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Kagerbauer SM, Wißler J, Andonov DI, Ulm B, Schneider G, Podtschaske AH, Blobner M, Jungwirth B. Implementation of a software-based decision support tool for guideline-appropriate preoperative evaluation: a prospective agreement study. Br J Anaesth 2024:S0007-0912(24)00335-0. [PMID: 38971713 DOI: 10.1016/j.bja.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Guideline adherence in the medical field leaves room for improvement. Digitalised decision support helps improve compliance. However, the complex nature of the guidelines makes implementation in clinical practice difficult. METHODS This single-centre prospective study included 204 adult ASA physical status 3-4 patients undergoing elective noncardiac surgery at a German university hospital. Agreement of clearance for surgery between a guideline expert and a digital guideline support tool was investigated. The decision made by the on-duty anaesthetists (standard approach) was assessed for agreement with the expert in a cross-over design. The main outcome was the level of agreement between digital guideline support and the expert. RESULTS The digital guideline support approach cleared 18.1% of the patients for surgery, the standard approach cleared 74.0%, and the expert approach cleared 47.5%. Agreement of the expert decision with digital guideline support (66.7%) and the standard approach (67.6%) was fair (Cohen's kappa 0.37 [interquartile range 0.26-0.48] vs 0.31 [0.21-0.42], P=0.6). Taking the expert decision as a benchmark, correct clearance using digital guideline support was 50.5%, and correct clearance using the standard approach was 44.6%. Digital guideline support incorrectly asked for additional examinations in 31.4% of the patients, whereas the standard approach did not consider conditions that would have justified additional examinations before surgery in 29.4%. CONCLUSIONS Strict guideline adherence for clearance for surgery through digitalised decision support inadequately considered patients, clinical context. Vague formulations, weak recommendations, and low-quality evidence complicate guideline translation into explicit rules. CLINICAL TRIAL REGISTRATION NCT04058769.
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Affiliation(s)
- Simone M Kagerbauer
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Ulm, Germany
| | - Jennifer Wißler
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dimislav I Andonov
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Ulm
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Ulm, Germany
| | - Gerhard Schneider
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Armin H Podtschaske
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany; Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Ulm, Germany.
| | - Bettina Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Ulm, Germany
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Kagerbauer SM, Wißler J, Blobner M, Biegert F, Andonov DI, Schneider G, Podtschaske AH, Ulm B, Jungwirth B. Anaesthesiologists' guideline adherence in pre-operative evaluation: a retrospective observational study. Perioper Med (Lond) 2024; 13:64. [PMID: 38943163 DOI: 10.1186/s13741-024-00424-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 06/18/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Surveys suggest a low level of implementation of clinical guidelines, although they are intended to improve the quality of treatment and patient safety. Which guideline recommendations are not followed and why has yet to be analysed. In this study, we investigate the proportion of European and national guidelines followed in the area of pre-operative anaesthetic evaluation prior to non-cardiac surgery. METHODS We conducted this monocentric retrospective observational study at a German university hospital with the help of software that logically links guidelines in such a way that individualised recommendations can be derived from a patient's data. We included routine logs of 2003 patients who visited our pre-anaesthesia outpatient clinic between June 2018 and June 2020 and compared the actual conducted pre-operative examinations with the recommendations issued by the software. We descriptively analysed the data for examinations not performed that would have been recommended by the guidelines and examinations that were performed even though they were not covered by a guideline recommendation. The guidelines examined in this study are the 2018 ESAIC guidelines for pre-operative evaluation of adults undergoing elective non-cardiac surgery, the 2014 ESC/ESA guidelines on non-cardiac surgery and the German recommendations on pre-operative evaluation on non-cardiothoracic surgery from the year 2017. RESULTS Performed ECG (78.1%) and cardiac stress imaging tests (86.1%) indicated the highest guideline adherence. Greater adherence rates were associated with a higher ASA score (ASA I: 23.7%, ASA II: 41.1%, ASA III: 51.8%, ASA IV: 65.8%, P < 0.001), lower BMI and age > 65 years. Adherence rates in high-risk surgery (60.5%) were greater than in intermediate (46.5%) or low-risk (44.6%) surgery (P < 0.001). 67.2% of technical and laboratory tests performed preoperatively were not covered by a guideline recommendation. CONCLUSIONS Guideline adherence in pre-operative evaluation leaves room for improvement. Many performed pre-operative examinations, especially laboratory tests, are not recommended by the guidelines and may cause unnecessary costs. The reasons for guidelines not being followed may be the complexity of guidelines and organisational issues. A software-based decision support tool may be helpful. TRIAL REGISTRATION ClinicalTrials.gov ID NCT04843202.
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Affiliation(s)
- Simone Maria Kagerbauer
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany.
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany.
| | - Jennifer Wißler
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - Ferdinand Biegert
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Dimislav Ivanov Andonov
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Gerhard Schneider
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Armin Horst Podtschaske
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Ulm
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - Bettina Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
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Aust H, Kranke P, Eberhart LHJ, Afshari A, Weber F, Brieskorn M, Heine J, Arndt C, Rüsch D. Impact of medical training and clinical experience on the assessment of oxygenation and hypoxaemia after general anaesthesia: an observational study. J Clin Monit Comput 2014; 29:415-26. [PMID: 25273623 DOI: 10.1007/s10877-014-9620-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 09/16/2014] [Indexed: 11/28/2022]
Abstract
In Germany it is common practice to use pulse oximetry and supplementary oxygen only on request in patients breathing spontaneously transferred to the post-anaesthesia care unit (PACU) following surgery under general anaesthesia. The main aim was to study the influence of medical training and clinical experience on assessing SpO(2) and detecting hypoxaemia in these patients. The second aim was to do a preliminary assessment whether this practice can be found in countries other than Germany. Anaesthetists, nurses and medical students estimated SpO(2) in patients breathing room air at the end of transfer to the PACU following surgery (including all major surgical fields) under general anaesthesia. Estimated SpO(2) was compared to SpO(2) measured by pulse oximetry. A survey was carried out among European anaesthesists concerning the use of pulse oximetry and supplementary oxygen during patient transfer to the PACU. Hypoxaemia (SpO(2) < 90 %) occurred in 154 (13.5 %) out of 1,138 patients. Anaesthetists, nurses, and medical students identified only 25, 23, and 21 patients of those as being hypoxaemic, respectively. Clinical experience did not improve detection of hypoxaemia both in anaesthetists (p = 0.63) and nurses (p = 0.18). Use of pulse oximetry and supplemental oxygen during patient transfer to the PACU in European countries differs to a large extent. It seems to be applied only on request in many hospitals. Considering the uncertainty about deleterious effects of transient, short lasting hypoxaemia routine use of pulse oximetry is advocated for patient transfer to the PACU.
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Affiliation(s)
- Hansjörg Aust
- Department of Anaesthesia and Intensive Care, University Hospital Giessen-Marburg, Marburg Campus, Baldingerstrasse, 35033, Marburg, Germany,
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Böhmer A, Defosse J, Geldner G, Mertens E, Zwissler B, Wappler F. Präoperative Risikoevaluation erwachsener Patienten vor elektiven, nichtkardiochirurgischen Eingriffen. Anaesthesist 2014; 63:198-208. [DOI: 10.1007/s00101-014-2288-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/19/2013] [Accepted: 12/30/2013] [Indexed: 12/18/2022]
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Aust H, Veltum B, Wächtershäuser T, Wulf H, Eberhart L. [Premedication visits in departments of anesthesiology in Hessen. Compilation of organizational and performance portfolios]. Anaesthesist 2014; 63:105-13. [PMID: 24499960 DOI: 10.1007/s00101-013-2287-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 11/13/2013] [Accepted: 11/20/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many anesthesia departments operate a pre-anesthesia assessment clinic (PAAC). Data regarding organization, equipment and structure of such clinics are not yet available. Information about modern anesthesiology techniques and procedures contributes to a reduction in emotional stress of the patients but such modern techniques often require additional technical hardware and costs and are not equally available. AIM This survey examined the current structures of PAAC in the state of Hessen, demonstrated current concepts and associated these with the performance and the portfolio of procedures in these departments. MATERIAL AND METHODS An online survey was carried out. Data on structure, equipment, organization and available methods were compiled. In addition, anesthesia department personnel were asked to give individual subjective attitudes toward the premedication work. RESULTS Of the anesthesia departments in Hessen 84 % participated in the survey of which 91 % operated a PAAC. A preoperative contact with the anesthesiologist who would perform anesthesia existed in only 19 % of the departments. Multimedia processing concepts for informed consent in a PAAC setting were in general rare. Many modern procedures and anesthesia techniques were broadly established independent of the hospital size. Regarding the individual and subjective attitudes of anesthetists towards the work, the psychological and medical importance of the pre-medication visit was considered to be very high. CONCLUSION The PAACs are now well established. This may make economic sense but is accompanied by an anonymization of care in anesthesiology. The high quality, safety and availability of modern anesthesiology procedures and monitoring concepts should be communicated to patients all the more as an expression of trust and high patient safety. These factors can be facilitated in particular by multimedia tools which have as yet only been sparsely implemented in PAACs.
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Affiliation(s)
- H Aust
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Baldingerstr., 35033, Marburg, Deutschland,
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