Standards of Electroconvulsive Therapy (ECT)
Services at Zomba Mental Hospital (ZMH)
Michael M. M. Udedi
Introduction
• The hospital acquired a donation of 2 ECT machines (Mecta
SR models) from Scotland and anaesthetic equipment through
the Ministry of Health in 2007.
• Modified ECT was introduced at Zomba Mental Hospital in the
first week of September in 2007 .
• Selis, Kauye & Leentjens, (2008:140) suggested that
modification of ECT approaching western standards was
possible with clear ECT guidelines, consent procedures, and
adequate monitoring of effect and side effects.
• It is against this background that there was need to conduct
ECT audit at ZMH in order to assess the provision of care
Objective
• To identify the quality of care in terms of ECT
provision to patients at Zomba Mental
Hospital
ZMH - SET STANDARDS FOR ECT
• The ECT should be done under anaesthesia (90%
of cases)
• Files for the patients undergoing ECT should
include ECT forms (95% of cases)
• The indication of ECT should be written down
(95% of cases)
• The
consent
form
should
completed
appropriately (90% of cases)
• Physical examination should be done and
recorded within a week before ECT (95% of cases)
ZMH - SET STANDARDS FOR ECT
• Vital signs should be checked before and after
the ECT and recorded (95% of cases)
• Each ECT, dose, seizure length and anaesthetic
given should be recorded (90% of cases)
• Every patient receiving ECT should be
reviewed and review recorded after every
two ECT sessions before further ECT session is
conducted (Clinical condition, side effects and
consent status) [90% of cases]
Design
• This was a retrospective case file audit study
• It looked at previous patients records who
underwent ECT and also the administration of
ECT itself in an attempt to determine the
quality of care in terms of patients.
Sampling & sample size
• Patients’ records for this study were randomly
selected using a systematic sampling technique
• A sample size of 30 case files belonging to the
patients who were previously admitted at the
hospital between August 2008 and December
2008 who underwent ECT
• 60 patients underwent ECT during the study
period thus in this case every 2nd case file of the
population was selected
Inclusion Criteria
• Cases included in the audit were all the case
files for psychiatric patients registered with
ZMH from August 2008 to December 2008.
• The patients selected were based on the fact
that they underwent ECT.
Data Collection
• Data was collected using specially designed form
which included the following:
• Demographics,
• Diagnosis
• Indication for ECT
• Consent
• Physical Examination and Vital signs check
• Procedure
• Reviews after ECT
General Results
• During the study period, 60 patients under-went ECT
but 30 were sampled - 6 men and 24 women.
• Their ages ranged from 16 to 54 years.
• 10 patients were diagnosed with a bipolar disorder
(33%), 5 with a depression (17%), 4 with a mania
(13%), 2 with a postpartum psychosis (7%), 3 with a
schizophrenia (10%) and 6 with a schizoaffective
disorder (20%).
• The total number of sessions varied from 4 to 6.
• The length of the clinically observed convulsions varied
from 11 to 160 seconds and the dose ranged from 225
to 400mc.
Criteria Results
ECT Criteria Graph
120
100
100
97
90
86
80
73
70
Percentage
90
63
60
Yes
No
37
40
30
27
20
14
3
10
10
0
0
Cons Form
AppConsent
Anaesthesia
Physical Exam
Procedure
Criteria
Review
Indwritten
Vitals
DISCUSSION
• All patients underwent modified ECT
• Almost all files had consent forms although most of the
consent forms were not completed appropriately
• ECT form did not cater properly for all pre ECT vital signs
and post ECT vital signs
• Consent form was in English language
• ECT information sheet was in English language and was not
available in all patient files
• 37% of patients did not undergo physical examination prior
to ECT
• Most of the indications written on the ECT form were also
the diagnoses
RECOMMENDATIONS FOR CHANGE
• Consent forms to be completed appropriately
• ECT form to be reviewed to cater properly for all
pre ECT vitals and post ECT vitals
• Consent form to be translated into vernacular
language
• ECT information sheet to be translated into
vernacular language and be put in patient files
• ECT protocol to be pasted in all wards and also to
be placed in procedure manuals
Cont’d
• The indication written on the ECT form should
be specific i.e. Emergency life saving, too
distressed to await response to medication,
severe psychomotor retardation/agitation,
suicidal ideation, patient preference,
medication resistance , previous good
response
RECOMMENDATIONS FOR FURTHER
AUDIT
•
•
•
•
•
Re-audit of the ECT standards
Dosing and seizures
Number of sessions per week
Average effective ECT sessions
Side effects of modified ECT
Conclusion
• The results revealed the gaps in the provision
of ECT services in relation to the required
standards.
• The results also indicated commitment to
satisfy the introduced standards
• Efforts to improve other treatment standards
should be undertaken i.e. consent &
indication.
Acknowledgements
• Dr Kauye for the support
• Dr Stewart for the guidance and support
• Records Clerks for their assistance in locating
the files
• Colleagues in Clinical Psychiatry Department
for moral support during the data collection