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REVISED FINAL 1/20/00 ROCKLAND PSYCHIATRIC CENTER ELECTROCONVULSIVE THERAPY PROGRAM POLICY AND PROCEDURES I. Policy The Rockland Psychiatric Center ECT program provides acute treatment for inpatients as well as continuation and maintenance treatments for same. The ECT suite is located in the ambulatory medical clinic area on the second floor of Building 57. Hospital staff participating in the ECT evaluation, counseling, treatment, and monitoring process include physicians (psychiatrists, internists, and anesthesiologists), dentists, and nurses. The Rockland Psychiatric Center ECT program is oriented towards serving the inpatients of Rockland Psychiatric Center. Among the most frequent psychiatric illnesses treated are major depressive disorder, mania, bipolar disorder, schizophrenia, and other psychotic illnesses. As clinically indicated, other illnesses may also be treated. Our treatment program is oriented towards treating adult and geriatric patients. Pregnant women and patients with high risk medical conditions shall be individually evaluated as to their appropriateness for being treated here. If indicated, they may be referred to a tertiary care center for treatment instead. As patients should abstain from food or fluid for at least six hours before treatment, ECT, in general, is administered in the morning. II. Procedures
III. ECT will be administered by appropriately MSO credentialed anesthesiologists and psychiatrists.
IV. ECT Equipment
V. Emergency Situations: Should an emergency situation occur, the staff will call ext. 5555 immediately. VII. Quality Assurance Program Each department will monitor equipment for safety, appropriateness and efficacy. Each discipline will implement their own QA program regarding ECT. ROCKLAND PSYCHIATRIC CENTER RPC ECT-1 (12/99) _______________________________________________________ | (TO BE COMPETED BY REFERRING PSYCHIATRIST) | NAME | | C# | | DOB | | UNIT/WARD |_____________________________________________________ | FACILITY A. INDICATIONS FOR ELECTROCONVULSIVE THERAPY AND REASONS: Treatment unresponsiveness_______ Suicide Attempts_______ Need for Accelerated Response______ Suicidal Ideation_______ Depression_______ Self Abuse_______ Mania_______ Assaultiveness_______ Psychosis_______ Homicidal Ideation_______ Previous Treatment with ECT_______ Other_______ # of Treatments, Response _____________________ Comments & Goals:________________________________ _______________________________________________ Diagnoses: Axis I: Allergies: Axis II: Axis III Current Meds: Previous Medication Trials (medication, dosage, duration):____________________________ ______________________________________________________________________ ______________________________________________________________________ Special Precautions/Comments: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ SMA-20 Date ___/___/___ Handedness: Right Left CBC Date: ___/___/___ ECG Date: ___/___/___ ECG Findings:_____________________________ Chest X-ray (if applicable Date: ___/___/___ CXR Findings: _________________ Hx of heart/lung problems? No: [ ] Yes: [ ] Describe: ______________________________________________ ECT video viewed: Yes [ ] No [ ] Date: ___/___/___ ECT Pamphlet Given: Yes [ ] No [ ] Date: ___/___/___ ECT Discussed with Patient/Family: Yes [ ] No [ ] Date: ___/___/___ Referring Psychiatrist: _________________________________________________ Signature Print Name Date Medical Director:_________________________________________________ Signature Print Name Date ROCKLAND PSYCHIATRIC CENTER RPC ECT-1 (12/99) __________________________________________________ | (TO BE COMPETED BY MEDICAL SPECIALIST) | NAME | | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY History of Present Illness/Pertinent Surgical History:______________________________________ ________________________________________________________________________________ Current medications: Allergies: Yes [ ] No [ ] Comments ________________ Alcohol/street drugs/tobacco use: Yes [ ] No [ ] Comments ________________ Family History (medical and psychiatric) _____________________________________________ ECT History (past response/side effects)_____________________________________________ Personal history of: Yes No Comments Heart disease (MI, Angina, Hypertension, Arrhythmia C.H.F., Pace-maker) _____ _____ _____________________ Space-occupying lesion or increased intracranial pressure _____ _____ _____________________ Recent head trauma _____ _____ _____________________ Recent Stroke _____ _____ _____________________ Retinal detachmcnt/Glaucoma _____ _____ _____________________ Back or neck problems, spinal fusion, disc surgery _____ _____ _____________________ Pheochromocytoma _____ _____ _____________________ Gastroesophageal reflux _____ _____ _____________________ Thromophlebitis/Diabetes _____ _____ _____________________ C.O.P.D./Asthma/Bronchitis _____ _____ _____________________ Osteoporosis _____ _____ _____________________ Major bone fracture _____ _____ _____________________ Neuromuscular disorders _____ _____ _____________________ Cancer history _____ _____ _____________________ Pregnancy (current _____ _____ Last Menstrual Period_______ Dental pathology (loose teeth etc.) _____ _____ _____________________ or temporomandibular joint problems _____ _____ _____________________ Dentures, hearing aids, contact lens _____ _____ _____________________ Oral examination findings: ________________________________________ Personal or family history of:. Problems w/ anesthesia or surgery _____ _____ _____________________ Aneurysm or vascular malformation _____ _____ _____________________ Porphyria _____ _____ _____________________ Recommendations Needed prior to ECT Yes No Comments Additional medical evaluation _____ _____ _____________________ Additional lab or radiologic studies _____ _____ _____________________ Medication changes _____ _____ _____________________ Dental Consultation _____ _____ _____________________ Chest X-Ray Indicated _____ _____ _____________________ Dorsal spine films indicated _____ _____ _____________________ ROCKLAND PSYCHIATRIC CENTER RPC ECT-1 (12/99) __________________________________________________ | (TO BE COMPETED BY ANESTHESIOLOGIST) | NAME | | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY ____________________________________________________________________________ FOR 1st ECT ONLY SMA-20 Date: / / Sodium:_____ Potassium:_____ S.G.O.T._____ Blood Glucose:___ BUN:_____ S.G.P.T._____ Alkaline Phosphatase_____________________________ CBC Date: / / Hemoglobin: / / Hematocrit:___ WBC:_____ ECG Date: / / ECG Findings:_______________________________ Chest X- Ray Date: / / CXR Findings:___________________________ Hx.of heart/lung problems? Yes [ ] No [ ] Comments: Pre-ECT Medical Clearance Note Date: / / MD:_________ Cleared: Yes [ ] No [ ] ____________________________________________________________________________ |___________________________________________________________________________| Anesthesia ASA Risk Category: 1 2 3 4 WEIGHT:_____ ECT#:______ Family or personal history of anesthesia problems Yes [ ] No [ ] Comments:_________________________________________ Pre-anesthesia Evaluation: Allergies:_______________NPO Since:____________ Any Medications?_____________________________Charted: _______________ Teeth:_______ Dentures:______ Glasses/Contact Lenses:_______Hearing Aids:_______ URI absent? Yes[ ] No[ ] Airway Clear? Yes[ ] No[ ] Patient status does [ ] does not [ ]match that described in plan. Comments: ANESTHESIA CLEARANCE: YES____ NO____ _________________________________________ _________ (Signature) (Date) ____________________________________________ (Print Name) ROCKLAND PSYCHIATRIC CENTER RPC ECT-1 (12/99) __________________________________________________ | (TO BE COMPETED BY DENTIST) | NAME | | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY ____________________________________________________________________________ Grossly mobile teeth? Yes [ ] No [ ] Cosmetic dentistry? Yes [ ] No [ ] Extensive fixed bridgework? Yes [ ] No [ ] Orthodontic appliances in place? Yes [ ] No [ ] Prosthesis supported by dental implants? Yes [ ] No [ ] Broken down/infected teeth? Yes [ ] No [ ] Complaints of mouth pain? Yes [ ] No [ ] Recent history of mouth trauma? Yes [ ] No [ ] History of temporomandibular joint dysfunction? Yes [ ] No [ ] Appliances or conditions that pose a risk of aspiration? Yes [ ] No [ ] Special precautions? Yes [ ] No [ ] Comments_________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _________________________________ (Signature) _________________________________ (Print Name) _________________________________ (Date) ROCKLAND PSYCHIATRIC CENTER RPC ECT-1 (12/99) __________________________________________________ |(TO BE COMPETED BY TREATING PSYCHIATRIST) | NAME | | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY ____________________________________________________________________________ CONSENT FOR ELECTROCONVULSIVE THERAPY I hereby authorize and voluntarily give my consent to Rockland Psychiatric Center to administer to me or to the named patient, a series of electroconvulsive treatments and general anesthesia. I understand that this consent will be valid for 6 months and the number of treatments will be decided by my treating psychiatrist and the ECT psychiatrist. 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, medications 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 medications and psychotherapy. I understand that the question whether ECT or 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: 1. 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 I in 40,000 treatments). 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 electroconvulsive therapy at any time throughout the course of the proposed treatment. RN ECT RECORD ECT# | Date: ____________________ |________________________ Nurse: _____________________________________________ Time Arrived: _____________________________________________\ Accompanied By: Patient Name (Last, First, MI): PART I - PRE ECT EVALUATION To be completed by sending unit RN Baseline V/S T: P: R: BP: Weight: ECT Order written: Yes 0 No 0 NPO since Midnight Yes 0 No 0 Has patient voided: Yes 0 No 0 Time: ID Picture checked Yes 0 No 0 Hair washed within 24 Hrs: Yes 0 No 0 Allergies: Yes 0 No 0 Any Meds since Midnight Yes 0 No 0 it Yes, Specify: CHECK IF PATIENT HAS: 0 Eyeglasses/Contact Lenses 0 Dentures 0 Prosthesis 0 Hearing Aid 0 Jewelry/Watch 0 Mouth Guard 0 Cane/Walker/Wheelchair 0 Physical impairment 0 Impaired Communication Medical Record sent with patient? Yes 0 No [] Doctor Order Sheetst/Med Kardex sent with patient? Yes 0 No [] Jewelry/Watch/Nail Polish/Contact Lenses removed ? Yes [] No 0 Sending Unit RN Signature/Title Date: Time: PART II - ECT TREATMENT RECORD To be completed by ECT RN ORIENTATION: PRE POST What are your first and last names? How old are you? What is your Birthdate? What is the Day of the Week, Today's Date, Month, Year? Where are you? Place, City, County. State, Country? What are you doing here ? Who is with you? How do vou feel? ____________________________________________________________________________ POST ECT RECOVERY AREA EVALUATION - Post ECT Recovery Room Monitoring Chart (on back) to be completed every 15 minutes Time Procedure began: Time moved to recovery room: _____________________________________________________________________________ PART III - POST ECT DISCHARGE EVALUATION Discharge Order written: Yes 0 No Patient Teaching Done: Yes 0 No 0 Instructions Reviewed with Patient and Accompanying Staff: Yes 0 No 0 Person accompanying the patient back: Time Discharged: RN Signature Print Name Date Is Patient Stable for Discharge: Yes 0 No 0 Patient Discharged to: 0 Unit 0 Home 0 Other (specify) MD Signature Print Name Date Monitoring Chart on back of form ->>> ECT ANESTHESIA RECORD ECT# | Date: ____________________ |________________________ Anesthesiologist: _____________________________________________ Psychiatrist: _____________________________________________\ Nurse: Patient Name (Last, First, MI): Patient Review: NPO after midnight? []Voided in last hour? [] Dentures? [] Contact Lenses? [] URI absent? [] Equipment Check: Anesthesia Machine[] Suction [] Laryngoscope[] Time Equipment checked: Anesthesia Start: Anesthesla Finish: Previous Treatment Complications: Hypertension []Hypotension []Arrhythmia []Apnea [] Confusion [] COPD [] Secretions [] Bronchspasm[] Difficult IV BP Cuff Size:Adult[]Large []Pediatric [] Medication/Dose: Glycopyrrolate: Atropine: Methohexital: Succinylcholine: Atracurium: Pentobarbital: Caffeine: Other (specify): IV Solutlon: D5W[] NS[] D5W.5NS[] Ringers[] IV Site: Right[] Left[] Hand[] Forearm[] Antecubital[] Bite Block used? Yes[ ] No[ ] Type: Gauze [ ] Foam [ ] Rubber [ ] TIME O2 FIO2 EKG EtCO2 TEMP BP P 240 230 220 210 200 190 180 170 160 150 140 130 120 110 90 80 70 60 50 40 30 20 10 0 Fluids Urine NOTE: SR=Sinus Rhythm, AR=Arrythmia Seizure Duration EEG Motor Energy Modify Next Treatment: Yes [] No [] REMARKS: Signature: GENERAL AIRWAY MANAGEMENT: Mask Blade Oral/Nasal Trach Tube Attempts Easy/Diff. Vision Impaired/Blind Bilat Breathe Sounds Airway Nasal/Oral TOTAL FLUIDS: IV: Urine: PACU TIME: SaO2: O2: BP: P: R: []Alert []Unresponsive []Responsive to Pain []Responsive to Voice []NOTES ON MAINTENANCE: []Temp (Rectal, Oral Otic) []Precordial/Esophageal []Pulse/Oximeter []EKG []EtCO2 []O2 Analyzer []NeuroBlock Monitor [] NIBP [] Spirometer ROCKLAND PSYCHIATRIC CENTER RPC ECT-9 (12/99) __________________________________________________ |POST ECT DISCHARGE INSTRUCTIONS FOLLOW-UP | NAME |APPOINTMENT | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY Instructions: To be reviewed by RN with the patient/family member/significant other prior to departure from the EC T recovery area. 1. As part of your ECT treatment you have received anesthesia. The medications wear off quickly. However, some effects may linger throughout the day. Therefore you should: -Not drive a motor vehicle or operate dangerous equipment as your judgement and reflexes may not be normal. -Not drink any alcoholic beverages. 2. Some common side effects of ECT are: -A slight headache. -Some nausea/stomach ache (from anesthesia). -Dry mouth (from anesthesia). -Temporary memory loss and slight confusion. You may have difficulty remembering new information. This usually goes away in a few weeks. -Fatigue during the first few hours after the treatment. -Stiffness or sore muscles. Most symptoms usually go away in a few hours. A warm bath/shower, acetaminophen (Tylenol) or ibuprofen (Motrin) 400 may help with some of these symptoms. 3. If you feel/experience any of the following symptoms please report them to the Nurse. These symptoms include: -Extreme headache, nausea, vomiting or confusion. -Temperature -Redness, swelling, drainage or pain at your IV site which lasts more than 24 hours. -Any mood changes There is a doctor available twenty four hours a day. Next ECT appointment:__________________at ________________AM/pm I have reviewed the above and had the opportunity to ask questions. _______________________ ___________________________ Patient Accompanying Staff/Family _______________________ ___________________________ Registered Nurse Signature Date handwritten: liquid lunch 2 hrs after discharge from ETC. pt. can eat often ROCKLAND PSYCHIATRIC CENTER __________________________________________________ |ECT PSYCHIATRIST RECORD | NAME | | C# | | DOB | | UNIT/WARD |_________________________________________________ | FACILITY Psychiatrist: NPO after Midnight Yes No Voided in Last Hour Yes No Anesthesiologist: ECT Order Written: Yes No Orientation Checked: Yes No Nurse: Patient Complaints After Last Treatment: Yes [] No [] Headache []Muscle pain/stiffness[] Back pain[] Jaw pain[] Confusion[] Staring spells[] Other []_______________________________________________________ Medications: Glycopyrrolate_____ Atropine_____ Methohexital_____Succinylcholine_____ Atracurium_____ Pentobarbital_____ Other_________________________________________________________________ Bite Block Used: Yes [] No [] Gauze [] Foam [] Rubber [] ECT Machine: Thymatron [] Mecta [] Lead Placement: R/L Unilateral [] Bitemporal [] Bifrontal [] Settings: Percent Energy_____Pulse Width_____ Frequency_____Duration_____ Current_____ Seizure Length: EEG_____ Motor_____ See Print Out [] Restimulated: Yest[]No [] Percent Energy-_____Pulse Width_____ Frequency_____ Duration Current_____ Seizure Length: EEG_____ Motor_____ See Print Out [] Restimulated: Yes [] No [] Percent Energy_____Pulse Width_____Frequency_____Duration_____Current_____ Seizure Length: EEG_____ Motor_____ See Print Out [] Treatment Complications: Hypertension [] Hypotensio [] Arrythmia [] Apnea [] Confusion [] Secretions [] Bronchospasm [] Difficult IV [] Other [] ________ Other [] __________________________________ Post ECT Mods Given: Yes [] No [] Medications & Time_____________________________________________________________ _____________________________________________________________ Modify Next Treatment Yes[] No [] Comments: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ __________________________ (Signature) __________________________ (Print Name) __________________________ (Date) PHYSICIANS NAME:________________________________________________________________ APPLICATION FOR CLINICAL PRIVILEG DEPARTMENT OF PSYCHIATRY Please check the box for each area in which you are requesting privileges. If you wish privileges in addition to those listed, please indicate at the end PRIVILEGES: Bask Clinical Privileges for Psychiatrists [] a. Admission of Patients [] b. Evaluation of Patients. [] c. Clinical history, mental status exam. [] d. Treatment of patients; crisis intervention, psychotherapy. [] e. Group therapy, family counseling. Routine Medical Practices [] a. Basic physical exam. [] b. Prescription of medications. [] c. Prescription of restraints & secluslons. [] d. Evaluation of lab results [] e. Emergency minor surgery. [] Supervision of Clinical Staff in Direct Patient Care [] Discharge of patients including pre-discharge Evaluation [] Interdisciplinary professional consultation SPECIAL PRIVILEGES: [] Acupuncture [] ECT (Electro Convulsive Therapy) REQUIREMENTS: M.D. degree recognized by Department of Education State of New York New York State license with current registration Completion of psychiatric residency (Those in training perform the functions under supervision) Current DEA registration a. MD Degree recognized by Department of Education, State of New York b. NYS License in acupuncture c. Evidence of specialized training and/or capability & experience as attested by trained supervisors a. MD Degree recognized by Department of Education, State of New York b. Evidence of specialized training and/or capability & experience as attested by trained supervisors. c. Completion of ECT training |
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