How and what to communicate to decision makers when acquiring quantitative TOF monitoring

In January 2023, the American Society of Anesthesiologists (ASA) developed a set of guidelines on monitoring and reversal of neuromuscular block. To review the guidelines, go to this page.

Although the clinical value is clear for utilizing quantitative train-of-four (TOF) monitoring, the methods to demonstrate economic value to procurement decision-makers are now starting to appear. 

To describe the economic value of utilizing quantitative TOF monitoring, it can be helpful to review the clinical value.

Timing of intubation

• One thing that surprises most anesthesiologists and other care providers when utilizing quantitative TOF monitoring is a more variable than previously suspected time to acceptable neuromuscular block for safe intubating conditions.

Guiding administration of neuromuscular block

• Traditional qualitative train-of-four assessment and older quantitative technologies, even with an ability to test after tetanic stimulation, do not provide the level of precision that can allow you to use less paralytic agent or guide appropriate dosing during critical surgical case portions or ICU care.

Reversal of neuromuscular block

• Frequently, qualitative assessment using peripheral nerve stimulators (PNS) is challenging for ulnar or tibial sites due to tucked arms and unavailable legs for assessment of neuromuscular block. Quantitative EMG monitoring may be used in tucked-arm, laparoscopic, and robotic cases.
• Monitoring responses at the face is no longer recommended as it is subjective and often yields false readings due to direct muscle stimulation and muscle movement despite total block. The 2023 ASA Practice Guidelines specifically discourage the use of eye muscles for monitoring. 

Judging actual recovery

• Clinically, few signs indicate recovery, mainly strong coordinated swallow and jaw clench.
• Humans are poor at comparing the fourth twitch response to the first, often comparing the fourth to the third unknowingly and overestimating recovery.
• A recent study by Thilen et al. demonstrated a 0% incidence of postoperative residual neuromuscular blockade (PRNB) when quantitative monitoring was used alongside guided reversal strategies. Read the study

Showing the direct and indirect cost savings of a healthcare intervention shows the “win-win” of cost savings and quality improvement.

Improving quality improves healthcare costs

• The cost of surgical or anesthetic complications will nearly always be higher than that of routine use of quantitative TOF monitoring.
• Preventing a single complication could offset monitored care for at least 1500 patients.

Enhancing patient satisfaction 

• Improved early neuromuscular recovery is good safety and grassroots advertising

Reduced pharmaceutical expenses

• Increased usage of neuromuscular blocking agent secondary to less precise monitoring costs significant amounts of money, particularly when annualized.
• Increased usage of reversal agent, particularly Sugammadex, is likewise a key cost metric in any pharmacy cost center.
• A new study from Children's Hospital Colorado demonstrated annual savings of over $300,000 and a 40% reduction in Sugammadex use by employing quantitative Train-of-Four (TOF) monitoring, which allowed anesthesia providers to identify spontaneous patient recovery, eliminating the need for unnecessary drug administration (Haberkorn et al 2024).”

Reduced PACU time and reduced likelihood of escalated acuity of care

• Improving OR throughput may allow more cases and less overtime per day.
• Reducing the need for higher levels of care or transfer are important to keeping overall costs down.
• Reducing postoperative respiratory compromise (PORC) has been shown to significantly decrease PACU discharge times and improve hospital efficiency, as noted in a study by Butterly et al. Read the full study 
   

• While quality and safety should always lead any discussion when discussing patient care, it is always a huge benefit to show that overall costs will be negligible or show some savings.
• While exact figures are ideal, presenting compelling and well-supported estimates can often suffice.
• Discussing expenditures with interdisciplinary roles is best approached by identifying how all roles are members of the same team, working towards the same goal: efficient, safe, cost-conscious care. 
• Implementing quantitative TOF monitoring in clinical practice has been shown to improve outcomes, as seen in Weigel et al.'s practice change initiative. Learn more . 

• Open a discussion with internal decision makers after researching clinical and financial benefits.
• Arrange for a no-cost trial to evaluate the technology.
• Collect qualitative anonymous feedback and analyze it.
• Present the request for adoption to a value analysis committee (if present) or those same key decision makers with financial authority.
• Present the outcome of value analysis to any capital committee or other key decision makers.
• Negotiate a contract (this may be an internal team as well).
• Deploy the product and provide in-service training.
• Circle back with personnel to ensure ongoing adherence to usage and identify any needs for process or implementation improvement.

To support your discussions with the value analysis committee and strengthen the case for implementing quantitative train-of-four monitoring, access the clinical society guidelines eBook and comprehensive clinical bibliography.