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NEW YORK STATE OFFICE OF MENTAL HEALTH CREEDMOOR PSYCHIATRIC CENTER POLICY / PROCEDURE POLICY / PROCEDURE: ELECTROCONVULSIVE THERAPY (ECT) DATE ISSUED: December, 1998 TO: See Distribution FROM: Charlotte Seltzer, CSW Chief Executive Officer SUBJECT: Policy / Procedure The attached policy / procedure, under the subject above, has been reviewed and approved for inclusion in the manuals listed below: Approved: Charlotte Seltzer, CSW Chief Executive Officer William A. Fisher, M.D. Clinical Director Eunice D'Souza, M.D. Pres., Medical Staff Organization Zafar Sharif, M.D. Dir. Schizophrenia Research Unit Aurelia Harris, CSW Dir., Treatment Serv. Alan Diner, M.D. Dir. of Medicine Caterina Grandi, M.D. Chief of Psychiatry Margaret Malone, MPS, RN Dir., Quality Assurance Gretchen Corcoran, RN, MP. Director of Nursing INSTRUCTIONS: _______________________________________________ _______________________________________________ ATTACHMENT DISTRIBUTION LIST: Cabinet, Physicians, Chiefs of Service, NAP I's, Health Information Management INSERT IN THE FOLLOWING MANUALS: Rules & Regulations c>f the Medical Staff . POLICY AND PROCEDURE GOVERNING THE USE OF ELECTROCONVULSIVE THERAPY (ECT) I. INTRODUCTION The Electroconvulsive Therapy (ECT) unit is part of the Schizophrenia Research Unit at Creedmoor Psychiatric Center (CPC). The unit is located on the first floor of Building 40 and is comprised of a treatment room, a waiting area, and a recovery area. The administrative offices of the ECT unit may be reached by calling Zafar Sharif, M.D. (Ext. 4191) or Michelle Hsieh, R.N. (Ext. 4169). The clinical staff of the ECT unit is comprised of psychiatrists, an anesthesiologist, and nurses who assume responsibilities for screening, evaluating, and treating patients referred to the unit. The primary aim of the unit is to provide ECT for a select subgroup of psychiatric patients for whom ECT may be indicated (see Section IV). Additional objectives of the unit are to conduct research on the efficiency and safety of ECT in various psychiatric disorders, and to investigate the physiological mechanisms associated with the therapeutic and cognitive effects of ECT. Research studies are conducted in accordance with the established policies and procedures of the CPC Institutional Review Board (MB), the joint Columbia University - New York State Psychiatric Institute (MYSPI) IRB, OMH directives, and JCAHO standards. Research and teaching are conducted only to the extent that these objectives do not conflict with the clinical treatment of the patients. II. INFORMED CONSENT A written informed consent (CPC form 0101-. 4/99 ) for the use of ECT shall be obtained in accordance with CPC policy and made part of the patient's records. The consent shall be limited to a three-month period from the time of signing. If ECT treatment is to continue past that period, a new consent must be obtained. A. Category I Patient has sufficient mental capacity to give informed consent for ECT. 1. Only the patient may give written consent for ECT. 2. If the patient refuses to give consent, ECT will not be administered. The hospital will not apply for a court order to administer ECT. B. Category II Patient does not have sufficient mental capacity to give informed consent for ECT and does not object to ECT. 1. Two psychiatrists, neither associated with the ECT Unit, must certify that the patient lacks the capacity to give informed consent because of impaired mental ability to comprehend the nature of the need for ECT, and does not object to ECT. 2. The hospital must obtain written consent from the patient's legal guardian, parent, spouse, or adult child for ECT. No other family member is permitted to give consent. If no family member is available, Category C below is applicable. C. Category III Patient does not have sufficient mental capacity to give informed consent for ECT and objects to receiving ECT. If ECT is considered to provide a reasonable chance of therapeutic benefit in the judgment of the clinical team and a psychiatrist from the ECT service, the hospital may apply for a court order (see policy on Consent for Surgery, Rules and Regulations of the Medical Staff). If an application is made for a court order, the patient should be converted to involuntary legal status, if this has not already been done. III. INDICATIONS FOR ECT In the absence of specific predictive measures in psychiatric disorders which could predict a favorable response to ECT, the use of this modality of treatment is mainly reserved for, but not limited to the following: A. Major Depressive Disorders with endogenous features showing one or more of the following characteristics: 1. Previous therapeutic response to ECT by history 2. Failure to respond to adequate pharmacotherapeutic trials emergencies) requiring prompt antidepressant response 4. Complicating medical conditions that could be worsened by the use of psychotropic medications 5. Complicating adverse reactions to psychotropic medications (e.g., delirium, ileus, urinary retention) that would contraindicate their continued use. B. Cases of manic states not responding to the usual psychopharmacological interventions, or where age or medical condition of the patient complicates the safe and effective use of such medications. C. Catatonic states where the withdrawal or agitation and/or refusal to eat or drink adequately may pose a serious risk to the patient's health. 2 D. Psychoses associated with seizure disorders and not responding to conventional pharmacological treatments. E. Cases of schizophrenia or schizoaffective disorder with affective features not responding to pharmacotherapy. F. In selected cases ECT may be used in chronic psychiatric disorders where the primary indication is one of the following: 1. A previous history of good response to ECT for a similar episode. 2. Failure of conventional pharmacotherapeutic attempts and/or inability of the patient to tolerate therapeutically effective doses of conventional medications. IV. REFERRAL AND SCREENING The following is a description of the procedures for referrals to ECT for eligible candidates. These procedures are subject to periodic review and revisions as the necessity arises. A. POLICY The SRU provides ECT for patients referred from any CPC unit. Referrals for ECT are initiated by the treating physician on the basis of their clinical judgement, but the independent opinion of two physicians is required for the approval of a patient to receive ETC. The treating physician and the Chief Psychiatrist of the referring unit must concur that ECT is indicated for the particular patient. The request along with all supporting documentation must then be submitted to the Clinical Director of CPC for review and approval. In all cases, it is the responsibility of the treating physician to provide an adequate description of the treatment to the patient and the family (when available) and to obtain the necessary written consent for treatment. This consent for ECT must include general anesthesia. It is the responsibility of the treating physician to document the clinical indications for ECT as well as patient history, current diagnosis, current symptomatology, and expected outcome of treatment. This documentation and documentation of medical clearance shall be submitted to the Clinical Director, for approval only after written consent is obtained. The treating physician is also responsible for obtaining a laboratory work-up (CBC, SMA 18, urinalysis), EKG, chest xray, physical examination and medical consultation for clearance for ECT by physician privileged to do so. B. PROCEDURE 1. CONSULTATION/SCREENING Treating Psychiatrist Contacts SRU Director or his designee to discuss the indications and appropriateness for ECT. 3 ECT Psychiatrist Within 3 working days will review with the treating psychiatrist the case history, current clinical condition, and if ambiguity exists about indications or appropriateness of ECT, interviews the patient. AU cases in which a court order for ECT is anticipated will be interviewed by an ECT psychiatrist. It is the prerogative of the ECT psychiatrist to disagree with the indications for ECT in any particular case. In the event of such a disagreement, the case is referred to the Director of SRU. The Director of SRU reviews the case and submits a report to the CPC Clinical Director for arbitration. 2. REFERRAL Treating Psychiatrist Documents in the progress note section of the patient's chart the rationale and clinical indications for ETC. The note must include the patient's previous treatment responses to somatic therapies, characteristics of the clinical status, the attitude of the patient towards past treatment, and evaluation of capacity to give an informed consent. Completes ECT referral form (CPC 0417-2/93) and presents it to the Chief Psychiatrist of his/her service. Chief Psychiatrist Reviews the recommendations and if supported, indicates approval on the ECT referral form. Treating Psychiatrist a) Discusses and describes ECT procedure to the patient. b) Obtains signed informed consent from the patient (or family when indicated) jointly with a psychiatrist privileged in ECT administration. c) Obtains pre-ECT work-up which includes but is not limited to: i) laboratory work-up CBC, SMA18 urinalysis) ii) electrocardiogram iii) chest x-ray iv) physical examination and medical consultation for clearance for ECT by a physician privileged to do so. *If patient is 50 years old or older or had cardiac or respiratory problems or is on diuretics, the medical clearance must be obtained within TWO WEEKS prior to the request for ECT. 4 Note: Spine x-rays will not be required on a routine basis, unless clinically warranted. d) Submits referral form, signed consent, and documentation for medical clearance to the Clinical Director for review and approval. Clinical Director or Designee Reviews ECT referral and indicates approval or disapproval on the form. Original is returned to the treating physician, to be filed in the patient's chart. 3. SCHEDULING ECT RESPONSIBLE PERSON/PROCEDURE Treating Psychiatrist Forwards copy of referral to the ECT nurse and schedules with her/him the treatment sessions. The patient is then informed of the treatment date. ECT Nurse Informs the ECT psychiatrist of appointment and forwards the pre-ECT information sheet (CPC 0213 - 2/93) to the nurse on the referring unit. V. TREATMENT PATIENT PREPARATION 1. Policy ECT is administered in the early morning, usually three times a week. In some cases ECT may also be administered once a week, or less often for maintenance therapy in selected patients who have responded to an index course of ECT. The patient is accompanied to the Unit by a staff member from the patient's ward. The patient must be N.P.O. after midnight of the night prior to treatment. The patient should be encouraged to void prior to treatment. If the patient uses dental prostheses, these should be removed. It shall be the responsibility of the ward staff where the patient resides to document the patient's clinical status (as outlined in CPC 0213) on the morning of each treatment, prior to being sent to the ECT unit. 5 2. Procedures a. Prior to Each Treatment Treating Psychiatrist i. Writes order for patient to be NPO after midnight the night prior to treatment. ii. Places patient on 1:1 observation after midnight to ensure NPO status. Ward Nurse i. Encourages patient to void prior to treatment and documents in patient's chart. ii. Ensures that the patient removes dental prosthesis prior to treatment. iii. Completes CPC 0213 form. iv. Insures that chart contains original consent, referral form and documentation of medical clearance. v. If appointment is cancelled, documents reason in chart. Ward Staff i. Brings patient with complete chart to the ECT unit. ii. Assists patient in preparing for the treatment and remains with the patient during the pre and post treatment period. iii. Escorts the patient back to the unit. ECT Staff Monitors vital signs of the patient before and after the treatment and assists in discharging the patient from the ECT unit after the ECT physician has determined that the patient is clinically stable (see Part B.2 documentation). B. ANESTHESIA CARE 1. POLICY General anesthesia is administered in the process of provision of electroconvulsive therapy by an anesthesiologist certified, or eligible, by the American Board of Anesthesiology and privileged by the facility to do so. Procedures for administration of anesthesia and its documentation are developed by the anesthesiologist in consultation with the Directors of Medicine and Psychiatry. Monitoring and Evaluation programs are similarly developed in coordination with the department directors, because the provision of electroconvulsive therapy requires inter-departmental cooperation and coordination. 6 Inhalational anesthetics are not employed at the facility. Accordingly, anesthesia machine issues are not relevant. 2. DOCUMENTATION Prior to anesthesia and electroconvulsive therapy, each patient must be evaluated by an internist specially privileged to render such consultations. In addition, the anesthesiologist also evaluates the patient prior to the administration of anesthesia. This anesthesiologist's evaluation is documented on the Anesthesia Administration Form (CPC 0302 - 2/93), as are the results of monitoring the patient during anesthesia, the drugs, dosages, and route of administration employed, all unusual events during the conduct of the anesthesia. The anesthesiologist also performs and documents a post-anesthesia evaluation, including vital signs, level of consciousness, drugs and fluids administered. The anesthesiologist is responsible for determining when the patient may be moved from the treatment room to the recovery room. 3. MONITORING AND EVALUATION PLAN All cases of ECT at Creedmoor are monitored. Process indicators include notation of data from the pre-anesthetic medical evaluation, notation of risk category, notation of presence or absence of airway obstructions, assurance that the patient has not eaten for at least eight hours prior to the administration of the anesthetic, absence of upper respiratory infection, and prior anesthetic history. Recovery time post-anesthesia and the presence or absence of adverse effects are indicators of outcome. The process indicators have target thresholds set at 100%, except for the absence of respiratory infection, recognizing that occasionally the risk of anesthesia in a patient with such an infection may be less than the risk of postponement of the electroconvulsive therapy. Excessively long recovery time has a threshold of 95% because this is a biological variable that cannot be totally predicted. Presence of adverse effects also has a 95% threshold for the same reason. Each individual instance of adverse effect of anesthesia is separately reviewed. C. PREPARATION OF THE TREATMENT ROOM 1. EQUIPMENT Each morning prior to the first treatment that day, the ECT nurse shall check for the availability, functioning capacity and/or maintenance of the following equipment: a. Oxygen tanks and masks: Oxygen tank in place, on anesthesia machine: 1 full, 1 in use and I full back-up Masks in various sizes clean and laid out b. Suction machine: Plugged in and tested that suction works New suction attachment in place for immediate use 7 c. Defibrillator - EKG: Plugged into panel Test battery, EKG strip, and readout monitor d. Emergency medication and equipment (e.g. ambu bag) e. Medical supplies For ECT Psychiatrist: alcohol preps, electrode paste, electrode jelly, EEG and EKG leads, electrodes, tongue blades, and surgical tape. For ECT Anesthesiologists: suction catheters, oxygen masks, airway equipment, infusion sets, tourniquets, alcohol wipes, and surgical tape. 2. STORAGE AND DISPENSION OF MEDICATION The following drugs and solutions shall be available for immediate administration during treatment: a. Dextrose 5% in water (250 ml units); atropine 0.4 mg/cc; sodium brevital 10mg/cc; succinylcholine chloride 20mg/cc; other medications as requested by the ECT physicians. The following are additional emergency medications that may be needed to counteract possible adverse effects of treatment: b. Atropine 0.4 mg/cc; lidocaine 25 mg/cc; propranolol 1 mg/cc; diazepam 5mg/cc. C. A routine emergency cart is regularly available (in the clinic area of Bldg. 40) for any emergency should it arise. Note: No flammable anesthetic agents are used in the ECT Unit. 3. SUPPLIES These are ordered as necessary from the pharmacy. Medications Brevital Sod. 10 mg/cc. Succinycholine chloride 20mg./cc Valium 5mg/cc 2% Lidocaine Hcl 20mg/cc Inderal 1mg/cc 8 Atropine Sulphate 0.4 mg/cc or I mg/cc Nitroglycerin tabs 0.4 mg (1/ 15 gr.) b. IV Solutions 5% dextrose in water, 250 cc. bottles c. IV Tubing d. Oxygen tanks e. Airways f. Oxygen masks g. Suction catheters h. Redux gel and paste i. Tape j. Bandages 4. METHODS OF DRUG CONTROL Drugs listed as controlled substances are under regulation of the hospital pharmacy, with the R.N. and M.D. signing control sheets each time medication is used. These sheets are kept in a locked medication cabinet in the treatment room. A one-week supply of controlled drugs (Brevital and Valium) are kept in a locked box in a locked cabinet in the ECT Treatment Room. There is only one set of medication keys, which is kept in the medication room on the Schizophrenia Research Unit. D. TREATMENT ADMINISTRATION 1. TREATMENT ECT is usually administered using a MECTA device (Custom Systems Associates, Biophysics Division). This device passes an 800 mAMP constant current. Pulse configuration is bidirectional square wave. Frequency may range from 20 to 140Hz; pulse width from 1.0-2.0 mec, and duration of stimulus from 0.5 sec to 4.0 seconds. The device measures patient impedance prior to ECT administration. If interface resistance is too high thus raising the possibility of electrode bum, the ECT stimulator is disabled by an automatic fail/safe mode and 9 will remain so until patient impedance is within acceptable safety limits. EKG is monitored constantly except during stimulus administration. Throughout the treatment period, the patient is attended by a psychiatrist, anesthesiologist, and nurse. EEG, EKG, and ECT electrode placements are prepared by the ECT psychiatrist prior to administration of anesthesia. All electrode placement sites are cleansed with alcohol. Disposable electrodes are used to monitor EKG, with electrodes placed over the precordium. EEG is monitored with gold electrodes by means of unilateral or bilateral frontal placements using the ear for placement of the reference electrode. Anesthesia is induced according to accepted standards of medical practice, at the levels that minimize the amount of current necessary to elicit a generalized seizure. Sodium brevital is administered in doses individualized for each patient, which typically ranges from 40 to 80 mg. The concentration is 10 mg/cc of normal saline solution which is injected into the plastic tubing attached to a catheter previously introduced into the patient's vein by the anesthesiologist. The IV is left in situ until treatment is completed and the patient is ready for transfer to the recovery area. The patient is oxygenated by face mask by the anesthesiologist prior to and following drug injection to maintain adequate oxygenation. A light anesthesia is produced which is deep enough to ensure that the patient remains unconscious throughout the ECT procedure. Succinylcholine chloride is injected IV as soon as the patient demonstrates a response to the anesthetic. The dose is individualized and typically ranges between 40 and 80mg. The concentration is 20mg/cc of normal saline. Succinylcholine chloride is administered as an IV bolus. To determine that a sufficient state of paralysis has been obtained, flexibility of the lower jaw is examined. Maximal effect of succinylcholine chloride usually occurs within 60 to 120 seconds after IV bolus administration. ECT is then administered. A method of limit procedure is used to determine the seizure threshold of each individual patient at the beginning of a course of treatment. The decision as to whether or not to treat the patient at threshold throughout the course of ECT or whether to treat at a higher than threshold current intensity is made by the ECT psychiatrist after the initial treatment. ECT may be administered bilaterally (bitemporal placements) or unilaterally (d'Elia placement). Duration of the seizure is measured by two methods simultaneously - a) the cuff method in which the ECT nurse inflated the blood pressure cuff 20/mgHg above the systolic pressure prior to administration of succinylcholine chloride and times the duration of convulsion in the nonparalyzed arm/leg; and b) EEG method in which the duration of seizure activity is measured from the EEG tracing. Oxygenation is resumed through controlled ventilation by the anesthesiologist as soon as the stimulus has been delivered. During the seizure, EEG is monitored by chart recording on the MECTA. In addition, the anesthesiologist monitors EKG through a CRT on a separate EKG monitor. Vital signs are monitored by the nurse throughout treatment and recovery. Oxygen saturation is continuously monitored by pulse oximetry. After administration of ECT, teeth, tongue, and nasopharynx are examined and secretions removed by suction, if necessary. 10 The. anesthesiologist notes the return of spontaneous breathing and opening of eyes to command. Oxygenation is continued until normal breathing resumes. Vital signs are monitored continuously until the patient returns to full consciousness. After the initial resumption of consciousness following treatment, the patient is transported by a stretcher to the recovery area. The patient is observed by ancillary ECT staff until full orientation is achieved and the patient is able to walk without assistance. The patient is then cleared for return to the ward by the ECT psychiatrist. In rare cases where the patient does not fully orient, the patient is discharged by the ECT psychiatrist only when the patient is able to ambulate independently. The patient is accompanied back to the ward by the staff member from the ward and served breakfast upon arrival at the ward. A psychiatrist from the ECT team remains in the ECT unit or in the vicinity until all the patients are discharged from the unit. 2. RECORD DOCUMENTATION The rationale and clinical indications for using ECT shall be documented in the patient's record by the treating physician in a narrative standardized form (CPC 0417). The original copy of the case summary with the written approval of the Clinical Director, CPC shall be kept in the patient's record, along with the medical clearance and the consent. In those rare cases where the patient refused ECT but such treatment was approved by a court order, the court order shall be filed in the patient's record. Throughout the treatment period, it shall be the responsibility of the treating physician to document changes, if any, of the therapeutic and adverse effects of the treatment. A brief note about the conduct of each treatment session will be written by the ECT psychiatrist. At termination of the treatment course, a note in the patient's medical record by the ECT psychiatrist shall indicate the reasons for termination and a summary of the therapeutic and/or adverse effects of the treatment course. A record of all the patients who have been treated shall be maintained by the ECT physician. This record shall contain the following information: patient's name, case number, sex, age, treatment number, modality of treatment, anesthetic and muscle relaxant dosage, and atropine (if any) given at treatment, settings on the MECTA (pulse width, stimulus duration, and pulse frequency) used to elicit seizures, and comments on recovery from anesthesia and treatment. The ECT Unit shall also maintain separate records of the time anesthesia was given; seizure duration; time to return of breathing and eyes open; and time patient leaves treatment room. For some patients, the ECT Unit shall maintain separate detailed records of the time taken for return of orientation of personal information, time, and place. As noted in section B.2., the anesthesiologist shall document anesthesia information and patient condition prior to during, and post treatment (CPC 0302). The nurse assigned shall maintain record of each patient's vital 11 signs prior to actual treatment and following a generalized seizure, or when, otherwise indicated (on form CPC 0302). E. GUIDELINES FOR INFECTION CONTROL IN ECT PROCEDURES 1. Hand washing to be done before and after contact with the patient, and after contact with any contaminated articles. 2. Articles that have come into contact with body fluids will either be discarded or appropriately bagged and labeled according to hospital policy and before being sent for decontamination and reprocessing. 3. Non sterile gloves must be worn by personnel in, direct contact with the patient; i.e., starting IV's, drawing blood samples, inserting airways, suctioning, or intubation. 4. The use of gowns, masks and protective eyewear by those personnel in direct contact with body fluids of patient is recommended. 5. Needles and syringes will be disposed of in rigid puncture-resistant type (red) containers as per CPC policy. To prevent needle-stick injuries, needles will not be recapped or purposely bent or broken. Parenteral injections, and blood drawing Will be done only by the ECT physicians or nurses using the preceding guidelines. If a glove is torn or other injury occurs, the glove will be changed as promptly as safety permits and the needle or instrument removed. 6. No health care worker who has exudative lesions or weeping dermatitis will perform or assist in direct patient care activities or handle equipment used for patient care in ECT area. 7. All blood specimens are considered potentially infected. Therefore, no special labeling will be used. All blood specimens are to be placed in a plastic bag for transport. 8. Soiled linen will be bagged and processed according to hospital policy 9. Bite blocks are discarded after each treatment in the appropriate red plastic bags. 10. Face masks are reused. The procedure for using the Cidex Plus disinfectant solution is as follows: a. Cleaning precaution - wear disposable latex gloves, eye protection, face mask and gown when cleaning and disinfecting masks. b. Directions for use: i. Activation - activate the Cidex Plus solution by adding the entire contents of Activator vial which is attached to the Cidex Plus solution container. Shake 12 well. Activated solution immediately changes color to green, thereby indicating solution is ready to use. ii. Cleaning/Decontamination - Step one: Blood and other body fluids must be thoroughly cleaned from surfaces before immersing in Cidex Plus solution. Step two: Immerse masks completely in Cidex Plus solution for at least 20 minutes at 68° - 77° F. Step three: Following immersion in Cidex Plus solution, thoroughly rinse the masks by immersing completely in three separate copious volumes of water. Each rinse should be a minimum of one minute in duration. iii. Reusage - during the usage of Cidex Plus solution, it is recommended that the Cidex Plus solution be tested with the Cidex Plus solution test strip prior to each usage. The PH of the activated solution may also by periodically checked to verify that the PH of the solution is between 7.5 and 8. 1. iv. Reuse period - efficacy of this product during its use-life must be verified by the Cidex Plus Solution test strip to determine that at least the minimum effective concentrate of 2. 1 % glutaraldehyde is present. v. Storage/Expiration date - 1. Cidex Plus solution should be stored in sealed container at room temperature (59°86°F). 2. The expiration date of the inactivated Cidex Plus solution will be found on the label of the immediate container. - 3. The use period for "activated" Cidex Plus solution is no longer than 28 days following activation or as indicated by the Cidex Plus solution test strip. Once activated, the solution requires no further dilution prior to use. VI. OUTPATIENT ECT Creedmoor Psychiatric Center does not currently provide outpatient ECT. However, on rare occasions, a patient who had received ECT while an inpatient may be discharged and continue to need maintenance ECT. These patients will be readmitted to Creedmoor the day before a scheduled treatment and the same procedure for inpatient ECT will be followed. The patient may be discharged on the day of the ECT treatment or as clinically determined by the treatment team. To ensure adequate communication between the ECT team and the outpatient treatment team, the treating outpatient psychiatrist will contact the ECT psychiatrist, or vice versa, for a case discussion at least once every three months. The core elements of this discussion will be communicated to the inpatient psychiatrist who is responsible for admitting and discharging the patient. The discussion and plan will be documented by both the treating outpatient psychiatrist, in the clinic record of the patient, and by the ECT psychiatrist, in the inpatient medical record. A new consent is obtained and routine physical examination is performed each time the patient is admitted for an ECT treatment. Routine labs (CBC with differential, SMA20) should be obtained every 3 months and formal medical clearance for continuing ECT every 6 months. 13 VII. ECT FOR INPATIENTS FROM OTHER INSTITUTIONS All guidelines which apply to the approval and use of ECT for inpatients shall apply to all patients referred for ECT from other State Facilities. For such referrals the Clinical Director of the referring facility must obtain administrative approval from the Clinical Director of Creedmoor Psychiatric Center. Once approved, the Clinical Director of Creedmoor Psychiatric Center, or his designee, will notify and request the ECT unit to contact the treating physician and provide the clinical guidelines for obtaining consent and medical clearance for general anesthesia and ECT. The completed referral packet should be forwarded to the Clinical Director of Creedmoor Psychiatric Center, for review and approval. The approved packet must then be forwarded to the ECT unit for review and scheduling of ECT. For patients already receiving ECT at other State facilities, Creedmoor Psychiatric Center will provide backup ECT service on a temporary basis. The same consent and medical clearance documentation required for Creedmoor patients will also be required for these patients. In addition, administrative approval by Clinical Director of CPC or his designee will be required to administer ECT. Final version 11. 17.98 14 State of New York Office of Mental Health CPC FORM 0101 (4/99) Patient's Name (Last, First, M.I.) CONSENT FOR ELECTRO CONVULSIVE THERAPY C. No. Unit/Ward No. Facility Name: I hereby authorize and give my consent to Creedmoor Psychiatric Center to administer to me. Or to the named patient, a series of electro-convulsive treatments, and general anesthesia. I understand that treatment entails a series of 4-15 treatments which may be administered over a three month period. I have been informed that each treatment involves the use of general anesthesia and that the specific treatment, ECT, Involves the passing of an electric current through a specific area of the brain. The risks and benefits to health and life associated with general anesthesia, the medication used, and the electro-convulsive treatments have been explained to me by the treating psychiatrist, Dr. _______ and the psychiatrist privileged in ECT administration, Dr. _______ . We have also discussed the risks and benefits and efficacy to life and health of alternate treatment modalities, which include medication and psychotherapy. I understand that the question whether ECT or an alternative treatment is most appropriate depends on prior experience with these treatments, and the nature of the psychiatric condition. While it cannot be guaranteed that any medical treatment will result in improvement, the majority of people with similar emotional difficulties show improvement following treatment. The side effects of ECT and general anesthesia, which may occur, include: I. Confusion. after treatment usually lasting 10-45 minutes; 2. Memory loss which usually subsides within the first few weeks following treatment; 3. Remote possibility of fracture, dislocation, brain damage or death (occurs less frequently than 1 In 40,000 treatment). I understand that, if during my hospitalization, as a result of ECT, Injuries occur from known or unknown risks of the treatment described to me, immediate medical care and treatment will be available. It is my understanding that I may withdraw my consent for electro-convulsive therapy treatment at any time throughout the course of the proposed treatment. Patient's Signature (Print Name Above) Signature of Witness: Date Signature of Treating Psychiatrist Date (Print Name Above) Signature of Psychiatrist Date (Privileged In ECT Administration) (Print Name Above) If patient lacks capacity but does not object, then a parent, spouse, adult child or legal guardian must complete the following: (In this category, two psychiatrists, neither associated with the ECT unit must certify that the patient lacks capacity to give Informed consent and does not object to ECT in progress notes in the patient's record.) I__________ (Print Name) of_____________ (Address) being the ____________ (Relationship) of _______________________ (Name of Patient) a patient at the Creedmoor Psychiatric Center hereby authorize _______________ (Doctor's Name) and whomever he may designate to administer Electro-Convulsive Therapy. Signature Date (Print Name Above) Signature of Witness: Signature of Treating Psychiatrist Date (Print Name Above) Signature of Psychiatrist Date (Privileged in ECT Administration) (Print Name Above) PSYCHIATRIST'S STATEMENT REGARDING PATIENT'S CAPACITY TO GIVE CONSENT FOR ECT I hereby certify that I have explained the nature, purpose, benefits, risks of, and alternatives to the proposed procedure, have offered to answer any questions and have fully answered all questions. Check One A. I believe the patient has the capacity and understands what I have explained and answered. B. I believe the patient lacks the capacity and does not understand what I have explained and answered but I believe that the relative/guardian understands what I have explained and answered. Treating Psychiatrist's Signature (& Print) Date Notes: 1) In case in interpreter is required: Signature of Interpreter Print Name Date CPC # 0417 (2/93) CREEDMOOR PSYCHIATRIC CENTER NARRATIVE SUMMARY Name of Patient Referred for ECT: Last________First__________ Age: Date of Birth: CH: Ward No.: I. IDENTIFYING INFORMATION: DESCRIPTION AND NARRATIVE OF CURRENT EPISODE (current diagnosis and symptoms should be noted). III. PAST PSYCHIATRIC HISTORY (Include # of episodes, duration of episodes, # of hospitalizations, age of illness onset, etc.). CPC # 0213 (2/93) CREEDMOOR PSYCHIATRIC CENTER PRE-ECT INFORMATION SHEET PATIENT'S NAME: ________________ C#________ Last, First (TO BE FILLED IN BY ECT STAFF) NEXT ECT DATE: TIME: RECCOMENDATIONS (If any): Bring Chart Nurse: Complete this form NPO: After midnite. Remove nail polish if applicable (to be completed by the ward RN the mornings on which ECT is administered) WEIGHT: DATE: NPO after midnight (YES) (NO) List of current medications (generic name and dose), including preanaesthetic medications; if none, state none: 1. 2. 3. Dentures removed (YES) Has patient voided? (YES) (NO). VITAL SIGNS: PULSE: BLOOD PRESSURE: TEMPERATURE: RESPIRATION: EYE GLASSES IF PATIENT REQUIRES THEM: (Yes) (No) (N.A.) Date WARD R.N. (signature/print) IV. TREATMENT AND MEDICATION HISTORY: (Include all types of treatment patient has received; dosages, duration and response. LIST all medications patient is presently taking; dosages: duration: and response. Note any adverse reactions due to treatment regimens). V. MEDICAL HISTORY: (Include any significant current or past medical problems). VI. REASONS FOR RECOMMENDING A TREATMENT COURSE OF ECT. VII. DESIRED OUTCOME: Yes No VIII: MEDICAL CLEARANCE OBTAINED IX: CONSENT SIGNED Treating Physician's Name/Signature Date X: Approved Disapproved Chief Psychiatrist's Name/Signature Date XI: Approved ________ Disapproved Clinical Director's Name/Signature Date XII: If disapproved, please state reason(s) Creedmoor Psychiatric Center Anesthesia Administration Form CPC # 0302 (2/93) Patient Name: C#: Ward: Date Last First Date of Birth:-/-/- Referring MD: Weight: Sodium:- Date:-/-/- Potassium: Date:__/__/__ Hgb/Hct: Date:-/-/- Blood Sugar/BUN: Date___/___/ ECG Date: ECG Findings: Chest X-ray Date: CXR Findings: Hx of heart/lung problems? NO YES: Medical Clearance Note Date: MD: Cleared? Yes No Anesthesia ASA Risk Category: 1 2 3 4 ECT #: Pre-Anesthesia Evaluation: NPO since: URI absent: Yes No Airway clear: Yes No Anesthesia Administration Record Anesthesioloqist: Psychiatrist: Nurses: Initial medications (IV) Atropine Brevital Anectine Additional Meds? Yes No Atropine Brevital Anectine Atropine Brevital Anectine Poct-Anesthesia Evaluation: Anesthesiologist's Signature: Vital Signs pre-ECT baseline post-ECT 30sec. 1min. 4min. 8min. 10min. 15min: 20min. Blood Pressure Pulses Respiration Time of: Last ECT Shocks AM PM Spontaneous Respirations AM PM OpenS Eyes: AM PM Nurse's Signature: Comments: (Include the presence or absence of adverse occurrences) |
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