In Response.

Abstract

We thank Brull et al1 for their interest in our work.2 We attempted to improve resident anesthesiologists’ practice of documenting train-of-four count (TOFc) or train-of-four ratio (TOFr) before extubation by generating an individualized quality feedback tool. In addition, we gave an educational lecture about the consequences of postoperative respiratory weakness and the importance of obtaining quantitative data on the degree of neuromuscular blockade before extubation. Unfortunately, the improved documentation by anesthesiology residents was not sustained. Incorporating mandatory charting of TOFc or TOFr into the electronic anesthesia record as suggested1 would certainly seem to strengthen our intervention. In fact, we have successfully used a “nudge” technique in the past to improve anesthesia providers’ adherence to lung-protective ventilation.3 We appreciate this suggestion and encourage all to consider such a technique to improve compliance with this and other important quality measures. Katherine T. Forkin, MDDepartment of AnesthesiologyUniversity of VirginiaCharlottesville, Virginia[email protected]Edward C. Nemergut, MDDepartment of AnesthesiologyDepartment of NeurosurgeryUniversity of VirginiaCharlottesville, Virginia