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 OB.

The nurses on my L&D unit raised cane when we began doing more epidurals and the anesthesiologists didn't want to hang around to manage them. Our policy also vaguely states that they need to be "readily available". They're often 30 minutes away. We came up with a policy that states that we may prime the tubing with the premixed medication solution (prepared by pharmacy), but the anesthesiologist must program the pump and hook the tubing up to the patient. We do no boluses! Our pumps are PCAs so the patients control it and we rarely need an additional bolus from anesthesia. I still think a lawyer would have a hey-day if a problem arose and there was no anesthesia doc in house, but I guess that's a risk the hospitals are willing to take. After all, we have to make the docs happy! :bowingpur Even if it does mean putting patients at risk!:angryfire

Specializes in Perinatal, Education.

I just spent some time on the CA BRN website and found nothing specific. I think that if they are doing this they need to have a system in place where nurses are trained and signed off on competency. Have you seen written policy and procedure? Do they have a Standardized Nursing Procedure for this? You need to see what they have in writing and ask to be trained/certified. I would say that this is not accepted standard of care in California and the BRN talks a lot about the need for policy and Standardized Nursing Procedure and competency training in this instance.

I think that I would at least ask them to be trained. You are obviously uncomfortable and not adequately trained for this (neither am I!) and you shouldn't do it until you are comfortable. If you are in California, the unit should have a charge nurse (to keep within ratios) that could maybe do the bolus for you. I work registry and understand that not all hospitals are following the ratio law well. If they aren't, maybe you want to find another hospital anyway!

NY BON specifically states nurses may not bolus, may not re-start an epidural which has been turned off. We have differing care providers using several different combos and dosages of continuous epidurals via pump. I am not comfortable re-loading the pump in their absence.......I don't care that they have left orders. I strongly feel nurses stroke their egos when asked to step out of their scope of practice as they perceive it to be a compliment to their intelligence or some such nonsense. I feel it to be risky behavior.......they chose to be a CRNA and they should be available IN HOUSE to do their jobs !!! They should be assessing the effectiveness of the epidural that they placed and bolused etc. They should also be assessing the responses of both patients as the babe is under their care as well. Again, bottom line usually ends up to be the Almighty Dollar and the nurse is hung out to dry.

Specializes in Labor.

AWHONN has a position statement about this. It states that nurses should not bolus (either by injection or through the pump), increase or decrease the rate, restart the pump once it has be stopped, change the PCEA intervals or doses, or obtain informed consent for epidurals. Nurses can stop the pumps, remove the catheters, and replace the syringe or bag of medication with the same medication per protocols. CRNAs or MDAs should be managing the epidurals. They are responsible and have the education, not to mention the fact that they are getting paid quite a large salary---they need to do what they are paid for. Just my 2cents.

soPraNo,

I completely agree with you. Do you have the exact reference for your AWHONN citation? Where can I get a copy of this? I would like to see this myself. I will ask the clinical nurse educator tomorrow if she has a competency for RN management of the epidural. It will be interesting to get her response. Tonight my pt got an epidural and I asked the charge nurse (same one I voiced concerns about last week) if she would help me with this situation as "I don't have an epidural pump key." This is true ... she hung the bag and programmed the pump, &c. I cosigned the paperwork with her. Maybe this is passive aggressive on my part, but if I can get by like this for the time being I will do so. (I had other issues with the CRNA tonight -- like she didn't introduce herself to the pt, discuss the epidural's risks with her, then did a lousy job of putting it in. Then got an attitude with me when I said, "and I have to program the pump?")

Specializes in Labor.

Selke: Go to AWHONN.org--I don't know if you have to be a member to access the practice statements, but if you are not maybe someone you are working with can help you. AWHONN is a great resource for all OB/GYN related questions. I know some may consider the guidelines they give merely suggestions, but I feel that if the organization feels strongly enough about an issue that they write the guidelines or practice statements that we should pay heed. And I'm with you--nothing irritates me more than a CRNA or anyone, for that matter, who acts as that CRNA did with you. No excuse for the way she treated the pt, either---she needed to get informed consent--and that means informed about risks, etc. Some of our CRNAs go a bit overboard on that, but they all do it. How would she like to have a procedure done by a stranger who doesn't even deign to introduce him/herself to her? Not good.

Specializes in Perinatal, Education.
Selke: Go to AWHONN.org--I don't know if you have to be a member to access the practice statements, but if you are not maybe someone you are working with can help you. AWHONN is a great resource for all OB/GYN related questions. I know some may consider the guidelines they give merely suggestions, but I feel that if the organization feels strongly enough about an issue that they write the guidelines or practice statements that we should pay heed. And I'm with you--nothing irritates me more than a CRNA or anyone, for that matter, who acts as that CRNA did with you. No excuse for the way she treated the pt, either---she needed to get informed consent--and that means informed about risks, etc. Some of our CRNAs go a bit overboard on that, but they all do it. How would she like to have a procedure done by a stranger who doesn't even deign to introduce him/herself to her? Not good.

OK, I am an AWHONN member. I went to the site and searched for epidural practice statement and was brought to the page to buy the statement. Can you tell me step by step how to read them on-line? I would greatly appreciate it!! Thanks!

Specializes in labor and delivery.

In my unit, RNs are responsible for epidural pumps and dermatone levels. I never realized that other hospitals do this other ways. I would be very interested in seeing what the BON says.

Specializes in Obs.

Selke,

I just went to the AWHONN website, and clicked on "Position Statements" under the Go Directly to menu. Under pregnancy and labor management you will find what you're looking for...in a pdf file, no less, you'll be able to print it off. Hope this helps!

My hospital has in-house anesthesia dedicated to L&D 24/7. We can replace the epi infusions in the pump with premixed syringes made up by pharmacy that we keep as part of our narcotic count, but that's it. Bolus top ups have to be done by the anesthesiologist (we don't have CRNAs in Canada). We monitor their block and motor/sensory function. Reading these posts help me realize how lucky we are...

Just to clarify a few things. I'm an anesthesiologist. I work with great OB nurses. An L&D nurse who follows a physicians instructions to change the pump settings or administer a pump bolus is NOT managing an epidural. She is carrying out a verbal order from a physician just as a nurse on a med surg floor is doing when she adjusts a PCA or changes the rate of a medication infusion. In fact the reality is A LOT more patients die every year from IV medication errors than do from epidural infusions (a number that approaches zero).

I think most of us realize that a nurse who can't start or modify an IV pump after recieving detailed instructions on drug/dose etc. is not particularly valuable to a hospital or a patient and will quickly be out of a job. Treating labor pain is a team effort. I make every attempt to get to L&D in a timely fashion but if I am stuck doing an Appy with a slow surgeon and a laboring patient is hurting there are basically 2 choices - 1) the patient hurts or 2) the nurse provides an epidural bolus and increases the rate per my instructions.

Having worked with many types of nurses over the years I particularly value the intelligence and education of an RN. There is no question in my mind that they are appropriately trained and skilled enough to modify epidural pumps and thereby provide a valuable service to their patients.

Specializes in L&D.

http://www.awhonn.org/awhonn/binary.content.do?name=Resources/Documents/pdf/5_Epidural.pdf

This is the link to the AWHONN position of management of an epidural in laboring women

Specializes in Maternal - Child Health.
Having worked with many types of nurses over the years I particularly value the intelligence and education of an RN. There is no question in my mind that they are appropriately trained and skilled enough to modify epidural pumps and thereby provide a valuable service to their patients.

Thank you for your kind words and vote of confidence in your RN colleagues!

But please understand that you position disagrees with that of some state boards of nursing and professional organizations:

Registered nurses who are not licensed anesthesia care providers should monitor, not manage, the care of

pregnant patients receiving analgesia/anesthesia by catheter techniques....The requisite education and clinical skill acquisition necessary to provide safe management of regional analgesia/anesthesia for the pregnant woman are not included in basic education programs for entry into practice as a registered nurse; therefore such analgesia/anesthesia

management should be reserved exclusively for licensed, credentialed anesthesia care providers. Whenever

regional analgesia/anesthesia is administered, a qualified, credentialed, licensed anesthesia care provider should

be readily available as defined by institutional policy.

Only qualified, credentialed, licensed anesthesia care providers as described by the American Society of

Anesthesiologists and the American Association of Nurse Anesthetists, and/or as authorized by state law should

perform the following procedures:

• Insertion, initial injection, bolus injection, rebolus injection or initiation of a continuous infusion of

catheters for analgesia/anesthesia

• Verification of correct catheter placement

• Increasing or decreasing the rate of the continuous infusion

Following stabilization of vital signs after either initial insertion, initial injection, bolus injection, rebolus

injection, or initiation of continuous infusion by a licensed, credentialed anesthesia care provider, nonanesthetist

registered nurses, in communication with the obstetric and anesthesia care providers, may:

• Monitor the patient’s vital signs, mobility, level of consciousness, and perception of pain

• Monitor the status of the fetus

• Replace empty infusion syringes or infusion bags with new, pre-prepared solutions containing the same

medication and concentration, according to standing orders provided by the anesthesia care provider

• Stop the continuous infusion if there is a safety concern or the woman has given birth

Nonanesthetist registered nurses should not:

• Rebolus an epidural either by injecting medication into the catheter or

increasing the rate of a continuous infusion

• Increase/decrease the rate of a continuous infusion

• Re-initiate an infusion once it has been stopped

• Manipulate PCEA doses or dosage intervals

• Be responsible for obtaining informed consent for analgesia/anesthesia

procedures; however, the nurse may witness the patient signature for

informed consent prior to analgesia/anesthesia administration....

from: http://www.awhonn.org/awhonn/binary....5_Epidural.pdf

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