Goriacko Pavel, Chao Jerry, Fassbender Philipp, Rudolph Maíra I, Beechner Paul, Shukla Harshal, Yaghdjian Vicken, Choice Curtis, Aroh Frank, Sinnett Mark, Karaye Ibraheem M, Eikermann Matthias
Center for Health Data Innovations, Montefiore Einstein, 3 Odell Plaza, Yonkers, NY 10703, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, USA.
Department of Anesthesiology, Montefiore Medical Center, 111 East 210(th) Street, Bronx, NY 10467, USA.
J Clin Anesth. 2025 Feb;101:111709. doi: 10.1016/j.jclinane.2024.111709. Epub 2024 Dec 12.
Residual neuromuscular block (NMB) after anesthesia poses significant risk to patients, which can be reduced by adhering to evidence-based practices for the dosing, monitoring, and reversal of NMB. Incorporation of best practices into routine clinical care remains uneven across providers and institutions, prompting the need for effective implementation strategies.
An interdisciplinary quality improvement initiative aimed to optimize NMB reversal practices across a large multi-campus urban medical center. Using the Institute for Healthcare Improvement (IHI) framework, interventions were designed to increase Train-of-Four (TOF) monitoring and promote evidence-based and cost-effective use of the NMB reversal agents. Process and outcome measures were tracked through Plan-Do-Study-Act (PDSA) cycles. Qualitative interviews provided insights into clinician perspectives.
The study encompassed 35,198 surgical cases utilizing NMB agents. The interventions led to a sustained increase in TOF monitoring from 42 % to 83 %. Significant increases were also observed in TOF ratio documentation and utilization of sugammadex. Postoperative respiratory complication rates decreased by 41 % (RR 0.59, 95 % CI 0.32-0.96) over the course of the initiative. The most pronounced increases in TOF monitoring were associated with financial incentives for the achievement of department-wide target monitoring rate.
This initiative demonstrates successful large-scale integration of quantitative TOF monitoring and evidence based NMB management across a diverse medical center, while highlighting important barriers in implementation. These findings contribute to the broader discussion on translating evidence into practice, offering insights for improving patient care and safety through tailored implementation strategies.
麻醉后残留的神经肌肉阻滞（NMB）对患者构成重大风险，通过坚持基于证据的NMB给药、监测和逆转实践可降低该风险。将最佳实践纳入常规临床护理在不同的医疗服务提供者和机构之间仍不均衡，这促使需要有效的实施策略。
一项跨学科质量改进计划旨在优化一个大型多校区城市医疗中心的NMB逆转实践。使用医疗改进研究所（IHI）框架，设计干预措施以增加四个成串刺激（TOF）监测，并促进基于证据和具有成本效益的NMB逆转剂的使用。通过计划-实施-研究-改进（PDSA）循环跟踪过程和结果指标。定性访谈提供了临床医生观点的见解。
该研究涵盖了35198例使用NMB药物的手术病例。干预措施使TOF监测持续增加，从42%增至83%。TOF比值记录和舒更葡糖的使用也显著增加。在该计划实施过程中，术后呼吸并发症发生率下降了41%（相对危险度0.59，95%置信区间0.32 - 0.96）。TOF监测最显著的增加与实现科室范围内目标监测率的经济激励措施相关。
该计划展示了在一个多元化医疗中心成功大规模整合定量TOF监测和基于证据的NMB管理，同时突出了实施中的重要障碍。这些发现有助于更广泛地讨论将证据转化为实践，为通过量身定制的实施策略改善患者护理和安全提供见解。
