key: cord-0793041-zlbei7mw
authors: Lapid, Maria I.; Seiner, Steve; Heintz, Hannah; Hermida, Adriana P.; Nykamp, Louis; Sanghani, Sohag N.; Mueller, Martina; Petrides, Georgios; Forester, Brent P.
title: Electroconvulsive Therapy Practice Changes in Older Individuals due to COVID-19: Expert Consensus Statement
date: 2020-08-07
journal: Am J Geriatr Psychiatry
DOI: 10.1016/j.jagp.2020.08.001
sha: 86ac0eec16822b79e703ccd628d6625e8e51f46a
doc_id: 793041
cord_uid: zlbei7mw

The ubiquitous coronavirus 2019 (COVID-19) pandemic has required healthcare providers across all disciplines to rapidly adapt to public health guidelines to reduce risk while maintaining quality of care. Electroconvulsive therapy (ECT), which involves an aerosol-generating procedure from manual ventilation with a bag mask valve while under anesthesia, has undergone drastic practice changes in order to minimize disruption of treatment in the midst of COVID-19. In this paper, we provide a consensus statement on the clinical practice changes in ECT specific to older adults based on expert group discussions of ECT practitioners across the country and a systematic review of the literature. There is a universal consensus that ECT is an essential treatment of severe mental illness. In addition, there is a clear consensus on what modifications are imperative to ensure continued delivery of ECT in a manner that is safe for patients and staff, while maintaining the viability of ECT services. Approaches to modifications in ECT to address infection control, altered ECT procedures, and adjusting ECT operations are almost uniform across the globe. With modified ECT procedures, it is possible to continue to meet the needs of older patients while mitigating risk of transmission to this vulnerable population.

With over 3.8 million cases in the U.S. alone 1 , the coronavirus 2019 disease (COVID-19) caused by the novel coronavirus (SARS-CoV-2) has had a profound impact on health care systems. Because COVID-19 primarily presents as a respiratory illness and is transmitted through respiratory droplets, great care must be taken to reduce the risk of transmission during as electroconvulsive therapy (ECT), which involves an aerosol-generating procedure from manual ventilation with a bag mask valve while under anesthesia. The danger of ECT practice during COVID-19 is compounded as patients who undergo ECT are often older, frail, and at higher risk than the general population. ECT is deemed an essential procedure by the American Psychiatric Association 2 and drastic changes to ECT practices have been necessary to mitigate risk for both patients and staff while continuing to provide essential care.

For the geriatric population with severe depression or psychosis who are highly burdened by psychiatric symptomatology, ECT is an important and necessary treatment. Data have shown that ECT is safe in older adults despite medical comorbidities and is highly effective in treating severe psychiatric illnesses such as major depressive disorder, psychosis, mania, and behavioral symptoms of dementia 3, 4 .

Disruption in the acute course of ECT in the absence of adverse events would be harmful for older patients, potentially precipitating clinical decline.

Continuing safe administration of ECT to those who need it while at the same time maintaining safety for patients and staff presents an extraordinary challenge in clinical practice. In this paper we describe modifications in ECT practices due to the COVID-19 pandemic based on expert consensus. The aim is to help guide ECT clinicians in continuing to provide ECT in a manner that is safe for patients and staff while still preserving public health efforts to mitigate and avoid infection spread.

The development of this expert consensus statement involved the following steps: (1) topic selection; (2) expert group discussion; and (3) systematic review of literature.

Topic selection. The focus of this paper is on the impact of COVID-19 on ECT practices. Questions have arisen regarding what modifications are needed to administer ECT in a manner that is safe for both patients and staff, within the available resources, and consistent with good clinical practice. With such rapidly evolving information, a consensus statement will consolidate and disseminate current knowledge and provide guidance to ECT practitioners and stakeholders. The authors serve as site PIs (ML, AH, LN, MM, GP, BF), site co-investigators (SS, SS), and project manager (HH), and have expertise in psychiatry, geriatric psychiatry, and ECT clinical administration and research. The conception, design, and content of the manuscript were discussed during weekly ECT-AD meetings from March thru May 2020. In-depth discussions were held regarding modifications that were being implemented at each of the sites. In addition, an email question "Are there any changes to your ECT practice specific to geriatric patients?" was sent out to the International Society for ECT and Neurostimulation (ISEN) listserv and responses were compiled. 

Results from ECT-AD discussions, insights from ISEN members, and information from the systematic review are collated and described below.

Of 37 articles identified from the search, 11 met inclusion criteria and were included in the review, reported in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram. (Figure 1 ) The articles summarized in Table 1 include 4 from the US and Canada, 4 from outside the US, and 3 statements and guidelines from professional associations.

Based on the expert group discussions and systematic review of the literature, there is a clear universal agreement that ECT is an essential treatment that should continue to be provided even during this pandemic. There is a clear consensus regarding the modifications that are essential to ensure that providing ECT care is safe for patients and staff. There are also changes to care processes and workflow that are common to all ECT practices. (Figure 2 ) Despite the clear consensus on current standards in ECT practice, there is a lack of literature specific to older adults. The following recommendations represent a consolidation of the expert group discussions, results of the systematic review, and incorporation of considerations specific to treating older adults with ECT in the current pandemic environment.

Based on the assumption that any patient is potentially infected or a carrier of COVID-19, ECT practices must follow standard, contact, and airborne precautions, as well as eye protection measures.

Personal protective equipment (PPE) protects health care workers, sanitation and disinfection practices reduce the risk of viral transmission, and clustering of ECT patients can help prevent cross contamination.

The use of PPE is imperative for staff protection, in order to reduce the spread of COVID-19 through patient contact. All health care personnel involved in the administration of ECT are required to wear N95 respirators, which require prior fit testing and education for N95 respirator use. A procedure mask can be worn over the N95 respirator as an additional precaution if prolonged or repeated use is anticipated. In addition to N95 respirators and procedure masks, goggles, eye shields, or face shields have been added to standard PPE to further prevent contact with potentially infected droplets. Gloves are required, and some use double gloves and replace the outer gloves after each patient in order to prevent cross contamination between patients. Gowns are standard and changed at varying times, although not required in some institutions.

While protecting health care personnel during ECT is paramount, the widespread shortage of proper PPE has presented extensive obstacles to this goal. Policies and guidelines on PPE are institutionspecific and evolving based on PPE availability. In ECT facilities with adequate PPE resources, staff in the screening area, waiting room, preparation or IV room, and recovery room are also fitted with N95 respirators. A lack of surplus in most locations requires staff to be assigned one set of PPE, and to reuse as appropriate. Maintenance of N95 respirators is the responsibility of individual staff, and the N95 respirators can be kept in the ECT facility for reuse in individual, labelled bags. Like the N95 respirators, other protective equipment such as procedure masks, goggles, eye shields, or face shields also often need to be reused due to supply shortages. Gowns and head coverings however should be disposed of at the end of each day. Gloves are not reused. Every personnel must be trained in proper donning (putting on) and doffing (taking off), as well as PPE disposal. In general ECT clinics are restricting or completely banning the presence of non-essential personnel in the treatment area to maximize the preservation of PPE for essential staff.

The SARS-CoV-2 virus has been shown to survive in aerosols and on surfaces for many days 5 . The need for environmental cleaning and decontamination lowers the risk of viral transmission. Treatment rooms are cleaned thoroughly after each treatment day, by housekeeping or facility staff. However, to protect janitorial staff or housekeeping, gloves and procedure masks are recommended, as well as limiting exposure to the treatment rooms to before or after the treatments are completed. This means that the treatment team personnel are responsible for sanitizing with hospital-grade wipes between patients, including the ECT machine, computer keyboards/mouse, anesthesia machine, and any countertop. ECT personnel replace outer gloves, or change gloves and wash hands, between each patient. Bite blocks, if used, should be disposable. To protect the anesthesia machine from being contaminated, a viral filter should be used for each patient. At the time of supply constraints, viral filters are placed in a paper bag, labeled and stored for future use on the same patient.

ECT treatment facilities that serve both inpatients and outpatients minimize patient-to-patient exposure by allocating the different populations to different treatment "clusters" or to different days, a practice which greatly decreases the chance of cross-contamination between groups during transport and recovery. Inpatients can be further clustered by unit. Some departments have also designated treatment "teams" who alternate working certain shifts to further reduce risk of exposure.

ECT patient census is also impacted greatly by the effects of COVID-19. As local incidence increases, having a patient test positive on a psychiatric inpatient unit becomes more likely. A moratorium on admissions for an inpatient unit thus leads to a lower inpatient ECT census, which can further affect the ability to schedule ECT for inpatients and outpatients on separate days and may require services to operate fewer days per week. Hospital administrations have also pressured many sites to reduce operational days.

Although never ideal, sites have had to reduce their current patient censuses -some by as much as half -in order to accommodate reduced operations. Reducing or altogether interrupting treatment can be somewhat standardized with the use of a flow chart or algorithm, but ultimately this must be carefully considered on a case-by-case basis. Important factors to consider are the age of the patient, their location (i.e., are they currently in a nursing home or living independently), and the potential outcome of relapse. When deciding whether or not to treat a patient during this time, a fundamental consideration is to weigh the risk of exposure to a hospital setting and potentially infected asymptomatic staff and/or other patients with the benefit of avoiding a severe relapse and admission to the emergency room.

Pre ECT COVID screening is performed prior to each visit. Screening questions include (1) Does the patient have close contact with a person with a laboratory confirmed case of COVID-19? (2) In the last 14 days, has the patient experienced fever or new symptoms of cough or shortness of breath, sore throat, diarrhea, respiratory distress, chills, myalgias, loss of smell, or change or loss of taste sensation.

If a patient is symptomatic, COVID-19 testing is indicated. Whether to test asymptomatic patients coming from a higher risk environment such as a nursing home is dependent on several factors.

If there have been known cases or contacts, then testing is recommended. However, some facilities have been on lockdown and have eliminated any contact between clients, and others may refuse to test asymptomatic individuals. Furthermore, state and federal guidelines regarding testing continue to evolve based on availability and other factors, making these decisions more complicated. Therefore, the decision to test an asymptomatic individual coming from a high-risk environment is case dependent but should be strongly considered.

Masked ventilation causing aerosolization may be the biggest risk to patients and staff in terms of potential exposure. The use of HEPA filters for masked ventilation and anesthesia prevent the anesthesia machine itself from becoming contaminated and exposing subsequent patients. Although not an ideal practice, rationing of these supplies is often necessary due to shortages; many sites are saving HEPA filters in biohazard bags to be used again for the same patient.

Some sites have used pre-oxygenation to avoid bagged mask ventilation (BMV) use during the procedure for appropriate patients 6 . Pre-oxygenation is done with a regular or non-rebreather mask (slight difference between sites) for several minutes pre-treatment, and then having the patients selfhyperventilate as they go off to sleep to try to minimize BMV. While some patients still require BMV, it is avoided as much as possible, which has the advantage of cutting down the risk of aerosolization, and helps preserve HEPA filters.

Given that BMV during ECT is an aerosol-generating procedure, facilities have revised the time interval between ECT treatments based on factors such as the size of ECT treatment rooms, capacity of the ventilation systems, air changes/ hour (ACH) in the building, and location of exhaust vents.

Determining the ACH or air circulation rate in the building will help roughly calculate time to clear up most of the room air and thereby the aerosols. The air circulation times can vary and are only estimates. Center for Disease Control has guidelines that help calculate the time required for air-borne contaminant removal by efficiency. Close attention should be paid to the assumptions in the tables provided in the appendices of the guideline 7 . A collaboration between engineering infection control departments can be helpful in trying to determine a reasonable amount of time to wait before bringing another patient into the room. Some institutions have used two or more treatment rooms and alternate between rooms to allow more air recirculation between patients in each room. Obviously, this option is not available at many ECT sites.

Anesthetic dosing generally has remained unchanged in response to the virus. However, some sites have tried to keep succinylcholine doses at the lower end of the safe range in order to allow for a quicker return of spontaneous breathing after the seizure. This minimizes BMV overall, and in sites using the pre-oxygenation/ self-hyperventilation technique described above, may allow for the elimination of BMV altogether in some cases.

For newly-initiated acute courses of ECT, some ECT psychiatrists continue the usual method of determining the seizure threshold, while others have stopped the titration method to determine seizure threshold. One method being used is starting at 100% energy at the first ECT, in order to minimize the time a patient is not breathing since they are not being ventilated. Other methods include use of a prior stimulus dose (if applicable) or an age-based approach. When titration method is used to determine seizure threshold, other ECT providers use 8-12 times the seizure threshold for subsequent ECT when using right unilateral placement.

Recovery room practice has not been dramatically altered by the risk of COVID. Recovery nurses though should wear eye protection and surgical masks, while some sites felt that nurses working with patients in immediate recovery should have N95 masks given the risk of exposure due to close contact while patients may be coughing and emitting secretions. Patients who are coughing and not fully awake should be allowed to recover in the treatment room and be brought out only when they are not coughing. As early as possible, before bringing the patient out of the treatment room, a procedure mask should be correctly placed on the patient's face. Patients should be separated by at least 6 feet and/or physical barriers such as partitions or curtains, if possible. Some sites have shortened their stay requirement in the recovery room or recovery lounge (if a 2-stage recovery) in order to avoid crowding in these areas and maximize social distancing.

Nursing homes and other long-term care (LTC) facilities for older adults are known to have high transmission rates for infectious diseases, and thus have unfortunately become "hot spots" for the spread of COVID-19 8 . For this reason, ECT services have had to be especially stringent when considering treating older patients referred from LTC facilities -not only due to the risk that an incoming patient may infect ECT staff and other patients, but also the risk of rapid spread to other vulnerable older adults if a patient carries COVID-19 back to their LTC facility. It is paramount to involve the medical staff at the LTC facility when weighing the pros and cons of treating these patients. In places where pre-op testing is not readily available, some ECT services have chosen to stop accepting any geriatric patients or those coming from long-term care facilities.

Due to the COVID-19 crisis, many centers felt significant pressure to quickly and dramatically reduce the size of their ECT census. Given this, and the increased mortality and morbidity risk of COVID-19 to geriatric patients, the decision regarding continuing ECT treatment, especially in the continuation or maintenance phase requires a risk/benefit analysis. Treatment discontinuation, in some cases, can result in dangerous relapse of symptoms that are not well controlled by other means which could send patients to the emergency room -an especially hazardous setting for a geriatric patient during this time.

Additionally, a full relapse can result in an inpatient admission and the need for another acute course of ECT, which both introduces additional risks to the patient and utilizes more valuable resources. To avoid this, clinicians are tapering down the frequency of ECT treatments slowly while patients are closely monitored by the primary psychiatric providers. Close communication between the ECT service and the outpatient treating psychiatrist is essential to establish a safe treatment plan.

In the US, it is clear across ECT practices that any known COVID-19 positive patient, whether symptomatic or not, does not get treated with ECT unless it is determined as life-saving for a lifethreatening condition. In such rare cases, ECT should be administered in an operating room set-up with negative pressure. However, in Belgium patients with COVID-19 continue to receive ECT with a special treatment schedule 9 , and a single case report in the UK described successful ECT treatment of a patient with severe catatonia who was ill with COVID-19 10 .

In patients who previously tested positive but are now asymptomatic, the criteria for treating with ECT are either (a) 2 weeks from being diagnosed and 3 days of being asymptomatic, or (b) 2 weeks of being asymptomatic. The same criteria can be used for people who had symptoms suggestive of COVID-19 but were never tested as the symptoms did not meet testing threshold. With all patients, 2 consecutive negative tests and no new exposure indicate it is safe to proceed with ECT. For patients who test positive during a course of ECT, the decision to extend testing to other patients is based on clinical indications and clinical judgment. These criteria vary by ECT practice.

An important issue that is missing in the literature is that of informed consent and disclosure of risks related to COVID-19 transmission, which is particularly important in older adults who have increased risk of more severe illness and morbidity from COVID-19. Based on expert group discussions, there is a consensus that the potential risk of COVID-19 transmission should be discussed with the patients and the legal authorized representatives or substitute decision-makers. Across all the ECT practice sites, written consent forms for ECT have not been altered to include specific COVID-19

wording, consistent with all other practices that involve aerosol-generating procedures.

There is a clear and universal consensus that ECT is a critical and essential treatment.  6 bitemporal ECT twice weekly.  Positive-pressure emergency OR.  4 professionals -anesthesiologist, anesthesiology assistant, psychiatrist and psychiatric nurse.  N99 respirator, cap, visor, gown, apron, shoe covers, 3 pairs of gloves.  Thorough disinfection of theatre and all equipment before next case.  Anesthesia induction with propofol, muscle relaxation with suxamethonium, inhibition of secretions with glycopyrrolate.

 4 of 6 ECTavoided BMV by using O2 via mask alone  ECT 3 and 5 -videolaryngoscopic intubation, followed by 20 minutes of inhaled sevoflurane and mechanical ventilation, after which suxamethonium was given and ECT was delivered.  Psychiatrist was only present to deliver ECT, but was outside the treatment room for intubation and extubation.  Successful outcome, catatonia and depression resolved after 6 ECT. Colbert, 2020 15 Ireland

To illustrate visually the PPE ensemble worn by members of the ECT team, including gowns, headgear, masks, goggles and gloves.

 ECT practitioners need to liaise with anesthesia colleagues for a safe ECT environment.  PPE is demonstrated in a picture.  Protocols should follow best practices.  PPE conservation should be considered in clinical decision-making processes. Sienaert, 2020 9

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Electroconvulsive Therapy in Geriatric Psychiatry: A Selective Review

Efficacy and Safety of ECT for Behavioral and Psychological Symptoms of Dementia (BPSD): A Retrospective Chart Review

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Modified Anesthesia Protocol for Electroconvulsive Therapy Permits Reduction in Aerosol-Generating Bag-Mask Ventilation during the COVID-19 Pandemic

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Nursing homes and COVID-19: We can and should do better

Electroconvulsive Therapy During COVID-19-Times: Our Patients Cannot Wait

Successful electroconvulsive therapy in a patient with confirmed, symptomatic covid-19

Electroconvulsive Therapy for Geriatric Depression in the COVID-19 Era: Reflection on the Ethics

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