Adrian Worrall on new guidelines for electroconvulsive therapy

Published: 07/10/2004, Volume II4, No. 5926 Page 37

Although controversial, electroconvulsive therapy remains an essential intervention for patients with the most severe forms of depression who are not responding to medication.

But national audits have shown that ECT is often administered in sub-standard clinics by inadequately trained and poorly supervised staff.

Inevitably, this has an adverse impact on the effectiveness of treatment and can also lead to unnecessary side-effects such as memory loss.

Hillingdon Hospital trust's Riverside Centre houses the first ECT clinic to be accredited by the new ECT accreditation service (ECTAS). The multidisciplinary team that manages the clinic has demonstrated compliance with ECTAS standards through a challenging process of self and peer review.

The ECTAS process is based on a set of demanding standards for ECT practice.Accreditation requires that clinics demonstrate a level of performance that would reflect safe and effective practice and an acceptable experience for the patient.

Good ECT practice requires teamwork.Although the treatment is given by a psychiatrist, clinics are run by nurses and the overall quality of care is largely determined by the nurse manager.

Anaesthetists also play an important role, and the patient's experience of treatment will be greatly affected by the quality of anaesthetic practice.

Most importantly, the patient's experience is central to the accreditation process. Standards that relate to patient safety and dignity must be met before a clinic can be accredited.

ECTAS has tried to combine elements of quality improvement systems that have been shown to be effective.

Although a clinic will not be accredited unless it demonstrates conclusively that it meets a minimum requirement, the process of review is owned by the frontline staff, whose practice is being evaluated and geared towards active improvement.

It also incorporates elements of clinical audit and feedback.

Peer support is another essential element, both through the review process and, communications between members of the growing ECTAS network.

Riverside Centre joined ECTAS in October 2003 along with 20 other clinics from around the UK and Ireland that enrolled for the first wave of accreditation reviews.

They embarked on a threemonth period of self-review that included questionnaires for the last 20 patients who completed a course of ECT. The review covered experience, auditing, training and supervision of ECT clinic staff.

ECT patients' case notes from the previous six months were also audited.

The period of self and peer review was not one of passive data collection. Engagement in the process encouraged the local team to consider all aspects of their work, and during this time, the team made important improvements to bring local ECT practice into line with ECTAS standards.

The report on Riverside included a number of recommendations about further improvements in local ECT practice.

The team is expected to make the report on their clinic available to everyone with a local interest, including commissioners, and will incorporate future submissions by the trust to regulators and service inspectors.

ECTAS has made a successful start. Riverside was awarded its accreditation just nine months after the initiative's launch, and by spring 2004 more than 30 ECT clinics had enrolled.

By the end of this year about a quarter of the 200 or so clinics in England, Wales, Northern Ireland and Ireland should be members.

Many clinics have reported improvements as a result of undertaking self-review. These range from changes in local protocols to increased user involvement in developing patient information, successful lobbying for better equipment and incorporation of a commitment to ECT in consultant job plans.

Adrian Worrall is a member of the college research unit at the Royal College of Psychiatrists.

Further information lInformation on ECT accreditation .Royal College of Psychiatrists.

www. rcpsych. ac. uk/cru/ECTAS. htm

Guidelines on the use of Electroconvulsive Therapy, National Institute for Clinical Excellence.

www. nice. org. uk/page. aspx? o=68305