Impact of Quantitative Versus Qualitative Train-of-Four Neuromuscular Monitoring on Patient Outcomes
Date of Award
8-14-2026
Document Type
Capstone
Degree Name
Doctor of Nursing Practice (DNP)
School Name
Donna and Allan Lansing School of Nursing and Health Sciences
Department
Nursing
Major Advisor
Carly Mitchell
Second Advisor
Chris Webb
Abstract
Postoperative residual neuromuscular blockade (RNMB) remains a significant patient safety concern despite advances in neuromuscular monitoring and pharmacologic reversal. RNMB is associated with postoperative hypoxia, airway obstruction, increased oxygen requirements, airway interventions, and prolonged recovery in the postanesthesia care unit. This DNP scholarly project synthesizes current evidence comparing quantitative and qualitative train-of-four (TOF) monitoring and proposes an evidence-based implementation plan to increase the consistent use of quantitative monitoring among anesthesia providers caring for adult surgical patients who receive nondepolarizing neuromuscular blocking agents. Current evidence demonstrates that subjective visual and tactile assessments frequently overestimate neuromuscular recovery and cannot reliably confirm a train-of-four ratio (TOFR) of at least 0.90 before extubation. In comparison, quantitative methods, including acceleromyography and electromyography, provide objective measurements that support accurate assessment of neuromuscular blockade, appropriate administration of reversal agents, and confirmation of adequate recovery before extubation. The proposed implementation plan is guided by the Iowa Model of Evidence-Based Practice and includes provider education, a standardized quantitative TOF monitoring protocol, integration of monitoring and documentation expectations into the clinical workflow, and ongoing audit and feedback. Anticipated outcomes include increased adherence to quantitative monitoring, improved documentation of a TOFR of at least 0.90 before extubation, more appropriate use of sugammadex, and reductions in RNMB and associated postoperative respiratory complications. Standardizing quantitative neuromuscular monitoring may reduce practice variability, strengthen adherence to current professional guidelines, and promote safer, evidence-based anesthesia care.
Recommended Citation
Holba, Lauren E.; Brewer, Lauren E.; and Schilling, Richard J., "Impact of Quantitative Versus Qualitative Train-of-Four Neuromuscular Monitoring on Patient Outcomes" (2026). Graduate Theses, Dissertations, and Capstones. 230.
https://scholarworks.bellarmine.edu/tdc/230
Included in
Critical Care Nursing Commons, Nursing Administration Commons, Other Nursing Commons, Perioperative, Operating Room and Surgical Nursing Commons