Effective implementation of anaesthesiology guidelines to improve patient safety

The effort required to gather sufficient evidence to write a guideline is enormous. Multiple clinical trials must be conducted, systematic reviews written, and a guideline committee established. Publications then need to be assessed and graded to reach a consensus on the best evidence-based treatment for our patients. We all agree that evidence-based guidelines are essential for advancing anaesthesiology, improving perioperative outcomes, and ultimately enhancing patient safety. However, translating evidence-based recommendations into consistent, high-quality clinical practice remains a major challenge. 

Barriers include limited resources, differences in institutional infrastructure, and inconsistent commitment among clinicians. Adherence to Enhanced Recovery After Surgery (ERAS) protocols¹, difficult airway algorithms in adults^2,3 and in infants⁴,  perioperative bleeding guidelines⁵ or the use of Cardiac Biomarkers in Risk Assessment⁶ remains highly variable despite solid evidence. 

One example of a guideline that is poorly implemented in many clinics is the ESAIC guideline on postoperative delirium (POD), 7,8, which is already available in an updated version. Multimodal prevention strategies, perioperative monitoring, avoidance of delirium-inducing medications, and the routine use of validated screening instruments for early detection and timely treatment of POD are recommended in these guidelines, especially for elderly and frail patients. Despite the proven benefits of delirium prevention and prediction, integration into daily practice is still insufficient in many places.  

Another guideline that is not being followed optimally concerns the prevention of perioperative hypothermia. International guidelines highlight the importance of continuous temperature monitoring and active warming methods (warm air systems, heated infusion fluids, and maintaining the ambient temperature in the operating room)⁹. Hypothermia is associated with increased blood loss, surgical site infections, and prolonged recovery time. Nevertheless, temperature monitoring and active warming are still far from being adequately implemented in every hospital. 

Strategies to improve acceptance in such areas include structured education and simulation training, embedding digital decision support tools in anaesthesia information systems, and systematic audit and feedback cycles. Local adaptation and multidisciplinary leadership are key to sustainable implementation without compromising the evidence base. There are various initiatives offering assistance in implementing current guidelines, with individual perioperative guideline-compliant measures being checked off in a checklist format¹⁰.

Ultimately, implementing guidelines from theory to practice requires a cultural change. Embedding guideline adherence in continuous quality improvement initiatives ensures safer, more consistent, and evidence-based anaesthesia care. 

Sustained improvements in patient safety will depend on strengthening adherence to guidelines and providing adequate training. 

Authors: Başak Ceyda Meço and Maria Wittmann 

References 

1. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A review. JAMA Surg. 2017;152(3):292–298. 
2. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31–81. 
3. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–848. 
4. Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2017;34(6):332–395. 
5. Kietaibl, Sibylle; Ahmed, Aamer; Afshari, Arash; Albaladejo, Pierre; Aldecoa, Cesar; Barauskas, Giedrius; De Robertis, Edoardo; Faraoni, David; Filipescu, Daniela C.; Fries, Dietmar; Godier, Anne; Haas, Thorsten; Jacob, Matthias; Lancé, Marcus D.; Llau, Juan V.; Meier, Jens; Molnar, Zsolt; Mora, Lidia; Rahe-Meyer, Niels; Samama, Charles M.; Scarlatescu, Ecaterina; Schlimp, Christoph; Wikkelsø, Anne J.; Zacharowski, Kai. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. European Journal of Anaesthesiology 40(4):p 226-304, April 2023.
6. Lurati Buse, Giovanna∗; Bollen Pinto, Bernardo∗; Abelha, Fernando; Abbott, Tom E.F.; Ackland, Gareth; Afshari, Arash; De Hert, Stefan; Fellahi, Jean-Luc; Giossi, Laure; Kavsak, Peter; Longrois, Dan; M’Pembele, Rene; Nucaro, Anthony; Popova, Ekaterine; Puelacher, Christian; Richards, Toby; Roth, Sebastian; Sheka, Mootii; Szczeklik, Wojciech; van Waes, Judith; Walder, Bernhard; Chew, Michelle S.. ESAIC focused guideline for the use of cardiac biomarkers in perioperative risk evaluation. European Journal of Anaesthesiology 40(12):p 888-927, December 2023. 
7. Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Audisio R, Borozdina A, et al. European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol. 2017;34(4):192–214.  
8. Aldecoa C, Bettelli G, Bilotta F, et al. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol. 2024;41(2):81–108. 
9. Sessler DI, Meyhoff CS, Zimmerman NM, Mao G, Leslie K, Vásquez SM, et al. Period-dependent associations between hypothermia and surgical site infection after inpatient surgery. Anesthesiology. 2021;134(4):545–557.
10. Radtke FM, Meco BC, Jakobsen KD, Berger J, Wittmann M, Buhre W, et al. Safe Brain Initiative (SBI): Advancing patient-centred precision anaesthesia and perioperative care. European Society of Anaesthesiology and Intensive Care. https://esaic.org/research/research-groups/sbi/.