Consent issue

[TurismoDreamin]

So I wanted to get people's feedback on this. My hospital originally had one consent which covered the surgery and anesthesia. Now, we have a separate consent for the surgical procedure (wording had not changed and we still use the same form that covered both originally) and the anesthesia consent.

So today, we were to do a simple cysto stent. I did the pre-op interview in our one day surgery area with the patient and went through the chart. She confirmed the surgery as it's written in the consent, spoke with an anesthesiologist earlier in the AM and all was well in her chart...except we were missing the anesthesia consent. No problem. I grabbed another one, clipped it to the front of the chart, and told the CRNA in the room about it. He said he would take care of it. You can already see where this is going. So my orderly wheels the patient to the OR doors and the CRNA, who had not yet spoken to the patient anyway, checked things over with the patient also and spoke to her about the anesthetic being used for the surgery, and the patient agreed and understood. At the same time, another CRNA came by and started speaking to my CRNA and said he was going to relieve him for a bit for a short break. Somewhere along there, there was a breakdown in communication and the anesthesia consent was not signed. I had to go back into the room to help the scrub and all the while I thought it was signed. Anyway, the patient is positioned, hooked up, and the propofol goes in. The Dr. asked me about something in the chart so I go to look and the first thing I notice is that the anesthesia consent still was not signed. I immediately went to anesthesia about it. Both CRNA's were still in the room at the time and they said don't worry about it and that they'll take care of it. At this point, what can we really do? We pushed forward and once my CRNA came back from his break, both of them approached me about what they did to the consent. They both signed under the witness area where we would normally have two people sign for those who can't sign for themselves and said that it should be acceptable that way. I was going to talk to my manager about it as well as fill out a variance, but since they seemed to be confident about it, I didn't worry about it, and my manager had left for the day (doesn't help to be second call with a ton of add-ons at shift change). The surgery went without a hitch, took 20 minutes, and the patient woke up just fine. In addition, the surgical consent was correct, and the patient did agree to the anesthetic when the CRNA spoke to them about it. Anyway, sorry for the fluffy story, but what does everyone think about this?

[Rose_Queen, BSN, MSN, RN]

No patient should enter the OR until all consents / H&P update / any other requirements are met. Period.

[rammstein]

this sounds like a simple case of someone was too lazy to do things properly so they half-a$$ed it and called it "good enough." good enough never is, in my opinion... and laziness is my #1 pet peeve.

[brownbook]

Yeah an error was made. I certainly can not see how any harm was done to the patient or any legal action could come out of this?

Laziness is not my pet peeve.....stupid redundant paper work made for and written by lawyers and insurance companies is my pet peeve.

I think.....assume....maybe.....that the wording of most surgical consents mention anesthesia.

It may come down to an issue of when, how, why, anesthesia gets paid, gets billed separately from the surgeon per their insurance.

[kaylabellinger]

Sounds like anesthesia should have had that covered before the patient was brought in...the anesthesia provider should be aware of whether the consent is signed or not...but you know who it would fall back on..the nurse!

[TurismoDreamin]

Sounds like anesthesia should have had that covered before the patient was brought in...the anesthesia provider should be aware of whether the consent is signed or not...but you know who it would fall back on..the nurse!

And that's absolutely my concern. I spoke with my team leader today and she just said to go ahead and fill out a variance anyway so I did. But she said that it's still covered under the operative consent since the wording was never changed and not to worry about it. Per management, the anesthesia consent was created to provide more backbone to legal cases only. Billing was not mentioned. They've been doing audits on themselves to see if they've been filling them out thoroughly and correctly, and so far, according to my manager, they're at 95%.

No patient should enter the OR until all consents / H&P update / any other requirements are met. Period.

So a little background on our hospital. The process of bringing our patient over use to go like this...Pre-op would get the patient ready and notify us in the OR that they are ready for pick-up. The orderly would go pick-up the patient and bring them back to the OR were we would do our patient interview/assessment outside of the actual OR room. Anesthesia would also do their assessment. We would bring the patient in, have them transfer to the OR table, and the surgeon would place a mark on the patient before anesthesia pushed meds in. At this time, H&P's outside of our 24 hr acceptable window would be updated in the room. After the surgery was completed, anesthesia and the orderly would take the patient to recovery and anesthesia would give report to the recovery room nurse. As you can see, this system isn't the best, but it has worked for many years.

Fast-forward to a month ago. Our new process goes like this...the Dr has to see the patient in pre-op to mark laterality only. If no laterality marking needed, they don't have to see the patient unless the patient has questions beforehand. H&P updates remain the same. The circulator has to speak with the patient in pre-op before we can bring the patient back. Anesthesia does not. They can still see the patient outside of the OR. Without anesthesia talking to them about the anesthesic, we can't get the anesthesia consent signed. Therefore, your argument, although valid, leads us to a conundrum that has been beaten to death and would be so easy to fix if our anesthesia group were not so resistant to change or have such a huge sense of entitlement. Our current process is still flawed and management promises us that they are actively working towards a mutual resolution. It's hard to get anesthesia to see the patient in pre-op because...wait for it..........it's too far to walk. The distance from the farthest OR suite to the farthest pre-op patient room is 1/5th of a mile, one way. Therefore, some anesthesia sees the patient in pre-op and some want the patient brought to the door still.

[Rose_Queen, BSN, MSN, RN]

I think your process opens up a lot of opportunity to abuse the system. We are required to go out to preop, interview our patient, verify consents and site marking, and then we are responsible for taking them back. Surgery is a big deal- things should be double and triple checked. As for too far a walk- what happens when things aren't correct or are missing? You leave the patient sitting in the hallway outside the OR until everything gets fixed? That's one way to drive up anxiety levels for the patient.

As for your surgical consents including anesthesia, my belief is that it should be a completely separate consent. A different person is obtaining it, it varies extremely by procedure and patient, and it's a way to verify that anesthesia's plan is communicated to everyone. Our anesthesia consents actually have a line the anesthesiologist must fill out with type of anesthesia (general, MAC, CS, epidural, etc.) as well as any other special things (arterial line, central line, swan, etc.). The Joint Commission actually mandated this change, as well as a change to our surgical consents to include that the surgeon also explained the risks of not having the surgery.

Your facility may actually be opening itself up for legal issues. Patient has a bad outcome from an epidural for example. In reviewing the chart, no consent documenting that risks/benefits of epidural anesthesia were discussed with the patient. The hospital may as well just open up their wallet. Might also have issues with the Joint Commission, like we did, and have to completely revise the consent process.

[MereSanity]

The RN should pick up the patient...make all the necessary checks to see everything is filled out correctly...its your license...and we are the "final" check before the patient comes back to the room. Period. The circulating nurse is responsible for the care of the patient in the OR....not the preop nurse. Who checks to make sure pre op did what they should before the patient comes back?

[MunoRN, RN]

I'm not seeing what the problem was, the CRNA/anesthesiologist already consented the patient, all that was left was for the nurse to have the patient sign the form and witness the signature, what else was the CRNA expected to do?

[MadpeysRN]

all Dr.s, anesthesia and nurses see patients in the preop holding area at my hospital . The anesthesia providers cannot(or atleast shouldn't-it has happened) bring patients back until the circulator signs the nurse to nurse handoff. So usually what ends up happening is anes calls a million times into the room, can we come back yet-can we come back yet?

no patient comes back with incomplete consents, period.

[springchick1, ADN, RN]

I'm not seeing what the problem was, the CRNA/anesthesiologist already consented the patient, all that was left was for the nurse to have the patient sign the form and witness the signature, what else was the CRNA expected to do?

The CRNA was expected to get the patient to sign the paper work. My problem with this whole situation is that no one in the OR is talking to the patient until they get into the OR.

[Rose_Queen, BSN, MSN, RN]

The CRNA was expected to get the patient to sign the paper work. My problem with this whole situation is that no one in the OR is talking to the patient until they get into the OR.

Exactly. Catching issues when already in the OR is catching them too late. All consents need to be done before the patient leaves preop.