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Research Snapshot Theater: Quality and Patient Safety, Pediatric III

Implementing a Structured Train-of-Four Monitoring Program for Paralyzed Patients

Monday, March 23, 2026
10:15 AM - 11:15 AM Central Time
Location: Connections Central - RST 10

  • Finley J. Shinnick, n/a

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • KG

    Karen Gozzi, R.N.

    Nurse Manager
    Golisano Children's Hospital University of Rochester

    Disclosure information not submitted.

  • TL

    Tanisha Lewis, R.N

    Nurse Educator/Clinical Nurse Leader
    Golisano Children's Hospital University of Rochester

    Disclosure information not submitted.

  • Adam C. Dziorny, MD, PhD

    Golisano Children's Hospital University of Rochester, New York

    Disclosure(s): No relevant financial relationship(s) to disclose.

Introduction: Critically ill patients on continuous neuromuscular blocking agents (NBMA) are at risk for under- or over-paralysis. Train-of-four (TOF) tests are considered best practice to quantify paralytic adequacy. In this data-driven quality improvement program, we aimed to increase TOF usage by 50% compared to historical practice through guideline development, just-in-time training, and regular reminders during the study period.


Methods: To measure baseline monitoring, we extracted retrospective data from our electronic health record (EHR). We defined a paralysis-day as a single patient on NMBA for 4 hours in any 6-hour interval. We developed TOF monitoring guidelines and bedside surveys with nursing leadership input. We conducted daily bedside surveys of nurses caring for patients on NMBAs from 6/1-7/21. Surveys asked nurses how they evaluated sedation and paralysis adequacy during their shift. Each nurse was provided just-in-time education for TOF monitoring. Data was recorded in REDCap. Pre-planned sustainability measures will occur six months following the conclusion of active intervention.


Results: Among baseline measurements 03/23 - 06/25, 74 patients experienced 493 NMBA-days; during that time period, only 9 NMBA-days (1.8%) contained recorded TOF measures. During the study intervention period, there were 7 unique paralyzed patients for 40 NMBA-days. We administered 18 bedside surveys for 6 unique patients. Of these, 14 (77%) prompted TOF tests, and 11 (79% of those) were entered into EPIC. Nurses performed an additional 29 unprompted TOF tests beginning on the third week of survey administration. During the intervention period, 24 (60%) of NMBA-days contained recorded TOF measures, a significant increase from the pre-intervention period (p < 0.001). Importantly, 4 TOF tests prompted by surveys had 4/4 responses, of which 3 (75%) noted patient movement during the shift. Additionally, 5 tests had a 0/4 score of which all nurses noticed no movement and evaluated the patient’s sedation as adequate.


Conclusions: During the intervention period of our quality improvement program, we saw a significant increase in TOF tests. Nurses perceived TOF tests as useful and increased unprompted usage. Subsequent PDSA cycles will address documentation challenges and measure sustained TOF performance rates.