What Do the Guidelines Say?

EMG technology has been clinically validated as a superior quantitative method for reducing the incidence of residual paralysis. When tested against the reference standard MMG technology, EMG technology has shown to “provide accurate ‘close to gold standard readings’”.(1) With EMG technology becoming more widely available, it is now considered the best-in-class for reducing residual paralysis and enhancing patient safety. 

When implementing new technologies, adopting proven methods ensures widespread acceptance within the system. These approaches enable health systems to integrate new tools effectively, ultimately providing higher quality care and improving patient outcomes. 

Implementing new technologies effectively requires the establishment of well-defined protocols. As of 2023, the American Society of Anesthesiologists (ASA) has set guidelines for quantitative TOF monitoring. To ensure compliance with these guidelines and the successful integration of new devices, it is crucial to develop clear, evidence-based protocols. These protocols should use specific, detailed language to set out new expectations for providers, guiding their practice and ensuring adherence to standards.

Collaborating with experts in the technology can be invaluable in developing these protocols. As recommended by Dr. Stephan R. Thilen, “It is recommended to use quantitative neuromuscular monitoring at the adductor pollicis and to confirm recovery of a train-of-four ratio greater than or equal to 0.9 before extubation. Sugammadex is recommended for deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium. Neostigmine is a reasonable alternative for minimal blockade (train-of-four ratio ranging from 0.4 to less than 0.9). Patients with adequate spontaneous recovery to train-of-four ratio greater than or equal to 0.9 can be identified only with quantitative monitoring, and these patients do not require pharmacological antagonism.”(2) 

We all know the phrase, “teamwork makes the dream work”. Effective implementation of new technology hinges on teamwork and collaboration across all departments involved. While quantitative TOF monitoring is primarily used in anesthesia, it impacts multiple departments, including IT and biomedical engineering, which must address integration and mechanical issues.

As noted by Dr. Thilen, “A systematic approach may include restructuring the clinical environment by placing monitors in all anesthetizing locations, educational efforts on the departmental and individual levels utilizing different mediums, and performance feedback on the departmental and individual levels.” (2)

Ensuring that everyone is aware of the implementation process and their role in it will facilitate a smoother transition.
 

Education is a vital component of successful technology implementation. It is essential to explain why the new technology is needed and how it will benefit patient safety. Education helps providers trust and effectively use the technology, transforming tools from mere decorations into essential aids for better outcomes.

As Thilen emphasizes, “Champions for adoption of routine quantitative monitoring must educate fellow anesthesia clinicians on the benefits of monitoring: increased understanding of the patient’s physiologic condition, more effective antagonism of blockade, decreased need for PACU airway interventions, and decreased morbidity.”(2)

Collaboration with the device team for proper teaching and continuous follow-up is best practice. Visual tools and real-time support can significantly enhance adaptation. 

Implementing new technology opens opportunities for quality improvement projects and studies. Such projects can provide concrete, objective data showing improvements, which can be compelling for providers and drive further adoption.

For example, Dr. Thilen reports that “One project reduced residual paralysis in the PACU over 9 years (1995 to 2004) from 62 to 3.5% of patients as a result of increasing quantitative neuromuscular monitoring in the operating room from 2 to 60% of patients. Another project resulted in a reduction of residual paralysis in the PACU from 31 to 15% after introducing quantitative monitoring in all operating rooms.”(2)

While implementation can be complex, following the methods outlined above can create a more seamless transition. Embracing change is essential to prevent adverse events, enhance patient safety, and maintain compliance with current guidelines. By fostering collaboration, education, and evidence-based practices, health systems can effectively integrate new technologies and improve patient outcomes.