<p>Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model</p>

Abstract

Purpose: Excessive bleeding is an acknowledged consequence of cardiac surgery, occurring in up to 10% of adult patients. This clinically important complication leads to poorer patient outcomes. Clinical practice guidelines are available to support best practice however variability in bleeding management practice and related adverse outcomes still exist. This study had two objectives: 1) to gain insight into current bleeding management practice for adult cardiac surgery in Australia and how that compared to guidelines and literature; and 2) to understand perceived difficulties clinicians face implementing improvements in bleeding management. Methods: A national cross-sectional questionnaire survey was utilized. Perspectives were sought from cardiac surgeons, cardiac anesthesiologists and perfusionists. Thirty-nine closedended questions focused on routine bleeding management practices to address pre and intraoperative care. One open-ended question was asked; "What would assist you to improve bleeding management with cardiac surgery patients?" Quantitative data were analysed with SPSS. Qualitative data were categorized into the domains of the Theoretical Domains Framework; the domains were then mapped to the COM-B model. Results: Survey responses from 159 Anesthesiologists, 39 cardiac surgeons and 86 perfusionists were included (response rate 37%). Four of the recommendations queried in this survey were reported as routinely adhered to < 50% of the time, 9 queried recommendations were adhered to 51-75% of the time and 4 recommendations were routinely followed >76% of the time. Conclusion: There is a wide variation in peri-operative bleeding management practice among cardiac anaesthesiologists, surgeons and perfusionists in Australian cardiac surgery units. Conceptualizing factors believed necessary to improve practice with the TDF and COM-B model found that bleeding management could be improved with a standardized approach including; point of care diagnostic assays, a bleeding management algorithm, access to concentrated coagulation factors, cardiac surgery specific bleeding management education, multidisciplinary team agreement and support, and an overarching national approach.

Research Article – BMC Health Service Research (IF -1.93) Barriers and Facilitators to Implementing Evidence Based Bleeding Management in Australian Cardiac Surgery Units: A Qualitative Interview Study Analysed With the Theoretical Domains Framework and COM-B Model

“…A lack of consistency of the team unit, particularly in public hospitals highlighted the use of standardised ways of working to improve clinician 'capability'. Decision support tools, checklists, protocols and procedures are well documented to reduce variation in care and improve outcomes (25,26,(44)(45)(46)50).…”

“…While the cardiac surgical team generally agreed with this concept; there was perceived need for autonomy in decision making. Clinical decision making is not always facts applied to a problem, and it was considered important to balance the use of standardisation and recommendations from guideline (considered to be aggregated needs of the cohort) with an intuitive, experiential approach, contextualising patient problems to determine best practice for the needs of the individual patient (25,51).…”

“…These issues are in con ict with the mandatory requirement to implement bleeding management strategies to achieve Australia's National Safety and Quality Health Service Standards (52). While this has been judged to drive organisational bleeding management change 'at a minimum', it was not considered to drive excellence (25,26,46,51).…”

“…While there is currently little qualitative research on facilitators to implementing bleeding management in cardiac surgery in Australia, the studies reporting on facilitators to change, highlight the success of monitoring, audit and feedback of data on outcomes and performance to reduce variability in practice (25,26). This is also demonstrated in studies across other cohorts which suggest capitalising on the driven and competitive behaviour of surgeons through regular analysis and feedback of data on outcomes and performance can be utilised as enabler to improve practice (53)(54)(55)(56)(57).…”

Barriers and Facilitators to Implementing Evidence Based Bleeding Management in Australian Cardiac Surgery Units: A Qualitative Interview study analysed with the Theoretical Domains Framework and COM-B model&nbsp;

“…An identi ed lack of consistency of the team unit, particularly in public hospitals highlighted the use of standardised ways of working to improve clinician 'capability'. Decision support tools, checklists, protocols, and procedures are well documented to reduce variation in care and improve outcomes (25,26,(47)(48)(49)53). While the cardiac surgical team generally agreed with this concept; there was perceived need for autonomy in decision making.…”