Download rcn nursing guidelines for ect, revised

NURSE GUIDANCE FOR ECT, APRIL 2005
There are four components of nursing care in ECT: (1) providing
emotional and educational support to the patient and family/carer; (2)
assessing the pre-treatment plan and the patient’s behaviour, memory,
and functional ability prior to ECT; (3) preparing and monitoring the
patient during the actual procedure; and (4) recovering patient, observing
and interpreting patient responses to ECT with recommendations for
changes in the treatment plan as appropriate. These elements of nursing
care should be reflected in the nursing care plan for patients receiving
ECT.
PROVIDING EDUCATIONAL AND EMOTIONAL SUPPORT
Nursing care starts as soon as the patient and family / carer are offered
ECT as a possible treatment option. At first, a vital role of the nurse will
be to give the patient and family / carer an opportunity to express their
feelings, including any myths or misconceptions about ECT. Patients may
describe fear of pain, dying from electrocution, suffering permanent
memory loss, or experiencing impaired intellectual functioning. As the
patient expresses these fears and concerns, the nurse can clarify
misconceptions and emphasise the therapeutic value of the procedure.
These first interactions allow for the building of trust and rapport
necessary to maintain a therapeutic nurse-patient relationship. Supporting
the patient and family / carer in their need to discuss, question, and
explore their feelings and concerns about ECT should be an essential part
of nursing care before, during and after treatment.
Continuing on from this initial meeting the nurse can begin “ECT
teaching”. Depending on the patient’s presenting mental state, this should
allow for the patient’s anxiety, readiness to learn, and ability to
comprehend. (1).
Where ever possible, family / carer teaching should take place at the same
time as patient teaching, and the amount of information given should be
individualised for each patient and family / carer. The nurse should
review the information the patient and family / carer have received from
the doctor regarding the procedure, and try to answer any questions the
patient and family / carer might have about this information. During this
assessment process, the nurse should also try to find out what specific
patient behaviours the family / carer associates with the patient’s illness,
and ascertain whether the patient or a family member has had ECT in the
past. Any information about the family’s previous experience with ECT
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will help the nurse identify familial beliefs about the patient’s illness, the
ECT treatment, and the expected prognosis. Patient and family / carer
should also be asked what other exposure they may have had to ECT,
such as through friends who have received it, or by reading about it, or by
seeing it portrayed in a film such as One flew over the cuckoos nest.
Open – ended questions can give the nurse the opportunity to identify and
correct misinformation and deal with specific concerns the patient or
family / carer may have about the procedure. E.g. What concerns do you
have about receiving the anaesthetic? How do you think you will feel
after the first treatment? What do you know about ECT? These nursing
actions may then promote the family’s ability to provide support to the
patient during the treatment and so further allay the patient’s anxiety. (1)
An information booklet and video presentation may be used to
supplement teaching the patient and family / carer about ECT. A tour of
the treatment suite itself may help familiarise the patient with the area,
procedure, and equipment. (2) Encouraging the patient to talk with
another patient who has benefited from ECT may be an additional source
of information. (3)
The nurse should facilitate flexibility in family / carer visiting
arrangements, particularly during the patient’s first few treatments,
allowing for family visitation before and after ECT if the patient and
family / carer desire. This allays the family’s anxieties and concerns
about the patient’s treatment, while encouraging the family / carer to
provide support for the patient. The nurse should also encourage the
family / carer to visit the patient frequently throughout the course of
treatment. The nurse should ascertain the changes family members
observe in the patient and answer questions that arise. In some instances
the patient may request that a member of their family or carer be present
in the treatment room whilst they receive ECT. They should discuss this
with their doctor. The appointed family member / carer should be
assessed and prepared , using such resources as a training video which
shows someone having ECT. The multi disciplinary team must be
informed of the pending presence of the family member / carer in the
treatment room.
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INFORMED CONSENT FOR ECT
In November 2001 the DOH published the Good practice in consent
implementation guide : consent to examination or treatment.(4)
Before beginning ECT, an informed consent should be signed by the
patient. In England and Wales, if the patient does not have the capacity to
consent, a form for section 58 of the Mental Health Act must be
completed by a second opinion approved doctor, or in an emergency and
with a view to a section 58 being arranged a form for a section 62 of the
Mental Health Act can be completed by the Responsible Medical Officer.
(5) The patient should be provided with Mental Health Act leaflet 3 in
these cases. The consent acknowledges the patient’s rights to obtain or
refuse treatment. The consent form must comply with the recent
Department of Health guidelines on consent documentation. (4) Even
though it is the doctor’s ultimate responsibility to provide an explanation
of the procedure when obtaining consent, the nurse plays an integral role
in the consent process. (6)
Informed consent is a dynamic process that is not completed with the
signing of a formal document, but it implies a process that continues
throughout the course of treatment. It suggests a number of nursing
activities. (7) It is helpful if a nurse is present at the time when the
information for consent is presented to the patient. The most appropriate
nurse is one who has established a trusting and therapeutic relationship
with the patient and who is best able to assess whether the patient
comprehends the explanation. The presence of a nurse at this time may
facilitate the patient’s confidence in asking questions, and the nurse may
be able to simplify the language if necessary. The nurse can also ensure
that the patient has been provided with a full explanation; understands the
nature, purpose, and implications of the treatment, including the option to
withdraw consent at any time; and has had all his or her questions
answered before signing the consent form. After signing the informed
consent, but prior to beginning treatment, the nurse should again
thoroughly review this information. The nurse should discuss the
treatment in an open and direct manner, so communicating that ECT is an
accepted and beneficial form of treatment. (1)
It is the responsibility of the psychiatrist to obtain the patient’s consent.
Depressed patients frequently experience impaired concentration and so
are less likely to comprehend and retain new information. For these
patients, it is essential that the nurse repeat the information given by the
psychiatrist at regular intervals, because new knowledge is seldom fully
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absorbed after only one explanation. Throughout the patient’s treatment
course, the nurse should reinforce what the patient already understands,
(note, the level of understanding varies from patient to patient, and some
patients may never understand the information given to them). Where
applicable, the nurse should remind the patient of anything he or she has
forgotten, and provide the patient with the opportunity to ask new
questions. Written information also available in other languages should
be provided to the patient and their family / carer. An interpreter should
be arranged if required. The patient should be informed about how to
obtain additional information and access to an independent advocate. (9)
PRETREATMENT NURSING CARE
The ECT treatment nurse should ensure that the treatment suite is
properly prepared for the ECT procedure. The equipment needed to
provide optimal ECT patient care, as recommended by the Royal College
of Psychiatrists is stipulated in their ECTAS standards. (9) An adjustable
height stretcher trolley should be available for the less ambulant patients.
Other moving and handling aids should also be accessible.
In order to provide best practice nursing care for the ECT patient, a pretreatment checklist should be completed as designated by local hospital
policy. (8) Arrangements should be made for the safekeeping of the
patient’s valuables. The ECT nurse should check that all relevant
documentation has been completed. The nurse should explain the
procedure to the patient again and ask whether they have any more
questions or queries, providing reassurance.
Because general anaesthesia is required for ECT, the patient should fast
from food and fluids, ( as per local policy) before treatment to prevent
possible aspiration. The exceptions could be the patients who are taking
cardiac medications, anti hypertensive, or H2 blockers routinely. These
medications should be administered before treatment as directed by the
doctor, with a sip of water. Day patients should avoid a heavy meal the
evening before the treatment. On the morning of treatment the patient
should be asked to remove make up, nail varnish, body piercing etc. The
nurse should ask the patient when he or she last ate and last drank. The
patient’s hair should be clean and dry to allow for electrode contact.
Hairpins, hairnets and other hair ornaments should also be removed for
the same reason. (10) The patient should be encouraged to pass urine
before the treatment to avoid incontinence during the procedure and to
minimise the likelihood of bladder distension and damage during
treatment. Prostheses, dentures, glasses, hearing aids, contact lenses,
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should be removed at the latest possible moment, prior to the
administration of the anaesthetic, to prevent problems of communication
with the patient. The patient’s identity is checked and the patient wears
an identity bracelet. (9) A protocol for day / out patients should be in
place which covers their needs, inclusive of : preparing them for leaving
hospital after treatment, and a written / verbal contract that they will not
drive and have a responsible adult to care for them for 24 hours after
treatment, arrangements for further appointments.
The patient must be escorted to the ECT clinic waiting area, through ECT
and recovery and back to the ward by a qualified nurse or equivalent. (9)
In the case of in-patients, the ideal escort is the patient’s Named Nurse,
while in the case of out-patients, the patient’s community nurse, keyworker, a member of the ECT team or out-patient department team
should perform a similar function. The escort should be known to the
patient and be aware of the patient’s legal and consent status and have an
understanding of ECT. (9) To further minimise anxiety the escort nurse
should consider the use of anxiety management techniques, ensuring as
short a wait as possible in the treatment waiting room, offering
reassurance and support. (12) The doctor may prescribe a pre-med as per
local protocol.
Special arrangements should be made when patients are given ECT in a
clinic remote from a hospital base, i.e. the patient should have an
individual trained nurse escort, and commuting patients should be treated
at the beginning of the session to allow maximum time for recovery. (9)
Regarding anaesthesia outside hospital, the view of the Association of
Anaesthetists is that the standards of monitoring used during general
anaesthesia should be exactly the same in all locations. (17)
NURSING CARE DURING THE PROCEDURE
Because there will be several people in the treatment room, including
psychiatrists, the treatment nurse and the anaesthesia staff, the patient
should be introduced to each member of the team and given a brief
explanation of the member’s role in the ECT procedure. The patient
should then be assisted on to a trolley and asked to remove his / her
prostheses, dentures, glasses etc. Removing the patients shoes will allow
for the clear observation of the patient’s extremities during the treatment.
Once comfortably on the trolley, a member of the anaesthetic staff will
insert a cannulae, while the treatment nurse and other members of the
team place leads for various monitors. One member of the team should
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provide explanation of the procedure as it occurs. Dual channel EEG
monitoring is recommended by the Royal College of Psychiatrists (RCP).
One electrode is placed to the side of the forehead and the other is behind
the ear, on either side. ECG, pulse oximeter and blood pressure
monitoring are also recommended by the RCP. Capnograph is also
recommended by the RCP, in the event of a patient needing to be
intubated. A peripheral nerve stimulator and a means of measuring the
patient’s temperature should also be available for use. Some ECT
machines incorporate monitoring equipment for movement when the
seizure is induced. An initial recording of the patient’s blood pressure,
pulse and oxygen saturation should be made at this stage.
The psychiatrist or nurse cleans areas of the patient’s head with alcohol
swabs and / or gel at the sites of electrode contact as per local protocol.
This is to reduce impedance and improve the contact of the electrodes
with the patient’s head. The areas being cleaned should be either both the
temples for bilateral ECT, or the temple on the non-dominant side of the
brain for unilateral ECT. Exact placement of electrodes for unilateral
ECT is dependent on RCP guidelines and local policy. The anaesthetic,
muscle relaxant and oxygen are administered. A disposable or
autoclavable bite block is inserted into the patient’s mouth prior to the
delivery of the stimulus to prevent tooth, tongue or gum damage or joint
dislocation. One member of the treatment team records the time elapsed
during the seizure. A local stimulus dosing policy should be in use.
Local protocols for missed seizures and termination of prolonged seizures
should be adhered to.
If required and in the absence of the psychiatric trainee, the nurse can
assist the treating psychiatrist by pressing the test / treat button on the
ECT machine, whilst the psychiatrist holds the electrodes on the patient’s
head. The nurse must have been trained and deemed competent by the
consultant psychiatrist responsible for ECT. A local protocol, to ensure
the psychiatrist is aware of the nurse’s actions at each stage of the
procedure and to check the dose given, should be adhered to. This
protocol must have been approved by the consultant psychiatrist
responsible for ECT.
Once the anaesthetist is satisfied that the patient is breathing again and
maintaining their own airway or able to do so with assistance, he / she
will be transferred to the recovery area.
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POSTTREATMENT NURSING CARE
The recovery area should be next to the treatment room to allow access
for the anaesthetic staff in the event of an emergency. Oxygen should be
administered routinely to the patient. The area must contain, suction,
monitoring and emergency equipment as recommended by the RCP. The
nurse should maintain the patient’s airway and monitor / record vital
signs at regular intervals or more frequently if complications arise. The
patient should be observed by a staff member in close proximity until he
or she awakens. The number of staff in the recovery area should exceed
the number of unconscious patients by one. (9) A post-operative checklist
prompts nurses to check for the presence or absence of common or
worrying side-effects at regular intervals after treatment. (11) The patient
may not remember having the treatment, and their thinking may be
somewhat concrete. The nurse should provide frequent reassurance and
reorientation until the patient retains the information. (1) When
interacting with the patient, brief distinct direction is best. Note, in some
instances the patient may never retain some information. Simple
cognitive testing pre and post treatment should give some indication of
any abnormality as a result of ECT.
The patient may become restless, agitated, aggressive (post-ictal
confusion) and / or disorientated for a short period of time. The nurse
should maintain the patient’s safety. Verbal interaction is usually
ineffective. When the episode has resolved the patient should be
reoriented. A small dose of a benzodiazepine may be effective. (10)
When the patient is ready he or she should be escorted to a final stage
area for refreshments and rest until the recovery staff deem him or her fit
to return to the ward.
The recovery nurse should pass on information to the ward nurse / escort
about the patient’s condition, medication administered, patient’s
behaviour, untoward procedures or treatment response. This information
should be recorded in the ECT notes. A lengthy seizure may cause an
increase in time of patient being disorientated or confused. A longer time
for rest and reorientation may be required. Closer observation may be
required. The patient should be assessed on return to the ward regarding
level of observation required and degree of orientation. If the patient
complains of a headache, muscle soreness, analgesia such as paracetemol
may be administered. The patient should be encouraged to rest. Nausea
may be treated with an anti-emetic. Ward staff should continue to provide
support, reminders to the patient of the treatment and reorientation to
eliminate patient distress from post treatment amnesia. The cognitive
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impairments associated with ECT treatment mostly reflect changes in
memory – i.e. temporary anterograde amnesia and retrograde amnesia.
Memory deficits do not seem to be restricted to personal autobiographical
memory. (13) Memory loss may be distressing to the patient. The nurse
should reinforce that the majority of the memory difficulties will pass
within several weeks, with a minimal amount of memory problems
lasting up to 6 months.
STAFFING
A trained nurse with relevant experience must be present at each stage of
the treatment. ECT should be administered only in a suitably equipped
unit by professionals who have been trained in its delivery and in the
anaesthetic techniques required for the administration of ECT. (15) In
busy ECT clinics it is advisable to use nursing assistants to assist the
“core team” with low skill tasks. (11) E.g. Assisting with moving a
patient, ensuring the patient receives refreshments post ECT, telephone
communication. All nursing staff working in the ECT team should
receive Basic Life Support training (6 monthly), Moving and handling
training (annual), Mental Health Act competency (annual). (14) Recovery
nursing staff should receive local recovery skills training inclusive of
airway management, aspiration and suction techniques (6 monthly). Their
competency in recovery must have been assessed. All staff should be
familiar with ECT policies and procedures. The same team should work
in the clinic every week for the purposes of continuity. (9) A budget for
staff training specific to ECT, should be available. Staff should be
encouraged to keep up to date with best practice and their training needs
should be formally assessed by appraisal. ECT nursing staff should attend
appropriate training and conference events, e.g. regional ECT nurse group
meetings, ECT nurse training conferences and the RCP ECT training
course.
THE ECT CLINC NURSE MANAGER (ECT NURSE)
This nurse (minimum grade F RMN or equivalent) is responsible for the
development and implementation of a cohesive ECT service acting as a
clinical and functional lead. Therefore, he / she should have appropriate
ECT related knowledge / experience and have undergone an induction
programme covering ECT policies and procedures, medical equipment
safety and clinical management. He / she should have an up to date job
description with clearly defined roles and responsibilities.
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He / she should ensure that the patients, equipment and personnel are
prepared and organised for the session. Emergency resus equipment and
drugs should be checked weekly, or as per local policy. The ECT
machine output and electrodes should be checked. The ECT nurse should
ensure that the ECT machine functioning and maintenance is checked and
recorded at least every year or according to machine guidance. (9) A
record of ECT administration should be maintained for quality assurance.
An example of good practice in this area is the Scottish ECT Audit
Network. (16) Appropriate induction and on-going training of staff
should be maintained, e.g. ECT policies and procedures, CPR, Moving
and Handling, Mental Health Act, Control and Restraint. The nurse
should offer clinical advice to services across the Trust and assist with
liaison between the ECT clinic team and the patient’s own team..
The nurse should have designated sessional time for the clinics, auditing,
teaching student nurses, risk assessments, administration, supervising and
research into best practise in ECT. He / she should support the ECT
consultant with the training of junior doctors. The ECT nurse should be
able to spend time with patients and relatives in order to provide support
and information. User / carer support groups related to ECT should be
supported by the ECT nurse. He / she should receive regular supervision
and maintain a personal development plan related to ECT. He / she
should attend specific ECT training sessions, e.g. Royal College
Psychiatrists Training Days, and / or become actively involved in their
regional ECT Nurse Group. The nurse should have protected time to
carry out all of the above duties and should not be expected to be
covering a ward or other responsibilities on the days of treatment. There
should be a nominated trained deputy to cover the absence of the ECT
nurse.
Stephen Finch RMN; RGN
With advice and contributions from :
North West ECT Nurse Group & The Glasgow ECT Nurses Forum.
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2. Baxter LRJ, Roy-Byrne P, Liston EH, et al: Informing patients
about electroconvulsive therapy: Effects of a videotape
presentation. Convulsive Therapy 2:25-29, 1986
3. Royal College of Nursing: RCN nursing guidelines for ECT.
Convulsive Therapy 3: 158-160, 1987
4. Health Service Circular: Good practice in consent. NHS Executive.
2001
5. Code of Practice. Mental Health Act 1983. DOH.
6. Ahern L: Electroconvulsive therapy: An effective treatment.
AORN J 24:463-470, 1981
7. Barker P, Baldwin S: Shock story. Nursing Times 86 (8): 52:55,
1990
8. Fine M, Jenike MA: Electroshock: Exploding the myth. RN 48:5866, 1985
9. ECTAS standards for the administration of ECT. Dec. 2004.
www.rcpsych.ac.uk/cru
10.Litwack K, Jones EE: Practical points in the care of the post
electroconvulsive therapy patient. Journal of Post Anaesthesia
Nursing 3: 182-184, 1988
11.Royal College of Psychiatrists: ECT handbook: 114-121, 1995
12.Royal College of Nursing: ECT – Guidance for nurses, 1996
13.The UK ECT Review Group: Efficacy and safety of
electroconvulsive therapy in depressive disorders: a systematic
review and meta-analysis. The Lancet 361:799-807, 2003
14.North West ECT Nurse Group Standards, RCN Mental Health
Zone website, 2003.
15.Guidance on the use of electroconvulsive therapy: NICE, April
2003. www.nice.org.uk
16.www.sean.org.uk
17.Recommendations for standards of monitoring during anaesthesia
and recovery. Association of anaesthetists of Great Britain and
Ireland. December 2000.
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