Closing the gap between guidelines and practice in perioperative care.

PATIENTS undergoing noncardiac surgery are at risk of adverse perioperative and long-term outcome. For example, data from the PeriOperative Ischemic Evaluation trial (POISE), which enrolled 8,351 patients undergoing noncardiac surgery, showed a perioperative mortality rate of 2.7%, 1.6% had a cardiovascular death, whereas nonfatal myocardial infarction (MI) was observed in another 4.4% subjects. The report by Ausset et al. in this issue of ANESTHESIOLOGY confirms this high risk of postoperative complications. When considering a patient for noncardiac surgery, a careful preoperative clinical risk evaluation and subsequent risk-reduction strategies are essential to reduce postoperative complications. To assist physicians with decision-making, clinical guidelines are developed. The aim of clinical guidelines is to improve patient care by providing recommendations about appropriate health care in specific circumstances. Development of clinical guidelines is an important component in improving quality of care. By translating the best available scientific evidence into specific recommendations, guidelines can serve as useful tools to achieve effective and efficient patient care. Additionally, successful perioperative evaluation and management of patients undergoing noncardiac surgery require careful teamwork and communication among all involved healthcare professionals. In 2009, the first European Society of Cardiology guidelines on perioperative care were developed. This decision-making process integrates clinical markers, early coronary evaluation, functional capacity, and the type of surgery involved. Ausset et al. examined the impact of a quality improvement program in practice on the incidence of perioperative MI (PMI) detected by serial measurements of troponin and long-term cardiac outcome. For this study, a total of 378 surgical procedures were included before (P1) and after quality enhancement (P2). The strength of this manuscript is the quality improvement program with a focus on multiple interventions instead of a single component. Their main results revealed a high incidence of 5.5% PMI with troponin release in the first 3 days after major orthopedic surgery. This type of surgery is categorized as intermediate-risk surgery in the European Society of Cardiology perioperative guidelines. The high incidence of PMI is in line with earlier research showing a 30-day incidence of troponin release of 6.9% in 1,066 intermediate noncardiac surgery procedures. On the other hand, in vascular surgery patients, which are recognized as high-risk surgery, perioperative troponin is demonstrated to be as high as 20%. These numbers underline the high cardiac risk of patients undergoing noncardiac surgery and the importance of careful perioperative risk management in these patients. In their study, Ausset et al. improved the quality of care with a relatively simple program. The protocol addressing issues such as hypovolemia, hypoxemia, and hyperglycemia was approved by and repeatedly explained to the staff and accessible in the operating rooms and the hospital electronic network. In our opinion, the addition of web-based patient management tools would be an ideal extra tool to assist physicians with providing decision support and collecting data. Quality of postoperative care was improved in different aspects. They report a tighter patient monitoring, with more patients receiving oxygen, insulin, and blood transfusion. Surprisingly, prescription of cardiovascular medication was not increased in P2, indicating room for further improvement. In our opinion, the improvement of quality care observed in the study of Ausset et al. is an important step in the improvement of contemporary care of noncardiac surgery patients. Unfortunately, they did not provide information on the performed or prescribed indicators in patients who had an indication for the specific quality of care indicator. This would give, besides the improvement of overall management, more insight in current status of evidence-based clinical practice. Importantly, improvement of postoperative care resulted in a decrease of both early and late major cardiac events in the study of Ausset et al. Incidences of PMI and major adverse cardiac events were 8.9% versus 3.9% (P 0.04) and 8.1% versus 1.9 (P 0.004) for P1 and P2, respectively. Furthermore, the occurrence of PMI with troponin release was correlated with poor long-term cardiac outcome. These data suggest that improving long-term outcome can be achieved by targeting PMI. There has to be some caution when interpreting these results. First, the study was not a randomized controlled trial,