Measure Abbreviation
Data Collection Method

This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data. This measure is explicitly not based on provider self-attestation.

Measure Type

Percentage of cases with a documented Train of Four (TOF) after last dose of non-depolarizing neuromuscular blocker.

Measure Time Period

Anesthesia Start to Earliest Extubation


All patients that have received either by bolus or infusion a non-depolarizing neuromuscular blocker (NMB) AND were extubated post-operatively or in the PACU.  The following NMBs are included:

  • Atracurium
  • Cisatracurium
  • Pancuronium
  • Rocuronium
  • Vecuronium
  • ASA 5 and 6 cases.
  • Patients that were not extubated in the immediate post-operative period.
  • Patients not given NMBs

Documentation of a Train of Four count (1, 2, 3, or 4), sustained tetany, or TOF ratio provided by acceleromyography AFTER last dose or stopping of infusion of neuromuscular blocker and before earliest extubation.  Note: A Train of Four value of ‘0’ is accepted for cases in which Sugammadex is administered for reversal.

Other Measure Build Details
Responsible Provider

The provider signed in at time of earliest extubation.

MPOG Concept IDs Required


Neuromuscular Blocker Medications


Train of Four




Intubation Extubated Awake or Deep


Train-of-four objective count (acceleromyography, electromyography, other)




Emergence- Patient Extubated


Train-of-four (Subjective assessment)




Airway – Laryngeal mask airway removed (deep or awake)


Train-of-four (Acceleromyography)







Data Diagnostics Affected
  • Percentage of Cases with a Non-Depolarizing NMB Administration
  • Percentage of Cases with an Extubation Note
  • Percentage of Cases with a Train of Four Observation
  • Percentage of Cases with any Staff Tracking
  • Percentage of Anesthesia Provider Sign-Ins that are Time
Phenotypes Used

Postoperative residual neuromuscular blockade can lead to significant 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 monitoring to allow for detection, and use of reversal agents like neostigmine and Sugammadex. Due to variability in duration of muscle relaxants, even in defasciculating doses, we recommend that TOF is monitored when any non-depolarizing neuromuscular blockers are administered.

Risk Adjustment

Not Applicable

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