ECT Referral Patient information

Transcription

1 ECT Referral Patient information of Assessment Telephone Number Ethnic Origin First Treatment Treatment Site (please tick) Male Female Antelope Hse Elmleigh Parklands St. James Responsible Clinician Referred from CMHT Base Inpatient Outpatient Previous ECT? Details Clinical Global Impression (CGI) Patient status at commencement of treatment 1. rmal, not at all ill 2. Borderline mentally ill 3. Mildly ill 4. Moderately ill 5. Severely ill 6. Amongst the most severely ill N.B. You will be required to confirm the ECT Prescription sheet and Anaesthetic work up are fully complete on page

2 ECT Referral Integrated Record 1: NICE indication Please tick one 1.1 Approved NICE indication (severe depressive illness, catatonia, prolonged or severe manic episode) 1.2 n approved NICE indication (it is strongly recommended that for non standard indications a second psychiatrist s opinion, stating that ECT is a reasonable and proper treatment, should be obtained and documented in the patient s notes) Second opinion sought 2: Indication for using ECT Please tick all that apply 2.1 Rapid and short term improvement of symptoms after an adequate trial of other treatment options has proved ineffective, including drug treatments 2.2 The condition is life threatening 2.3 Continuation / maintenance ECT for an approved indication where the service user has previously responded to ECT 2.4 ECT worked before 3: Diagnosis Please tick one 3.1 Severe depressive illness 3.2 Catatonia 3.3 Severe manic and prolonged episode 3.4 Other please specify: 4: Risk 4.1 Risk benefit balance of having ECT treatment discussed with Consultant/ team and recorded 1.2

3 ECT Referral Integrated Record continued 5: Legal Status 5.1 Does the patient have capacity and able to give consent? Comments Please tick and complete boxes where appropriate 5.2 Informal and consenting, consent form signed (without implicit or explicit coercion) 5.3 Detained under Section, consenting. Consent form signed, Form T4 completed 5.4 Detained under Section, without capacity to consent. Second opinion obtained, Form T6 completed by Second Opinion Approved Doctor 5.5 Detained under Section, urgent treatment. Trust form for Section 62 completed by Approved Clinician in charge 5.6 Community Treatment Order patient form CTO11 (SOAD form) 5.7 If detained, is relevant MHA documentation complete and copied in ECT file? 5.8 If second opinion sought, number of treatments approved: 1.3

4 ECT Referral Integrated Record continued 6: Patient Care 6.1 Does the patient have an Advocate/Carer/Partner? Involvement of patient s relatives advocate or carer in decision to give ECT (specify) (If yes, please complete below) Telephone Address 6.2 Does the patient require a referral to the Independent Mental Health Advocate (IMHA)? Comments 1.4

5 Hamilton Depression Rating Scale Complete at referral and before 4th, 8th & 12th treatment Score Score Score Score 1. Depressed Mood (Sadness, hopeless, helpless, worthless) 0 = Absent. 1 = These feeling states indicated only on questioning. 2 = These feeling states spontaneously reported verbally. 3 = Feelings expressed non-verbally - i.e., through facial expression, posture, voice, and tendency to weep. 4 = VIRTUALLY ONLY these feelings spontaneously expressed both verbally and non- verbally. 2. Feelings of guilt 0 = Absent 1 = Self reproach, feels he has let people down 2 = Ideas of guilt or rumination over past errors 3 = Present illness is a punishment. Delusions of guilt 4 = Hears accusatory or denunciatory voices. Sees threatening visual hallucinations 3. Suicide 0 = Absent. 1 = Feels life is not worth living. 2 = Wishes he were dead or thoughts of own death. 3 = Suicidal ideas or gesture. 4 = Attempts at suicide (any serious attempt rates 4). 4. Insomnia Early 0 = difficulty falling asleep. 1 = Complains of occasional difficulty falling asleep - i.e., more than 1/2 hour. 2 = Nightly difficulty in falling asleep. 5. Insomnia Middle 0 = difficulty. 1 = Complains of being restless and disturbed during the night. 2 = Waking during the night - any getting out of bed (except to use the toilet) rates Insomnia Late 0 = difficulty. 1 = Waking in the early hours of the morning but goes back to sleep. 2 = Unable to fall asleep again if he gets out of bed. 7. Work And Activities 0 = difficulty. 1 = Thoughts and feelings of incapacity, fatigue or weakness related to activities - work or hobbies. 2 = Loss of interest in activity-hobbies or work, either directly or indirectly in listlessness, indecision and vacillation - feels he has to push himself. 3 = Decrease in actual time spent in activities or decrease in productivity 4 = Stopped working because of present illness. 1.5

6 Hamilton Depression Rating Scale continued Complete at referral and before 4th, 8th & 12th treatment Score Score Score Score 8. Retardation: Psych Obs (Slowness of thought and speech; impaired ability to concentrate; decreased Obs activity). 0 = rmal speech and thought. 1 = Slight retardation at interview. 2 = Obvious retardation at interview. 3 = Interview difficult. 4 = Complete stupor. 9. Agitation 0 = ne. 1 = Fidgetiness. 2 = Playing with hands, hair, etc. 3 = Moving about, can t sit still 4 = Hand wringing, nail biting, hair -pulling, biting of lips. 10. Anxiety (Psychological) 0 = difficulty. 1 = Subjective tension and irritability. 2 = Worrying about minor matters. 3 = Apprehensive attitude apparent in face or speech. 4 = Fears expressed without questioning. 11. Anxiety Somatic: (Physiological signs of anxiety, butterflies, indigestion, stomach cramps, belching, diarrhoea, palpitations, hyperventilation, paresthesia, sweating, flushing, tremor, headache, urinary frequency). 0 = Absent. 1 = Mild. 2 = Moderate. 3 = Severe. 4 = Incapacitating. 12. Somatic Symptoms (Gastrointestinal) 0 = ne. 1 = Loss of appetite but eating without encouragement from others. rmal intake. 2 = Difficulty eating without urging from others. Marked reduction of appetite and food intake 13. Somatic Symptoms General 0 = ne 1 = Heaviness in limbs, back or head. Backaches, headache. Loss of energy and fatigue. 2 = Any clear - cut symptoms rates Genital Symptoms (Loss of libido; impaired sexual performance; menstrual disturbances) 0 = Absent. 1 = Mild. 2 = Severe. 15. Hypochondriasis 0 = t present. 1 = Self-absorption (bodily). 2 = Preoccupation with health. 3 = Frequent complaints, requests for help, etc. 4 = Hypochondriacal delusions. 1.6

7 Hamilton Depression Rating Scale continued Complete at referral and before 4th, 8th & 12th treatment Score Score Score Score 16. Loss Of Weight 0 = weight loss. 1 = Probably weight loss associated with present illness. 2 = Definite (according to patient) weight loss. 3 = t assessed. 17. Insight 0 = Acknowledges being depressed and ill. 1 = Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest, etc. 2 = Denies being ill at all. 18. Diurnal Variation A. te whether symptoms are worse in morning or evening. 0 = variation 1 = Worse in AM 2 = Worse in PM B. When present, mark the severity of the variation. 0 = ne. 1 = Mild. 2 = Severe. 19. Depersonalization And Derealization ( Feelings of unreality; Nihilistic ideas) 0 = Absent. 1 = Mild. 2 = Moderate. 3 = Severe. 4 = Incapacitating. 20. Paranoid Symptoms 0 = ne. 1 = Ideas of reference. 2 = Delusions of reference and persecution. 21.Obsessional and Compulsive Symptoms 0 = Absent. 1 = Mild. 2= Severe. Total 1.7

8 ECT Referral Investigations 7: Medical History 7.1 General Anaesthesia Checklist Shortness of breath Comments Asthma or bronchitis High Blood Pressure Rheumatic Fever Heart Attack or other Heart Trouble Chest Pain on exercise or at night Antibiotics when you visit the dentist Hiatus Hernia or Frequent Heartburn Tuberculosis Diabetes Fits (Epilepsy) Kidney or Urinary Trouble Jaundice or Liver Disease Anemia or other Blood Disease Arthritis Muscle Disease Allergies Chest X-ray If in doubt discuss with anaesthetist 7.2 ECG: All patients over 45 years OR diabetic OR previous cardiac history 7.3 Any family history of anaesthetics problems? 7.4 Past Medical History 1.8

9 ECT Referral Medical Pre-ECT Physical Examination DVT Risk (inpatients only) High Medium Low Any actions required by ECT staff 8: Physical Examination Findings CVS Respiratory Abdomen CNS 8.1 Physical Baseline Results BP Pulse Temp Weight Height BMI 9: Routine Investigations U & Es Results 10: Other Investigations (if indicated) Lithium level (all patients on Lithium) Results LFTs Hepatitis B & C serology FBC Cerebral CT scan TFTs Random BSL Sickle-cell test (Afro-Caribbean, Middle Eastern, Asian & Eastern Mediterranean patients unless previously investigated) Other 1.9

10 ECT Referral Medical Pre-ECT continued 10.1 Current Medication 10.2 Cognitive Function including memory 10.3 MMSE Score out of (MMSE on admission is adequate) if not available please complete page : Lifestyle Information 11.1 Cigarettes Consumption per day 11.2 Alcohol Units per week 11.3 Pregnant Unknown 11.4 Baseline ASA Category (see over for categories) ASA 1 ASA 2 ASA 3 ASA 4 ASA 5 Inform Anaesthetist if ABOVE 2 I have explained any dental risks that could occur during treatment and I confirm the ECT Prescription sheet and Anaesthetic work up are fully complete and I have entered all physical health monitoring results onto RIO. Doctor s Initials (print) 1.10

11 Mini Mental State Examination (Adapted from Folstein et al) Patient of test Section Questions: Max points Patient score 1. Orientation a) Can you tell me todays (date)/(month)/(year)? Which (day of the week) is it today? Can you slso tell me which (season) it is? 5 b) What city/town are we in? What is the (county)/(country)? What (building) are we in and on what floor)? 5 2. Registration I should like to test your memory (name 3 common objects:.e.g. ball, car, man ) Can you repeat the words I said? (Score 1 point for each word) 3 (repeat up to 6 trials until all three are remembered) (record number of trials needed here: ) 3. Attention & a) From 100 keep subtracting 7 and give each answer: Calculation stop after 5 answers. (93 _ 86 _ 79 _ 72 _ 65 _ ). Alternatively b) Spell the word WORLD backwards. (D_L_R_O_W) Recall What were the three words I asked you to say earlier? 3 (Stop the test if all three objects were not remembered during registration test) 5. Language Naming these objects (show a watch) (show a pencil) 2 Repeating Repeat the following: no ifs, ands or buts 1 6. Reading (show card or write CLOSE YOUR EYES ) Read this sentence and do what it says 1 Writing w can you write a short sentence for me? 1 7. Three stage (Present paper) Command Take this paper in your left (or right) hand, fold it in half, and put it on the floor Construction Will you copy this drawing please? 1 Total score 30 Examiner 1.11

12 ECT Referral ASA Classification The American Society of Anaesthesiologists classified patients into a number of grades according to their general condition. ASA 1 The patient has no organic, physiological, biochemical or psychiatric disturbance. The pathological process for which operation is to be performed is localised and does not entail a systematic disturbance. ASA 2 Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological processes. Mild organic heart disease, diabetes, mild hypertension, anaemia, old age, obesity, mild chronic bronchitis. ASA 3 Limitation of life-style. Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with any finality, e.g. angina, healed myocardial infarction, severe diabetes and cardiac failure. ASA 4 Severe systematic disorders that are already lifethreatening, and not always correctable by operation, e.g. marked cardiac insufficiency, persistent angina, active myocarditis, advanced pulmonary, renal, endocrine or hepatic insufficiency. ASA 5 Moribund. Little chance of survival, but submitted to operation in desperation. Little, if any, anaesthesia is required. If the operation is an emergency, the letter E is placed beside the numerical classification, and the patient is considered to be in poorer physical condition. The ASA scheme is the most comprehensive system, but ignores the risk of the asymptomatic patient who, for example, may have severe coronary artery disease. It also ignores the inherent risks of a particular operation. The system (which has now been revised) has been criticised in that different anaesthetists do not always agree about the classification. Moreover, it does not account for the asymptomatic but severe risk of myocardial infarction in those with coronary disease. However, is has stood the test of time. 1.12

13 Electro Convulsive Therapy Treatment/ Maintenance Consent Form Responsible Consultant Consultant Signature 11: Treatment type Please circle Treatment BI/L Both U/L & BI/L U/L MHA Status at time of consent Maximum number of treatments : Statement of Health Professional (to be filled in by health professional with appropriate knowledge of proposed treatment) I have explained the treatment to the patient. In particular I have explained: The Intended Benefits Serious or Frequently Occurring Risks including dental damage Any extra procedures, which may become necessary during the treatment (please specify) This treatment will involve General Anaesthesia and muscle relaxant I have also discussed what the treatment is likely to involve, benefits and risks of any available, alternative treatments (including no treatment), driving risks and any particular concerns of this patient. The following leaflets have been provided MHA Guidance leaflet 3 Royal College fact-sheet Local information leaflet Signed/designation (Print) Contact Details (if patient wishes to discuss options further) 2.1

14 Statement of Patient Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy, which describes the benefits and risks of the proposed treatment. If not you will be offered a copy now. If you have any further questions, do ask we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the treatment or course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the treatment. The person will, however, have appropriate experience. I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the treatment unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia). I understand that any treatment in addition to those described on this form will only be carried out if it is necessary to save my life or prevent serious harm to my health. I have been told about additional treatments, which may become necessary during my treatment. I have listed below any treatments, which I do not wish to be carried out without further discussion Treatments which I do not wish to be carried out I have religious beliefs that will not accept blood or blood derivates. I have made an advance directive Copy accepted by patient Patient s Signature (Print) If no signature please indicate why 12.2: Statement of Interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Signature of Interpreter (Print) A witness should sign below if the patient is unable to sign but has indicated his or her consent. Witness Signature (Print) 2.2

15 ECT Consent / Treatment Record Maximum number treatments consented 13: ECT Prescription (prescription to be reviewed at least weekly) of prescription Any changes in capacity will require a new consent form. Any treatments without notification of change will be taken as no change. of treatment RU / LU / Bilat Signed HDRS Score of prescription of treatment RU / LU / Bilat Signed HDRS Score 2.3

16 Confirmation of Consent (to be completed by the patient and a health professional each time the patient attends for the treatment.) 14.1: Treatment. of 12 Current consent dated Treated under (please circle) Informal consenting T4 T6 Sec 62 CTO Other On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions Signature/designation (Print) I have confirmed that I have no further questions and wish the treatment to go ahead. Outpatients only: I confirm I have received and understood the information leaflet on conditions of discharge Patient Signature (Print) Patient will be taken home by Treatment. of 12 Current consent dated Treated under (please circle) Informal consenting T4 T6 Sec 62 CTO Other On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions Signature/designation (Print) I have confirmed that I have no further questions and wish the treatment to go ahead. Outpatients only: I confirm I have received and understood the information leaflet on conditions of discharge Patient Signature (Print) Patient will be taken home by 2.4

17 ECT Consent / Treatment Record Confirmation of Consent (to be completed by the patient and a health professional each time the patient attends for the treatment.) Treatment. of 12 Current consent dated Treated under (please circle) Informal consenting T4 T6 Sec 62 CTO Other On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions Signature/designation (Print) I have confirmed that I have no further questions and wish the treatment to go ahead. Outpatients only: I confirm I have received and understood the information leaflet on conditions of discharge Patient Signature (Print) Patient will be taken home by Treatment. of 12 Current consent dated Treated under (please circle) Informal consenting T4 T6 Sec 62 CTO Other On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions Signature/designation (Print) I have confirmed that I have no further questions and wish the treatment to go ahead. Outpatients only: I confirm I have received and understood the information leaflet on conditions of discharge Patient Signature (Print) Patient will be taken home by 2.5

18 ECT Consent / Treatment Record Psychiatrist Signature: Treatment : : Consent : Stimulation 1 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Stimulation 2 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Stimulation 3 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Comments and Plan for next session 2.6

19 ECT Consent / Treatment Record Psychiatrist Signature: Treatment : : Consent : Stimulation 1 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Stimulation 2 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Stimulation 3 Electrode placement Dose setting/dose delivered Seizure pattern (bilateral) Visible seizure duration (secs) EEG seizure duration Seizure quality Comments and Plan for next session 2.7

20 ECT Preparation Record Nursing Checklist for pre ECT Patients : Legal Status of Patient at each session of ECT : section/informal/cto Patient advised not to bring valuables Current CGI Prescription record ECT record including: a) Consent form in ECT pack b) MHA documentation in care pathway Investigation results in care pathway (CXR ECG blood results Appropriate meds given and recorded Blood sugar level if appropriate Encouraged to empty bladder Weight Depression scale completed Time patient last ate Time patient last drank Temperature Pulse Blood pressure SPO 2 Ward staff signature 3.1

21 ECT Preparation Record Treatment Room Checklist for pre ECT Patients DVT careplan checked & actions completed Anaesthetist informed of any abnormalities Contact lenses/spectacles removed Dentures/hearing aid removed Correct patient (fit name band INCLUDE ALLERGIES) Time to orientation record baselines completed Nail varnish / make up / hair clean and lacquer free Jewellery and piercings removed ECT Treatment Nurse Signature Comments Additional information 3.2

22 Anaesthesia Consent / Treatment Record Anaesthesia Record for ECT 4.2 Risk benefit analysis of having an anaesthetic has been discussed and recorded 15: Pre anaesthetic assessment / reveiw assessment: PMH Prev GA 15.1 Is the patient a smoker? 15.2 Consent for anaesthesia discussed with patient 15.3 BMI checked? 15.4 Does the patient have Reflux? 15.5 Teeth Dentures Own teeth Crowns/ bridge work Mouth opening/ neck movement 15.6 Patient informed of risk of damage? 15.7 Medication? 15.8 Allergies? 15.9 Investigation results checked Any other discussions /designation Signed 4.1

23 ASA Grade Oxygen Prescribed Tooth Guard Anaesthetic Machine Checked Suction Checked Induction Agent Mg Muscle Relaxant Mg Change Dose? ECG ETCO2 Time SaO 2 Consultant Anaesthetist sign and print Recovery Nurse sign and print Comments 4.2

24 ASA Grade Oxygen Prescribed Tooth Guard Anaesthetic Machine Checked Suction Checked Induction Agent Mg Muscle Relaxant Mg Change Dose? ECG ETCO2 Time SaO 2 Consultant Anaesthetist sign and print Recovery Nurse sign and print Comments 4.3

25 Recovery Record Sheet Second Stage Recovery on entering 16: Record ongoing observations using the Adult Track and Trigger Tool if needed 1 Remain with patient until conscious 2 Support the airway until normal breathing 3 Check reflexes have returned to normal 4 Administer oxygen if required Orientation 5 Suction if required 6 Encourage deep breathing when conscious 7 Maintain records below 8 Discharge when stabilized Check baseline answers on the morning of each ECT when confirming patient consent. Once the patient has opened their eyes record that time, then at the specified minutes afterwards, assess reorientation by asking the patient to respond to the questions below. Once they have achieved 4/5 correct responses then stop. Record the actual time 4/5 achieved. Time Place Age D.O.B. Day of week Baseline pre-ect Opens eyes 8 10 mins 15 mins 20 mins 25 mins 30 mins : Christian name and surname Place: Town, hospital or knowledge they have just had ECT will be acceptable Age: 1 year either side of actual age will be acceptable please record the age they give /designation Signed 5.1

26 Recovery Record Sheet Third Stage Recovery and time in to third stage recovery 18: Prior to Discharge 18.1 ECT staff please confirm that the patient has: Belongings returned Any nausea Discomfort is within patient s own acceptable limits Mobile without feeling faint Taken food and fluids (delete as appropriate) Has their post-operative instructions Has someone to take them home Has someone to stay with them overnight Aware they shouldn t drink alcohol for 24 hours Outpatient information and treatment summary given Cannula removed Confusion? Orientated? Headache? Agitated? If not fit for discharge, action taken Reg. Practitioner Initials and designation Time of Discharge Discharge into care of 5.2