Appendix D. Detail on criteria for audit of the use of electroconvulsive therapy | Guidance on the use of electroconvulsive therapy | Guidance

Objectives for an audit

An audit on electroconvulsive therapy (ECT) could be carried out to ensure that ECT is used appropriately.

Patients to be included in the audit

All individuals who have received ECT in a suitable time period for audit, for example, 6 months or 1 year. Alternatively, the audit could be undertaken concurrently with the provision of ECT treatments.

Measures that can be used as a basis for audit

**Table 1 Measures that can be used in an audit on ECT**
Criterion	Standard	Exception	Definition of terms
1. The individual receiving electroconvulsive therapy (ECT) has 1 of the following: a. severe depressive illness b. catatonia c. a prolonged or severe manic episode	100% of individuals receiving ECT	None	Local clinicians will have to agree on how and where the indications for ECT are documented for audit purposes.
2. ECT is used to achieve rapid and short-term improvement of severe symptoms when an adequate trial of other treatment options has proven ineffective, and/or the individual has a potentially life-threatening condition	100% of individuals receiving ECT	None	Local clinicians will have to agree on how severe symptoms and response to other treatment options and potentially life-threatening conditions are documented for audit purposes.
3. An assessment of the risks and potential benefits of ECT for the individual is documented	100% of individuals receiving ECT	None	The documented assessment before treatment should note: risks associated with the anaesthetic; current comorbidities; anticipated adverse events, including cognitive impairment; and the risks of no treatment.
4. The individual provides consent for each course of ECT treatment	100% of individuals receiving ECT	A. The individual does not have the ability to grant or refuse consent, in which case advance directives are fully taken into account and the individual's advocate and/or carer are consulted. B. The individual is detained under the Mental Health Act	Local clinicians should agree on how consent to ECT is documented for audit purposes. A course of ECT is usually 6 to 12 sessions, usually given at the rate of 2 a week. The individual who has had/is having ECT should be asked for his/her views as to whether or not this criterion is being met.
5. The consent process provides that the clinician(s) responsible for treatment carries out all of the following: a. involves the individual's advocate and/or carer where possible b. provides full and appropriate information in a suitable format and language to enable an informed discussion c. explains and discusses the general risks of ECT, risks specific to the individual, enhanced risks for individuals in specific groups and potential benefits to the individual d. does not pressure or coerce the individual into consent to the ECT treatment e. reminds the individual that he/she has the right to withdraw consent at any point	100% of individuals receiving ECT	A. The individual is detained under the Mental Health Act B. The individual does not have the ability to grant or refuse consent but is compliant with treatment and 5a-e is carried out with an advocate and/or carer	Local clinicians should agree on how the format and language used to communicate the information provided and the involvement of advocates or carers prior to consent to ECT are documented for audit purposes. See 3 above for a list of general risks to be discussed. Groups of people for whom there may be enhanced risks to be discussed include individuals who are pregnant, older or a child or young person. The individual who has had/is having ECT should be asked for his/her views as to whether or not this criterion is being met.
6. The individual's clinical status is assessed after each ECT session	100% of individuals receiving ECT	None	Local clinicians should agree on what constitutes an assessment of clinical status following an ECT session.
7. The individual's cognitive function is monitored: a. on an ongoing basis and b. at a minimum at the end of each course of treatment	100% of individuals receiving ECT	None	Local clinicians should agree on what constitutes monitoring of cognitive function and how monitoring is documented for audit purposes. The individual who has had/is having ECT should be asked for his/her views as to whether or not this criterion is being met.
8. ECT is stopped if 1 of the following occurs: a. a response is achieved b. there is evidence of adverse effects c. the individual withdraws consent	100% of individuals receiving ECT	None	Local clinicians will have to agree on what constitutes a desired response and evidence of adverse effects for audit purposes. The individuals who has had/is having ECT should be asked for his/her views as to whether or not this criterion is being met.
9. A repeat course of ECT is provided only for an individual in either one of the following circumstances: a. the individual meets criteria 1 and 2 above and has previously responded well to ECT or b. the individual has not responded previously but is experiencing an acute episode and all other options have been considered and following discussion with the individual and/or where appropriate the carer or advocate of the risks and benefits of such a course of action	100% of individuals receiving a repeat course of ECT	None	Local clinicians will have to agree on what constitutes a good response to ECT for audit purposes. See 4 above for definition of course of treatment. See 3 and 5 above for reference to risks.
10.ECT is used as a maintenance therapy in depressive illness	0% of individuals receiving ECT	None
11.ECT is used for the management of schizophrenia	0% of individuals receiving ECT	None

Calculation of compliance with the measures

Compliance with the measures described in the table is calculated as follows.

Number of individuals whose care is consistent with the criterion plus the number of individuals who meet an exception

Divided by

Number of patients to whom the measure applies

Multiplied by 100

Clinicians should review the findings of measurement, identify whether practice can be improved, agree on a plan to achieve any desired improvement, and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.