Hip fractures are one of the most common presentations to emergency departments in the United Kingdom with 66,000 cases reported per year (1). This is a significant injury that carries a 6.9% mortality risk within one month and requires prompt management (1). Delay of surgical intervention (if indicated) beyond 48 hours is associated with increased death rates and complications such as pressure sores (2). Trauma & Orthopaedics departments are therefore required to make the pathway to operation as efficient as possible to ensure that patients are operated on within this window.
A key element of this pathway is gaining the patient’s consent for the procedure. Patients should have their treatment options explained to them, along with the benefits of any intervention, along with associated risks, burdens and side effects before then reaching a decision on whether to proceed (3). Commonly for acute trauma admissions, this consenting process is performed by the clerking doctor to prepare the patient for an imminent operation. However often the clerking doctor may not be the surgeon performing the procedure and can be a relatively junior grade who is working under significant time or work pressure (4). These pressures have been noted to result in poor documentation and missed elements of admission notes (5) which can render important documentation such as consent forms substandard or even invalid (4).
In order to reduce the variation in the admission and consenting process, several approaches have been evaluated, ranging from enhanced training to the use of procedure-specific proformas (6) and consent stickers with pre-printed risks (7). Although these have demonstrated benefit, their usage remains limited and best practice is still unknown. This quality improvement project aimed to assess our baseline consenting practice within a large 774-bed district general hospital while also reviewing the impact of ongoing improvement efforts such as teaching sessions and the use of proformas and consent stickers.
Reviews of consent documentation for common trauma procedures have found poor documentation of risks (8) often with a wide variety of complications listed for the same procedure in varying frequencies (9). These deficiencies in documentation have been attributed to not only the aforementioned work pressures but also poor overall awareness of local or national guidelines and standards (10), which is often exacerbated by a relatively rapid turnover of junior staff (rotating as frequently as every 4 months) (5). This is despite Department of Health and Royal College of Surgeons guidelines on consent that state the person obtaining consent should have clear knowledge of the procedure along with the potential risks and complications (11, 12).
Poor or incomplete documentation during the consent process denies the patient a full understanding of the procedure they are about to undergo, negatively impacting their decision making autonomy (13). This can also then subsequently expose hospitals and doctors to possible litigation (14), (15). Previous reviews of litigation relating to informed consent in the United States found errors in recording the risks of a procedure accounted for up to 70% of complaints alone (16). Furthermore, if consent documentation is of poor enough quality to be rendered entirely invalid, this can delay the operative pathway, potentially resulting in cancellation of procedures (4). In a time critical situation such as hip fractures, these unnecessary delays can therefore significantly negatively impact patient care and outcomes.
Set proformas/checklists for common presentations have been found to improve the documentation of important items which can commonly be missed (17). Checklists of essential pre-operative tasks have been used to improve the rate of completion of requested jobs (18) and their usage in surgical ward rounds has also been found to improve the quality of documentation (19). It has also been established that checklists can have a significant role in changing cultural practice and improving safety (20) with work by the Safe Surgery Saves Lives Study Group finding that a checklist was associated with concomitant reductions in both rates of death and complications in patients undergoing non-cardiac surgery (21)
Stickers have been used as part of a checklist, for documentation of ward rounds and demonstrated to be a simple and effective way of evidencing good practice against recommended standards (22). A quality improvement program in NHS Lanarkshire where the use of ward round stickers was audited found them to be a simple and effective safeguard to ensure basic aspects of care were not missed while maintaining standards (23). The benefits of this standardized approach subsequently led to the development of websites devoted to consent for specific procedures. The goal of these resources was to provide a uniform approach to documenting risks, and their use has been shown to produce an improvement in quality of consenting (24). Similar benefits were found when using pre-printed consent labels for consenting patients (7, 25).
However, these efforts are prone to abandonment when local champions of their use move on (26) and it is recognized that the usage of proformas often tails off over time for a variety of reasons (e.g. logistical issues with re-printing when initial supplies are depleted) (27). Use of pre-printed stickers for consent may also pose a medico-legal issue given the implications of recent Supreme Court judgements, who found in Montgomery vs Lanarkshire Health Board that pre-procedure risk documentation should not only be generic but also reviewed for significance to the individual patient (28). Other projects using stickers have attempted to address this by having suggestion boxes to advise the consenter of the legal obligation to pause and engage in discussion with the patient (7), but documenting this individualized analysis of risks remains a challenge.