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Table 4 Variability in the reported and perceived processes for reviewing the PAC visit note by residents, nurse practitioners, and staff surgeons

From: Barriers and facilitators of following perioperative internal medicine recommendations by surgical teams: a sequential, explanatory mixed-methods study

Driver of missed recommendations Exemplar quotation
Unintentionally missed recommendations
 Individual-level drivers
  Knowledge of the PAC visit note (Barrier) “It’s hard to know who was seen by internal medicine before and who was not” (P06, nurse practitioner)
  Behaviour regulation (Facilitator) “Certainly before we’re operating on any patient I look to see if there’s [a PAC visit] note on [our EHR], and so if there is, I read it... it took me a while to make it into a habit where I like will look at it before every patient, to make sure there’s anything I need to do”
(P08, surgical resident, ENT)
  Behaviour regulation (Barrier) “It’s just not in [the resident's] routine practice [to look at the PAC visit note], cause not everyone has preop consults… they just have their plan of postop orders, and they just put them in without looking, even for patients that go to the OR from the unit, they just do the same thing all the time”
(P06, nurse practitioner)
  Relative priority (Barrier) “When we finish a surgery [and] we put in a post-op order, [that's] typically the first sense we’ll get to as to how medically complex they are. Having said that, when you have time in the evenings, like at the Sunday before your week it is nice to be able to sit down and look through the cases that you have coming for the week, but that takes time and is not always something that’s realistic”
(P04, surgical resident, neurosurgery)
 Systems-level drivers
  External and internal networks (Barrier) “No, I mean not any more than any other service where there’s fellows and senior residents and juniors residents and everyone’s is part of the team, and everyone’s trying to do what’s best for the patient, so we’re all looking at things, we’re all trying to you know help each other out, but there’s no, I don’t think there’s a formal process unless the chief resident has made it a priority for him or herself to go through and say I’m gonna look at every preop assessment and make a point of it, there’s no like safety check”
(P12, obstetrics and gynecology)
“Not terribly often, no... if I had to double check every drug [or] order a resident put in I wouldn’t get anything else done,”
(P18, neurosurgery)
  External and internal networks (Facilitator) “The junior resident puts the orders, but I look up the medicine consult and still review it, ok they asked for troponins, they did this and that, so don’t forget about this and that...then [the fellow] double [checks], he looks at it too”
(P01, general surgery resident)
“No, there’s not [a mechanism to check if orders are entered], if it’s a medication we have a pharmacist on our unit... I would say she’s like a safety net”
(P17, gynecologic oncology staff)
Intentionally missed recommendations
 User error
  Skills (Barrier) “I know you’re supposed to do basal bolus insulin... but the concern would be like how do you titrate it, how do you get them off of it to go home, all those things and so, I just use the sliding scale to like bring them down if they’re high and then let them ride it out”
(P06, nurse practitioner)
  Knowledge of guidelines and evidence (Barrier) “We are not understanding whether all those [troponin] suggestions apply to all patients and then who should act [on abnormal results]... [implementation] initially was a little bit vague... I can’t do this so I’m gonna ignore it, and that’s maybe not the best thing for people overall”
(P14, staff spine surgery)
 Appropriate modifications
  Adaptability (Barrier) “A lot of times their recommendations tend to be to prevent that from happening, so by that point the cat’s kind of out of the bag in terms of what they thought when the patient was well two weeks prior to surgery... maybe [their recommendation] doesn’t apply anymore, we need a more updated plan”
(P04, neurosurgery resident).
 Unclassifiable
  Evidence strength and quality “Things like Xarelto, these other blood thinners, I tell patients different instructions than internal medicine simply based on experience, not evidence”
(P14, neurosurgery staff)