SP2.3 Evaluating the Impact of Electronic Documentation on the Consent Process for Laparoscopic Choelcystectomies Within a HPB Department

Abstract

Abstract Background Over 60,000 laparoscopic cholecystectomies are performed annually in the UK. There are common complications such as bleeding and infection. More infrequently, there are serious risks of bile leak, bile duct or visceral injury. Documented risks and additional procedures stated on a consent form often vary significantly depending on the consenting clinician. We aim to assess the effect of a transition to an entirely electronic patient record (EPR) system on the documentation of consent and the subsequent impact of standardised electronic consent forms. Methods Comparison of documented risks and additional procedures against gold standard EIDO consent leaflet for laparoscopic cholecystectomies performed by a tertiary centre hepatobiliary surgery department. Paper consent forms from July to September 2022 compared to electronically signed consent forms obtained from the EPR from September to November 2022. Intervention in December 2022 (introduction of automated consent forms for clinicians to use). Re-audit from December 2022 to January 2023. Descriptive statistical analysis. Results Twenty-one risks and four additional procedures in gold standard consent. 84% of consents performed by middle grades (53/63). Transition to EPR shows infrequent documentation of common complications, such as pain, bleeding and infection. Rarer complications such bile duct injury mentioned more often with EPR. Additional procedures poorly documented with paper consent forms not improved by transition to EPR. All risks and additional procedures documented more frequently with pre-filled consent form. Conclusions Large variation in the consenting process. Simple, targeted interventions have added uniformity and consistency to the consenting process. Further assessment of the consenting process for other index procedures of hepatobiliary surgery to follow.