Survey of barriers to the implementation of ROTEM guided critical bleeding protocols on Randwick Campus.

Abstract

Background: The use of point of care viscoelastic testing such as ROTEM in critical bleeding scenarios enables the implementation of precision medicine with benefits on patient outcomes and resource utilisation.[1-2] Viscoelastic testing forms a key component of evidence based blood management.[1,3] Despite the growing body of evidence, barriers to implementation exist.[3] These barriers can have a profound effect on translating evidence into real-life clinical applications.[3] Critical bleeding scenarios are often stressful, involving time-sensitive decisions.[1] Understanding barriers and the educational needs of clinicians is vital in empowering staff to implement viscoelastic testing in high-pressure situations.[3]

Randwick campus comprises four major hospitals in Sydney namely Prince of Wales Hospital, Sydney Children’s Hospital, Royal Hospital for Women and Prince of Wales Private. It was one of the first centres in Australia to successfully adopt ROTEM sigma guided algorithms adapted to each patient population.4 Since our early success, we have seen a local trend of increasing use of blood products especially platelets. This project was a survey of our medical and nursing staff aiming to identify barriers to compliance and strategies for improvement. We subsequently developed education interventions based on the learning preferences of our staff to improve our blood management practices.

Methods: Our survey was developed as part of our large-scale ongoing audit on the use of ROTEM for transfusion in critically bleeding patients. Ethics approval was obtained from SESLHD HREC - 2019/ETH11664. We developed a questionnaire building on previous work in this area, encompassing the Theoretical Domains Framework (TDF) and the Capability, Opportunity and Motivation Behaviour Model (COM-B).[3] This incorporated both closed and open-ended questions reviewing barriers to compliance with our local critical bleeding algorithms and personal learning preferences, allowing us to direct future educational interventions. The survey was distributed in March 2024 to consultant and trainee anaesthetists, intensivists, obstetricians and nursing staff. While our educational interventions are aimed hospital wide, we focused these interventions initially on groups that more routinely utilised our ROTEM/critical bleeding algorithms.

Results: Requests for participation were sent out to approximately 220 medical professionals across various specialties and seniority levels as well as nursing staff. We gathered 105 responses predominantly comprising consultant anaesthetists (38%), anaesthetic fellows and trainees (21%) ICU staff (19%) and nurses (11.4%). The majority of responses were positive and 89% of our respondents found our algorithms easy to use. However, 9% reported never using the algorithms before with 2% of respondents finding the process difficult to follow.

Over two thirds of respondents felt they were fully engaged with the ROTEM algorithms and the campus critical bleeding protocol with no identifiable barriers to their compliance. With regards to specific domains affecting ROTEM compliance – 7% of respondents felt it was not their clinical role to instigate ROTEM or interpret result. A total of 15% identified issues related to their confidence or knowledge regarding ROTEM interpretation and a subsequent subgroup analysis revealed that the majority of this group were junior medical staff.

Logistical issues formed the third major group with regards to barriers to implementation of our local critical bleeding protocols. A total of 15 respondents identified issues with the length of the process, machine location or redistribution of personnel resources during a critical bleeding event as major barriers.

With regards to specific barriers, the key themes that emerged from the free text survey responses were as follows: 1. Consultant preference (surgical and ICU) to overrule algorithm recommendations – junior medical and nursing staff felt it was difficult to go against a specific preference voiced by a consultant involved in the patient’s care 2. Accessibility – respondents felt that improved accessibility to the algorithms and ROTEM results in real time would improve compliance 3. Logistical reasons – needing to dedicate a staff member to run/interpret the viscoelastic testing

In terms of learning preferences, half of all respondents preferred educational videos and simulation-based education over shorter theory based presentations. Online courses were preferred by 59% of respondents. Nursing staff respondents preferred industry based teaching and education regarding servicing and troubleshooting the ROTEM sigma machines.

Discussion: Some key themes emerged with regards to barriers to implementation particularly in the open-ended responses. One key aspect that emerged was that more education was required to support junior medical and nursing staff to feel empowered in interpreting ROTEM and clinician decision making. Consultant preference was identified as a key feature in episodes where there was non-compliance with the algorithms/protocols – whilst this may be the result of clinical experience, our educational interventions will be extended to consultants with the development advanced videos and advanced simulation sessions as well as courses with associated professional development/CPD points. We have also already implemented a targeted series of lectures focused on our various junior and senior groups including consultant surgeons and intensivists.Additional identified barriers included logistical challenges and the physical locations of our machines. To address logistical issues, we have incorporated QR codes attached to staff ID lanyards for ease of access to our algorithms. The effect of these interventions will be analysed as part of our larger campus audit in 2024-2025.

Other factors such as accessibility of wifi/internet in theatres are more difficult to address. However, printed copies of all ROTEM algorithms have been made available at every ROTEM machine and in all theatres where critical bleeding procedures are more likely to occur. We will extend these printed copies to all theatres on the campus to improve accessibility to the algorithm.

With regards to industry teaching, we have organised several sessions run by machine technicians and industry experts to upskill our nursing and medical staff in trouble shooting the ROTEM sigma machine.

With the development of a multi-pronged educational approach, we anticipate increased compliance and staff confidence in utilising ROTEM and our critical bleeding protocols. We have been performing an audit of our staff compliance with the algorithms in 2024 and will be repeating the audit in 2025 once our educational interventions have been fully implemented.