Labor Epidurals : Stupid Administrative Question

[Precedex]

At my institution, when a parturient gets an epidural we load up and begin an infusion with LA/opioid mix that we draw up into a 50 cc syringe. The catch is that every 3-5 hours (depending on what you set the rate at), the anesthesia team is responsible for changing the syringe. Very easy, you go check out he LA/opioid from the drug dispenser and load up another syringe and swap. The trouble begins when you have about 10 or so of these on the floor and the nurses are coming to you every 20 minutes or so asking for a new syringe. They dont like it we dont like it. The justification, I'm told, is that this allows us to justify billing for the entire time they've had the epidural because we've been keeping an eye on them (of sorts), insomuch as we change the syringe and say hows it going. We can also of course be called for boluses, hypotension, or any other reason.

Im curious what the setup is at your institutions. Does this system seem as odd to you as it does to me? Do the labor nurses change the syringes and/or give boluses through the epidural or are you called in for that? Do you have PCEA? Do you know of any billing criteria that requires the anesthesiologist to document a check-up ~q4 hours. Curious - Thanks.

P

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[Bertelman]

We place the order for the infusion. Nurses get the bag from pharmacy (not sure if it is 100 or 250 cc). Nurses load it into a pump. I use PCEA, cuts down on my calls for boluses. I'm sure we bill for the entire infusion duration. If you feel the need to check in on your patients every few hours to justify billing, go ahead and do so, but I would remove yourself from the responsibility of actually changing the syringe of meds.

 

[Planktonmd]

I am not sure why you need to be a physician to refill a syringe!
The best way to do that is to get the pharmacy to premix your solution and send it to the nurses to replace the syringe or the bag per standing orders like all the other meds they give.

 

[Monty Python]

At my institution, when a parturient gets an epidural we load up and begin an infusion with LA/opioid mix that we draw up into a 50 cc syringe. The catch is that every 3-5 hours (depending on what you set the rate at), the anesthesia team is responsible for changing the syringe. Very easy, you go check out he LA/opioid from the drug dispenser and load up another syringe and swap. The trouble begins when you have about 10 or so of these on the floor and the nurses are coming to you every 20 minutes or so asking for a new syringe. They dont like it we dont like it. The justification, I'm told, is that this allows us to justify billing for the entire time they've had the epidural because we've been keeping an eye on them (of sorts), insomuch as we change the syringe and say hows it going. We can also of course be called for boluses, hypotension, or any other reason.

Im curious what the setup is at your institutions. Does this system seem as odd to you as it does to me? Do the labor nurses change the syringes and/or give boluses through the epidural or are you called in for that? Do you have PCEA? Do you know of any billing criteria that requires the anesthesiologist to document a check-up ~q4 hours. Curious - Thanks.

P

The wording in some states' Nurse Practice Act forbids non-CRNA RNs from having anything to do with local anesthetic. My RNs cannot touch the labor epidural pump, bag, or line, except to completely turn it off per obstetrician's order. They absolutely cannot change out an empty naropin bottle.

Ask your hospital Director of Nursing to investigate your state's Nurse Practice Act, or call the Board of Nursing yourself for a direct answer. Could be that their hands are tied due to technical wording in their Act. If their Act doesn't prohibit RN involvement in your scenario, then you're free to find a happy medium which keeps everyone satisfied.

Why not switch from the syringes to 100 cc bottles of naropin? Lasts a lot longer.

 

[Jeff05]

we have PCEA. 100mL bags. usually one bag is enough.
run at 10mL/hr (bupiv 0.625/fent 2), bolus 5mL with lockout 20min. some will augment the bag with 20mL of 0.25%bupiv. making it about 0.9% and 120mL.

 

[2ndyear]

What gets done for post op pain epidurals, same thing? That would really really suck...

 

[PainRN]

This is actually a topic I can weigh in on. The wording in our state's Nurse Practice Act is pretty clear that only a CRNA or higher trained can start or modify a local anesthetic infusion. This is true for neuroaxial or peripheral nerve blocks with infusions. This is a restriction that the Board of Medicine encouraged the Board of Nursing to place in the Nurse Practice Act and it was done. So despite the fact that I can initiate and modifify some of the most dangerous IV medications under protocol or order (including chemo) I cannot initiate an extremely dilute analgesic concentration of local anesthetic for a continuous peripheral nerve block based on an order. Kinda dumb if you ask me. I'm just wondering what evidence base the Board of Medicine had for this one?? So don't kill the messenger when the nurses are paging you to change the bags/syringes on all of the continuous peripheral nerve blocks, post op pain epidurals, or labor epidurals that you placed earlier that day, it wasn't our idea.

 

[aredoubleyou]

On the OB floor we typically have premixed bags, now and then have to make it from scratch. Other floors they come from pharmacy. On every other floor than the OB ward, the nurses connect the tubing, set the pump up, and attach it to the epidural. Interestingly, the OB nurses who deal with epidurals EVERY day, are unable to set the tubing up, change a bag, program a rate, or hook the tubing to the epidural. Therefore, the reluctance to do any of these things are obviously not dictated by a state nursing board or hospital policy...it is pure laziness and/or incompetence. Good thing I'm not bitter

 

[Farmer Jane]

I've worked as an OB nurse in two Wisconsin hospitals, and in both cases we set up the pump and changed the medication bag/vial.

Our state practice act forbids us from making decisions about epidural analgesia. This came up in a rural hospital with only CRNAs, because they wanted us to increase the rate or give boluses when the patient was having pain, without having a PCEA and without even consulting them via phone (this was particularly for night shift, as they were home and didn't want to be woken up). When I've discussed this with anesthesiologists, they were horrified.

 

[coprolalia]

I've worked as an OB nurse in two Wisconsin hospitals, and in both cases we set up the pump and changed the medication bag/vial.

Our state practice act forbids us from making decisions about epidural analgesia. This came up in a rural hospital with only CRNAs, because they wanted us to increase the rate or give boluses when the patient was having pain, without having a PCEA and without even consulting them via phone (this was particularly for night shift, as they were home and didn't want to be woken up). When I've discussed this with anesthesiologists, they were horrified.

Wait a minute. They didn't want to come and assess the patient?



Not horrified. But, not surprised either.

-copro

 

[Farmer Jane]

Nope, they didn't even want to be called.