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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Department of Psychiatry, University of Hong Kong, Pokfulam Road, Hong Kong SAR, China
Kwai Chung Hospital, Hong Kong SAR
Department of Psychiatry, United Christian Hospital, Hong Kong SAR
Castle Peak Hospital, Hong Kong SAR
Correspondence: Tel: 852-28554487, fax: 852-28551345. e-mail: kfchung{at}hkucc.hku.hk
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Abstract |
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We conducted the first systematic territory-wide survey of electro-convulsive therapy (ECT) practice and utilisation in Hong Kong. All public ECT services were evaluated with a postal questionnaire, a visit and observations of ECT administration. All private ECT practitioners were surveyed using a postal questionnaire.
RESULTS
Most practice areas at the public ECT services in Hong Kong complied with College guidelines. However, a few private practitioners were still using outdated ECT machines. The number of ECT courses completed in 1998 was 0.34 per 10 000 population, which was much lower than the rate of ECT use in Western countries.
CLINICAL IMPLICATIONS
We obtained basic information on ECT services in Hong Kong and on areas requiring immediate attention.
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Introduction |
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Method |
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Results |
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ECT premises, ECT machines and other equipment
Only three of the eight ECT premises in public hospitals met College
guidelines. Treatment and recovery rooms at four units were separated only by
wooden or plastic partitions and one unit did not have a waiting area. ECT in
the private sector was mostly carried out in a single or shared room in
hospital or in a room in a clinic. All eight public units had installed
up-to-date ECT equipment. Seven units were using a Mecta US domestic version
SR1 and one had recently installed a Mecta spECTrum 5000M. However, three of
the four private ECT practitioners were still using Ectron Mark 4 models. For
back-up, the public units had installed either Ectron series 5 or Mecta SR1
machines. No back-up machine was available in the private sector. ECT machines
and resuscitation equipment in the public sector were serviced every 3 to 12
months by qualified personnel, whereas in the private sector the machines were
not regularly checked.
Supervision and training of psychiatric personnel
At all centres, junior doctors were given an informal briefing on ECT and
had at least one supervised ECT administration before giving treatment on
their own. The average number of supervised patient treatments was four
(range=1-15). Doctors at four of the eight public ECT units performed blocks
of treatment sessions and their periods on duty varied from 1 week to 3
months. The ECT sessions at the remaining four public units were attended by
three to 20 doctors in rotation. All the private ECT practitioners were
experienced psychiatrists. However, they performed treatments infrequently and
their last ECT administrations were from one to 20 months prior to the survey.
The audit team observed that the training at only two centres had covered the
back-up ECT machine.
Administration, documentation and response monitoring of ECT
The most commonly used anaesthetic agents and muscle relaxants in Hong Kong
were thiopentone and suxamethonium, respectively. In addition, bilateral
electrode placement was usually performed. The pre-selected dosage method was
the most commonly used dosing procedure among the public ECT units (63%). The
remaining three hospitals employed the dose titration method. In the private
sector, there was no standardisation of ECT stimulus dosing policy. Most of
the public units (88%) monitored both electroencephalographic and motor
seizure duration. Only two of the eight hospitals used the Hamilton cuff
technique. In the private sector, two of the four ECT practitioners did not
measure seizure duration during treatments. Most of the public units (88%) had
standardised records, but no standardised documentation was used in the
private sector. Only one private practitioner had recorded seizure duration
during ECT treatment. All public ECT units required doctors to assess their
patients every one or two treatments, but only one unit had a procedure in
place to enforce this practice. Private ECT practitioners usually assessed
their patients before each treatment.
Observed treatment sessions
In most units, patient preparation and delivery of treatment was consistent
with College recommendations. On one occasion, we observed the use of the
‘impedance override’ on the Mecta SR1 after repeated checking of
cable connections and electrode contact because of a ‘self-test’
failure. Seizure was not produced in the session. On the same occasion, the
back-up ECT machine was found not to be ready for use. Another important
observation during hospital visits was that, although hospital policy required
patients to be assessed every one to two treatments during a course of ECT,
the policy was only practised in four of the nine patients we observed. The
last written entry of clinical information for one patient was 8 days before
the session we observed.
Utilisation
The eight public units completed 221 courses of ECT in the calendar year of
1998. The use of ECT varied widely between the units. Three units (37%)
performed less than 20 courses of ECT in the 12-month period and the number of
ECT courses per 100 acute hospital beds ranged from 0 to 83.8. Five courses of
ECT were completed in the private sector in 1998. With a total population in
Hong Kong of 6 645 600 by mid 1998 (Census
& Statistics Department, 2001), the number of ECT courses per
10 000 population was 0.34.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In previous studies, the estimated number of patients treated with ECT per year per 10 000 population varied from 0.8 to 4.9 (Duffett et al, 1999; Glen & Scott, 1999; Hermann et al, 1995; Kramer, 1999), which is higher than the annual rate of use in Kong Kong. ECT usage varied widely between the psychiatric units in Hong Kong and at some public ECT units and among the private practitioners, the usage was so small as to raise concerns about maintaining the service.
The study has several limitations. We only examined ECT practice in Hong Kong, and a study that covered ECT treatment in mainland China and other Asia-Pacific countries would be useful. Our analysis of ECT utilisation was based on a postal questionnaire, which did not examine usage in terms of the number of individual treatments per year. Factors that might influence the utilisation rate, such as age and gender of the patients, were also omitted. A replication study on ECT utilisation and factors that influence the rate of ECT use will contribute to the literature on ECT use worldwide.
We found that most practice areas in Hong Kong's public ECT services complied with College recommendations. Although the private ECT practitioners accounted for a very small proportion of ECT treatments in Hong Kong, their practice was not in line with the most recent ECT guidelines. The results of the study have been disseminated to the units involved so that they may consider ways of improving their services. A second audit cycle is planned in due course.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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DUFFETT, R. & LELLIOTT, P. (1998) Auditing
electroconvulsive therapy. The third cycle. British Journal of
Psychiatry, 172,
401-405.
DUFFETT, R., SIEGERT, D. R. & LELLIOTT, P. (1999)
Electroconvulsive therapy in Wales. Psychiatric
Bulletin, 23,
597-601.
FINK, M. (2001) Convulsive therapy: a review of the first 55 years. Journal of Affective Disorder, 63, 1-15.[CrossRef][Medline]
GLEN, T. & SCOTT, I. F. (1999) Rates of electroconvulsive therapy use in Edinburgh (1992-1997). Journal of Affective Disorder, 54, 81-85.[Medline]
HERMANN, R. C., DORWART, R. A., HOOVER, C. W., et al
(1995) Variation in ECT use in the United States.
American Journal of Psychiatry,
152,
869-875.
KRAMER, B. A. (1999) Use of ECT in California, revisited: 1984-1994. Journal of ECT, 15, 245-251.[Medline]
PIPPARD, J. (1992) Audit of electroconvulsive therapy
in two national health service regions. British Journal of
Psychiatry, 160,
621-637.
ROYAL COLLEGE OF PSYCHIATRISTS (1995) The ECT Handbook: The 2nd Report of the Royal College of Psychiatrists' Special Committee on ECT (Council Report CR39). London: Royal College of Psychiatrists.
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