ASHP Advantage e-Newsletter
Spring 2019

Postoperative respiratory events are a common complication associated with residual neuromuscular blockade and muscle weakness. It is estimated that approximately 30-60% of patients experience some degree of postoperative muscle weakness in the postanesthesia care unit (PACU).[1] The use of quantitative (i.e., objective) neuromuscular monitoring has been shown to reduce postoperative morbidity (e.g., the incidence of respiratory complications), PACU length of stay, and healthcare costs.[2] Quantitative monitoring is underused in the United States despite the potential benefits.[3]

Barriers to Monitoring

In a survey by the Anesthesia Patient Safety Foundation (APSF) of more than 50,000 anesthesiologists, nurse anesthetists, anesthesiologist assistants, and PACU nurses, a lack of equipment was the primary reason for not using quantitative neuromuscular monitoring to ensure adequate recovery of neuromuscular function at the end of surgical procedures and prevent postoperative complications.[4] Other barriers to the use of quantitative monitors include lack of user-friendly devices (i.e., lack of ease of use), cost, lack of familiarity with the technology, inadequate training, failure to appreciate the potential benefits, and lack of recognition of such monitoring as the standard of care.[2,4]

Clinician knowledge deficits and misperceptions can hinder acceptance of the technology.[4] For example, some clinicians perceive residual neuromuscular blockade as a rare event without clinical significance despite evidence to the contrary. Another common misconception is that neuromuscular monitoring is not needed during the use of sugammadex, a selective relaxant binding agent used for reversal of rocuronium and vecuronium.[4] Staff education and training about the importance of neuromuscular monitoring and use of quantitative monitoring equipment are needed.

Need for Guidelines

In a 2018 consensus statement by anesthesia clinicians on the perioperative use of neuromuscular monitoring, quantitative monitoring with documentation of a train-of-four ratio (TOFR) of at least 0.9 is recommended for patients receiving neuromuscular blocking agents (NMBAs) to ensure adequate recovery of neuromuscular function before tracheal extubation.[2] The need for time and education to implement institutional use of quantitative devices is acknowledged in the consensus statement, and the mandatory use of qualitative monitoring with a conventional peripheral nerve stimulator (PNS) is advocated when quantitative devices are not available.

This approach is consistent with that of the APSF Collaborative Panel on Neuromuscular Blockade and Patient Safety, which recommends quantitative monitoring and considers the use of conventional qualitative PNS devices mandatory during the period of transition to quantitative monitoring in an institution.[4] Similarly, the Enhanced Recovery After Surgery (ERAS) Society suggests the use of quantitative neuromuscular monitoring whenever possible to ensure a TOFR of at least 0.9 before extubating the patient, and qualitative monitors should be used to determine the depth of blockade in the absence of quantitative devices, recognizing that without a measure of the degree of fade, the anesthesia provider will not know the TOFR prior to extubating the patient.[5]

According to the 2019 American Association of Nurse Anesthetists (AANA) standards for nurse anesthesia practice, neuromuscular response should be monitored to determine the depth of blockade and degree of recovery when NMBAs are administered, but the use of quantitative monitoring is not specified.[6] The American Society of Anesthesiologists (ASA) has no guidelines addressing neuromuscular monitoring.[2]

Three out of four APSF survey respondents agreed on the need for a collaborative effort involving the AANA, ASA, and American Academy of Anesthesiologist Assistants to develop clinical practice guidelines for perioperative monitoring of neuromuscular function.[4]

Which of the following was suggested before tracheal extubation in patients receiving NMBAs in a 2018 consensus statement by anesthesia clinicians on the perioperative use of neuromuscular monitoring?
A Qualitative monitoring and a train-of-four count (TOFC) <4
B Qualitative monitoring and a TOFC of 4
C Quantitative monitoring and a train-of-four ratio (TOFR) <0.9
D Quantitative monitoring and a TOFR ≥0.9

Quantitative monitoring and a TOFR ≥0.9 was suggested in the 2018 consensus statement.[2] A TOFR of at least 0.9 is needed to ensure adequate recovery of neuromuscular function before tracheal extubation. Qualitative monitoring is not recommended because it is less reliable than quantitative monitoring and cannot discern presence of fade.

Modifying Clinical Behaviors

Bridging the gap between scientific evidence and clinical practice can be challenging.[2] Changing outmoded behaviors that are no longer supported by current evidence often is time consuming and costly, even when published data are widely available.

Many anesthesia clinicians have limited experience with quantitative neuromuscular monitoring, and they often are unaware of the consequences of residual neuromuscular blockade that develop in the PACU.[2] Personal belief systems vary among individuals, and resistance to change among clinician leaders can be particularly problematic because they may be responsible for leading the change among the clinicians they supervise.[7] Education about why the use of quantitative monitoring is necessary to ensure patient safety when neuromuscular blockers are given will help change the behavior of anesthesia clinicians who do not use quantitative monitoring.[2] Unlearning outdated knowledge and practices may be needed.

Providing data demonstrating harm from failure to follow evidence-based practices can be helpful because of misperceptions that the potential for harm is minimal.[4] Providing incentives also may prompt behavior change when combined with the use of cognitive aids and standardizing reversal management procedures.[8] Clinicians with limited experience should undergo focused training by anesthesia care personnel experienced in the use of quantitative monitors.[2]

Which of the following is a common cause of resistance among anesthesia clinicians to adopt the use of quantitative neuromuscular monitoring?
A Lack of current knowledge
B Insufficient supporting clinical evidence
C Lack of incentive
D Need for extra effort

Lack of current knowledge about quantitative monitors is a common cause of resistance among anesthesia providers to adopt the technology.[2] Evidence of the benefits from quantitative neuromuscular monitoring is well documented. Providing incentives may help modify clinician behavior but lack of incentives is not a common cause of resistance to change. The need for extra effort could delay adoption of new procedures, but it has not been identified as a cause of resistance among anesthesia clinicians to the use of quantitative neuromuscular monitoring.

Elements of Implementation Success

Research into the factors that contribute to meaningful improvement in patient outcomes from interventions in healthcare settings has identified key elements that contribute to success and provide a framework for successful organizational change (see Table).[9] It is useful to consider this framework for implementation research when thinking about change within the context of efforts to improve the safety of neuromuscular blockade and reversal.

Elements that Contribute to Successful Organizational Change[9]
Intervention characteristics
  • Intervention source
  • Evidence strength and quality
  • Relative advantage
  • Adaptability
  • Trialability
  • Complexity
  • Design quality and packaging
  • Cost
Outer setting
  • Patient needs and resources
  • Cosmopolitanism
  • Peer pressure
  • External policy and incentives
Inner setting
  • Structural characteristics
  • Networks and communications
  • Culture
  • Implementation climate
  • Readiness for implementation
Characteristics of individuals
  • Knowledge and beliefs about the intervention
  • Self-efficacy
  • Individual stage of change
  • Individual identification with organization
  • Other personal attributes
Implementation process
  • Planning
  • Engaging
    • Opinion leaders
    • Formally appointed internal implementation leaders
    • Champions
    • External change agents
  • Executing
  • Reflecting and evaluating

Consider first the characteristics of the intervention, such as key stakeholders’ perceptions about whether the intervention comes from within or outside of the organization and the quality of the evidence supporting the expectations that the intervention will result in the desired outcome.[9] For example, the results of a study involving 300-400 patients showing that an intervention is safe are not necessarily generalizable to an organization that provides care annually for thousands of surgical patients and hundreds of anesthesia clinicians.

Adaptability (i.e., the extent to which the intervention can be modified or tailored to meet organizational needs) is also an important characteristic of the intervention to consider.[9] For example, if a multihospital system is considering an intervention to improve safety of neuromuscular blockade and reversal, a very rigid program may not meet the needs of all sites if different NMBAs are on formulary and different monitoring devices are used at different sites.

The outer setting reflects economic, political, and social characteristics outside the organization that influence implementation success.[9] The adoption of proven external solutions is likely to engage clinician champions who connect deeply with addressing patient needs that currently are not met within the organization. Likewise, sharing organizational performance data through external quality interfaces, such as healthcare performance improvement companies or the National Surgical Quality Improvement Program, can improve insight into benchmarks for postoperative respiratory failure.

The inner setting reflects structural, political, and cultural contexts within the confines of the organization that influence the implementation process and success.[9] It is critical to understand the implication of these contexts on the ability to engage positive social networks and create a strong climate for implementation success.

Another important characteristic of the inner setting is the organizational culture.[9] An organization’s absorptive capacity for change and indicators of its commitment to the decision to implement an intervention, such as leadership presence, are crucial elements that allow for implementation to take place successfully.

Engaging key opinion leaders, formally appointed internal implementation leaders, champions, and external change agents is vital for successful implementation.[9] In addition, for successful implementation of an intervention, clinicians must be involved not only in the planning process, but as change agents implementing the change at the point of patient care. There are many characteristics of individuals that directly impact implementation success. For instance, if clinicians have preexisting bias against the intervention despite evidence to the contrary, they are less likely to comply. Further, clinicians generally have a strong belief in their individual expertise and influence on patient outcomes. Successful implementation requires change from individuals who may be at different stages of openness to change and who have differing degrees of identification with the organizational goals. Alignment of these individual belief systems with the overall goals of the intervention is essential for successful implementation.

An organization’s absorptive capacity for change is part of which of the following elements of success in implementing an intervention?
A Intervention characteristics
B Outer setting
C Inner setting
D Implementation process

An organization’s absorptive capacity for change is part of the inner setting, which reflects structural, political, and cultural contexts within the organization that influence the implementation process and success.[9] The outer setting is characterized by factors outside the organization, such as patient needs and resources, cosmopolitanism, peer pressure, and external policy and incentives. Intervention characteristics affecting implementation success include the source of the intervention, strength and quality of evidence, relative advantage, adaptability, trialability, complexity, design quality and package, and cost. The implementation process involves planning, engaging, executing, reflecting, and evaluating.

Careful attention to all of these factors when planning and implementing interventions to improve the safety of neuromuscular blockade and reversal should increase the success of the interventions, especially given the high risks associated with NMBAs.

Improving Communication

The Joint Commission and various patient safety organizations recognize ineffective hand-off communication at transitions of care as a major healthcare safety concern contributing to patient harm, increased healthcare costs, and patient dissatisfaction.[10] The Joint Commission has developed a tool for organizations to use to guide the quality improvement (QI) process in addressing this problem. This process involves building a team, assessing the current situation, identifying specific causes of problems, and linking the causes to proven solutions. This approach might be used to improve hand-off communication at the transition of care from the operating room (OR) to the PACU.

Policies and procedures should be established to optimize hand-off communication about neuromuscular blockade management at this transition of care. Anesthesia providers should provide the PACU nursing staff with information about the TOFR before and after reversal of neuromuscular blockade and for patients who did not receive reversal. In the absence of organizational policies and procedures for using quantitative monitoring, communication of the TOFR is unlikely to be part of the handoff to the PACU nursing staff at the transition of care.[4]

Quality Improvement

Perioperative neuromuscular monitoring and hand-off communication at the transition of care between the OR and PACU should be addressed in institutional QI activities.[8] An interprofessional approach involving surgery, anesthesiology, nursing, pharmacy, and patient safety and quality professionals is needed. A continuous QI process with repeated education, assessment, and provision of feedback to clinicians should be used.[2] Comparing performance before and after implementation of quantitative neuromuscular monitoring using various outcome measures (e.g., TOFR documented at the time of tracheal extubation, appropriate reversal provided) can provide insight about opportunities for improvement. Shortcomings should not be viewed as failures, but rather as opportunities to learn and make changes as appropriate.

Rudolph and colleagues conducted a single-center multifaceted QI initiative to reduce variability in intraoperative neuromuscular blocker and reversal management.[8] The intervention involved a reduction in available neostigmine aliquot sizes, distribution of a cognitive aid, educational activities, and provision of a financial incentive for intraoperative documentation of train-of-four measurement before neostigmine administration.

Compared with nearly 3,000 surgical cases before the intervention, significant reductions in the risk of postoperative respiratory complications (odds ratio 0.73, p = 0.001), length of hospital stay (p < 0.001), and costs (p < 0.001) were observed in more than 9,000 surgical cases after the intervention. The success of the intervention can be attributed to the strength and quality of evidence of harm from excessive neostigmine doses, the implementation climate, leadership engagement, and effective planning and evaluation. This study serves as a good example of changes that are possible in the OR to improve the safety of neuromuscular blockade and reflects the importance of key elements of the consolidated framework for implementation research in ensuring project success.[9]


  1. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring: challenges and opportunities. Anesthesiology. 2017; 126:173-90.
  2. Naguib M, Brull SJ, Kopman AF et al. Consensus statement on perioperative use of neuromuscular monitoring. Anesth Analg. 2018; 127:71-80.
  3. Naguib M, Kopman AF, Lien CA et al. A survey of current management of neuromuscular block in the United States and Europe. Anesth Analg. 2010; 111:110-9.
  4. Murphy G. Anesthesia Patient Safety Foundation. Presentation of the APSF Collaborative Panel on Neuromuscular Blockade and Patient Safety at the 2017 ASA Annual Meeting. APSF Newsletter. 2018; 32(3):68-9. (accessed 2019 Mar 5).
  5. Renew JR, Naguib M, Enhanced Recovery After Surgery Society. Monitoring neuromuscular blockade. (accessed 2019 Mar 5).
  6. American Association of Nurse Anesthetists. Standards for nurse anesthesia practice. 2019. (accessed 2019 Mar 5).
  7. Saint S, Kowalski CP, Banaszak-Holl J et al. How active resisters and organizational constipators affect health care-acquired infection prevention efforts. Jt Comm J Qual Patient Saf. 2009; 35:239-46.
  8. Rudolph MI, Chitilian HV, Ng PY et al. Implementation of a new strategy to improve the peri-operative management of neuromuscular blockade and its effects on postoperative pulmonary complications. Anaesthesia. 2018; 73:1067-78.
  9. Damschroder LJ, Aron DC, Keith RE et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009; 4:50.
  10. Joint Commission Center for Transforming Healthcare. FAQ section: hand-off communications TST. Online Reference (accessed 2019 Mar 5).
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