Neuro Status Change or Miscommunication? Improving Handoff Between Anesthesia and the Neurocritical Care Unit

BACKGROUND: Neuromuscular blocking agents or muscle relaxants utilized within the operating room can mask the accuracy of neurologic examinations, leading to treatment delays and unnecessary testing. Muscle relaxant reversal and clear communication of the neuromuscular status is imperative to reduce cost and morbidity.

LOCAL PROBLEM: There was no standard practice for reversing a muscle relaxant in mechanically ventilated postoperative Neuro Critical Care (NCC) patients at the project site. Variations in reversal administration were present among anesthesia providers. The aims included increasing the administration of muscle relaxant reversal medication and provider paging postoperatively.

METHODS: The Evidence-Based Practice Improvement Model was used to guide the project. Evidence consistently demonstrated support for the utilization of a handoff process from OR to ICU settings and timely muscle relaxant reversal. The handoff process was developed by reviewing the pre-existing handoff process at the project site and implementing interventions in areas requiring improvement. Outcome measures of time frame to reversal administration and frequency of Advanced Practice Provider (APP) paging were measured for a 3-month period.

INTERVENTIONS: Interventions included reinforcing the use of the anesthesia-to-ICU handoff tool, implementing paging the APP to the bedside for report upon patient arrival to the NCC, implementing a time frame for administration of a muscle relaxant reversal medication, educating the APP on muscle relaxants and their reversal agents, and ensuring APPs could view anesthesia medication administration on the patient’s chart.

RESULTS: For mechanically ventilated patients, 61% received reversal within 10 minutes of NCC arrival. The APP was paged for bedside report 70% of the time for all patients returning directly from the operating room to the NCC.

CONCLUSIONS: Both project aims were exceeded. APPs reported more consistent paging, concise reports, and multidisciplinary interest in patient reversal. Future initiatives should continue to target a standardized, team-integrated handoff process that further increases the rate of muscle relaxant reversal.