Variation and knowledge translation gaps in day-of-surgery glycaemic management by anaesthesiologists: a qualitative exploration of a quality gap in Canadian hospitals.

Abstract

Day-of-surgery hyperglycaemia is a modifiable risk factor for adverse patient outcomes including infection and 30-day mortality. Despite these risks, important quality gaps in day-of-surgery glycaemic management have been demonstrated in multiple settings. To describe barriers and facilitators to high-quality glycaemic management from the perspective of anaesthesiologists. This qualitative study was designed using two implementation frameworks, the Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR), to understand individual and organisational drivers and barriers to high-quality glycaemic management by anaesthesiologists. A patient partner with type 1 diabetes mellitus who had undergone surgery in our setting participated in study design and analysis. Four academic hospitals within a single provincial (Alberta) healthcare system in Canada. Anaesthesiologists practising at any academically affiliated hospital in Edmonton or Calgary, Alberta, Canada. One-on-one semi-structured interviews exploring day-of-surgery glycaemic management. Deductive thematic analysis of one-on-one interviews with anaesthesiologists was based on the TDF and CFIR. Saturation was reached after 13 interviews. There was important between-provider variation within the TDF constructs of <i>memory, attention and decision-making processes</i> and <i>goals</i>. Anaesthesiologists differed in whether they postponed surgery based on glycaemic status, whether they administered dexamethasone for postoperative nausea and vomiting prophylaxis for patients with diabetes, and in their definition of hyperglycaemia. Participants attributed this variation to patient and surgical factors, low knowledge of existing guidelines and lack of skills to select a dose of insulin. This variation in perioperative glycaemic management and treatment of hyperglycaemia is likely an important contributor to observed day-of-surgery glycaemic management quality gaps. Quality improvement interventions meant to improve day-of-surgery glycaemic management should address between-anaesthesiologist variation in glycaemic management processes and targets.