Epidural Catheter Removal by L&D nurses

Jolie, BSN · Dec 11, 2007

I can only speak to NC, since that is the only state where I've worked L&D and had responsibility for epidurals.

The hospital where I worked was preparing to change over from epidural Duramorph to epidural PCA for C-section patients. In order for RNs to participate in the care of patients with epidural PCAs we were required to take a BON approved education course. (If I remember correctly, it was 2 days in length and was presented by our anesthesiologists.)

The epidurals were placed by anesthesia prior to the patient going to the OR, and during the surgery, and for about 8 hours afterward, contained a mixture of fentanyl and a -caine drug. (I don't remember which one.) When that cartridge of medication ran out, we were allowed to change the cassette to one which contained only the -caine drug. The pumps were programmed by anesthesia. We could not alter the bolus schedule, but could increase or decrease the maintainence rate with a physician order. We were also allowed to DC the catheter, which was a 2 RN procedure, requiring both signatures.

We had to demonstrate on-going competence. (I'm not sure if it was yearly or every other year.) Someone from anesthesia was always in house, either an MD or CRNA.

This applied only to C-section epidurals. While we would DC labor epidurals, we never adjusted rates or bolused patients. Anesthesia had to do that.

RNLaborNurse4U · Dec 11, 2007

We are a "show one, do one, teach one" teaching hospital when it comes to removing epidural catheters. The precepting RN shows her orientee how to pull an epidural the first time. The second time, the orientee pulls it. That's it. We teach them that if you have any resistance, make sure the patient is curled up in the epidural placement position, and try to gently remove it. If it still won't come out, call anesthesia. Once you do remove the catheter, check to make sure the blue tip is intact and chart it as so.

littlepeach · Dec 11, 2007

our labor room nurses d/c eba caths, they have to document tip intact and have to have a witness; does not require in-house anesthesia, they just have to be notified of pt. delivery. if they end up a c-section, the postpartum nurses d/c it. we used to have a crna in house at all times, but now that has changed. cutting costs and all. not necessarily safe,:angryfire but proven to be cost effective:uhoh3:

BeccaznRN, RN · Dec 11, 2007

We pull the catheters as well. No formal education, just the "show one, do one, teach one" that previous poster mentioned. We have anesthesia on call that can be in house within 15 minutes (plus a second and third call in case first call is tied up with a case).

imenid37 · Dec 11, 2007

I am told, but have not personally consulted PA BON, that in our state of PA we cannot dc epidurals. AWHONN has issued a position statement which discouraged RN's from adjusting rate, bolusing, verifying catheter placement, etc. of epidurals. It can be found on their website under position statements. I do not get paid the big $ to manage the patient's anesthesia. It is a big responsibility. Let those who are truly responsible do their job and be accountable for the management of the pt's. anethesia. AWHONNis okay w/ dc of the cath if "proper" education has been completed.

imenid37 · Dec 11, 2007

We are a "show one, do one, teach one" teaching hospital when it comes to removing epidural catheters. The precepting RN shows her orientee how to pull an epidural the first time. The second time, the orientee pulls it. That's it. We teach them that if you have any resistance, make sure the patient is curled up in the epidural placement position, and try to gently remove it. If it still won't come out, call anesthesia. Once you do remove the catheter, check to make sure the blue tip is intact and chart it as so.

Hey. I see you are in PA too. I guess it is our institution's policy. They blame lots of stuff on the state that is their own doing.

Jolie, BSN · Dec 11, 2007

Hey. I see you are in PA too. I guess it is our institution's policy. They blame lots of stuff on the state that is their own doing.

I worked in PA (as a NICU nurse), and the RNs in OB didn't DC epidurals, either. The suspicious side of me wonders if other hospitals are having their RNs take on a task for physician convenience that is not approved by the BON.

I'd much rather err on the side of caution!

crysobrn · Dec 12, 2007

We pull our own epidural caths. We're also a "show one, do one, teach one" unit.

We do not turn up or bolus epidurals on labor patients (although when I worked on the floor it was common practice for surgical patients). We do start the continuous after the doc does the test dose and initial bolus (not sure if this is okay or not, honestly have had many different answers) and we can and do turn them off or down, for pushing or after delivery.

We have an anesthesia person on call for our unit... At night and on the weekends I'm sure they're at home so within 15-30 min (which to me is a REALLY long time). During the day they are generally in cases all day but we'd probably be more likely to be able to get someone to the floor in a reasonable amt of time. The joys of working in a small hospital :uhoh3:

queenjean · Dec 12, 2007

Usually the L&D nurse who is recovering the mother pulls the epidural catheter. I've done it once (under observation) when the nurse got busy and wasn't able to do it before handing the pt off to me (pp nurse). As I don't do L&D here, I have no idea about the rest of the questions, but I think that anesthesia comes and does the boluses etc. I don't think our nurses do them.

RNLaborNurse4U · Dec 13, 2007

Here are some excerpts from the PA BON:

21.413. Interpretations regarding the administration of drugs—statement of policy.

(b) The following nursing practices fall within the scope of registered nursing practice under 21.11 and 21.14:

(5) Monitoring and administering medications by epidural catheter or other pain relief devices to be used as analgesia for pain control. Administration of medications as used in this paragraph does not include initiation of the medication.

This is from AWHONN:

"Non-anesthetist registered nurses, in communication with the obstetric and anesthesia care providers may:

-Remove the catheter, if educations criteria have been met and institutional policy and law allow. Removal of the catheter by an RN is contingent upon receipt of a specific order from a qualified anesthesia or physician provider."

The link for AWHONN is here: http://www.awhonn.org/awhonn/content.do?name=05_HealthPolicyLegislation/5H_PositionStatements.htm

The PA BON and AWHONN seem to be at odds about specifically whether a non-anesthesia RN can administer epidural medications. The PA BON appears to have it as a policy that it's ok to do so, while AWHONN clearly says no.

RAIZIE · Dec 13, 2007

Thanks everybody for your replies! This is more confusing than I thought it would be.

I will need to check with the NY BON as there seem to be different policies by state.

I do want to clarify however that the major issue that AWHONN has is about the management of epidurals when there is a fetus involved. I don't think it is even controversial for RN's to manage epidural infusions on med/surg. I believe that is done all the time.

(This is apart from the issue of removing the catheters which is what my question was about........There is no way we are managing the infusions!!)