Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines

Effect of a Cognitive Aid on Adherence to Perioperative Assessment and Management Guidelines for the Cardiac Evaluation of Noncardiac Surgical Patients

“…The recent works by Vigoda et al highlight the inability of residents and practicing anesthesiologists to apply the ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. 4,5 Our results among residents taking the first test without the assistance of DST correctly answered an average of 4.8/9 (53%) questions. Similar to Vigoda's studies, our rate of error beckons for a mechanism of improvement-and the improvement is seen with our simple DST.…”

“…The goal of keeping this brief was to test the true capacity of residents to apply guidelines based on their existing functional knowledge of these published guidelines, rather than testing them immediately after an extensive review, as was used in two prior studies. 4,5 Orientation was performed a minimum of two weeks prior to implementation of the cognitive aid at all sites to prevent score inflation associated with very recent exposure. Testing was performed with local participation in a standardized (classroom) environment, which included supervision from trained study personnel who administered the test and gave access to the DST according to group assignment.…”

“…4,5 Although there is no defined guideline for the design and assessment of MCQs, our process was similar to that previously described. 4,5 The clinical stems and corresponding MCQ answer options were assessed for construct and content validity by evaluating whether they actually represented an adequate test of knowledge of the ACC/AHA guidelines under consideration, both in the specifics of each question being asked and in the scope of the questions as a whole concerning the information contained in the guidelines. This was done by having a cohort of anesthesiology faculty from 3 institutions who are actively involved in preoperative assessment take the quizzes and assess the manner in which the content of the quiz reflected the content of the guidelines and adequately tested the scope of knowledge represented in the guidelines.…”

“…4,5 Reasons for poor adherence to established guidelines appear to be multifactorial, with several general categories of barriers having been identified. 6 Barriers include inadequate physician knowledge (lack of familiarity), physician attitudes about the guidelines (lack of efficacy, outcome expectancy, agreement, or motivation due to previous practice), and behavior (communication issues between patient and practitioner, characteristics of each guideline, and environmental factors effecting the marginal effort to follow guidelines).…”

“…6 The authors of the two previous studies in this specific area recommended evaluation of decision support tools (DSTs) as a future direction to improve adherence to published guidelines. 4,5 DSTs often improve adherence to published guidelines and in many instances improve clinical outcomes, although this has not been universally true. [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] However, most research on clinical decision support has focused upon patient management after initial assessment and diagnosis or through mandatory alerts for providers, such as reminders for intraoperative antibiotic prophylaxis, postoperative nausea and vomiting prophylaxis, or proper use of alarms for separate from cardiopulmonary bypass.…”