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August 31, 2023Anaesthesiology Intensive TherapyOpen Access

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative

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Key result

A quality improvement initiative for quantitative neuromuscular blockade monitoring in fast-track cardiac surgery patients achieved an overall 69% rate of TOFR recording, with 47% of monitored patients showing residual paralysis on PACU arrival.

Why the study?

Although quantitative monitoring of neuromuscular blockade is recommended, it is not routinely used in daily practice.

Does a quality improvement initiative improve quantitative neuromuscular blockade monitoring and reduce residual paralysis in patients undergoing elective cardiac surgery eligible for fast-track extubation?

Population

859 patients undergoing elective cardiac surgery

Comparison

A quality improvement initiative with educational sessions vs standard practice

Design

Prospective quality improvement pilot study

Authors

SPSelene Martinez PerezJSJuan C. Segura-SalgeroMWMarcin Wąsowicz

Discussion

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Member takes

Overview

QI pilot shows incomplete uptake of quantitative NMB monitoring with high residual paralysis rates; leaves open effective strategies for sustained practice change.

Structured PICO

Does a quality improvement initiative improve quantitative neuromuscular blockade monitoring and reduce residual paralysis in patients undergoing elective cardiac surgery eligible for fast-track extubation?

P
Population
341 adult patients undergoing elective cardiac surgery eligible for fast-track extubation, evaluated during a quality improvement initiative to optimize neuromuscular blockade management.
I
Intervention
Optimizing neuromuscular Blockade management for Improving patient Safety and Perioperative Outcomes (OBISPO) quality improvement (QI) initiative, including educational sessions, cognitive aids, and new quantitative neuromuscular transmission (NMT) monitors.
C
Comparator
Baseline clinical practice and sequential Plan-Do-Study-Act (PDSA) cycles over time.
O
Outcome
Incidence of residual paralysis on PACU arrival, defined as a train-of-four ratio (TOFR) < 0.9, and fidelity of implementation (target to record TOFR in at least 70% of the cohort).surrogate

A quality improvement initiative for neuromuscular blockade monitoring in fast-track cardiac surgery highlights that changing clinician behavior is challenging and requires continuous education and process evaluation.

Limitations

  • COVID-19 outbreaks affected the study, with cancellation or postponement of elective surgeries.
  • A different brand of quantitative NMB monitor replaced those used at the beginning of the study, requiring new training.
  • Short study time to change clinicians' behavior.
  • COVID-19 outbreaks causing cancellation of elective surgeries and workflow disruptions
  • Change in the brand of quantitative NMB monitors during the study requiring new training
  • Short study time to observe significant behavioral changes

Cite This Study

Perez et al. (2023) studied Elective cardiac surgery eligible for fast-track extubation (n=341). Quality improvement initiative (OBISPO) for quantitative neuromuscular blockade monitoring was evaluated on Fidelity of implementation (TOFR recorded) and incidence of residual paralysis on PACU arrival (TOFR < 0.9). A quality improvement initiative for quantitative neuromuscular blockade monitoring in fast-track cardiac surgery patients achieved an overall 69% rate of TOFR recording, with 47% of monitored patients showing residual paralysis on PACU arrival.

synapsesocial.com/papers/6a95d2fd8372d5bc845395b0https://doi.org/10.5114/ait.2023.130805
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