Labor Epidurals; What is your availability after placement?

[pastafan]

There has been some discussion locally about whether it is within the standard of care to place a labor epidural and then:

1. Leave the hospital with ~20 minute response time to return if needed.
2. Perform other cases when there will be no provider available to tend to patient with epidural if needed.
3. OB at home ~15 minutes away.

This is a small facility with an ER doc available 24/7 but limited OR availability and at times only one anesthesia provider. What is your practice and do you think that having a labor epidural service within these parameters would meet the currently acceptable standard of care?

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[92122]

Given the ever-litigious nature of the business, I would personally be very reluctant to get involved with a case in the general OR while covering OB for (stat) c-sections. The issue of epidural coverage is less concerning to me.

You probably could get away with being in a 20-minute call radius for epidurals.

 

[pgg]

2. Perform other cases when there will be no provider available to tend to patient with epidural if needed.

So if there's no anesthesia provider available to tend to the patient, who does that stat c-section (epidural in situ or no) when the OB calls it? Either someone's available or someone isn't, and if you're doing a case, then someone isn't.


Everywhere I've worked has required anesthesia to be promptly available any time a labor epidural is running.

I know some people don't view labor epidurals as "anesthetics" but I do and I can't really imagine starting one and then being totally unavailable to manage it. 15 min away at home, fine.

 

[drccw]

I feel that you need to be able to respond in tune with the OB...

If the OBs at home while a labor epidural is running, then it's ok for you to be at home when a labor epidural is running...

conversely, when an OB is ready to cut that STAT C-section, then you need to be ready to cut that STAT C-section.....

So, I would definitely not cover a main OR case if I was covering OB... unless your OB was ready to do a C-section under local...

drccw

 

[olaf]

of the 7 hospitals ive worked at with ob one had a policy that you could leave with an epidural running as long as you could be there in 30 min. personally, if i had an epidural running at that facility i went to the call room and didnt leave. i am not comfortable billing per hour if i am not physcially in house. if we had a crna/aa in house then i would be comfortable leaving.

 

[jetproppilot]

There has been some discussion locally about whether it is within the standard of care to place a labor epidural and then:

1. Leave the hospital with ~20 minute response time to return if needed.
2. Perform other cases when there will be no provider available to tend to patient with epidural if needed.
3. OB at home ~15 minutes away.

This is a small facility with an ER doc available 24/7 but limited OR availability and at times only one anesthesia provider. What is your practice and do you think that having a labor epidural service within these parameters would meet the currently acceptable standard of care?

Dude, whatever you do, please

DO NOT

start a case and leave an epidural unattended if no one else is available. As luck will have it, you'll do it and they'll call a C section. That's bad medicine man. This is an issue that needs to be addressed at the small hospital you speak of... you, they, everyone in that situation is asking for trouble. Trust me man.

You always have to have someone available for problems/C section/etc.

I was never comfortable leaving the hospital if I had an epidural running. That being said, I probably could've gone home after the obligatory 2AM epidural since I've always lived within 15 minutes of any hospital I've worked at.

 

[Yangkower]

I've had this same question. I've heard of anesthesiologist in small community hospitals taking home call but have to be within 20 minutes of the hospital for stat cases or to tend to a running epidural. My question is what do they do if you are stuck in the OR? I guess they must have a second call person that has to within 20 minutes?

At a small community hospital it just seems a little unreasonable to have an anesthesiologist in house for a STAT C/S when the OB is home in bed.

 

[B-Bone]

we are always available for labor epidurals (placement and followup). I supervise 100% when on call, so I can always run upstairs even if I have a case going in the main OR (based on the CMS exception).

My question for you guys who won't put on a case if a labor epidural is running: what do you do when someone without a labor epidural (or someone just in off the street, for that matter) needs a stat C-section while you're doing a call case? Or what if you just started a lap explore or ruptured AAA in the middle of the night and you get called for a labor epidural? I have a backup anesthesiologist at home (we are in-house 24/7), but could always go start a stat c-section while that guy's on his way in (per the CMS emergency of short duration exception). Just curious as to how MD only groups handle this kind of thing on call.

 

[Idiopathic]

Dude, whatever you do, please

DO NOT

start a case and leave an epidural unattended if no one else is available. As luck will have it, you'll do it and they'll call a C section. That's bad medicine man. This is an issue that needs to be addressed at the small hospital you speak of... you, they, everyone in that situation is asking for trouble. Trust me man.

You always have to have someone available for problems/C section/etc.

I was never comfortable leaving the hospital if I had an epidural running. That being said, I probably could've gone home after the obligatory 2AM epidural since I've always lived within 15 minutes of any hospital I've worked at.

i rarely agree with you 100%. this is one of those times.

 

[pastafan]

Fortunately, I am not in the situation described as I do not offer an epidural service for the reasons enumerated. There are times where there is only one anesthesia provider in town. If a case is running and a stat C section was needed the OB would be in a difficult situation doing the case under local. The hospital pays for 1 room 24/7 coverage and that is the service provided. The hospital wants to have labor epidurals so they are attempting to justify understaffing. I don't agree and I want to gather some data about current practice.

 

[fakin' the funk]

You always have to have someone available for problems/C section/etc.

This is IVORY TOWER DOGMA

...just kidding. As with Idiopathic, I agree with you on this, and I'm a bit surprised to do so. Perhaps you could elaborate a bit on your rationale.

 

[jetproppilot]

This is IVORY TOWER DOGMA

...just kidding. As with Idiopathic, I agree with you on this, and I'm a bit surprised to do so. Perhaps you could elaborate a bit on your rationale.

Fake,

I'm all about

1)ELIMINATING NEEDLESS ROADBLOCKS

2)REMOVING POWER FROM THE NURSE STUPIDVISORS AND GIVING IT BACK TO THE DOCTORS by actually..NO...REALLY...giving the decision making back to the doctors.

3)Recruiting nurses that believe in The Way To Do Things To Make It Easy (and if you recruit them and they don't see The Way, they're quickly gone. Very simple.)

That's my M.O., dude. And that's what I LIVE. I make my living at a physician owned boutique hospital. I helped set it up. We made our own PATHWAYS that have virtually no OBSTRUCTION.

Fake, do you work at a place that can have a patient arrive and you can

HAVE THEM READY FOR SURGERY IN LESS THAN THIRTY MINUTES?

I do.

Because I set it up that way.

And the reason I said "thirty minutes" instead of " ten minutes" is because we do alotta regional.

If a pt arrives and their anesthetic plan is a "general", our nurses will have them ready to go to the back in ten minutes. Clothes off, (proprietary warming) gown on, IV started, questions asked, in...Ten. Minutes. Add an epidural or an ultrasound guided interscalene/popliteal/femoral to that mix and we can have them ready in less than thirty..probably closer to twenty...

I'll push the envelope where I know ADMINISTRATIVE S H IT IS TO BLAME AND INCOMPETENT NURSES/LAZY NURSES/ADMINISTRATIVE LAYERS/

ARE TO BLAME by eliminating those parts of the equation...we have none of the above listed problems at our hospital...we've been in existence for two years now with an outstanding reputation..

BUT I AIN'T STUPID.

LEAVING AN EPIDURAL UNMANNED IS STUPID.

Always have to have a body available to do a C section.

Babies and moms DO WEIRD THINGS.

Leaving an epidural unmanned is bad medicine.

I don't practice bad medicine.

Enough elaboration for ya, FAKE?

 

[Idiopathic]

couldnt have said it better, but thats my general take as well.

 

[Gern Blansten]

Jet, I give you grief sometimes, but I agree with you on many things. I think, in real life, you would be a good guy to hang out with.

 

[jetproppilot]

Jet, I give you grief sometimes, but I agree with you on many things. I think, in real life, you would be a good guy to hang out with.

I CAN TAKE THE HEAT!!!

Cheers, Dude.
Let's grab a beer sometime.