10. CONCLUSIONS
Since the start of the audit in 1996 the primary aim has remained the same - to ensure that ECT is delivered to a high standard in every ECT clinic in Scotland. The audit has made significant progress towards achieving this objective.
Early on in the preparation of the Good Practice Statement on ECT it became evident that there was a lack of central information on the standards and procedures in place in Scotland. The national audit has provided a mechanism for the central collection of data on ECT providing a valuable database to dispute erroneous claims, for example, that ECT is being used inappropriately and given preferentially to minority groups, women and the elderly. Such data can help educate and allay the fears of the public and profession alike.
The major conclusion of the audit is that ECT given in a routine clinical setting is an effective treatment for the clear majority of patients. There was a definite clinical improvement with treatment in 71.2% of patients treated for a depressive illness and 65% of those treated for other (psychotic) illnesses.
The audit has supported clinicians locally in improving ECT facilities. Since the initial survey of Scottish ECT clinics in 1994, standards have been raised by the efforts of the clinical teams as evidenced by the improvement in facilities, equipment, procedures and training between the 1994 survey and the most recent results of this audit (see Table 22 below). The project has provided systematic evidence to demonstrate that all equipment (including anaesthetic equipment) is now up to date and all centres have a satisfactory back up machine or arrangement.
The arrangements for the training of junior staff have improved overall but whilst all juniors are supervised for their first ECT session, there are some definite problems with continuing supervision. This is partly a consequence of the fact that few consultants have protected contractual time for ECT despite spending an average of 5 hours per month (range 1 12 hours) on ECT related activities.
The audit has underlined the need for consultant led teaching and supervision if standards of good practice are to be achieved and maintained. This supports the calls by ECT consultants for dedicated sessional time to pursue ECT related activities. With only two consultants having such sessional time for ECT during the first phase rising to five in the third phase there is clearly room for improvement. Sessional time was one of the recommendations of the CRAG Good Practice Statement on ECT. It was considered that one session per week (three and a half hours) would be adequate to administer, train and supervise an ECT service, except in the two larger centres where two sessions per week may be required.
The audit has highlighted the important role of nursing staff in the delivery of ECT and has provided support to the development of the ECT Nurses Forum. It was noticeable that the audit was completed twice as efficiently at those sites where the ECT nurse has an extended role often including patient preparation and follow up. If this is reflected by clinical outcome results then there would be a case for the appointment of an ECT nurse specialist to every service.
Through comparing these results from Scotland with those from England and Wales it is clear the quality of the ECT practice in Scotland as a whole is considerably better than in England and Wales.
Table 22: Comparisons with the Good Practice Statement Survey of ECT in Scotland in 1994 (GPS ) and the Royal College of Psychiatrists third cycle audit of England and Wales 1996 (E&W)
| 1994 (GPS) | 1996 (E&W) | 1997 (Phase 1) | 1999 (Phase 3) | ||
|---|---|---|---|---|---|
| 'ECT Suite | |||||
| Dedicated rooms up to standard | 90% | 74% | 97% | 100% | |
| one tipping trolley per patient | 48% | 84% | 97% | 100% | |
| Recommended ECT machine | 79% | 59% | 100% | 100% | |
| Staffing | |||||
| dedicated nursing staff | 80% | * | 92% | 91% | |
| operating department personnel | 15% | 48% | 33% | 37% | |
| Contracted consultant psych. time | 16% | 6% | 9% | 14% | |
| Protocols - written | |||||
| restimulation of missed seizures | 93% | 62% | 89% | 94%** | |
| schedule for alteration of dose | 77% | 34% | 89% | 94%** | |
| termination of prolonged seizures | * | 11% | 61% | 71% | |
| written patient information | * | 80% | 100% | 100% | |
| Training and Supervision | (consultant rating) | (trainee rating) | |||
| induction and demonstration | 77% | 90% | 100% | 97% | |
| initial supervision by senior | 74% | 60% | 88% | 88% | |
| continued supervision | Exemplary | 0% | 34% | 41% | |
| Adequate/good | 19% | 16% | 23% | 15% | |
| poor/very poor | 81% | 84% | 43% | 44% |
* data not collected as such
** Since completion of the audit all centres (100%) now employ protocols for restimulation of missed seizures and alteration of treatment dose.
The project has done much to highlight and clarify issues of patient consent. Around 20% of patients are detained under the Mental Health (Scotland) Act 1984. One development arising from the audit has been the recommendation that a copy of the consent to treatment form relating to patients subject to Part X of the Act (consent to treatment) should be available in the ECT suite. More generally, the audit has proved to be a useful sounding board for The Mental Welfare Commission in their development of new guidelines on consent issues related to ECT (Annex F).
An initial survey of consultants responsible for ECT carried out in 1994 as part of the development of the CRAG Good Practice Statement produced a 100% return and this interest has been reflected in the support for the national audit and by good attendance at the six monthly SEAN meetings. Whilst the success of the project to date has to a large extent been based on the adoption of the audit by each of the local co-ordinators, a crucial factor of the audit has been the availability of central support the project co-ordinator, the project worker, the SEAN forum - to stimulate and sustain interest in the audit.
The reception of the audit and its results has been pleasing. All parties involved have shown interest and enthusiasm and this has led to a high level of support allowing the audit to be accepted, practiced and hopefully maintained. Through better channels of communication and collaboration information on good practice is being shared and used.
