Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative

Abstract

Background Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. We embarked on a professional practice initiative to attain train-of-four (TOF) ratio ≥ 0.90 documentation for all patients for improved patient outcomes through reducing residual paralysis. Methods We utilized equipment trials, educational videos, quantitative monitors in all anesthetizing location, electronic clinical decision support with real time alerts and initiated an ongoing professional practice metric. This was a retrospective assessment (2016-2020) of TOF ratio ≥ 0.9 documentation prior to extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients receiving a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. Results From pre- to post-implementation, more patients were ASA 3-5, fewer were inpatients, rocuronium average dose was higher, and more patients had a pre-reversal TOF count < 4. Manually reviewed anesthesia records (n=2807) had 2/172 (1%) cases with TOF ratio ≥ 0.90 documentation in November 2016 which was less than the 250/269 (93%) cases in December 2020. Post-implementation (2/1/2020-12/31/2020) sugammadex 650/935 (70%), neostigmine 195/935 (21%), and no reversal 90/935 (10%) were used to attain TOF ratio ≥ 0.90 in 856/935 (92%) of patients. In the electronically searched medical charts (n=20181), post-implementation inpatients had a shorter PACU length of stay (7% difference, median minutes [25th, 75th percentile], 73 [55,102] to 68 [49,95], p<0.001), pulmonary complications were less (43% difference, 94/4138 (2.3%) to 23/1817 (1.3%), p=0.010, difference -1.0%, 95% CI -1.7% to -0.3%) and hospital length of stay was less (median days [25th, 75th percentile], 3 [2,5] to 2 [1,4], p<0.001). Conclusions In this professional practice initiative TOF ratio ≥ 0.90 documentation occurred for 93% of patients in a busy clinical practice. Return of strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

What Anesthesiology Has to Learn from Implementation Science and Quality Improvement

“…8 Unfortunately, as many of us know, the existence of evidence and creation of guidelines or recommendations are rarely sufficient to change practice. Weigel et al 4 noted inertia with respect to the adoption and use of quantitative neuromuscular blocker monitoring in their institution and undertook a quality improvement initiative to change practice. In so doing, they designed a robust project that combines tenets of quality improvement and implementation science.…”

“…Quality improvement is often funded locally, while implementation science has enjoyed increasing attention from research funding agencies that see the field as a way to realize the return on investment in basic and clinical research innovations. Despite the fields' differences, quality improvement-and implementation scienceinformed approaches to change management are not mutually exclusive; techniques from each can be combined to powerful effect, as demonstrated by Weigel et al 4 The astute reader will note that Anesthesiology does not often publish quality improvement reports. What do we have to learn from single-site experiences?…”

“…These changes were associated with decreases in postanesthesia care unit and hospital length of stay and a decrease in pulmonary complications. 4…”

“…These changes were associated with decreases in postanesthesia care unit and hospital length of stay and a decrease in pulmonary complications. 4 The use of nondepolarizing neuromuscular blocking drugs to facilitate intubation and surgery is second nature to anyone practicing anesthesia. We must use these drugs with care, however, because residual neuromuscular blockade after surgery has clearly demonstrated adverse outcomes for patients, including hypoxemia, a need for reintubation, and pneumonia.…”

“…The evidence-here, the use of quantitative neuromuscular blocker monitoring-must reach practice to improve the care and outcomes of our patients. The report by Weigel et al 4 provides insight into how that translation into practice might happen. It also demonstrates that change occurs over time and that sustained changes (i.e., those lasting months to years) may require different strategies over time to reach a goal performance target.…”