Over a 4-week period in August 2017, consent forms for patients admitted as emergency trauma due to hip fracture were audited against Royal College of Surgeons Standards (28). Patients were included if deemed to have mental capacity to consent for a procedure and excluded if they did not. This was achieved by only selecting consent form documentation that was used for those people aged 16 and over and having capacity, or for those under 16 years who were determined to be Gillick competent (referred to locally as Consent Form 1 (29)). All other consent form types were not reviewed for the purposes of this project (such as those for paediatric cases or for those lacking capacity.)
All data on the forms were analysed, with special attention being given to three process measures of clarity of documentation, whether the listed risks were appropriate for the intervention and if a copy of the consent form had been given or offered to the patient. Evaluation of clarity focussed on if all the patient details had been filled in correctly, along with if the procedure details were correct including laterality and site of surgery and whether abbreviations had been used.
In this period, 24 consent forms for neck of femur fracture patients with capacity were identified. While 93% had accurate completion of patient details and documentation of the patient’s agreement to consent, 38% of forms used abbreviations instead of fully writing out the procedure. Documentation of generic risks such as infection, bleeding and thromboembolic events was completed in 95% of reviewed forms. However, significant procedure-specific risks such as dislocation and leg length discrepancy were documented in just 31% of forms. Finally, only 12% of patients were offered or given a copy of their consent form.
Given the significant omissions in consent form documentation and the consenting process, it was clear that improvement was necessary. The majority of documentation had been completed by junior members of the team, over a period that represented their first four weeks within the speciality. It therefore was felt that to improve documentation of procedure-specific risks, further teaching would be necessary to improve their understanding of the operation and what significant complications could arise. Improved oversight was also to be implemented with ongoing senior clinician review of documentation to be performed on the morning ward round to identify any errors (such as abbreviations) or omissions. Recognizing also that junior staff were completing these documents often in time or work pressured environments, further memory aids were also reviewed and developed including pre-printed consent form stickers with all key procedure-specific risks included. These could then be directly applied to the generic consent forms that were currently in use.
Strategy and Improvement Cycles
Having determined that lack of experience in junior trainees was a key reason for poor documentation, interventions were planned to align with each rotation where new trainees would start working within the department. Practice would then be re-audited over another four-week period to determine the impact of any interventions made.
Improvement Cycle 1 (January 2018) – Teaching for junior colleagues was carried out, including a session at induction for newly rotated junior doctors on how to complete consent in accordance with Royal College of Surgeons guidelines (12). Other teaching sessions were also performed for the department as a whole, covering the most common risks of procedures performed for high frequency presentations. Alongside this, senior review of consent forms in the morning ward round to identify errors was implemented. However, errors still occurred with procedure-specific risks found to be absent in 28% of cases.
Improvement Cycle 2 (August 2018) – As part of an updated approach to managing hip fractures, a proforma was developed including pre-printed consent stickers with all risks (both generic and procedure-specific) included (example for intracapsular neck of femur fractures requiring arthroplasty shown in Figure 1). These stickers were then to be used in conjunction with existing consent form documentation and act as a memory prompt for the doctor’s discussions with the patient. A teaching session on the use of this form along with the key procedure-specific risks was given to junior staff at their induction as they began their rotation.
Summary of Results
Following the teaching interventions in cycle 1, re-audit of practice identified 26 consent forms suitable for analysis. Significant improvement was seen in reducing the usage of abbreviations, which fell from 38% to 20% and procedure detail documentation improved further from a baseline of 93% to 96%. Improvement was also found in documentation of all risks improving from 66% to 81% and procedure-specific risks documented in 72% of analysed forms, more than doubling baseline measurements. More patients were also offered a copy of their consent forms, rising from 12% to 48%.
With the introduction of the hip fracture proforma and consent stickers in cycle 2, a further 24 consent forms were evaluated (see Figure 2 – summary runchart). Sustained improvements were seen in documentation of procedure details, rising to 100% completion on all forms sampled. Abbreviation usage continued to fall further, decreasing to 7%. However, documentation of procedure-specific risks remained similar to the prior cycle at 67% while a significant deterioration was seen in patients being offered a copy of their consent form, falling to just 8% of patients. Raw data for all aforementioned quality outcome indicators is presented in Table 1.