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OBJECTIVES: Although there are published guidelines for procedural consent, there is evidence to suggest that deficiencies still occur with recording of patient demographic data, documentation of procedural risks and information regarding alternative therapies. We assessed the accuracy and completeness of vascular consent within our unit.
METHODS: A retrospective review of patients undergoing vascular intervention between February 2010 and February 2011 was performed. Chart reviews included the analysis of consenting doctors’ seniority, responsible vascular attending, completeness of procedural entry, documentation of correct side, use of abbreviations, discussion of benefits and complications, additional information and overall legibility. Interpretation of consent documentation and overall legibility was performed using CRABEL scoring model for medical record assessment.
RESULTS: 323 patient consent forms were reviewed (male=203, mean age 68.0 years, elective surgery=241) including 50 AAA repairs, 27 carotid endarterectomies, 88 peripheral arterial reconstructions, 96 amputations and 69 elective varicose vein surgeries. 294 (91%) consent forms were completed by a senior resident or above with 286 (88.5%) forms having the responsible attending documented. 85.4% of patients were consented within 48 hours of surgery. 245 (75.9%) consent forms had legible printed names. However, only 75 (23.2%) had a legible signature. 306 (94.7%) consent forms had the procedure documented in full but 165 (51.0%) had used abbreviations. 103 (31.9%) had documentation of the intended benefits of surgery whilst 293 (90.7%) had documentation of potential complications. 3 patients had documented evidence of receiving written information and 1 patient received a copy of the consent form. Of those surveyed, procedural mortality was discussed in 97% of open and 94% of endovascular AAA repairs. Stroke was documented in 96% of consent forms for carotid endarterectomy. Scarring was included most commonly in patients undergoing venous procedures. CRABEL scores for completion of name and hospital number were 98.1%, full operation documentation 94.7%, risks/complications 90.7% and provider signatures 99.9% for all completed consent forms.
CONCLUSIONS: Vascular consent is a complex process involving a number of discussions and meetings with patients. Our unit has demonstrated compliance of nearly 90% for all consent related processes and remains consistent with current published guidance. However, further improvement including the documentation of intended benefits, provision of additional written information whilst reducing the use of abbreviations is desired.