• Simone M Kagerbauer, Jennifer Wißler, Dimislav I Andonov, Bernhard Ulm, Gerhard Schneider, Armin H Podtschaske, Manfred Blobner, and Bettina Jungwirth.
• 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.
• Br J Anaesth. 2024 Sep 1; 133 (3): 519529519-529.

BackgroundGuideline 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.MethodsThis 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.ResultsThe 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%.ConclusionsStrict 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 RegistrationNCT04058769.Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.

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