Improving quantitative neuromuscular monitoring: an education initiative on stimulating electrode placement

Quantitative neuromuscular monitoring reduces the incidence of residual neuromuscular block, but broad acceptance of monitoring has been elusive despite recommendations for quantitative monitoring for decades. Acceptance of quantitative monitoring may, in part, be related to the quality of the data from monitoring systems. This evaluation explored proper stimulating electrode positioning for electromyographic (EMG) monitoring, the impact of an educational intervention on electrode positioning and anesthesia provider (anesthesiologist, resident, anesthetist) confidence in the monitoring data from the device. In a single-center, observations of EMG electrode placement by anesthesia technicians, in 55 adult elective surgery patients were made by an independent observer. Separately, the anesthesia provider satisfaction with EMG derived data was recorded after reversal of neuromuscular block. An educational intervention then occurred on proper electrode positioning, including prior observations of electrode positioning, and prior anesthesia provider satisfaction with the EMG derived data. After the intervention, stimulating electrode position was observed with an additional 60 patients and anesthesia provider satisfaction with the data was again ascertained. The educational intervention significantly increased the proportion of ideal ulnar nerve groove electrode positioning from 74.5% to 95% (P < 0.003) and ideal wrist crease positioning (distal electrode within 2 cm of crease) from 61.8% to 96.7% (P < 0.001). Anesthesia provider confidence with EMG derived information during anesthesia delivery, increased from 67 to 90% after the education (P = 0.005). There was a significant relationship between correct stimulating electrode placement and anesthesia provider confidence in the EMG derived data on neuromuscular block status. An educational intervention to improve EMG electrode positioning proved meaningful. It increased anesthesia provider confidence in the EMG derived data during anesthesia case management.