Consent and documentation of risks for anaesthesia audit.
Consent for anaesthesia is a hot topic. Guidelines from the AAGBI published in 2006 exist, and
salient points are as follows;1
"5.3.8 Information should be provided about:
• generally what may be expected as part of the proposed anaesthetic technique. For
example, fasting, the administration and effects of premedication, transfer from the ward to
the anaesthetic room, cannula insertion, non- invasive monitoring, induction of general
and/or local anaesthetic, monitoring throughout surgery by the anaesthetist, transfer to a
recovery area, and return to the ward. Intra-operative and postoperative analgesia, fluids
and antiemetic therapy should also be described;
• postoperative recovery in a critical care environment (and what this might entail), where
appropriate;
• alternative anaesthetic techniques, where appropriate. Patients do not have to agree to
the anaesthetist's preferred anaesthetic technique;
• commonly occurring, 'expected' side-effects, such as nausea and vomiting, numbness
after local anaesthetic techniques, suxamethonium pains and post dural puncture
headache;
• rare but serious complications such as awareness (with and without pain), nerve injury (for
all forms of anaesthesia), disability (stroke, deafness and blindness) should be provided in
written information, as should the very small risk of death. It is good practice to include an
estimate of the incidence of the risk [22]. Anaesthetists must be prepared to discuss these
risks at the pre-operative visit if the patient asks about them;
• specific risks or complications that may be of increased significance to the patient, for
example, the risk of vocal cord damage if the patient is a professional singer;
• the increased risk from anaesthesia and surgery in relation to the patient’s medical
history, nature of the surgery and urgency of the procedure. If possible, an estimate of the
additional risk should be provided;
• the risks and benefits of local and regional anaesthesia in comparison to other analgesic
techniques;
• the risk of intra-operative pain, and the need to convert to general anaesthesia, should a
proposed local or regional technique be inadequate or ineffective. The risks and benefits of
adjunctive sedation or general anaesthesia should be discussed;
• the benefits and risks of associated procedures such as central venous catheterisation,
where appropriate;
• techniques of a sensitive nature, such as the insertion of an analgesic suppository."
Current advice does not deem formal written and signed consent necessary for anaesthesia;
however documentation of discussions of risk for proposed anaesthesia and anaesthesia
techniques should be considered best practice in all circumstances. In a large Australian study2 of
850 cases risk discussion was found to be the least likely preoperative details to be adequately
documented. The anaesthetist possesses skills necessary to assess and estimate risk and guide
patients in choosing the safest and most efficacious techniques for them. Indeed it is among the
1
http://www.aagbi.org/sites/default/files/consent06.pdf
Perioperative anesthetic documentation: Adherence to current Australian guidelines
Elhalawani Islam, Jenkins Simon, Newman Nicole
Year : 2013 | Volume: 29 | Issue Number: 2 | Page: 211-215
2
most important facet of the anaesthetist’s role to provide patients with relevant and accurate
information to allow decision making about anaesthetic technique decisions.
This audit follows recommendation from the 3rd edition of the RCOA audit recipe book3 and can be
mapped to the following curriculum areas;
CPD matrix code: 1F01
Basic curriculum competences: OA_BK_01, OA_BK_11, OA_BK_12, OA_135_06
Intermediate curriculum competence: GU_135_06
It seeks to understand the current practice of documentation of risk across the regions hospitals as
the first phase in a three step process to clarify the broader questions raised surrounding consent
for anaesthesia.
Phase ONE
Data collection to be performed from anaesthetic records prospectively across the region over a
one week period using the attached data collection proforma, which should hopefully yield a
sufficient number to provide a cohesive snapshot. We should attempt to collect data from every
anaesthetic performed in patients over the age of 18 from all areas within the collection time.
Obtaining a % of patients with whom discussion of risk and benefits of a particular technique is
documented along with simple demographic data ( ASA and Urgency of surgery)
Data to be collected includes demographic detail and detail on documentation of risk for GA,
Regional technique and/or Neuraxial blockade.
Proposed audit goals.
Common risks in anaesthesia should be discussed and documented in 100% of elective
cases
Common and rare but significant risks should be discussed and documented in 100% of
cases undergoing Neuraxial blockade
Common and rare but significant risks should be discussed and documented in 100% of
cases undergoing a regional anaesthetic technique
Common and rare but significant risk should be discussed and documented in 100% of
emergency cases
Phase TWO
A region wide survey of anaesthetists to stratify the importance attributed to the individual facets of
risk.
Phase THREE
Patient survey of attitudes to which risks patients feel are important to them.
3
https://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_1.pdf
DATA COLLECTION TOOL
Please ring or tick appropriate answers
PRIORITY
ELECTIVE
DAY CASE
EMERGENCY
CONSULTANT
SASG
ST3-7
CT1-2
1
2
3
4
5
NUHNHST
RDHNHST
SFNHSFT
CRNHST
ULHNHST
DEATH
DIFFICULT
INTUBATION/
FAILED
INTUBATION
ASPIRATION
DURING
ANAESTHESIA
POSTOPERATIVE
COGNITIVE
DECLINE
POSTOPERATIVE
DELERIUM
DROWSINESS
DIZZINESS
HEADACHE
CVA
PAIN
PONV
SORE
THROAT
DENTAL
DAMAGE
AWARENESS
PERIPHERAL
NERVE
INJURY
ANAESTHETIST
ASA
HOSPITAL
TRUST
GENERAL ANAESTHESIA
OTHER
(Please write)
NEURAXIAL
BLOCKADE
SPINAL
EPIDURAL
PARAPLEGIA
PERMANENT
NERVE
DAMAGE
HAEMATOMA/
BLEEDING
ABCESS/
INFECTION
TRANSIENT
NERVE
DAMAGE
DEATH
FAILURE
BACKACHE
URINARY
RETENTION
PAIN
UNILATERAL
BLOCKADE
POST DURAL
PUNCTURE
HEADACHE
PATCHY
BLOCKADE
CONVERSION
TO GA
OTHER
(Please write)
PERIPHERAL NERVE BLOCKADE
PERMENANT
NERVE
DAMAGE
TRANSIENT
NERVE
DAMAGE
FAILURE
INFECTION
PAIN
PNEUMOTHO
RAX
SYSTEMIC
LA TOXICITY
DEATH
OTHER
(Please write)
BLEEDING