Role of electronic consent in emergency surgery – A QIP in a high volume surgical emergency unit at a tertiary hospital
Afroza Sharmin, Vishani Loyala, Ola Shams, Giles Bond-Smith
British Journal of Surgery, 7 December 2022
The Royal College of Surgeons of England discusses the significance of maintaining a written record of consent in addition to completing the consent form under section 4.10 of the supported decision-making guide to good practice – “any written information given to the patient should also be recorded and copies should be included in the patient’s notes”. Studies show high error rates (27–50%) with handwritten consent forms due to poor legibility, incomplete/ inaccurate information, increased variability, and risk of misplacement. The consequences of these errors can lead to poor patient experience as well as unfavourable outcomes at the operational and institutional levels. Missing or incomplete consent is also the most common reason for first case delay (average 1–75mins). This prompted the QIP and generation of a standard template for the common emergency general surgery procedures in a high-volume Surgical Emergency Unit (SEU) at the John Radcliffe Hospital.
Procedure-specific Electronic Surgical Consent (eSConsent) template for common emergency general surgery operations was added to the online database to easily be added to the electronic patient record. The format, as outlined below, was designed to allow even junior surgical trainees to adapt and perform the consent process early on in their placement-
- Patient details and occupation
- Intended benefit
- All common procedures listed, risks and additional procedures pre-populated
- Additional information (eg: discussion with next of kin, P-POSSUM score, NELA score etc)
- Sign off
The consent for all the emergency general surgery cases in a given week was reviewed and the compliance to maintaining eSConsent was audited. The first cycle between 20th-26th September 2021 showed compliance of only 18% (9 out of 49 operations). After discussing the audit findings with the members of the surgical team involved in the consenting process in the local meeting and implementing eSConsent, the compliance increased to 83.7% (36 of 43 cases) in the following week, 78% (33 of 43 cases) between 12th-18th November 2021 and 73% (28/38 operations) in the beginning of March 2022.
A consent form is a medicolegal document. Health care systems have taken advantage of technology to facilitate accuracy and robust monitoring. The emergency surgical consent process can benefit from this to avoid delays, errors and litigation. This transition is justifiable from our results and easily translated to practice particularly by using simple technology demonstrated in our QIP. Challenges including trainee changeover and new recruitments will expectedly affect the compliance of eSConsent but a proper induction to ensure adequate staff education will help overcome this. Weekly data capture has been adopted in our department as a surveillance protocol to ensure adherence and to standardize our practice.