Chapter 5122-3 | Electroconvulsive Therapy; Incident Reporting; Patient Abuse/Neglect; Etc

Rule 5122-3-03 | Evaluation and referral for electroconvulsive therapy (ECT).

• Effective: September 20, 2010
• Promulgated Under: 111.15

(A) The purpose of this rule shall be to establish standards and criteria, indications, contraindications and limits for referral of adult ODMH regional psychiatric hospital (RPH) inpatients to an outside facility for ECT.

(B) The provisions of this rule shall be applicable to all RPHs under the managing responsibility of the department.

(C) Definitions

(1) "Chief clinical officer" and "CCO" mean the medical director of an RPH as defined in division (K) of section 5122.01 of the Revised Code.

(2) "Psychiatrist" means a licensed physician who has satisfactorily completed a residency training program in psychiatry, as approved by the residency review committee of the American medical association, the committee on post-graduate education of the American osteopathic association, or the American osteopathic board of neurology and psychiatry, or who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state medical association or the Ohio osteopathic association on the basis of formal training and five or more years of medical practice limited to psychiatry.

(3) "ECT" is a somatic psychiatric treatment mediated by a modified grand mal seizure, which is induced by the application of electrical current of the brain.

(4) "Informed consent" means the voluntary and knowing permission given by a person who has received all appropriate information.

(D) Requirements for referral

(1) ECT shall not be administered in ODMH RPHs.

(2) Only adult ODMH RPH inpatients shall be referred for ECT.

(3) The RPH psychiatrist must present clinical data to the RPH CCO to obtain approval for ECT referrals.

(4) It is required that any patient, voluntary or involuntary, competent or incompetent, shall be given a full explanation of ECT consistent with the specific items cited below:

(a) An explanation of the procedures to be followed and their purposes including identification of any procedures which are experimental. This explanation is to be given in such a way as to enable the individual to make a decision to grant/deny consent;

(b) A description of any attendant discomforts and risks reasonably to be expected;

(c) A description of any benefits reasonably to be expected;

(d) A disclosure of any appropriate alternative procedures/treatments that might be advantageous for that patient including an explanation of the consequences of those procedures/treatments;

(e) An offer to answer any inquiries concerning the procedures and answers to any such inquiries;

(f) An instruction that the individual may refuse to consent and that the individual is free to withdraw his consent and to discontinue the treatment at any time without prejudice unless informed consent for the ECT is given by guardian or court-ordered; and

(g) A notification that the individual may consult with an independent specialist and counsel.

(5) The competence of a patient to give informed consent shall be determined by the attending psychiatrist. The written opinion shall be incorporated into the patient's permanent medical record.

(6) The criteria for determining the competence of the patient, include but are not limited to:

(a) Whether or not the patient is physically and mentally able to receive the information required to be furnished;

(b) Whether or not the patient is able to explain his/her understanding of the information provided; and

(c) Whether or not the patient demonstrates that he/she has evaluated the information provided.

(7) Competent adult patients

No competent adult patient shall be given ECT unless his/her informed consent has been obtained.

(8) Adult incompetent involuntary patients

(a) If an adult patient has been adjudicated incompetent to give informed consent for medical treatment by a probate court, the patient's guardian may give informed consent.

(b) If an adult patient has been determined to be incompetent to give consent according to the procedure outlined above, and has no guardian, ECT may be administered only under the following conditions:

(i) The attending psychiatrist must certify in writing that an indication for ECT use as outlined in paragraph (E) of this rule is evident;

(ii) The chief clinical officer recommends in writing the administration of ECT; and

(iii) If a durable power of attorney for healthcare issues exist, it should be followed. Otherwise, approval for ECT shall be obtained from the probate court.

(E) Indications for use

(1) General statement

Referrals for ECT are based upon a combination of factors, including the patient's diagnosis, nature and severity of symptomatology, treatment history, consideration of anticipated risks and benefits of viable treatment options, and patient preference. At present there are no diagnoses which should automatically lead to treatment with ECT. In most cases, ECT is used following treatment failure on psychotropic agents, although specific criteria do exist for use of ECT as a first-line treatment.

(2) Primary use of ECT

Situations where ECT may be used prior to a trial of psychotropic agents include, but are not limited to, the following:

(a) Where a need for rapid, definitive response exists on either medical or psychiatric grounds; or

(b) When the risks of other treatment outweigh the risks of ECT; or

(c) When history of poor drug response and/or good ECT response exists for previous episodes of the illness; or

(d) Patient preference.

(3) Secondary use of ECT

In other situations, a trial of an alternative therapy should be considered prior to referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

(a) Treatment failure, taking into account issues such as choice of agent, dosage, and duration of trial;

(b) Adverse effects which are unavoidable and which are deemed less likely and/or less severe with ECT; and

(c) Deterioration of the patient's condition such that criterion in paragraph (E)(2)(a) of this rule is met.

(4) Major diagnostic indications

Diagnoses for which either compelling data are present for efficacy of ECT or a strong consensus exists in the field supporting such use.

(a) Major depressive disorder. ECT is an effective treatment for all subtypes of major depressive disorder;

(b) Bipolar disorder. ECT is an effective treatment for all sub-types and phases of bipolar disorder including manic, depressed and mixed phases.

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(c) Schizophrenia, schizoaffective disorder and other psychoses.

ECT may be an effective treatment for psychotic schizophrenic exacerbations including catatonia, when prominent affective symptoms are present and when there is a history of favorable response. ECT may be effective in other psychotic disorders.

(d) Mental disorders due to a general medical condition. ECT may be effective in the management of severe affective and psychotic symptoms concomitant with general medical conditions, or in treating delirium of various etiologies, including toxic and metabolic.

(e) Other diagnostic indications.

(i) For people with diagnoses for which efficacy data for ECT are only suggestive, or where only a partial consensus exists in the field, support its use. In such cases, ECT should be recommended only after standard alternatives have been considered as a primary intervention. The existence of such indications, however, should not deter the use of ECT for treatment of a concurrent major diagnostic medication.

(ii) Although ECT has sometimes been of assistance in the management of mental disorders other than those described above, such usage i snot adequately substantiated and should be carefully justified in the clinical record on a case-by-case basis.

(f) Medical disorders

(i) The neurobiologic effects associated with induced generalized seizure activity may be of benefit in treating a small number of medical disorders.

(ii) Such conditions include, but are not limited to:

(a) Catatonia secondary to medical conditions (ECT is indicated for catatonia of all causes);

(b) Hypopituitarism;

(c) Intractable seizure disorder;

(d) Neuroleptic malignant syndrome; and

(e) Parkinson's disease.

(F) Contraindications and situations of high risk

(1) There are no absolute contraindications to ECT.

(2) Situations associated with substantial risk

(a) Situations exist in which ECT is associated with an appreciable likelihood of serious morbidity or mortality. In such cases, the decision for ECT should be based upon the premise that the patient's condition is too grave, (i.e., life threatening) to leave untreated, and that ECT is the safest treatment available.

(b) In these instances, careful medical evaluation of risk factors should be carried out prior to ECT, with specific attention to treatment modifications which may diminish the level of risk.

(c) Specific conditions associated with substantially increased risk include the following:

(i) Space-occupying cerebral lesion, or other conditions with increased intracranial pressure;

(ii) Seizure disorder;

(iii) Recent myocardial infarction with unstable cardiac function;

(iv) Recent intracerebral hemorrhage;

(v) Bleeding, or otherwise unstable, vascular aneurysm or malformation;

(vi) Retinal detachment;

(vii) Pheochromocytoma; and

(viii) Significant anesthetic risk.

(d) Concomitant medications. The following medications should be discontinued or dosage reduced:

(i) Benzodiazapines, as they are anti-convulsants - should be held for at least eight hours;

(ii) Lithium, as it can increase postictal delirium and prolong seizure activity - should be reduced in dose;

(iii) Bupropion, as it can induce late appearing seizures - should be discontinued;

(iv) Lidocaine markedly increases seizure threshold - should be held for at least eight hours;

(v) Theophylline increases the duration of seizures - should be discontinued;

(vi) Reserpine can cause respiratory and cardiovascular problems and should be discontinued; and

(vii) Other medications as determined by the IBHS pharmacy and therapeutics committee.

(G) Medical evaluation

When a patient remains an ODMH RPH patient when receiving ECT, the following medical evaluation will need to be completed by the ODMH RPH staff:

(1) Medical examination;

(2) Neurological examination;

(3) Laboratory evaluations including CBC and differential; blood and urine chemistries;

(4) Electrocardiogram;

(5) X-ray of lumbosacral region if spinal problems are suspected;

(6) Chest x-ray, if clinically indicated;

(7) In the presence of central nervous system symptoms (seizure disorder or a space occupying lesion), EEG and brain computed tomographic scan or magnetic resonance imaging;

(8) Dental examination for elderly patients and those with dental problems; and

(9) Anesthesiologist consults to evaluate risk of anesthesia. This may be completed at the facility where ECT is administered prior to ECT occurring.

(H) Referred facility requirement

(1) Properly accredited hospital or outpatient facility.

(2) The psychiatrist who is responsible for the administration of ECT has been credentialed and privileged in ECT by the facility where the ECT is being administered.

(I) Training

When ODMH RPH patients are receiving ECT as outpatients, the RPH nursing staff shall be provided with appropriate training on nursing care for these patients to assure competent care of pre- and post-ECT treatment.

(J) Reference

"Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association, 2nd ed., 2001".

Supplemental Information

Authorized By: 5119.01, 5122.271, 5122.29
Amplifies: 5119.01, 5122.271, 5122.29
Five Year Review Date:

Rule 5122-3-05 | Competency to stand trial assessment and restoration services for serious youthful offenders (SYOs).

• Effective: January 24, 2011
• Promulgated Under: 111.15

(A) Purpose and background

(1) The purpose of this rule shall be to establish guidelines for competency assessment and restoration treatment of serious youthful offenders (SYOs). Pursuant to section 2152.13 of the Revised Code, effective January 1, 2002, SYOs are afforded all the rights a person who is criminally prosecuted would have if the crime were committed by an adult. This includes the right to be competent to stand trial and utilization of the procedure outlined in Chapter 2945. of the Revised Code, related to competency to stand trial.

(2) Placement/treatment of young children on adult units raises fundamental concerns about the safety and effectiveness of treatment, since ODMH only operates adult inpatient facilities. Treatment of children/adolescents must consider the child's developmental needs and mental status in order to be safe and effective. This rule establishes separate and distinct procedures and guidelines for competency assessment and restoration of children/adolescents. This rule will provide procedures for handling potential referrals from the juvenile courts in Ohio to ODMH facilities. Substantial precedent and common sense support the separation of children from adults in inpatient settings. Prior to the closure of ODMH children's hospitals, in accordance with section 5119.03 of the Revised Code, the department operated separate institutions for children and adults. ODMH private psychiatric hospital licensure rules require that children and adult beds be separate, except for certain emergency admissions of brief periods (forty-eight to seventy-two hours) for older adolescents, aged fifteen through seventeen.

Under this rule, seventeen year olds may be admitted and treated in an adult bed if the person is functioning as an adult in such areas as employment, family, or marriage, or if the diagnosis or problem is such that treatment is warranted in an adult bed.

National professional guidelines clearly recognize that children and adolescents younger than fourteen should be admitted only to programs that are designed for youth and physically distinct from adult psychiatric inpatient programs. Adolescents sixteen and older may be admitted to adult units for valid clinical reasons, but should be treated in a program designed to meet their specific needs. Children and adolescent programs should address the youth's developmental needs including those for education and age-appropriate social interaction.

(B) Definitions

The following definition shall apply to this rule in addition to or in place of those appearing in rule 5122-1-01 of the Administrative Code:

"Serious youthful offender" and "SYO" have the same meaning as in division (X) of section 2152.02 of the Revised Code, i.e., a person who is eligible for a mandatory SYO or discretionary SYO, but who is not transferred to adult court under a mandatory or discretionary transfer.

(C) General guidelines

(1) Young children (under age fourteen years) and younger adolescents (ages fourteen to fifteen) should not be placed in an ODMH regional psychiatric hospital (RPH) because adult facilities are not designed or staffed to provide age-appropriate services for youth. Additionally, because interaction with adult patients on these units may be problematic, these children should be placed in an age-appropriate inpatient psychiatric unit for children or a community residential treatment facility that would specifically meet their individual needs. Older immature adolescents and those not medically cleared for admission to an adult facility should also be treated in these types of settings

(2) Older adolescents (ages sixteen to seventeen) and some younger adolescents (ages fourteen to fifteen) in limited exceptional cases, may be admitted to adult units for valid clinical reasons but should be treated in an individualized program designed to meet their specific needs.

(D) Procedures for admission of adolescents to ODMH RPH inpatient units. Prior to such admissions for competency restoration services, the RPH chief clinical officer shall assure the following:

(1) The child must be medically assessed as appropriate for admission to an adult inpatient unit by a board-eligible or board-certified child psychiatrist with documented specialized training and experience in working with adolescents and their families in an inpatient treatment program;

(2) Other available less restrictive treatment resources (e.g., residential treatment, intensive outpatient), must have been considered and determined to not be available or not appropriate to meet the youth's mental health and safety needs; and

(3) An individual plan of care must be developed by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist to meet the adolescent's restoration to competency needs including the developmental, educational, safety, and environmental needs.

(E) Guidelines for adolescent competency to stand trial restoration treatment services provided in the RPH.

(1) Treatment for the adolescent should be supervised by a child/adolescent psychiatrist or in consultation with a child/adolescent psychiatrist;

(2) All relevant components of the competency to stand trial restoration service are to be adjusted to meet the adolescent's developmental, educational, safety, and environmental needs;

(3) Upon admission, an objective competency assessment should be performed. Standardized competency assessment tools may be utilized;

(4) Multi-modal, experiential competency restoration educational experiences, (e.g., discussions, reading, video, role playing or mock trial), may be utilized;

(5) An educational component should be included regarding the criminal charges, severity of charges, sentencing, pleas, plea bargaining, roles of the courtroom personnel, adversarial nature of the trial process and evaluating evidence;

(6) Periodic reassessment of competency should be made regarding the adolescent's progress toward restoration to competence; and

(7) Medication treatment may be needed in order for restoration to competence to occur.

Supplemental Information

Authorized By: 5119.01
Amplifies: 2152.13
Five Year Review Date:
Prior Effective Dates: 1/2/2002 (Emer.)

Rule 5122-3-12 | Duty to protect.

• Effective: August 5, 2011
• Promulgated Under: 111.15

(A) The purpose of this policy is to implement the duty to protect requirements per section 2305.51 of the Revised Code.

(B) This policy shall apply to all mental health professionals employed or contracted by Ohio department of mental health hospitals.

(C) Definitions:

(1) "Independently-licensed mental health professional" means psychiatrists, psychologists, social workers, counselors and clinical nurse specialists licensed to independently provide mental health services.

(2) "Knowledgeable person" means any person who has reason to believe that a patient has the intent and ability to carry out an explicit threat of inflicting imminent and serious physical harm to a clearly identifiable potential victim(s), who is either an immediate family member of the patient, an employee of the hospital, or an individual who, otherwise, personally knows the patient.

(3) "Mental health professional" means any individual who is licensed, certified or registered under the Revised Code, or otherwise authorized in this state, to provide mental health services.

(D) Procedures:

(1) Any mental health professional to whom an explicit threat of serious physical harm to another person or persons or identifiable structure is made, or who is made aware by a knowledgeable person of an explicit threat made by a patient, will initiate the duty to protect process.

(2) Any explicit threat by a patient shall be promptly communicated by the mental health professional who heard the threat or was made aware of the threat, to a registered nurse or psychiatrist on the patient's treatment team. The treatment team shall determine, based on the patient's history and current condition, whether the threat represents a credible danger to others.

(a) If the treatment team does not consider the threat to be a credible danger to others, this decision and the reason for this determination shall be documented in the medical record.

(b) If the treatment team considers the threat to be a credible danger, the threat shall be reported promptly by the treatment team to the chief clinical officer or designee of the hospital.

(3) The chief clinical officer or designee of the hospital shall assign an independently-licensed mental health professional to conduct a face-to-face evaluation with the patient as soon as possible after receiving notification of the threat, but no longer than two working days, in order to give a second opinion risk assessment of the threat.

(4) If the independently-licensed mental health professional determines that the threat does not meet the threshold requiring discharge of the duty to protect (e.g., threat is not imminent), this assessment should be documented on a form authorized by the regional psychiatric hospital (RPH) or in a progress note in the medical record.

(a) Each RPH shall establish policies and procedures that assure patient re-evaluation occurs prior to the patient being discharged or receiving unsupervised movement, including placing a "Duty to Protect" sticker on the patient's chart and adding a "Duty to Protect" problem on the treatment plan. (See Appendix 1 [DMH-0040a] for "Duty to Protect Tracking Form" which may be used by the RPH to monitor procedure compliance).

(b) The independently-licensed mental health professional shall record, in a progress note or indicate on a RPH form, that the patient does not have either the intent or ability to carry out the threat and record the reason(s) for this conclusion.

(c) Other clinical recommendations may be considered for this patient and should be documented as appropriate in the medical record.

(5) If the independently-licensed mental health professional determines that there is an explicit threat of imminent and serious physical harm and there is reason to believe the patient has the intent and ability to carry out the threat, the independently-licensed mental health professional completing the RPH form or documenting this assessment in a progress note in the medical record, must address each of the relevant options to discharge the duty to protect in section 2305.51 of the Revised Code and indicate the reason(s) each was, or was not, chosen.

(a) Since the patient in these instances is already hospitalized, the relevant options for further action under section 2305.51 of the Revised Code for discharging the duty to protect are as follows:

(i) Establishing and undertaking a treatment plan that is reasonably calculated to eliminate the possibility that the patient will carry out the threat (having performed this second opinion risk assessment consultation); and

(ii) Communicating to a law enforcement agency either where the victim or patient resides and, if feasible, communicating with the potential victim(s) and/or guardian(s) about the threat;

(b) If the option chosen by the independently-licensed mental health professional is to warn the potential victim(s) and appropriate law enforcement agency, the independently-licensed mental health professional shall notify the chief clinical officer (or designee) who will designate the person to give the warning;

(i) The information about who was warned, what information was shared, and the time of the warning shall be documented on the RPH form (Appendix 2 [DMH-0040]) or in the progress note in the medical record; and

(ii) Information shared should be restricted to the name and the description of the patient, the nature of the threat, and the name of potential victim(s) and/or potential structure threatened.

(6) Progress notes in the medical record should reflect any contacts with consultants, chief clinical officer (or designee), or the patient's treatment team as appropriate.

(7) The RPH authorized form, or a copy of the progress notes about the threat should be filed in the legal section of the medical record. A copy should be forwarded to the legal assurance administrator of the hospital.

(8) If the threat is considered to be serious but not imminent, and the independently-licensed mental health professional believes the threat should be re-evaluated closer to unsupervised movement, conditional release or discharge of the patient, the independently-licensed mental health professional will contact the treatment team social worker who will affix or cause to be affixed, a prominent sticker on the front of the patient's medical record noting a "Duty to Protect" and add a "Duty to Protect" problem to the treatment plan.

(9) When a "Duty to Protect" sticker is affixed to the medical record and a problem is added to the treatment plan, prior to unsupervised movement, conditional release or discharge, the treatment team social worker will notify the chief clinical officer (or designee) who will assign an independently-licensed mental health professional to conduct a face-to-face re-evaluation of the presence or absence of the threat, and if present, the credibility of the threat.

(10) If a patient with a "Duty to Protect" problem goes AWOL from a RPH, the treatment team (or on evenings, weekends, and holidays, the nurse manager) shall promptly give a recommendation to the chief clinical officer regarding warning law enforcement and, if feasible, potential victims in the community.

(11) In all re-evaluations, the independently-licensed mental health professional should locate the original RPH form or progress notes about the threat in the medical record or in the file of the legal assurance administrator.

(a) After the face-to-face re-evaluation, a new RPH authorized form or medical record progress note shall be completed and filed in the legal section of the medical record with a copy to the legal assurance administrator.

(i) If no active serious threat is present, this should be noted on the RPH form or in a progress note and no further formal action is necessary;

(ii) If an active, serious, and imminent threat remains, this should be documented on the RPH form or in a progress note and the actions identified in paragraphs (D)(5) to (D)(7) of this rule should be followed. In addition, the independently-licensed mental health professional shall promptly notify the treatment team for appropriate action regarding the pending unsupervised movement, conditional release, or discharge.

View Appendix

Supplemental Information

Authorized By: 111.15, 5119.01
Amplifies: 2305.51
Five Year Review Date:
Prior Effective Dates: 1/1/2006