Exploring Barriers to Use of Train of Four Peripheral Nerve Monitoring in the ICU

Peripheral nerve stimulation (PNS) Train of Four (TOF) monitoring is indicated for use in patients receiving neuromuscular blockade (NMBA). Nurses are responsible for TOF monitoring, yet little is known about barriers to use. NMBA guidelines recommend quantitative electromyography (Q-EMG) monitoring not yet used in ICUs. The aim of this study was to explore ICU nurses' experiences with TOF and perceived barriers to use. This qualitative study explored ICU nurses' perspectives and perceived barriers to use of TOF. Semi-structured interviews were analyzed using thematic analysis. Thirty nurses from 6 ICUs participated. Two main themes emerged: (1) lack of confidence in visually monitoring TOF and (2) inconsistent procedures. Lack of confidence was related to device concerns, difficulty visualizing twitches, absence of baseline data, TOF not aligned with clinical presentation, and provider preference for ventilator synchrony vs. TOF. Barriers to skin access were reported. Objective measurement of Q-EMG twitch ratio may improve confidence. Nerve stimulation reported as minor discomfort (mean = 2, scale 0-10). Current barriers have led to misuse or disuse. Use of Q-EMG TOF may increase confidence in TOF monitoring and overcome current barriers. Further research is indicated to test Q-EMG in the ICU setting.