Epidural management in RN scope of practice?

Specialties Ob/Gyn

Published

I am working as a traveler in a SFBA CA hospital in L&D; after I got here I learned that the RNs are responsible for managing epidurals: priming the tubing for the infusion bag, loading and setting the pump, and connecting it to the patient. They do require the RN to follow the written order of the MD/CRNA for drip rates, and another RN must be present to double check and sign off on everything, but .... The RN is also responsible for hourly assessment of dermatome levels, and for giving a bolus if the patient wants it. This bolus dose is in the orders. The anesthetist does not see the patient again unless the RN calls them ...

I have worked in many hospitals from coast to coast and this is a new one for me. I know this is a hot legal topic everyplace else. I am very concerned that I am practicing outside my scope of practice. I fear my won't cover me if god forbid there is a problem with the patient and the lawyer discovers the epidural is RN managed .... I couldn't find this situation addressed on the CA BON website and am thinking of calling them. To say that I am uncomfortable about this is an understatement. I am not a CRNA by training, licensure, or pay. I feel like I am doing their job. I expressed misgivings to the charge nurse and she indicated I should talk to the manager about my patient care assignment. I want to quit before they decide to nullify my contract over this issue.

Have any of you encountered this before? Any comments, suggestions, words of advice? Thanks.

Specializes in Perinatal, Education.

Thank you Jolie! That is exactly true. I would also like to add a thanks for the confidence to JP MD, but please know that this is not under our control. As Jolie has presented, this is mandated practice through our state law and boards. A lot of these restrictions are physician driven. They don't want us taking over their practice. If this is to change, it needs to come from the physician side and extra training of RNs needs to be in place. I am tired of being the object of some MDs misplaced anger that I won't adjust an epidural for them, and I agree that the only other option is to watch the patient be in pain which is not a good option either. JP MD, bring it up with your specialty organization, but don't expect an RN to risk their license over this as simple as it may seem to you.

Thank you Jolie! That is exactly true. I would also like to add a thanks for the confidence to JP MD, but please know that this is not under our control. As Jolie has presented, this is mandated practice through our state law and boards. A lot of these restrictions are physician driven. They don't want us taking over their practice. If this is to change, it needs to come from the physician side and extra training of RNs needs to be in place. I am tired of being the object of some MDs misplaced anger that I won't adjust an epidural for them, and I agree that the only other option is to watch the patient be in pain which is not a good option either. JP MD, bring it up with your specialty organization, but don't expect an RN to risk their license over this as simple as it may seem to you.

Strange - CRNA's want to expand their scope of practice into the practice of medicine and most RN's shout hooray and tell them to go for it - but ask an L&D RN to simply adjust a pump and they fall back on the nursing board? Hmmmmm

At least Jolie points out that this is only from SOME state BON's - it's not nationwide, and in fact, it's common practice at many hospitals for the RN's to adjust the pumps.

Just curious - is delivering a baby within an RN's scope of practice? No, but I'm willing to bet a lot of you do it fairly frequently.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Rarely (honestly it's been more than 2 years)--- do I deliver babies and ONLY under circumstances that require it(mainly a woman "precip'ing)" . It's not taken cavalierly by RNs and we are required to notify the MD , who must come in to evaluate the patient ; we RNs are further required to write up an incident report afterward. And our policies cover these incidences and exactly what an RN role is under such circumstances. We follow them to the letter, as you may guess.

SO it's not as simple as "doing it fairly frequently" and we DO NOT take the place of the MD in the delivery of babies( UNLESS CNM) SO goes with CRNA's; they (and CNMs) are advanced practitioners, unlike RNs, with a very different scope of practice that is much, much more broad.

So nope, I won't risk my *RN LICENSE* or patient safety, to do the job of an advanced practice scope, like that of an MD or CRNA willingly or cavalierly.

But jwk, you already KNOW all of this! It's not a matter we can argue here. Not unless MDs /CRNA's effect the changes .

Specializes in Perinatal, Education.

It's not a matter of wanting to expand my practice. I am stuck with the scope of practice the State of California gives me. This is dictated, to some extent, by what the MDs will give up to us. If they want to give us the right to change pump settings within our scope and train us in this, I will gladly do it. As of now, I agree with Smilin Blue Eyes and practice within my scope.

Comparing this with delivering babies is apples and oranges. Babies will pretty much come on their own eventually whether I like it or not. Adjusting an epidural pump can only occur after it has been inserted by an advanced practitioner.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Anyone tell me where RNs are adjusting epidural rates or bolus'ing patients? Any state? I have yet to run into that with anyone I have worked with from across many states.

Specializes in High Risk OB.

I work in CT, we do about 4000 deliveries/year and have a high epidural rate. We, as nurses, do not prime the tubing, set the pump or give the initial bolus. The pump is programmed by the CRNA or the anesthesiologist, they are PCEA pumps, therefore, the bolus is programmed in. If additional boluses are needed we call anesthesia to come and assess the patient. I think an RN is practicing out of her scope if she/he is adjusting the epidural rate or administering boluses manually through the catheter.

Specializes in High Risk OB.

JWK, Obviously not an OB nurse....proficient nurses have few if ANY unattended deliveries!

Anyone tell me where RNs are adjusting epidural rates or bolus'ing patients? Any state? I have yet to run into that with anyone I have worked with from across many states.

Georgia - happens all the time at many of the hospitals I've worked at or are familiar with their practices.

I work in CT, we do about 4000 deliveries/year and have a high epidural rate. We, as nurses, do not prime the tubing, set the pump or give the initial bolus. The pump is programmed by the CRNA or the anesthesiologist, they are PCEA pumps, therefore, the bolus is programmed in. If additional boluses are needed we call anesthesia to come and assess the patient. I think an RN is practicing out of her scope if she/he is adjusting the epidural rate or administering boluses manually through the catheter.

It depends on the state. And we're talking about several different things.

1 - Programming or adjusting the rate on a pump pursuant to written order/protocols - assuming it's within scope of practice of course ;) why would that be a problem? It's no different than programming any other medication pump.

2 - Administering boluses via the pump (as in PCEA) - can be done by the patient pushing the little button, or by the nurse at the bedside. The epidural pumps have pressure limits built in, so if there's an injection issue, the pump stops and alarms. Assuming it's within the scope of practice of course, the RN can also, pursuant to written order/protocols, give an additional bolus. These are usually very low concentration Ropivicaine/bupivicaine/fentanyl combinations. Don't any of your hospitals use PCEA in other areas via pump? All those pumps have a button the patient can push to deliver a bolus. Logically (ignoring the scope arguments) does it make sense that the patient can do it themselves but a trained RN cannot?

3 - Administering boluses MANUALLY should indeed be reserved for the anesthesia provider. When we give a bolus, compared to the pump, it is a much higher concentration of drug in a shorter period of time.

Specializes in Perinatal, Education.

The issue is not the pump--it is the route. In California, I am not allowed, as an RN, to administer medications via the epidural or intrathecal route--pump or not. That is reserved for MDs and CRNAs. I am in agreement that it is silly that there are epidurals with PCA function. Go figure--it was not my call. Like I said before, it would be fine with me if they changed the rules and let me do it--with some additional education regarding administering meds by that route. Until then--no go.

Specializes in Maternal - Child Health.

I can only speak to the standards of practice in NC at the time I worked in L&D there, during the 1990's.

At that time, care of a patient with an epidural catheter was a "Category II" procedure, requiring completion of a state BON approved education course. Ours was 2 days long and involved learning the care of epidural PCEA, which was used for post-op C-sections. For those patients, we were allowed to change the medication cartridge, provided it was the same as the initial medication cartridge initiated by the MD/CRNA, raise or lower the rate on the pump with a written order (no verbals were allowed), discontinue an infusion and remove a catheter with a written order and verification of a 2nd practitioner of the intactness of the catheter.

With laboring patients, we were allowed only to stop an infusion. No boluses, no rate changes, no cartridge changes, no discontinuing of catheters, nothing other than turning the pump off.

Sorry if this is bothersome to MD's and CRNA's. They are free to lobby for changes in professional standards of practice and nurse practice acts. Until then, eidural management is their responsibility.

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