Exploring management reasoning when discharging high-risk postoperative patients from the post-anaesthesia care unit

INTRODUCTION: Decision-support tools for detecting physiological deterioration are widely used in clinical medicine but have been criticised for fostering a task-oriented culture and reducing the emphasis on clinical reasoning. Little is understood about what influences clinical decisions aided by decision-support tools, including professional standards, policies, and contextual factors. Therefore, we explored management reasoning employed by anaesthesiologists and PACU nurses in the post-anaesthesia care unit during the discharge of high-risk postoperative patients.

METHODS: A qualitative constructivist study, conducting 18 semi-structured with 6 anaesthesiologists and 12 nurses across three Danish teaching hospitals. We analysed data through thematic analysis, utilising Michael Lipsky's theory of "street-level bureaucracy" in combination with David A. Cook's Management Reasoning Framework as a sensitising concept.

RESULTS: Standards are frequently ambiguous, requiring interpretation and prioritisation. This allows for professional discretion by circumventing established policies, reducing task-oriented culture and enhancing the clinical reasoning processes. However, discretion in management reasoning depends on whether the clinician is inclined to uphold or adjust policies to maintain professional standards, influencing discharge decisions.

CONCLUSION: While decision-support tools offer cognitive aid and help standardise patient trajectories, they also limit professional discretion in management reasoning and can potentially compromise care and treatment. This highlights the need for a balanced approach that considers both the benefits and limitations of these tools in clinical decision-making.