Department of Anesthesiology and Pain Medicine, Toronto General Hospital, University of Toronto, Canada.
Anaesthesiol Intensive Ther. 2023;55(3):196-204. doi: 10.5114/ait.2023.130805.
Although quantitative monitoring of neuromuscular blockade (NMB) is recommended, it is not routinely used in daily practice. The optimizing NMB management to improve patient safety and perioperative outcomes (OBISPO) quality improvement (QI) initiative intends to address this issue and change clinicians' behaviors.
A pilot phase of the prospective QI intervention was conducted. The primary objective was implement clinical practice change that emphasizes improving NMB monitoring in patients undergoing elective cardiac surgery who are eligible for fast-track extubation between February 2021 and December 2021. The secondary objective was to reduce the train-of-four ratio (TOFR) < 0.9 incidence before tracheal extubation to less than 20%. The intervention included educational sessions for teams.
A total of 859 patients underwent elective cardiac surgery, 40% were eligible for fast-track extubation. From our cohort of fast-track cardiac cases, 69% had reported TOFR; 47% of them had residual paralysis (TOFR < 0.9) on arrival to PACU, 22% persisted with residual paralysis after extubation, and 27% were extubated without monitoring. The survey identified cognitive biases, knowledge gaps, unfamiliarity, and lack of trust in quantitative monitoring devices. Workflow disruptions imposed by COVID and changes in NMB monitoring devices have negatively affected our initiative.
Our study showed that changes in clinician behavior are among the most challenging issues in perioperative medicine. Continuous teaching and QI initiatives, focused on quantitative NMB monitors and adequate reversal agent use, are mandatory to improve perioperative outcomes. Therefore, new proposals are required to promote changes in current practices.
尽管推荐对神经肌肉阻滞（NMB）进行定量监测，但在日常实践中并未常规使用。优化 NMB 管理以改善患者安全和围手术期结局（OBISPO）质量改进（QI）计划旨在解决这一问题并改变临床医生的行为。
进行了前瞻性 QI 干预的试点阶段。主要目标是实施临床实践的改变，强调在 2021 年 2 月至 2021 年 12 月期间接受择期心脏手术且有资格快速拔管的患者中加强 NMB 监测。次要目标是将气管拔管前 train-of-four 比值（TOFR）<0.9 的发生率降低到 20%以下。干预措施包括团队教育课程。
共有 859 名患者接受了择期心脏手术，其中 40%有资格快速拔管。在我们的快速心脏手术病例队列中，69%有报告 TOFR；其中 47%在到达 PACU 时仍有残余麻痹（TOFR<0.9），22%在拔管后仍有残余麻痹，27%在没有监测的情况下拔管。调查确定了认知偏见、知识差距、不熟悉和对定量监测设备的不信任。COVID 带来的工作流程中断以及 NMB 监测设备的变化对我们的计划产生了负面影响。
我们的研究表明，改变临床医生的行为是围手术期医学中最具挑战性的问题之一。必须进行持续的教学和 QI 计划，重点是定量 NMB 监测和充分使用逆转剂，以改善围手术期结局。因此，需要提出新的建议来推动当前实践的改变。
