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 of research 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 educational needs of clinicians is vital in empowering staff to implement evidence-based practice 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 adopt ROTEM guided algorithms adapted to each patient population. However, we have seen a local trend in increasing utilisation of products such as platelets. As a result, we aimed to identify areas of potential improvement based on a survey of our medical and nursing staff and develop education interventions aimed at improving 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/ETH116642019/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 staff comfort and compliance with our local critical bleeding algorithms and their learning preferences to develop educational interventions. The survey was distributed in March 2024 to consultant and trainee anaesthetists, intensivists, obstetricians and nursing staff in operating theatres. While our educational interventions are aimed hospital wide, we believed focusing on groups that most routinely utilised our ROTEM/critical bleeding algorithms would highlight key areas of potential improvement. 

 

We gathered 105 responses predominantly comprising consultant anaesthetists (38%), anaesthetic fellows and trainees (21%) ICU staff (19%) and nurses (11.4%). 89% of our respondents found our algorithms easy to use and were positive regarding their experiences but 9% reported never using the algorithms before. Some key themes emerged with regards to barriers to implementation particularly in the open-ended responses. These were related to the domains of confidence/knowledge/skills, logistical challenges and the physical locations of our machines. Based on analysis of preferred learning styles we have developed multiple videos explaining both basic and advanced ROTEM interpretation, multi-plate analysis and are in the process of developing simulation and face-to-face courses. We have implemented a targeted series of lectures focused on our various junior and senior groups. 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 campus audit in 2024. 

 

The authors have no conflicts of interest to disclose. 

[1] Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol. 2019 Aug;72(4):297-322. doi: 10.4097/kja.19169

[2] Wikkelsø A, Wetterslev J, Møller AM, Afshari A.Thromboelastography (TEG) or thromboelastometry (ROTEM) to monitor haemostatic treatment versus usual care in adults orchildren with bleeding.Cochrane Database of Systematic Reviews 2016, Issue 8. Art. No.: CD007871.DOI: 10.1002/14651858.CD007871.pub3.

[3] Pearse, B.L., Keogh, S., Rickard, C.M. et al. 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. BMC Health Serv Res21, 550 (2021). https://doi.org/10.1186/s12913-021-06269-8