equipment
* ECT Service Procedure Manual: PAR Nurse Qualifications
* ECT Service Procedure Manual: Clinical Nursing Procedures in the PARR
* ECT Service Procedure Manual: Documentation In the PARR
* ECT Service Procedure Manual: Nurse to Patient Ratio in the PARR
* ECT Service Procedure Manual: Post Anaesthesia Recovery Room
* ECT Service Procedure Manual: Medical Emergency - Code Blue
* ECT Service Procedure Manual: Criteria For Discharging Patients from the PARR
* ECT Outcome Evaluation

Recommendations:
These guidelines are comprehensive and clear and only minor changes are recommended:
a) Aortic Stenosis is not listed in the "Medical Staff Policy and Procedure Manual (1997)" as a relative contraindication
b) The document "CLI-005 Description of the ECT Treatment Process" contains inaccurate information and is poorly written. It needs to be revised and the author and purpose of such a document identified.

4. Preparation and Aftercare

Assessment: Preparation of the patient begins as soon as a decision has been made that ECT is a recommended treatment choice for the patient. The attending physician discusses treatment options with the patient including the possibility of ECT. An "Information for Patients and Families" booklet on ECT is given to the patient and family members if possible, prior to being asked to sign consent for ECT. The patient and family members both have the opportunity to meet with the attending physician to ask questions about the recommended ECT. If the patient is capable of giving informed consent the attending physician will meet with the patient and review and explain the information on the back of the ECT form.

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

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

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

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

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

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

5. Patient Selection

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

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

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

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

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

6. Patient Education / Consent

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

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

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

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

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

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

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

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

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

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

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

7. Staff Training

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

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

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

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

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

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

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

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

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

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

Recommendations: a) The ECT program at RV is in need of a database in order to gather statistics that will answer the questions regarding utilization of the practice of ECT. A year and a half delay is unacceptable and needs to be reassessed. b) An appropriate ECT outcome tool needs to be completed for each patient at the completion of the Index Course of ECT and then on an ongoing basis for those patients receiving Maintenance ECT. It should be included and easily identified in the patient chart.

c) Riverview needs to enhance and formalise an outpatient ECT clinic. This would involve an expansion of resources. A full-time ECT nurse coordinator could take on several roles including: i. Enhancing ECT education to patients, families and staff (e.g. managing groups) ii. Participating in planning for further education iii. Liasing with the community referral source for patient management iv. Maintaining outpatient ECT statistics.

Additional resources would also allow for additional ECT days (Tuesday and Thursday). This would reduce the total number of patients treated in one day and therefore reduce the waiting time for patients requiring who must fast prior to treatment.

Additional observations: While Riverview is filled with talented and caring professionals, it appears to struggle in the area of developing a healthy work culture.

In our review, we met with a wide variety of professionals including psychiatrists, nurses, anesthesiologists, general practitioners and administrators. Many described their interdisciplinary relationships with colleagues and other health care providers as thoroughly satisfactory. Others expressed fear that speaking out about controversial subjects leads to retribution by the administration in the form of termination of contracts or demotions.

These are serious allegations. They point to a culture which feels unwelcome of diverse opinions, which threatens people's sense of security, and which is strongly hierarchical. The involvement of the media and letters to the health minister may be reflections of this culture.

Riverview Hospital needs to foster an improved quality of internal communication and provide manifestation of respect for individuals' freedom of expression.

Concluding Remarks:

ECT delivery at Riverview Hospital is of high quality. Protocols and guidelines for safe and effective application are in effect. A Reasonable and acceptable informed consent process is in place which is in keeping with current legislation. There are some areas for improvement such as revising second opinion protocols, updating education for Riverview Staff, and expanding resources for outpatient ECT.

Although questions have arisen pertaining to ECT utilization, the lack of trust that such issues will be fairly addressed within the organization has caused this issue to become public. The staff, patients, and families of Riverview Hospital have experienced distress as a result of adverse publicity. There is a need for Riverview Hospital and other health care professionals to improve public understanding about ECT.

The number of ECTs at Riverview Hospital has increased. Data explaining this increase are currently unavailable and therefore conclusions regarding utilisation cannot be made at this time. A comprehensive Province-wide database, including appropriate outcome measures, is essential.

February 21, 2001 Riverview Report

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