5. PHASE 1

Objectives and method

All ECT consultants were recruited as local ECT co-ordinators for the audit and the Scottish Electroconvulsive Therapy Audit Network (SEAN) was formed. This group was to meet regularly (twice a year) through the life of the project encouraging local ownership of the audit and its results. The project co-ordinator and project worker then visited all the ECT sites in Scotland, 36 sites in total in 1997 (35 NHS and 1 from the private sector). A list of all current ECT sites is included at Annex A. Each ECT site was assessed for the quality of their ECT process in respect of the current Royal College of Psychiatrists guidelines on premises, staffing (psychiatrist, nurse, anaesthetist), ECT and anaesthetic equipment, treatment protocols, training and supervision (Annex D). Additionally at each site training on managing the audit and administering the MADRS was given to as many members of the ECT treatment clinic team (ECT co-ordinators, trainee doctors and nurses) as possible using a standardised training video. This training was supplemented by two central teaching days (Edinburgh and Paisley) to which all personnel involved in ECT were invited. Otherwise consultants at all sites took on the responsibility for disseminated learning, using the same teaching video, for those unable to attend the formal sessions.

After each visit, units were encouraged to start the audit even though data collection would not officially begin until August 1997 (i.e. at the start of phase 2). This was to introduce the audit into clinical practice and allow any unforeseen practical difficulties to be identified and resolved. Each site decided on the most practical means to record outcome data depending on staff resources; either nursing or medical staff or a sharing of this responsibility. Where there was a dedicated ECT nurse they took clear responsibility for co-ordinating the audit and ensuring forms were complete.

Also during this stage of the project user group representatives formed a reference group which was also to meet twice a year and was kept informed of the audits progress (see Annex C).

Results (July 1997)

i. Premises and equipment: Thirty two out of the total thirty six services delivered ECT in an acceptable designated ECT suite. Two others had sole use of a theatre ante room and only one unit gave ECT in a ward side room which was unacceptable. In the one private sector facility ECT is delivered in the patients own room. All centres were using an acceptable ECT machine and had a backup arrangement. Anaesthetic equipment was of a generally high standard with only one site rated as poor on account of their obsolete defibrillator which was expected to be replaced. Only one site still had static patient trolleys but replacements were on order. A pulse oximeter to measure patient oxygenation was available at all sites and a capnograph for measuring end tidal carbon dioxide in case of an emergency endotracheal intubation was available (although never used) at seven locations.

ii. Staffing: A senior psychiatrist was responsible for each ECT service. In all NHS units trainee doctors are involved in the delivery of ECT although a rota may be shared with a senior colleague. At no clinics did junior anaesthetists work unsupervised and most could expect input from a regular core of one to three anaesthetists (28/36). An anaesthetic assistant was available at 12 locations. All patients for ECT were accompanied by a nurse familiar to them. Just over half of the ECT services employed specially designated nurses, 16 units used named nurses from the ward pool and in only 3 units did the deployment of staff appear to be a haphazard arrangement.

iii. ECT practice: Patient information sheets were available at all sites. All clinics kept a log book of ECT numbers. ECT was always prescribed by a senior psychiatrist and all patients were reviewed at least weekly. 80% of consultants were aware of the College recommendation that ECT prescription should be for no more than two treatments at a time and 52% of units had adapted the ECT record form accordingly. Bilateral electrode placement was the treatment of choice in all areas. The ECT dosing schedule was the responsibility of 89% of ECT clinic consultants and of the patients consultant in the remaining 11% of hospitals. For those clinics operating a treatment schedule the first dose of ECT was:

• measured by seizure threshold (22%)
• estimated according to sex/age (56%)
• fixed (22%)

Subsequent doses of ECT were adjusted according to response in 89% of clinics.

A written protocol for the termination of prolonged seizures was easily available in 61% of treatment rooms. Clinical information from case notes was available at 89% of sites.

iv. Training and supervision: Induction training and a demonstration of ECT was available in all services. Initial supervision of delivery of treatment was carried out by a College member on 86% of occasions but good ongoing supervision was only available at 42% of clinics. On average consultants felt they devoted 5 hours per month to ECT related activity (range 1 - 12 hours ).

Table 1: Phase 1 (1997) overall ratings (refer to Annex D)