Improving Compliance With Institutional Performance on Train of Four Monitoring

We performed a multistep quality improvement project related to neuromuscular blockade and monitoring to evaluate the effectiveness of a comprehensive quality improvement program based upon the Multi-institutional Perioperative Outcomes Group (MPOG) Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE) metrics targeted specifically at improving train of four (TOF) monitoring rates.

We adapted the plan-do-study-act (PDSA) framework and implemented 2 PDSA cycles between January 2021 and December 2021. PDSA Cycle 1 (Phase I) and PDSA Cycle 2 (Phase II) included a multipart program consisting of (1) a departmental survey assessing attitudes toward intended results, outcomes, and barriers for TOF monitoring, (2) personalized MPOG ASPIRE quality performance reports displaying provider performance, (3) a dashboard access to help providers complete a case-by-case review, and (4) a web-based app spaced education module concerning TOF monitoring and residual neuromuscular blockade. Our primary outcome was to identify the facilitators and barriers to implementation of our intervention aimed at increasing TOF monitoring.

In Phase I, 25 anesthesia providers participated in the preintervention and postintervention needs assessment survey and received personalized quality metric reports. In Phase II, 222 providers participated in the preintervention needs assessment survey and 201 participated in the postintervention survey. Thematic analysis of Phase I survey data aimed at identifying the facilitators and barriers to implementation of a program aimed at increasing TOF monitoring revealed the following: intended results were centered on quality of patient care, barriers to implementation largely encompassed issues with technology/equipment and the increased burden placed on providers, and important outcomes were focused on patient outcomes and improving provider knowledge. Results of Phase II survey data was similar to that of Phase I. Notably in Phase II a few additional barriers to implementation were mentioned including a fear of loss of individualization due to standardization of patient care plan, differences between the attending overseeing the case and the in-room provider who is making decisions/completing documentation, and the frequency of intraoperative handovers. Compared to preintervention, postintervention compliance with TOF monitoring increased from 42% to 70% (28% absolute difference across N = 10 169 cases; P < .001).

Implementation of a structured quality improvement program using a novel educational intervention showed improvements in process metrics regarding neuromuscular monitoring, while giving us a better understanding of how best to implement improvements in this metric at this magnitude.