BACKGROUND: We assessed the association between education-based interventions, the frequency of train-of-four (TOF) monitoring, and postoperative outcomes. METHODS: We studied adults undergoing noncardiac surgery from February 1, 2020 through October 31, 2021. Our education-based interventions consisted of 3 phases. An interrupted time-series analysis, adjusting for patient- and procedure-related characteristics and secular trends over time, was used to assess the associations between education-based interventions and the frequency of TOF monitoring, postoperative pulmonary complications (PPCs), 90-day mortality, and sugammadex dosage. For each outcome and intervention phase, we tested whether the intervention at that phase was associated with an immediate change in the outcome or its trend (weekly rate of change) over time. In a sensitivity analysis, the association between education-based interventions and postoperative outcomes was adjusted for TOF monitoring. RESULTS: Of 19,422 cases, 11,636 (59.9%) had documented TOF monitoring. Monitoring frequency increased from 44.2% in the first week of preintervention stage to 83.4% in the final week of the postintervention phase. During the preintervention phase, the odds of TOF monitoring trended upward by 0.5% per week (odds ratio [OR], 1.005; 95% confidence interval [CI], 1.002–1.007). Phase 1 saw an immediate 54% increase (OR, 1.54; 95% CI, 1.33–1.79) in the odds, and the trend OR increased by 3% (OR, 1.03; 95% CI, 1.01–1.05) to 1.035, or 3.5% per week (joint Wald test, P < .001). Phase 2 was associated with a further immediate 29% increase (OR, 1.29; 95% CI, 1.02–1.64) but no significant association with trend (OR, 0.96; 95% CI, 0.93–1.01) of TOF monitoring (joint test, P = .04). Phase 3 and postintervention phase were not significantly associated with the frequency of TOF monitoring (joint test, P = .16 and P = .61). The study phases were not significantly associated with PPCs or sugammadex administration. The trend OR for 90-day mortality was larger by 24% (OR, 1.24; 95% CI, 1.06–1.45; joint test, P = .03) in phase 2 versus phase 1, from a weekly decrease of 8% to a weekly increase of 14%. However, this trend reversed again at the transition from phase 3 to the postintervention phase (OR, 0.82; 95% CI, 0.68–0.99; joint test, P = .05), from a 14% weekly increase to a 6.2% weekly decrease in the odds of 90-day mortality. In sensitivity analyses, adjusting for TOF monitoring, we found similar associations between study initiatives and postoperative outcomes. TOF monitoring was associated with lower odds of PPCs (OR, 0.69; 95% CI, 0.55–0.86) and 90-day mortality (OR, 0.79; 95% CI, 0.63–0.98), but not sugammadex dosing (mean difference, -0.02; 95% CI, -0.04 to 0.01). CONCLUSIONS: Our education-based interventions were associated with both TOF utilization and 90-day mortality but were not associated with either the odds of PPCs or sugammadex dosing. TOF monitoring was associated with reduced odds of PPCs and 90-day mortality.

中文翻译：

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通过基于教育的干预措施改善神经肌肉监测并研究其与不良术后结果的关系：一项回顾性观察研究

背景：我们评估了基于教育的干预措施、四人组 (TOF) 监测频率和术后结果之间的关联。方法：我们研究了 2020 年 2 月 1 日至 2021 年 10 月 31 日期间接受非心脏手术的成年人。我们以教育为基础的干预措施分为 3 个阶段。使用中断时间序列分析，根据患者和手术相关特征以及随时间的长期趋势进行调整，用于评估基于教育的干预措施与 TOF 监测频率、术后肺部并发症 (PPC)、90 天之间的关联死亡率和舒更葡糖剂量。对于每个结果和干预阶段，我们测试了该阶段的干预是否与结果或其随时间变化的趋势（每周变化率）的立即变化相关。在敏感性分析中，针对 TOF 监测调整了基于教育的干预措施与术后结果之间的关联。结果：在 19,422 例病例中，11,636 例 (59.9%) 记录了 TOF 监测。监测频率从干预前第一周的44.2%增加到干预后最后一周的83.4%。在干预前阶段，TOF 监测的几率呈每周上升 0.5% 的趋势（优势比 [OR]，1.005；95% 置信区间 [CI]，1.002–1.007）。第一阶段的几率立即增加了 54%（OR，1.54；95% CI，1.33–1.79），趋势 OR 增加了 3%（OR，1.03；95% CI，1.01–1.05）至 1.035，或每周 3.5%（联合 Wald 检验，P < .001）。第 2 阶段与 TOF 监测（联合测试、 P = .04)。第 3 阶段和干预后阶段与 TOF 监测频率没有显着相关（联合测试，P = .16 和 P = .61）。研究阶段与 PPC 或舒更葡糖给药没有显着相关性。与第 1 阶段相比，第 2 阶段 90 天死亡率的趋势 OR 增加了 24%（OR，1.24；95% CI，1.06–1.45；联合检验，P = .03），从每周下降 8% 到每周下降每周增加14%。然而，在从第 3 阶段过渡到干预后阶段时，这一趋势再次逆转（OR，0.82；95% CI，0.68-0.99；联合检验，P = 0.05），从每周 14% 的增长变为每周下降 6.2% 90 天死亡率的几率。在敏感性分析中，根据 TOF 监测进行调整，我们发现研究举措与术后结果之间存在类似的关联。TOF 监测与较低的 PPC 几率（OR，0.69；95% CI，0.55–0.86）和 90 天死亡率（OR，0.79；95% CI，0.63–0.98）相关，但与舒更葡糖剂量无关（平均差，- 0.02；95% CI，-0.04 至 0.01）。结论：我们基于教育的干预措施与 TOF 使用率和 90 天死亡率相关，但与 PPC 或舒更葡糖剂量无关。