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Background:
The consent process for lumbar puncture (LP) in Wellington Emergency Department/Te Pae Tiaki (WED/TPT) is non-standardised. This allows a variety of practice, risking inadequate information and consent practices.
Objectives:
To identify current and best practice for consent and documentation for lumbar puncture in WED/TPT.
To identify current and best practice for consent and documentation for lumbar puncture in WED/TPT.
Method:
Electronic records for WED/TPT attendances from June – November 2021 were searched for “lumbar puncture”, “LP” and “spinal tap”. Information regarding patient and doctor demographics, presence of documented consent (written, verbal) and the contents of the consent were collected (inclusion of benefits, risks, alternative options, explanation in patient’s primary language, use of an ED information sheet). A survey was collected from ED consultants regarding opinions for best practice for lumbar puncture consent.
Electronic records for WED/TPT attendances from June – November 2021 were searched for “lumbar puncture”, “LP” and “spinal tap”. Information regarding patient and doctor demographics, presence of documented consent (written, verbal) and the contents of the consent were collected (inclusion of benefits, risks, alternative options, explanation in patient’s primary language, use of an ED information sheet). A survey was collected from ED consultants regarding opinions for best practice for lumbar puncture consent.
Results:
55 patients had an LP. 36(65.5%) records had documentation of consent, with 28 obtaining verbal consent, 5 written consent and 3 obtaining consent from EPOA. Where consent was documented, specific risks were documented in 16(44.4%) cases. An information sheet was used in 6(10%) cases. 3(5%) cases had no documentation of the procedure. In the consultant survey, 53% responded that verbal consent was sufficient for LP and the rest responded that written consent was sufficient. 100% responded that either forms of consent should be documented in the ED notes. 75% responded that they would want and use a standardised explanation and consent form for LP.
55 patients had an LP. 36(65.5%) records had documentation of consent, with 28 obtaining verbal consent, 5 written consent and 3 obtaining consent from EPOA. Where consent was documented, specific risks were documented in 16(44.4%) cases. An information sheet was used in 6(10%) cases. 3(5%) cases had no documentation of the procedure. In the consultant survey, 53% responded that verbal consent was sufficient for LP and the rest responded that written consent was sufficient. 100% responded that either forms of consent should be documented in the ED notes. 75% responded that they would want and use a standardised explanation and consent form for LP.
Conclusion:
The identified standard is to gain written or verbal consent, with clear documentation. This is not current practice in WED/TPT. An educational session and checklist will be implemented prior to repeat audit.
The identified standard is to gain written or verbal consent, with clear documentation. This is not current practice in WED/TPT. An educational session and checklist will be implemented prior to repeat audit.
