14 www.mymsahq.org
ASPIRE FEATURED MEASURE: NMB 01
Nirav Shah, M.D.
Program Director, ASPIRE
Meridith Bailey, MSN
Quality Improvement Coordinator, ASPIRE
ASPIRE (Anesthesiology Performance
Improvement and Reporting Exchange) is
a national anesthesia quality improvement
collaborative that includes 21 hospitals across
Michigan. Michigan hospitals are a core
component of ASPIRE and make up almost half
of all participating sites. We are pleased to share
our 2
nd
featured measure article, as part of our
ongoing collaboration with the MSA.
An important focus for ASPIRE over the
last two years has been reducing respiratory
complications among patients undergoing
general anesthesia with mechanical ventilation.
ASPIRE has built four measures that, collectively
can track processes of care that reduce
perioperative pulmonary complications. ese
measures are:
1. Maintaining tidal volumes at ≤ 8cc/kg ideal
body weight (PUL 02)
2. Maintaining positive end expiratory pressure
(PUL 03)
3. Appropriate neuromuscular monitoring
(NMB 01)
4. Appropriate neuromuscular blockade
reversal (NMB 02)
In this issue, we discuss information and
performance for our neuromuscular monitoring
measure.
APPROPRIATE NEUROMUSCULAR
MONITORING
NMB 01 measures train of four (TOF)
monitoring. More specically, the percentage of
cases using a non-depolarizing neuromuscular
blocker that have a TOF documented aer the
last dose of neuromuscular blocker and prior to
earliest extubation.
Postoperative residual neuromuscular blockade
can lead to signicant complications. Several
studies have found associations between
the use of neuromuscular blockade agents
(NMBA) and residual neuromuscular blockade
in the recovery room. Adverse postoperative
respiratory outcomes are even more frequent
when patients receive NMBA and reversal agents
are not used. A mainstay of residual blockade
prevention continues to be TOF monitoring to
allow for detection, and use of reversal agents
like neostigmine and sugammadex. Clinical
measures, such as head li and grip strength,
are ineective measures of muscle recovery.
Due to variability in duration of muscle
relaxants, even in defasciculating doses, ASPIRE
recommends that TOF is monitored when any
non-depolarizing neuromuscular blockers are
administered.
1-7
Exclusion criteria for this measure include
cardiac procedures where patients are expected
to go to ICU intubated. Additional measure
details can be found at https://mpog.org/les/
quality/measures/NMB-01_spec.pdf.
DISCUSSION
ASPIRE sites participating in Michigan (and
around the country) have used a variety of
quality improvement techniques to improve their
performance. ese include adding train of four
monitors to every operating room, ensuring
replacement batteries for monitors are readily
available, introducing quantitative monitoring
devices, providing performance feedback to
individual providers, and sharing best practices
via lecture and discussion sessions. Tools are
available from a variety of sources, including our
website (https://mpog.org/quality/toolkits/). We
are encouraged that overall, performance across
ASPIRE sites is consistently high, and hope that
sites that are not participating in ASPIRE will be
able to use this vignette, and access additional
information on our website (see links above) to
address this important topic.
ASPIRE recommends that TOF is
monitored when any non-depolarizing
neuromuscular blockers are administered
Summer/Fall 2019 15
Figure A. Performance for NMB 01 Across ASPIRE sites in Michigan- 2019
Figure B. Performance trend for ASPIRE sites in Michigan since the release of NMB 01
REFERENCES
1. Brull SJ, Murphy GS. Residual neuromuscular block: lessons
unlearned. Part II: methods to reduce the risk of residual
weakness. Anesthesia and analgesia. 2010;111(1):129-140.
2. Grosse-Sundrup M, Henneman JP, Sandberg WS, et al.
Intermediate acting non-depolarizing neuromuscular blocking
agents and risk of postoperative respiratory complications:
prospective propensity score matched cohort study. BMJ
(Clinical research ed). 2012;345:e6329.
3. Harrison GG. Death attributable to anaesthesia. A 10-
year survey (1967--1976). British journal of anaesthesia.
1978;50(10):1041-1046.
4. Lien CA, Kopman AF. Current recommendations for
monitoring depth of neuromuscular blockade. Current opinion
in anaesthesiology. 2014;27(6):616-622.
5. Pedersen T, Viby-Mogensen J, Bang U, Olsen NV, Jensen E,
Engboek J. Does perioperative tactile evaluation of the train-of-
four response inuence the frequency of postoperative residual
neuromuscular blockade? Anesthesiology. 1990;73(5):835-839.
6. Beecher HK, Todd DP. A study of the deaths associated with
anesthesia and surgery: based on a study of 599, 548 anesthesias
in ten institutions 1948-1952, inclusive. Annals of surgery.
1954;140(1):2-35.
7. Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical
mortality. Anaesthesia. 1983;38(11):1090-1096.
