Table 3

Respondents’ opinions regarding the use of management guidelines

Benefits of management guidelines	Reservations around management guidelines
‘It was really helpful to be able to match the clinical picture I was seeing up to something that was in the consult handbook and then feel comfortable that I making the right management decision for the patient.’	‘There’s a reason why many physicians don’t adhere to [protocols], because they don’t believe that they apply to the patient population that they're taking care of.’
‘The consult handbook was especially nice because it was concise, focused on the things we see most often, and I could feel comfortable knowing that I had appropriately assessed the patient and placed them into one of the buckets and that my management decision was going to be in the realm of it was reasonable to treat the patient. It was nice to have that reassurance.’	‘I think it is possible [to protocolize treatment], but I think it’s never that clean. We just need to find out what emergency cases fit into which category… I think in some ways it’s comparable to injury grading and how we use that, but we may find out it’s not. We don’t really have any data.’
‘The consult handbook was great, especially starting out, to really guide what to do in these situations and give you the resource quickly make a diagnosis and know “these are the things I need to think about.” It’s not just take them to the OR. It’s also remember to start antibiotics, start fluids, and these ancillary details might get lost in all the focus of “this patient has got to go to the OR”.’	‘I think for straightforward things it’s probably a good idea. Like for proven appendicitis or cholecystitis. But, I think for other kinds of emergency general surgery consults, like perforated viscus, you have no idea if its upper GI or lower GI. Perhaps the pathway for those scenarios is probably not the best thing and might lead people to the wrong route.’
‘I think with any grading or classification system, it provides a rubric and a starting point with suggested management based on disease severity, but you’re not obligated to do that regardless of what your team ends up doing, it provides a baseline, agreed upon management and I think that is only going to be helpful.’	‘There are definitely times when the patient falls in between 2 different classes, but you’re supposed to use your clinical judgment to be able to determine what their treatment is. That’s the fault of any classification system. Sometimes there is gray. It’s not always black and white.’
‘Having a classification system with a clear outline on what management steps we take, what tests to order, what studies to be done. I think that lets us make sure we don't miss any important workups or plans.’	‘I mean the residents may use that, but I don’t think the faculty member is going to pull up a handbook. They’re just not, it doesn’t fit the workflow.’
‘I think that with the diagnostic information being brought in through the EGS classification system, it’s going to really stratify branch points and management based on classification systems of these typical emergency general surgery problems.’	‘Sometimes I feel like there is almost a discrepancy between what my assessment and plan is as compared to the a few words that are in the classification itself. I think sometimes there’s a little bit of a disconnect there. Sometimes I would think to myself “is it ok to say other or select this criteria even if its not 100% applicable to the patient in one way but it is in another?”’
‘It makes it much more black and white in terms of how to communicate about the patient. I also provides a little bit of a checklist in the middles of the night when you're tired to make sure you don't forget anything.’	‘I think you’re going to run into the same problem where you have now a second layer of “how do I interpret these guidelines?” I’m not sure how much it will be helpful, because the decision making process in always complicated no matter what. Patients are not that straightforward and they may not fit into certain guidelines. If the guidelines are written very carefully with definite hard points where there is certain criteria where for like 95% certainty this next step should happen, then I think it would be useful.’