Pre‐audit survey of documentation of invasive procedures in paediatric anaesthesia
Authors: Patil A. , Wilkins I. , Aitchison S. , Wilkinson K. 
Published: March 2003

Introduction  Consent of patients for any medical procedure is an essential part of good practice (1). Verbal consent is increasingly sought for invasive anaesthetic procedures and documentation of this is an important feature of risk management. Paediatric consent is a complex issue and although it is common practice to explain things to the child, written consent is generally still sought from the parent (2). Recent guidelines from the Royal College (3) are quite specific about having a ‘child centred approach’. They clearly state that ‘where special techniques (e.g. epidurals, other regional blocks including caudal, and invasive monitoring or blood transfusion) are used there should generally be written evidence that these have been discussed with the child (when appropriate) and the parents’.

Our aim was to discover the current amount of documentation on invasive procedures in our paediatric anaesthetic notes and to subsequently agree on a local standard.

Method  We looked retrospectively at anaesthetic records of children aged 10, 11 and 12 years undergoing general anaesthesia for elective surgery over a 2‐month period. We specifically looked for documentation of who was present at the pre‐operative discussion and where an invasive anaesthetic technique was planned. written evidence that it had been discussed.

Results  73 anaesthetic records were examined. The case mix was as follows: 37% ENT, 28% Plastic Surgery, 24% General Surgery, 11 % Orthopaedic and Oral Surgery. A Consultant was present for 98% of the anaesthetics and was accompanied by a trainee in half of those cases. In 82% (60 patients) there was no documentation of who was present at the pre‐operative discussion. In 2 cases (3%) the child was seen alone, in 8 cases (11 %) both a parent and child were documented to have been involved in the discussion and in 3 cases (4%) only the parents appeared to have been involved. Of the 73 anaesthetic records, 11 did not have invasive procedures planned or performed and the following data is from the remaining 62 anaesthetic records

83.5% of invasive procedures were documented pre‐operatively

12 patients (19%) had more than one procedure.

Only 7 notes (11 %) had a record of the procedure being specifically discussed with the child.

2 out of the 4 caudal (50%) were done without documentatior, of discussion about the procedure

7 out of 48 suppositories (14%) were given without record of verbal consent

5 out of 16 (31 %) of the local anaesthetic techniques were performed without documentation of discussion.

Discussion  This pre‐audit survey demonstrates that in 82% of cases there was no record of exactly who was present at the preoperative discussion and that some invasive procedures were carried out without any record of a discussion having taken place. We feel that this level of documentation is insufficient. We looked at the age range 10–12 years as this might be regarded as approximately the age at which agreement should be sought for relatively simple procedures such as those chosen in this survey. This is not to imply that children below this age should not be involved in a plan of management or that all children of this age will be fully competent to participate in decisions. We deliberately chose to look at elective surgery, as there should be better documentation in these cases. One reason for such poor results may be that most anaesthetists do not realise the importance of documentation. Our current chart provides no means of prompting the anaesthetist to record who was present at pre‐operative discussions. There is also a lack of a clear standard as to an age when invasive procedures should generally be discussed. We feel that this is probably a common problem and hope this surveys increases awareness on this important topic.

Conclusions  The results of this survey are to be brought to the attention of the local department. Having identified the problem we hope to agree on a local standard and audit against these standards.