Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation?

While cardiovascular complications remain a leading cause of perioperative morbidity and mortality, studies have shown that prophylactic beta-blocker therapy can reduce the incidence of ischemia, myocardial infarction (MI), and cardiac death. Consensus guidelines and the publication of a recent meta-analysis support the use of perioperative beta-blockade in patients who are at risk for adverse cardiac events, but few studies have examined the practical application of these clinical guidelines. We performed a multicenter intervention study in five acute care hospitals to measure, characterize, and increase the utilization of perioperative beta-blocker therapy for surgical patients at intermediate to high risk of cardiac complications. We also reviewed all cases of perioperative MI. Following baseline observations, we developed a multifaceted educational intervention using grand rounds, academic detailing, and peer profiling to disseminate current guidelines for perioperative beta-blocker use. We then collected postintervention data to assess changes in practice patterns and clinical outcomes. Preliminary results demonstrate a significant underutilization of perioperative beta-blocker therapy among patients at risk for adverse cardiac events, and we have identified several barriers to implementing the guidelines. This paper highlights the lessons learned while implementing a clinical guideline and working to promote an evidence-based intervention aimed at improving patient safety.