Epidural management in RN scope of practice?

nscalern · Mar 3, 2008

I work in combined SICU/MICU at a VA medical center in Oregon. We frequently have epidurals for post-op (AAA, lung surgery, various abdominal procedures) pain management. Our anesthesiologists usually have them all set up and infusing, but the ICU RNs do this once in awhile, usually for pts who were hypotensive during surgery. We assess dermatomes, respiratory status, and side effects hourly for the first 24 hours and may adjust the infusion within an ordered range.

An anesthesiologist or CRNA reassesses the pt after arrival to ICU and at least every daily until the catheter is removed, and only they may give boluses by epidural. I haven't encountered an anesthesia provider who would let anyone else do epidural boluses.

allnurses Guide · Mar 3, 2008

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 malpractice insurance 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.

I haven't heard of any scope of practice conflicts with RNs managing epidurals. The only thing that I know of that RNs don't seem to be allowed to do is manage continous spinal infusions, but again I don't know if it is against RN scope of practice or just the norm where I am at.

Out of curiosity, what kind of epidural infusions are you managing (anesthetic only and/or combination of narc/anesthetic infusion)?

Selke · Mar 3, 2008

...
Out of curiosity, what kind of epidural infusions are you managing (anesthetic only and/or combination of narc/anesthetic infusion)?

These are bupivacaine/fentanyl continuous epidurals.

Labor epidurals are a bit different from post op epidurals for pain relief in an ICU -- I could see the latter being within the scope of practice of an ICU RN more than managing labor epidurals in scope of practice of L&D RNs. In a way the ICU patient is more stable than a woman in labor with a baby inside with a dyamically changing physiology (maybe I'm wrong but certainly the liability is different). When I get time I need to find AWHONN's practice guidelines on this. I do know this has been a hot topic on perinatal listservs in the past and now wish I saved the information. I never anticipated being in this situation.

jmgrn65, RN · Mar 3, 2008

We have to have comptentecies for epidurals, I work on Cardiothoracic stepdown unit, we do bolus titrate gtt if needed and d/c once there is an order of course. I do know our L&D nurses can d/c them as well. But like i said we have competencies.

Jolie, BSN · Mar 3, 2008

This varies widely from state to state. Some states require a specific BON-approved course (ours was 2 days long, and completely separate from standard orientation to the LDRP unit) before RNs can manage epidurals. Even after completing the course, we were not legally authorized to manage labor epidurals, only post-C-section epidural PCA.

Sounds like you need a BON opinion on this.

Good luck!

magz53 · Mar 3, 2008

I have issues with epidurals as well. I did contact the NYS BON and received some answers that fall into a very gray area and that is taken advantage of by our hospital. An epidural in a pregnant patient falls into a completely different category and thus different stricter standards apply. NYS claims anesthesia must be "readily available". mmmmmmmm Now what does that mean ?? The person I spoke with said she would think it to mean "in house" ( as I would ). No, our hospital interprets it to mean available within 30 minutes as our anesthesia is not in house 24 hours. Some hospitals in the bigger cities in NY do not allow nurses to touch the pump......much less program or titrate it !! The hospital I work in has us out on a limb..........and they will be sawing it off behind us in an adverse event !!!!!!!!!!!!!!! Can I say again that I can't wait to retire ???????

jwk · Mar 3, 2008

Our L&D nurses attach the epidural pumps to the catheter, program and start the pumps per anesthesia orders, and call if there's a problem. It's just not that big a deal. These are low concentration fentanyl/ropivicaine infusions. If the patient ends up with a C/S, they get a different type of pump in the PACU, also programmed and hooked up by the nurses. IV PCA pumps are far more dangerous overall with a much higher rate of complications and adverse events than epidural pumps.

Jill10191130 · Mar 3, 2008

I recently started at a larger hospital where the nurses manage the epidurals as well. I had never had any type of experience with this as the CRNA's did this at the hospital where I had previously worked. At the new workplace, the nurses get the meds out, primp the tubing, and set up the pumps. The MDA comes over and presses start and the nurse connects it to the patient. Then you pretty much never see them again unless there is a major problem or a section is called. I was very uncomfortable with this at first because I had alwasy been told that nurses were to do nothing with the epidurals because it was out of our scope of practice.

JaneyW · Mar 3, 2008

Selke-

Please post your findings if you are able to speak with the CA BRN. I work in so CA and have not encountered this yet--but I work registry and who knows?? Thanks.

eandgsma · Mar 3, 2008

I work in CA and in our hospital we have anesthesia 24/7. We are responsible for getting the meds, priming the tubing, setting up the pump (all pts receive the same set rate), attaching it to the catheter, etc. We don't do any boluses. If the pt is not receiving adequate pain relief even after pressing her PCA button the max number of times an hour, we call anesthesia and he/she will give the pt a bolus.

To the OP: when you say giving a pt a bolus, do you mean drawing up the meds, detaching the tubing and giving a direct bolus into the pts catheter? If so, that sounds a bit scary to me.

- N

Selke · Mar 3, 2008

When I say give a pt a bolus, I literally mean the bolus given for additional pain relief. I have much less problem with setting up the pump part and priming the tubing, although I do feel this is in CRNA/MDs scope of practice, not mine, but I don't feel so vulnerable legally nor as likely to hurt the pt. I mean there is a standing order for the RN to give the initial bolus, which is from the infusion bag hanging. If a second bolus is needed, then the RN has "permission" to call the CRNA/MD. We are also required to check dermatome levels Q1h and chart that.

I was talking with another traveler at work and she said most of the travelers have issues with this practice; she said one of them did go to the CA BON and got some vague answer -- apparently it is a gray area. I might still call them and will post here what I find out. I can't call until later in the week, however.

I have no problem with removing epidural catheters -- easy, have done lots of those.