Document Title… · CNTW(C)51 – Electroconvulsive Therapy (ECT) – V04.1-Oct 19 5 Be familiar...

Document Title Electroconvulsive Therapy (ECT) Policy

Reference Number CNTW(C)51

Lead Officer Medical Director

Author(s) (name and designation)

Kate Appleby – Clinical Lead Nurse

Alison Ford-Brown – Lead Practitioner Dr Jane Newby – Trust wide Lead ECT Consultant

Ratified by Business Delivery Group

Date ratified Jun 2019

Implementation Date Jun 2019

Date of full implementation

Jun 2019

Review Date Jun 2022

Version number V04.1

Review and Amendment

Log

Version Type of change

Date Description of change

V04 Review Jun 19 Re-write

V04.1 Update Oct 19 Governance Change

This policy supersedes the following documents which must now be destroyed:

Reference Number Title

CNTW(C)51 – V04 Electroconvulsive Therapy Policy (ECT)

CNTW(C)51

Electroconvulsive Therapy (ECT)

Section Contents Page No.

1 Introduction 1

2 Purpose 1

3 Aim 1

4 Duties 1

5 Definitions of terms used 5

6 Identification of Stakeholders 6

7 Equality Impact assessment 6

8 Training 6

9 Implementation 6

10 Monitoring compliance and effectiveness 6

11 Standards / Key Performance Indicators 7

12 Fair Blame 7

13 Associated documentation 7

14 References 7

Standard Appendices – attached to policy document

A Equality Impact Assessment Tool 8

B Communication and Training check list & Needs Analysis

10

C Audit/Monitoring Tool 12

D Policy Notification Record Sheet - click here

Practice Guidance Notes – listed separately to policy

Document No: Description

ECT-PGN-01 ECT Pathway

https://www.ntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(C) 51

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(C)51 – Electroconvulsive Therapy (ECT) – V04.1-Oct 19

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1 Introduction 1.1 In 2003 The Royal College of Psychiatrists (RCP) established ECTAS

(Electroconvulsive Therapy Accreditation Service) 1.2 ECTAS (ECT Accreditation Service) govern the national accreditation of clinics

according to agreed standards in line with the ECT handbook 3rd Edition (Royal College of Psychiatrists, 2013), National Institute of Health and Clinical Excellence (NICE) Appraisal of ECT (NICE 2003: reviewed 2005, updated 2010) and the Scottish National Audit of ECT (SEAN 2015)). They have been subject to extensive consultation with all professional groups involved in ECT and with

service users and their representative organisations. 1.3 This document relates to the process of administration of ECT and in this regard

is consistent with NICE guidance. It also links directly with the practice guidance document ECT PGN-01

1.4 NICE Technology appraisal No. 59, (2003: reviewed 2005, updated 2010)

provides guidance on the use of ECT. Additionally, commissioned by NICE, NICE: Management of Depression in Primary and Secondary Care – CG 90 1.10. (Updated 2018) reflects latest available research in providing further contemporary guidance on the use of ECT.

2 Purpose 2.1 The purpose of this document is to ensure clear, accessible information and a consistent, high quality approach to the delivery of ECT within Cumbria Northumberland, Tyne and Wear NHS Foundation Trust (the Trust), which meets national standards (ECTAS). 3 Aims 3.1 To provide guidance, support and standard documentation to referring teams to ensure safe and legal delivery of ECT within the Trust. 4 Duties, accountability and responsibilities 4.1 Chief Executive Officer 4.2. The Chief Executive is responsible for ensuring that an appropriate and adequate infrastructure exists to support the delivery of ECT services throughout the organization. 4.3 Board of Directors 4.4 The Board of Directors will ensure all ECT Trust wide services will be

accredited members of ECTAS; for current ECTAS accreditation status, queries should be made to local ECT departments.’

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4.5 The Board of Directors will assume the following roles and responsibilities in respect of ECT services across the Trust:-

To formally review at least on an annual basis the arrangements for provision of ECT services within the Trust.

The Trust will ensure that service level agreements (SLA) are in place with another Trust for anesthetic provision and that these agreements are formally reviewed and agreed at least annually by the Trust board.

4.6 Clinical Business Groups (CBU)

CBU Directors have overall responsibility to oversee implementation of the ECT policy.

The CBU Director(s) has responsibility to receive and review regular reports on any ECT incidents occurring within the Trust, and feed into relevant committees.

To manage incidents and subsequent action plans.

To attend Multi-disciplinary forum for structured management of ECT services that feeds into patient safety/patient experience domain committee/s.

The CBU Director(s) is responsible for the strategic and operational management of the ECT service within their locality.

Be an integral member of the organisations clinical governance and patient safety teams and structures.

Produce an annual report on ECT services and the organisation for which he/she is responsible for and release it publicly.

4.7 Roles and responsibilities of the ECT team will be to –

Provide a twice weekly effective and efficient ECT service with appropriately skilled staff in attendance.

Provide appropriate and up to date clinical advice on ECT treatment and services to staff.

Promote safe and legal practice of ECT within respective localities as part of the integrated governance system and supporting referring teams.

Obtain, maintain and promote ECTAS accreditation in all Trust ECT services.

Undertake audit, reporting and training activity associated with maintaining ECTAS accreditation.

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Work in cooperation with each ECT providers trust wide to optimize effective and efficient service.

4.8 Senior Manager

Maintain (service contracts) for equipment. Ensure cleanliness/environmental assurance checks of treatment areas and equipment are carried out.

Participate in a culture of continual improvement with reference to evidence based practice.

Oversee the ECT service and regularly attend ECT Clinical standards Group (CSG) meetings.

4.9 ECT Medical Team

Responsible for the safe and professional delivery of ECT.

Available for regular, twice weekly ECT sessions.

Undertakes appropriate CDP in ECT in line with appraisal and revalidation requirements and keeps up to date with new developments with research.

Has a sound knowledge and competency based skills regarding ECT.

Junior members of the medical team are supervised for at least three sessions until fully competent. Thereafter they must seek advice as appropriate from senior medical staff responsible for ECT.

Senior medical staff are responsible for training and supervision of junior medical staff and provide teaching to medical students.

Liaise with other members of the medical and anaesthetic team regarding patients and ECT.

Check documentation verifying the indication and legal basis for ECT.

Ensure in conjunction with other staff members that ECT is safe to give.

The consultant will be available to provide advice to referring consultants regarding all aspects of treatment including advice on the indication, maintenance and discontinuation of ECT and will communicate with referring clinicians during the treatment course where require.

Together with ECT staff promotes audit, research and development of services to a high standard.

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4.10 Nominated Locality Lead Consultant

The locality lead ECT Consultant is named and adheres to all relevant ECTAS standards and are available for scrutiny from www.rcpsych.ac/cru

The locality lead Consultant ensures other medical staff working into the ECT team are aware of and adhere to ECTAS standards.

The locality lead Consultant will liaise with Consultant colleagues to promote awareness of ECT standards, available training for referrers, local training and act as a medical link for communicating issues and developments relating to ECT.

As a member of the ECT medical team has the same responsibilities as other senior members of the medical team but with a greater emphasis on future development of the services and promotion of audit and research.

The locality lead consultant overseas the delivery of ECT and ensures the appropriate ECT training of medical staff.

The locality lead consultant will be involved in management tasks and meetings which involve the ECT service.

4.11 Roles and responsibilities of Lead ECT nurse will be to:

Provide nursing leadership within ECT team, supporting staff in implementation of a safe, legal and quality service.

Work closely with locality lead ECT consultant to ensure ECTAS, NICE and Trust policy standards are met and maintained.

Safeguarding service user/carer involvement in treatment and evaluation of services.

Monitoring compliance with ECTAS standards and maintaining accreditation status. Facilitate system of multidisciplinary review, forward (action) planning, and evaluation.

Assessing need for, and providing an ongoing programme of education and Training to teams.

Produce data upon request for monitoring purposes and ‘Freedom of Information’ requests.

Report incidents, breaches of type one standards, and any other concerns to their line manager and/or appropriate support service.

4.12 Clinical Trust staff - For services where it is likely that referrals to ECT may be indicated, have a responsibility to:

http://www.rcpsych.ac/cru

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Be familiar with and adhere to the ECT and related Trust policy and guidance notes, CNTW(C) 05 Consent to Treatment and the CNTW ECT PGN-01 ECT pathway document.

Participate in relevant training (via local ECT services). Training is available for student nurses, qualified nurses, unqualified escorts and staff from all other disciplines. Training is available for medical staff via contact with ECT lead Medic within local services

Discuss referrals with appropriate members of the ECT team 4.13 The ECT Team

The Trust will ensure that teams have access to properly constituted, supported and ECTAS accredited ECT services.

ECT teams will be supported with appropriate secretarial and clerical support, secure office and storage space, access to IT services, specialist equipment and other general resources as required for performing its functions.

The ECT teams will have access to educational, training and development opportunities sufficient to ensure that staff and up to date and informed about current ECT practice and can fulfill ongoing requirements for ECTAS accreditation.

A multidisciplinary Trust wide ECT development forum should be in place and meet regularly to address standardized clinical and development issues.

4.14 Trust Wide Lead ECT Consultant

Responsible for collaborative working with the Associate Director for ECT considering operational issues

Will review and develop Trustwide protocols in collaboration with senior nursing staff

Will work with locality lead consultants and nursing teams to ensure delivery of a high quality service by supporting and auditing the ECTAS standards

Will support teaching to maintain clinical learning and expertise for medical staff and work with locality lead consultants to ensure induction programmes and professional development sessions are delivered Trustwide

Chair the Trustwide ECT clinical standards group

5 Definition of terms used

ECT - Electroconvulsive Therapy.

ECTAS - Electroconvulsive Therapy Accreditation Service.

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NICE - National Institute of Health and Clinical Excellence.

CRAG - Clinical resource and audit group.

NALNECT - National Association of Lead ECT Nurses

6 Identification of Stakeholders

North Locality Care Group

Central Locality Care Group

South Locality Care Group

Cumbria Locality Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

7 Equality and Diversity assessment

7.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

8 Training (See Appendix B) 8.1 Where training is required it is the responsibility of both managers and staff to

ensure that this is undertaken and that attendance is verified and recorded.

9 Implementation 9.1 Taking into consideration all the implications associated with this policy, it is

considered that a target date of one year from date of issue is achievable for the contents to be embedded within the organisation.

10 Monitoring and compliance

10.1 All relevant staff to be made aware of this policy and its practice guidance notes; ECT Team to have completed training as per Appendix B - Training Checklist and Needs Analysis.

10.2 All escorting staff to undertake the appropriate training as outlined in Appendix B - Training Checklist and Needs Analysis.

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10.3 All medical staff consenting and prescribing ECT to have documented evidence of competency to do so, via mandatory training and appropriate updates.

10.4 All patients receiving a course of ECT treatment should undergo cognitive and mood assessments in accordance with minimum policy standards.

11 Standards/Key Performance Indicators 11.1 ECTAS standards March 2018 (revised 2019) and Trust guidance notes ‘How to

produce policy’ was referred to within the drafting of this policy. 12 Fair Blame

12.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

13 Associated documentation CNTW (O) 01 - Development and Management of Procedural Documents

CNTW(C) 05 - Consent to Treatment and Examination Policy

All relevant ECT patient information leaflets are documented in PGN 01 of this policy, section 2.4.

14 References

ECT Handbook (College Report) RCPsych Publications; 3rd edition (1 May 2013)

NICE ECT guidance: ‘Guidance on the use of Electroconvulsive Therapy’ TA 59 2003 (reviewed 2005, updated 2010)

‘Standards for Administration of ECT’ – The ECT Accreditation Services (ECTAS) fourteenth edition March 2018 (revised January 2019)

National Institute for Clinical Excellence. Depression in adults (update), National Clinical Practice Guideline 90, 2009 (updated April 2018)

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Alison Ford-Brown

Kate Appleby

Jun 19 Jun 22 Trustwide

Policy to be analysed Is this policy new or existing?

CNTW(C)51 - Electroconvulsive Therapy (ECT)-V04

Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

To ensure a quality service. Deliver safe, consistent, effective and legal ECT to service users. To ensure staff are working to ECTAS standards and have access to required level of information, support and training needed to fulfill statutory obligations

To aspire to ECTAS accreditation. To manage ECT services Trust wide utilizing resources cost effectively. To ensure staff have required level of knowledge in order to adequately support service users and carers within decision making process. To ensure staff adhere to associated Trust policies e.g. CNTW(C)05, Consent to Treatment and Examination; CNTW(C)23, Infection, Prevention Control

Who will be affected? e.g. staff, service users, carers, wider public etc

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability All ECT services across trust have disabled access

Sex -

Race -

Age Guidance provided in policy pathway for older persons and young people

Gender reassignment

(including transgender)

-

Sexual orientation. -

Religion or belief -

Marriage and Civil Partnership

-

Pregnancy and maternity Guidance provided in policy pathway

Carers -

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Other identified groups Guidance in policy pathway for people with learning disability

How have you engaged stakeholders in gathering evidence or testing the evidence available?

N/A

How have you engaged stakeholders in testing the policy or programme proposals?

N/A

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

N/A

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

YP have specific protocol for receiving ECT within the policy. Disabled access to all ECT services. All other groups unaffected as treated equally in accessing services across the Trust.

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

This policy does not discriminate

Advance equality of opportunity Yes

Promote good relations between groups Yes

What is the overall impact?

Addressing the impact on equalities

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Alison Ford-Brown Date: Jun 19

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Appendix B Communication and Training Check list for policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

Change

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

No

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Solutions etc.

Please identify the risks if training does not occur.

Needs cascading via usual new policy procedures.

ECTAS stipulates ongoing awareness training will be incorporated into ECT training provided by local ECT suites. These are normally 2 hours in duration. Also to be incorporated into referrers training for Consultants and other medical staff provided locally. Duration of 1 hour.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

ECT training is available for all disciplines, qualified or unqualified. It is essential for non-qualified acting as escort. Training is also provided for cohorts of new junior medical staff and referrers to ECT e.g. Consultants.

Is there a staff group that should be prioritised for this training / awareness?

Priority should be given to referring and escorting staff.

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Management cascade Newsletter/leaflets Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session , E Learning

Regular ongoing training in the form of teaching sessions supported by power point slides is delivered by respective ECT teams.

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

All Lead ECT Practitioners

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Appendix B – continued

Training Needs Analysis

Staff/Professional Group Type of training Duration of Training

Frequency of Training

Medical staff

Qualified nursing staff

Unqualified nursing staff

Awareness of ECT policy and practice guidance notes

In line with policy review period

Consultant Medical staff The Royal College of Psychiatrists training for referrers to ECT. Local training for referrers to ECT

Once unless legislative changes

Qualified nursing staff

Unqualified nursing staff

ECT nurse escort training (local) Once only

Qualified nurses working within ECT team

The Royal College of Psychiatrists ECT 3 day Course for Nurses

Once

Qualified nurses and medical staff - ECT team

The Royal College of Psychiatrists ECT team training day

Available for annual

update

Qualified nursing staff - ECT team

Anaesthetics and recovery training (local)

Annually

Qualified nursing staff – ECT team

Immediate life support (ILS) Annually

Lead medic or Anaesthetist from ECT team

Advanced life support Annually

Qualified nurses –ECT team

Attend NALNECT practice update and attend North East ECT Nurse Forum

Annually

Copy of completed form to be:

Retained in relevant ECT department

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Appendix C Monitoring Tool

Statement

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

CNTW(C)51 – ECT Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group).

1 Referring teams, trust wide staff and escorting staff will receive once only training that is advertised by training and development.

Individual attendance recorded via dashboards, monitored by managers.

Trust wide clinical standards ECT group

2 All ECT team staff completed required training as per training section

Training will be recorded on training dashboards once completed competency framework is submitted. Training attendance report will be obtained by policy authors annually and submitted by Associate Director to governance group Also part of ECTAS accreditation process every 3 years

Trust wide clinical standards ECT group. Trust wide Quality & Performance group. ECTAS accreditation outcome reported to Trust wide Q&P .

3 All medical staff consenting and prescribing ECT should have documented evidence of competency to do so.

Via annual appraisal and CPD groups.

Attendance records from CNTW training retained by Lead Consultant.

Trust wide ECT development group.

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CNTW(C)51 – ECT Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where results and any associated action plan will be reported to, implemented and monitored; (this will usually be via the relevant governance group).

4 All patients receiving a course of ECT treatment should undergo cognitive and mood assessments in accordance with minimum policy standards

Evidenced within ECTAS audit results as part of ECTAS accreditation process & annual, health records audits of electronic patient records ECT documentation and progress notes. These audits carried out by ECT team members locally. .

Annual audits results reported to Trust wide ECT Clinical Standards Group

ECTAS accreditation outcome reported to Trust wide Q&P

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line

with the frequency set out.

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