AWHONN position statement says that RN's can remove epidural catheters "if educational criteria have been met". I would like to know:
1- Do L&D nurses at your facility remove epidural catheters?
2- If so, what were the "educational criteria"? Who developed/conducted the educational program? How is competency validated?
3- How does your facility define "readily available" anesthesia care when regional analgesia/anesthesia is administered? Is anesthesia available in house any time any epidural is in use (even if they are not in house 24/7) to back nursing up in case of any epidural issues?
i work for 2 hospitals in new york state. the first hospital (on a post partum unit) i am allowed to bolus epidural catheters with an order, give fentanyl or duramorph (standing anesthesia orders) and remove epidural catheters. no witness is required, just need to document that the blue tip is intact. on the labor & delivery unit at the other hospital where i work, rn's are only allowed to pull the epidural catheter and shut off the epidural at pushing. my co-workers are astonished that i am able to do what i do with epidurals at my other job. they state i am working outside my scope of practice.
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.
Ok, yesterday an epidural was put in for a labor patient. The epidural was in for 7 hours. The epidural was pulled out on accident by the patient. It was replaced by the CRNA. Then after 9 hours total, the patient had to have a C section. The patient is on medicade. So the "big bucks" are not so big. The total reimbursement for this case will be about $325.00. Medicade does not pay by the hour and will not pay for a labor epidural and a csection. So the anesthesia payment per hour is $32.00 per hour if you break it down. That may sound like big bucks, but it isn't given the risk the anesthesia providers are taking. The family can file suit against the anesthesia provider for the next 18 years over that big buck epidural catheter.
Ok, yesterday an epidural was put in for a labor patient. The epidural was in for 7 hours. The epidural was pulled out on accident by the patient. It was replaced by the CRNA. Then after 9 hours total, the patient had to have a C section. The patient is on medicade. So the "big bucks" are not so big. The total reimbursement for this case will be about $325.00. Medicade does not pay by the hour and will not pay for a labor epidural and a csection. So the anesthesia payment per hour is $32.00 per hour if you break it down. That may sound like big bucks, but it isn't given the risk the anesthesia providers are taking. The family can file suit against the anesthesia provider for the next 18 years over that big buck epidural catheter.
I believe you are making the point that reimbursement for this patient's epidural will be woefully inadequate. But that does not justify passing the responsibility of its management to the bedside RN instead of the anesthesia care team.
I believe you are making the point that reimbursement for this patient's epidural will be woefully inadequate. But that does not justify passing the responsibility of its management to the bedside RN instead of the anesthesia care team.
Do nurses pull out surgical drains? Do nurses pull out IVs put in by other people? Do nurses pull out arterial lines? Do nurses pull out central lines? Do nurses pull out internal OB monitors? Do nurses pull out foley catheters? Are these task being passed off to bedside nurses?
do nurses pull out surgical drains? sometimes, depending on the situation.
do nurses pull out ivs put in by other people? yes, iv management is a well-established aspect of nursing care.
do nurses pull out arterial lines? sometimes, again depending on the situation.
do nurses pull out central lines? not anywhere i've worked.
do nurses pull out internal ob monitors? not in my experience. they are removed by the practitioner managing the delivery.
do nurses pull out foley catheters? yes, again foley catheter management is a well-established aspect of nursing care.
for the most part, you are comparing apples and oranges. most of these functions are well-established aspects of nursing care, not tasks that have been reserved (by statute) for mid-level or physician providers. in some states, dosing and removal of an epidural catheter is completely outside the scope of nursing practice, per the nurse practice act. in other states, it is allowed, but only upon the completion of a bon approved education course and proof of proficiency. i am not familiar with any state that freely allows rns to manage epidurals without restrictions or additional training.
i understand that anesthesia providers are at times inadequately compensated for their practice, but that is not a justification for pressuring nurses to take on duties that may not be legal in their state of practice, or for which they have not been adequately prepared. just as anesthesia care providers are acutely aware of liability issues in their practice, so are ob nurses. if a nationally-recognized professional organization (awhonn) recommends against nurses managing ob epidurals, then ob nurses had better take notice. i suspect that if a malpractice issue arose involving an epidural that you placed, but was dosed or removed by an rn, you would not be looking out for the rn's interests.
take on the 3rd party payors for additional reinbursement. check bon regulations in your state and offer to provide an epidural course for the nursing staff, if allowed in your state. but don't deny the patient your expertise or expect an rn to take on duties that she cannot legally perform or hasn't been properly trained because of annoyance over low reimbursement or middle of the night phone calls.
do nurses pull out surgical drains? sometimes, depending on the situation.
do nurses pull out ivs put in by other people? yes, iv management is a well-established aspect of nursing care.
do nurses pull out arterial lines? sometimes, again depending on the situation.
do nurses pull out central lines? not anywhere i've worked.
do nurses pull out internal ob monitors? not in my experience. they are removed by the practitioner managing the delivery.
do nurses pull out foley catheters? yes, again foley catheter management is a well-established aspect of nursing care.
for the most part, you are comparing apples and oranges. most of these functions are well-established aspects of nursing care, not tasks that have been reserved (by statute) for mid-level or physician providers. in some states, dosing and removal of an epidural catheter is completely outside the scope of nursing practice, per the nurse practice act. in other states, it is allowed, but only upon the completion of a bon approved education course and proof of proficiency. i am not familiar with any state that freely allows rns to manage epidurals without restrictions or additional training.
i understand that anesthesia providers are at times inadequately compensated for their practice, but that is not a justification for pressuring nurses to take on duties that may not be legal in their state of practice, or for which they have not been adequately prepared. just as anesthesia care providers are acutely aware of liability issues in their practice, so are ob nurses. if a nationally-recognized professional organization (awhonn) recommends against nurses managing ob epidurals, then ob nurses had better take notice. i suspect that if a malpractice issue arose involving an epidural that you placed, but was dosed or removed by an rn, you would not be looking out for the rn's interests.
take on the 3rd party payors for additional reinbursement. check bon regulations in your state and offer to provide an epidural course for the nursing staff, if allowed in your state. but don't deny the patient your expertise or expect an rn to take on duties that she cannot legally perform or hasn't been properly trained because of annoyance over low reimbursement or middle of the night phone calls.
i have worked in many icus and in all of them i pulled central lines. the icu is a unit that gives its nurses extra responsiblity, and so is a l&d unit. i am tired of nurses trying to get out of work. i want you to find a single malpractice case against an rn who pulled an epidural catheter. i will save you the effort, there are none in the anesthesia closed claims reports. our l&d nurses pull all the epidural catheters and have done so for years. not one single problem. our l&d nurses remove the internal monitors before all csections,again no problems. our icu nurses pull all the central lines and arterial lines placed, again no problems. i guess our nurses are just taking on extra work outside of their scope of practice. i guess we have been lucky so far. remember at on time there were no physical therapist, phlebotomist, xray techs, or respiratory therapist. all those jobs were originally nursing responsiblities. nurses gave all that away because they didn't want the extra work, but in doing so they became care givers who mainly chart while other care givers do the care giving! think how much nurses could get paid if they had retained all they originally had the ability to do. but no. we will just continue to complain, chart, and point to what we can't legally do, rather than attempting to grow as other health care professions do.
I think perhaps there is a little animosity between nurse and nurse anesthetist here. That is unfortunate since we are all here to provide exceptional care to our patients. Here in Louisiana our BON practice act specifically addresses the issue of epidural pain management. It specifies acts that are covered here in this blog. Article 3705 of the LA Professional and Occupational Standards Rules and Regulations for Professional Nurses states that while as Jolie stated above RNs are not allowed to place epidural catheters, initiate infusions, or titrate infusions of loca anesthetics through the use of epidural catheters. However, if a registered nurse has successfully completed a course of instruction (basic nursing preparation)than he or she can be placed in charge of the following nursing care responsibilities:
a. observation
b. procedures
c. catheter maintenance
d. proper calibration and operation of infusion pump; and
e. removal of the epidural catheter.
I firmly believe that we as professional nurses should embrace further education and responsibility. If we do not stand up and accept the challenges of our fellow medical professionals, we will soon find ourselves surrounded by "trained technical patient care providers". As RNs we will be solely responsible for passing out pills. That means that there will be one RN for 20 patients. Then there will be 4 nursing technicians, for bedside care, dressing changes, and telemetry monitoring. A separate IV therapy team for IV starts and discontinuation. That sort of thing. Eventually there will be a charting system that is voice activated and medication records that record a medicine that is removed and those records will be printed at the end of the shift. There will be no more "I have to chart", so passing pills will be the only responsibility. We will eventually become nothing more and these things in themselves will drive down the pay and the respect that all professional nurses have worked so hard for over the years.
So it is with respect and admiration for all bedside nurses, ICU nurses, nurse managers, all specialized nurses that I encourage all in our profession to push the limit. Ask for more responsibility (of course within the constraints of your respective practice act), feed your brain with continuing education. Be the one in your hospital that everyone admires and respects because of your unending search for improvement.
Elvish, BSN, DNP, RN, NP
4 Articles; 5,259 Posts
Raizie, I think checking with the NY BON is a very good idea.