(385) Exploring Barriers to Use of Train-of-Four Peripheral Nerve Monitoring in the ICU

Introduction: Peripheral nerve stimulation (PNS) Train of Four (TOF) monitoring is indicated for use in patients receiving neuromuscular blockade (NMB) in ICU and perioperative settings. TOF monitoring is not standardized in ICU for assessing depth of NMB for drug titration or for residual NMB before extubation. Nurses are responsible for TOF monitoring in ICU patients, yet little is known about perceived barriers to TOF use. Anesthesia NMB guidelines recommend quantitative electromyography (Q-EMG) monitoring over visual assessment of TOF response, yet this is not used in ICUs. The aim of this study was to explore ICU nurses’ experiences with TOF and perceived barriers to use.

Methods: Using a descriptive qualitative design, the study explored ICU nurses’ perspectives regarding TOF monitoring including perceived barriers to use. Semi-structured interviews were conducted with a convenience sample of ICU nurses at an academic medical center. Narratives were examined using thematic analysis. Feedback about Q-EMG TOF was also collected.

Results: Thirty nurses from 6 ICUs participated in interviews. A majority (25/30) participated in post-op recovery; 2/30 reported TOF use to assess readiness to extubate; 11/30 reported use of NMB reversal agents; and none had used the Q-EMG TOF before. Two main themes emerged: 1) Lack of confidence in using visually monitored TOF response to measure depth of NMB and 2) Inconsistent procedures with TOF use. Lack of confidence in TOF was related to device function concerns; difficulty visualizing twitches; absence of baseline TOF data at handoff; TOF response not aligned with clinical presentation; and preferred use of ventilator synchrony to assess degree of NMB. Variable TOF procedures related to site of monitoring and barriers to skin access for device placement in patients with burns were reported. Q-EMG adds objective measure of twitch ratio and may impact confidence.

Conclusions: Understanding ICU nurses’ experiences and perceived barriers with TOF can inform practice improvements that impact accurate and reliable monitoring. Appropriate dose titration of NMB relies on accurate TOF monitoring. Use of Q-EMG TOF may increase confidence in TOF monitoring. Further research is indicated to test Q-EMG in the ICU setting.