Measure Abbreviation
NMB-01
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
Process
Description

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

Inclusions

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
Exclusions
  • ASA 5 and 6 cases.
  • Patients that were not extubated in the immediate post-operative period.
  • Patients not given NMBs.
  • Cardiac surgery without pump (CPT: 00560)
  • Cardiac surgery with pump and <1 year old (CPT: 00561)
  • Cardiac surgery with pump and > 1 year old (CPT: 00562)
  • Cardiac surgery with hypothermic arrest (CPT: 00563)
  • CABG with pump (CPT: 00567)
  • Heart Transplant (CPT: 00580)
  • Any cardiac case with an intraoperative note mapped to one of the following MPOG Concepts:
    • 50399    Cardiopulmonary bypass -- aortic clamp on/off note
    • 50409    Cardiopulmonary bypass terminated
    • 50410    Cardiopulmonary bypass initiated (full)
    • 50416    Cardiopulmonary bypass -- crossclamp and circulatory arrest time totals
    • 50417    Cardiopulmonary bypass -- Access cannula removed note
    • 50714    Cardiopulmonary bypass - Bypass start / stop event
  • Cases performed by cardiac surgical service: MPOG concept 80005.
Success

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.

Threshold
90%
MPOG Concept IDs Required

 

Neuromuscular Blocker Medications

Extubation

Train of Four

10043

Atracurium

50127

Intubation Extubated Awake or Deep

3033

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

10129

Cisatracurium

50202

Emergence- Patient Extubated

3330

Train-of-four (Subjective assessment)

10344

Pancuronium

50145

Airway – Laryngeal mask airway removed (deep or awake)

3485

Train-of-four (Acceleromyography)

10393

Rocuronium

 

10446

Vecuronium

 

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
Rationale

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

References
  1. 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. Ann Surg 1954; 140:2-35.
  2. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg. 2010. 111(1): 129-40.
  3. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, Ehrenfeld JM, Martinez EA, Kurth T, Eikermann M. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329
  4. Harrison GG. Death attributable to anaesthesia. A 10-year survey (1967-1976). Br J Anaesth 1978; 50:1041-6.
  5. Lien CA, Kopman AF. Current recommendations for monitoring depth of neuromuscular blockade. Curr Opin Anesthesiol. 2014; 27(6): 616-622.
  6. Lunn JN, Hunter AR, Scott DB. Anaesthesia-related surgical mortality. Anaesthesia 1983; 38:1090-6.
  7. Pedersen T, Viby-Mogensen J, Ringsted C. Anaesthetic practice and postoperative pulmonary complications. Acta Anaesthesiol Scand 1992; 36:812-8.