**Background:** Severe bleeding and coagulopathy are critical conditions with high mortality. Viscoelastic haemostatic assays like rotational thromboelastometry (ROTEM) provide real-time assessment of clot formation and dissolution, enabling faster, targeted haemostatic interventions compared to standard coagulation tests. Despite widespread clinical use and endorsement by transfusion guidelines, accurate interpretation of ROTEM results can be challenging. This study aimed to explore anaesthetists' perceptions of ROTEM to identify strengths and areas for improvement.
**Methods:** This single-centre, mixed qualitative–quantitative study was conducted at the University Hospital Zurich over three weeks in January–February 2022. In Part I, 77 anaesthesia staff (8 senior physicians, 35 residents, 34 nurses; 59.7% female; median anaesthesia experience 8 years [IQR 3–10]; median 26 ROTEM interpretations/year [IQR 5–41]) were interviewed immediately after participating in a high-fidelity simulation of perioperative bleeding scenarios. Participants freely verbalized positive and negative perceptions of ROTEM. Field notes were translated from German to English, and a coding template was used to identify themes. Interrater reliability (Cohen's kappa) was 0.799 (95% CI 0.776–0.822). Word count analysis identified the most frequent terms. In Part II, 52 participants (20 senior physicians, 17 residents, 15 nurses; median anaesthesia experience 8 years [IQR 4–10]; median 44 ROTEM interpretations/year [IQR 7.75–50]) completed an anonymous online survey rating six statements derived from interview themes on 5-point Likert scales. Statistical significance was assessed using the Wilcoxon signed-rank test (p < 0.05).
**Key Results:** A total of 288 statements were collected: 148 (51.4%) positive and 140 (48.6%) negative. The most frequently mentioned positive words were 'quick/quickly/quicker/fast/faster' (23.4% of participants), 'visible/visual/visualization' (16.9%), 'information' (14.3%), and 'quantification/quantitative' (11.9%). The most common negative words were 'interpretation' (23.4%), 'experience' (15.6%), and 'complex/complicated' (11.7%). Positive themes included: high accuracy (36/288, 13.2%), positive usability features (34/288, 12.5%), positive design features (30/288, 11%), quick availability of results (28/288, 10.3%), and proven coagulation management tool (16/288, 2.9%). Negative themes included: need for training (54/288, 19.8%), usability problems (48/288, 17.6%), negative design features (12/288, 4.4%), interference susceptibility (8/288, 2.9%), and incompleteness (7/288, 2.6%). In the online survey, 81% of respondents agreed or strongly agreed that they would find recurrent training beneficial. Except for one statement, all sample medians differed statistically significantly from neutral (p < 0.05).
**Clinical Implications:** This study confirms that clinicians value ROTEM for its accuracy, speed, and role as a standard tool in haemostatic resuscitation. However, the substantial proportion of negative comments—particularly regarding cognitive load, complexity, and training demands—highlights a critical gap. The findings support the development of user-centred decision-support tools, such as Visual Clot (an animated 3D blood clot representation), and artificial intelligence applications to reduce cognitive burden and improve situation awareness, especially in time-critical emergencies. The single-centre design and potential influence of the preceding simulation (which included exposure to Visual Clot) are limitations; multi-centre studies in diverse settings are warranted.