Author ORCID Identifier
Semester
Summer
Date of Graduation
2025
Document Type
Problem/Project Report
Degree Type
DNP
College
School of Nursing
Department
Anesthesiology
Committee Chair
Aaron Ostrowski
Committee Member
Emily Moore
Committee Member
Eric Likar
Abstract
Problem Statement: Despite the availability of quantitative train of four (TOF) monitoring, anesthesia providers more frequently rely on tactile (qualitative) TOF monitoring, which is associated with underestimation of recovery from muscle relaxation. Inadequate recovery from muscle relaxants results in residual weakness and its associated complications in the postoperative period, including compromised respiratory function (Thilen et al., 2023).
Background: Neuromuscular blockade (NMB) drugs are required to facilitate endotracheal intubation and allow for surgical manipulation. When these drugs are used, train of four (TOF) stimulations are used to monitor and assess the depth and recovery from NMB. TwitchView monitors (quantitative monitoring) is an electronic method that gives a more accurate ratio of the first and fourth twitches which correlates with better recovery from muscle relaxation. Though readily available to all staff, TwitchView monitoring is not used as frequently as tactile TOF monitoring in clinical practice.
Literature Review to Support Planned Intervention: The American Society of Anesthesiologist (ASA) guidelines support quantitative TOF monitoring as the standard for care (Thilen et al., 2023). The use of quantitative TOF monitors decreases the incidence of residual NMB and respiratory complications in postoperative patients when compared to tactile TOF monitoring (Naguib et al., 2007).
Project Aims: The purpose of this project was to improve compliance with clinical practice guidelines (CPG) of NMB and improve utilization of quantitative NMB monitoring at the project’s clinical site. An analysis of cost-effectiveness of TwitchView monitoring vs. cost of the residual effects of NMB will be performed.
Methods: IHI model for improvement was used along with the Plan-Do-Study-Act (PDSA) (AHRQ, 2020) as a framework to implement education and monitor for changes in utilization and compliance with CPG documentation of adequate muscle recovery over three months.
Implementation: Three cycles of the PDSA model were completed monthly using patient chart review for data collection to monitor for changes and areas for improvement.
Evaluation: Data regarding utilization was collected monthly to evaluate by a regression analysis using multinomial logistic models.
Recommended Citation
Blair, Carley S., "Improving Neuromuscular Blockade Surveillance in Anesthesia Care with Quantitative Train of Four Monitoring" (2025). Graduate Theses, Dissertations, and Problem Reports. 12936.
https://researchrepository.wvu.edu/etd/12936