336 - Improving Documentation and Accuracy of Medical Consent for Hospitalized Pediatric Patients

Publication Number: 4329.336

Mallika B. Iyer-Horiuchi, University of California Davis Children's Hospital, Sacramento, CA, United States; Jessica C. Witkowski, University of California, Davis, School of Medicine, Sacramento, CA, United States; DeAnn Bilotta, University of California, Davis, Sacramento, CA, United States; Jihey Yuk, University of California Davis Children's Hospital, Sacramento, CA, United States; Ulfat Shaikh, University of California, Davis, School of Medicine, Sacramento, CA, United States; Michelle Hamline, University of California Davis Children's Hospital, Sacramento, CA, United States

Background: Caring for hospitalized children with child protective service (CPS) involvement presents unique challenges related to medical consent. At baseline, only 1% of Pediatric Hospital Medicine (PHM) patients at our institution, including those with CPS involvement, had consent clearly documented in their electronic medical record. This documentation allows clarification of consent prior to an urgent or emergent need.

Objective: Our goal was to increase accurate documentation of consent for PHM patients by 20% above baseline within 9 months.

Design/Methods: Baseline data was collected through retrospective manual chart review of 100 randomly selected patients over 10 months. We collected demographic data, documentation of consent, and accuracy of consent for patients with CPS involvement through comparison with social work (SW) documentation. A multidisciplinary team consisting of PHM attendings, a pediatric resident physician, a social worker, and a general pediatrician with expertise in foster care determined key drivers of consent non-documentation and identified interventions (Table 1). In the intervention phase, an electronic health record (EHR) tool was added to the social section of PHM H&Ps and monthly PHM discharges were reviewed. The tool contained a specific section for consent documentation along with instructions. It also contained a data element that was used to track if consent was documented. If not, further chart review was undertaken. Data was stratified by admission location until the tool was added to transfer summary notes. Data was graphed on run charts and reviewed regularly with the multidisciplinary team.

Results: Following the first month of the intervention, consent documentation increased from 1% to 74.5% overall and 92.8% when excluding ICU admissions. In subsequent months, 97-98% of PHM discharges (excluding ICU admits) had consent documented. After adding the EHR tool to transfer summary templates, 98% of all PHM discharges, including ICU admits, had consent documented (Fig 1). For patients with non-biological parents listed as consenters, PHM notes where consent matched social worker's notes increased from 1 out of 2 notes available in Month 1 to 10 out of 11 notes available in Month 9. (Fig. 2).

Conclusion(s): Implementation of a standardized EHR tool into PHM notes and educational interventions significantly increased the frequency and accuracy of documentation of consent. The direct integration of these tools into notes is likely to be sustainable, despite frequent clinical team turnover, to enable consistent consent documentation for all PHM patients.

Figure 1
Run Chart showing percentage of Pediatric Hospital Medicine (PHM) patients with consent documented over time

Figure 2
Concordance of Pediatric Hospital Medicine (PHM) and Social Work (SW) notes in patients with non-biological parent consenters

Table 1
Table of Interventions During Study