Intervention Title:
Documenting How Language Needs are Met when Obtaining Informed Consent – UC Davis Health System; Sacramento, Calif.

Goal:
Encourage health care providers to include qualified medical interpreters in the consent process for elective procedures in the Pediatric Intensive Care Unit (PICU).

Innovation:
The team at UC Davis developed a standard list of all elective procedures requiring informed consent, then provided all pediatric unit physicians with a form to document the use of a medical interpreter through dictated notes when such procedures involved patients and/or family members with limited English proficiency (LEP).

Result:
The hospital's PICU went from informed consent documentation for only 40 to 50 percent of elective procedures to documentation of consent in nearly 95 percent of procedures, with negligible difference between LEP and non-LEP families.

Institution:
UC Davis Health System
2315 Stockton Boulevard
Sacramento, CA 95817
P: (916) 734-2011

From the expert:
“Our goal was two-fold: to make it a hospital standard of care to include the services of a medical interpreter for all patients not fluent in English and to improve our overall rates of documented, informed consent – including for English-speaking patients and families. The end result is that we've accomplished both. We're documenting informed consent in nearly 95 percent of elective procedures, and we've increased the frequency with which our physicians enlist interpreters, which ultimately means better care for all of our patients.”

Robert K. Pretzlaff, M.D.
Chief, Pediatric Critical Care Division

Profile:
UC Davis Health System is the leading referral center in a region covering 65,000 square miles. It is the region's only academic medical center with 577 licensed beds, approximately 34,000 annual admissions and nearly 53,000 annual Emergency Department visits.

Clinical areas affected:

• Pediatrics

Staff involved:

• Interpreters
• Physicians

Timeline:
Staff spent three months laying the groundwork, including determining which procedures should be included and which format of dictation should be used; it took approximately six months before there were measurable results.

Contact:
JoAnne Natale, M.D., Ph.D.
Associate Professor of Pediatrics
P: (916) 734-4545
Joanne.natale@ucdmc.ucdavis.edu

Innovation implementation:
Due to questions and uncertainty amongst staff regarding which elective procedures required informed consent from patients, their parents or other designated family members, the UC Davis team developed a list of such procedures. The team solicited input via email from all PICU physicians, compiling a list of more than a dozen procedures, from placement of an arterial line to endotracheal intubation. After discussion at a monthly staff meeting, the final product was an agreed-upon list of procedures that require informed consent if performed in non-emergent circumstances.

The team presented physicians with a “Pediatric Procedure Note” to document consent. The form's third question asked: “If appropriate, was an interpreter used?” This was followed by: “If no, state reason (other than emergency).”

Finally, physicians were provided with a script and a list of required items to be included in dictation. They were then informed that a member of the team at their facility participating in the Speaking Together program would be reviewing their dictation to ensure they followed procedures, obtained consent and when necessary, enlisted an interpreter.

When the Speaking Together team began to review dictation notes, there was minimal immediate improvement in the rate at which informed consent was being obtained and documented. Surprisingly, there was also negligible difference in the rate of informed consent between LEP patients and their families and English-speaking patients/families.

Follow-up e-mails about failure to document consent in dictation and appearances at PICU staff meetings turned things around. After about six months of relatively little change, the team began to see a steady increase in informed-consent documentation for both English-speaking and LEP patients and families.

Advice and lessons learned:

1. Agree upon elective procedures before beginning. There may be discrepancies in what procedures physicians view as requiring informed consent. Consistency across providers is key in order to accurately measure and secure improvement. A list of procedures that all physicians endorse will make the process go more smoothly.
2. Be prepared for a cumbersome tracking process. Dictation notes are virtually impossible to review and track in an automated manner. Consequently, a hospital must allow the time/resources for a labor- and time-intensive review process.

Cost/benefit estimate:
While there has been no cost/benefit analysis conducted to date, the PICU is nearing 100 percent rates for obtaining informed consent from both English-speaking and LEP families – a more than doubling of initial rates.