OB epidurals

[militarymd]

In my practice, doing laboring epidurals is a pain. It is something that someone runs up to OB to do while usually attending 3 or 4 rooms with fast surgeons.

This means that there are constantly patients to pre-op, cases to start, issues to address to, and patients to sign out in the PACU.

So it is important for us to time things...meaning if you run off to do an epidural, you need to know how long you will be gone, and arrange for a partner to take care of your crap.

So....I 've got it down to between 15 and 20 minutes from walking into the room and leaving the room with the patient comfortable and on a PCEA with all documentation done....

My record is a couple of seconds shy of 13 minutes, and the longest was around 30 minutes.....but 95% of the time it is between 15 and 20 minutes.

What are you all's times?

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[Laryngospasm]

Usually 5-10 minutes for epidural with another 5 minutes for the paperwork, When Im in a hurry I can do 4 epidurals in an hour, my record is 8 epidurals in two hours.

 

[deleted126335]

.

 

[militarymd]

Usually 5-10 minutes for epidural with another 5 minutes for the paperwork, When Im in a hurry I can do 4 epidurals in an hour, my record is 8 epidurals in two hours.

Damn, That's pretty impressive!!!

You walk into the room, do the preop & consent, examine the patient, do the epidural, set up the pump, do the paper work, and walk out ALL in 5 minutes????


I' ve tried EVERY variation, but I'm stuck at 10 + minutes for my routine.

 

[militarymd]

Similar practice to yours. Supervising 3-4 rooms and having to place an epidural. Typically 20-25 minutes in and out. our paperwork s**** and we have to set up the PCEA pumps ourselves.

Our labor nurses "are not allowed" to set up ANY epidural related stuff.

 

[VentdependenT]

15 minutes usually with charting and setting up the the pump and flushing the tubing. I've hit 8-10 minutes a few times.

Count on 20-30 for the moderately bad scoliosis folks. I have had to do low thoracic's on these folks every once in a while because the lumbar curve can lead to unpredictable LOR. I take my time.

 

[Gas]

I'm new in my group - they have told me to chart that we were in the room for at least 30 minutes for insurance purposes. I get in the room, talk/consent to the patient while they are getting positioned by the nurse, perform the epidural, and then chart as I am dosing it/setting up infusion with the patient now supine again, all in about 15-20 minutes. I do sit around in the room for another 10 minutes if I can, but not always possible. Since I am a new attending, I probably write a lot more detail than others, including a full procedure note.

 

[coprolalia]

Honestly, 20-25 minutes after the call to put it in.

-copro

 

[Laryngospasm]

Damn, That's pretty impressive!!!

You walk into the room, do the preop & consent, examine the patient, do the epidural, set up the pump, do the paper work, and walk out ALL in 5 minutes????


I' ve tried EVERY variation, but I'm stuck at 10 + minutes for my routine.

We have a preop clinic that almost all patients come through for an interview, those that dont it can take a while longer, the nurses get the cart in the room with gloves and drug and kit and have the patient sitting for me when I get there. The pump solution is standardized and provided by the pharmacy, the nurses place it in the pump and flush the tubing. So, all in all my times are probably not that impressive, we have helpful nurses.

 

[militarymd]

We have a preop clinic that almost all patients come through for an interview, those that dont it can take a while longer, the nurses get the cart in the room with gloves and drug and kit and have the patient sitting for me when I get there. The pump solution is standardized and provided by the pharmacy, the nurses place it in the pump and flush the tubing. So, all in all my times are probably not that impressive, we have helpful nurses.

Whew...I feel better now.

Our nurses don't do d i c k.

I have to get all my gear...set everything up...and finish with priming and programiming the pump...etc.etc...

I even have to turn the fu ckin lights on..and our rooms have like 4 friggin light switches located BEHIND various pieces of equipment placed strategically to get in my way......I hate getting called to do an epidural , and walk into a dark room.

 

[DuckhuntingDoc]

I wonder how many lawsuits against anesthesiologist stem from "production pressure". It takes as long as it takes to do a good H/P ,consent, careful positioning, meticulous sterile technique, careful advancement, conformation of safe position, dressing, mixing solution, setting up pump, assuring pt satisfaction, and succinct documentation. If I'm holding up a room because It takes a few extra minutes to do it right, so be it. If I kill some 20 yo girl because I'm trying to hurry was it worth it. Think the surgeon appreciates your efforts. There are to many jobs out there to put up with that BS. It's a system problem, don't screw up your future to save a few minutes.

 

[militarymd]

I wonder how many lawsuits against anesthesiologist stem from "production pressure". It takes as long as it takes to do a good H/P ,consent, careful positioning, meticulous sterile technique, careful advancement, conformation of safe position, dressing, mixing solution, setting up pump, assuring pt satisfaction, and succinct documentation. If I'm holding up a room because It takes a few extra minutes to do it right, so be it. If I kill some 20 yo girl because I'm trying to hurry was it worth it. Think the surgeon appreciates your efforts. There are to many jobs out there to put up with that BS. It's a system problem, don't screw up your future to save a few minutes.

thanks for your advice, but we decided to fire the guys who thought that way.

 

[coprolalia]

Our nurses don't do d i c k.

I have to get all my gear...set everything up...and finish with priming and programiming the pump...etc.etc...

Ain't that the truth.

-copro

 

[urge]

I don't do many OB epidurals now. Probably less than 20 a year and are all supervised. From my resident years I could tell you that an epidural "well done" takes ~ 35-40 min. That's wheeling the cart in, looking at the H+P, checking labs in computer, talking to the pt~ 5 min, having to wait for OB to check pt again, waiting for pt to take a piss~10 min, positioning, procedure~5 min, charting ~5 min, preparing drip and setting up pump~5 min, treating hypotension~5min.

Having the pt positioned as you walk in, doing the procedure without a real H+P or consent, and leaving immediately does not take too long~10-15 min.

 

[rsgillmd]

In my practice, doing laboring epidurals is a pain. It is something that someone runs up to OB to do while usually attending 3 or 4 rooms with fast surgeons.

This means that there are constantly patients to pre-op, cases to start, issues to address to, and patients to sign out in the PACU.

So it is important for us to time things...meaning if you run off to do an epidural, you need to know how long you will be gone, and arrange for a partner to take care of your crap.

So....I 've got it down to between 15 and 20 minutes from walking into the room and leaving the room with the patient comfortable and on a PCEA with all documentation done....

My record is a couple of seconds shy of 13 minutes, and the longest was around 30 minutes.....but 95% of the time it is between 15 and 20 minutes.

What are you all's times?

For the whole process, I average 15-20 minutes also. If I have a cooperative patient and decent spaces, the time from skin prep to the time I finish putting on the tape is 5 minutes. I prepare my equipment after skin prep.

Interviewing the patient, getting the patient positioned, setting up and starting an infusion, and doing the paperwork take up the rest of the time. I do CSE's on >95% of my patients (combo of institutional practice and the fact that we are frequently called when the patient is in severe pain) so at least I see the effects quickly. Fortunately I see hypotension rarely -- probably lucky I guess.

 

[DuckhuntingDoc]

thanks for your advice, but we decided to fire the guys who thought that way.

I'm not surprised, most guys don't have the stones to tell the surgeons to shut their pie holes...

 

[militarymd]

I'm not surprised, most guys don't have the stones to tell the surgeons to shut their pie holes...

I don't have any stones....but I do have $$$

 

[Fastrach]

On a somewhat related note, what's the deepest loss of resistance people have personally noted?

I've hit 10 cm, but I've heard as high as 14 cm.

 

[lobelsteve]

On a somewhat related note, what's the deepest loss of resistance people have personally noted?

I've hit 10 cm, but I've heard as high as 14 cm.

I've used every bit of a 6" Tuohy before. 400lb patient. Of course I have the luxury of fluoro, and I scout laterally in the tubbies to get a feel for spine depth.

 

[lobelsteve]

MODERATOR:

This thread needs to get deleted: legal risk is way too high. This thread can be used as evidence when a doc races in to do an epidural and it does not go perfectly, or the patient has complications. The lawyers will pull this crap off the internet and say the doc was racing and not providing quality care.
Please lock and delete this......

 

[zippy2u]

Problem is that you're gettin' tooled by the bean counters. It's analagous to the bean counters wanting you to run a pain clinic at the hospital. Ya can't do pain and anesthesia well, it has to be one or the other. Tell the hospital to hire a dedicated CRNA to stay over in OB from say 7AM to 5PM M-F. This won't fly for you because you have already set a precedent with the administrators---you're their hero--fellowship trained, ex-military, take charge kind of guy, hard worker, at all the meetings, blah, blah, blah. Hiring another CRNA may show a vulnerable weakness and perhaps your ego will not allow this. If your ego will allow this, the bean counters will surely take notice as "something is amiss with our hero" and send ya on one of them "Southern weekend retreats" where ya pow wow about "feelings" and "bonding with hospital staff." All designed to keep your a$$ in line so they can reach their monetary goals. Regards, ----Zippy

 

[militarymd]

Problem is that you're gettin' tooled by the bean counters. It's analagous to the bean counters wanting you to run a pain clinic at the hospital. Ya can't do pain and anesthesia well, it has to be one or the other. Tell the hospital to hire a dedicated CRNA to stay over in OB from say 7AM to 5PM M-F. This won't fly for you because you have already set a precedent with the administrators---you're their hero--fellowship trained, ex-military, take charge kind of guy, hard worker, at all the meetings, blah, blah, blah. Hiring another CRNA may show a vulnerable weakness and perhaps your ego will not allow this. If your ego will allow this, the bean counters will surely take notice as "something is amiss with our hero" and send ya on one of them "Southern weekend retreats" where ya pow wow about "feelings" and "bonding with hospital staff." All designed to keep your a$$ in line so they can reach their monetary goals. Regards, ----Zippy

all good....except we do an epidural once every other day

 

[militarymd]

MODERATOR:

This thread needs to get deleted: legal risk is way too high. This thread can be used as evidence when a doc races in to do an epidural and it does not go perfectly, or the patient has complications. The lawyers will pull this crap off the internet and say the doc was racing and not providing quality care.
Please lock and delete this......

ooohhh......I feel a discussion on Gaba (guy from Stanford) and his views on safety coming up....

 

[DuckhuntingDoc]

I don't have any stones....but I do have $$$

Speaks volumes about you......I'm done talking to children. Maybe I can find an Anesthesia forum were there are some adults around...

 

[Gas]

MODERATOR:

This thread needs to get deleted: legal risk is way too high. This thread can be used as evidence when a doc races in to do an epidural and it does not go perfectly, or the patient has complications. The lawyers will pull this crap off the internet and say the doc was racing and not providing quality care.
Please lock and delete this......

I think you bring up a good point. Lawyers will blow up this thread on a powerpoint in the courtroom. For the record, I will never rush an epidural. If I don't feel a good loss, or I keep hitting bone, I take my time, reposition the needle/patient, etc. The OR's can wait a few minutes to start a case, or one of my partners covers.

I think the stakes are too high to just randomly keep poking a pregnant woman's back because you are in a rush to get back to the OR, plus it's not good for the patient. However, I do think that if the epidural is straightforward, 20 minutes is not an unreasonable amount of time to provide quality patient care.

On a side note, if you are in the middle of driving your Tuohy and the woman decides to have a contraction, do you pause until it's done or keep driving? Personally, I pause if I can. I don't want them moving at all when I am close. I just tell them to breathe through it and that this will likely be their last painful contraction.

 

[militarymd]

Speaks volumes about you......I'm done talking to children. Maybe I can find an Anesthesia forum were there are some adults around...

bye bye



one of the dudes that I fired called me a child too.......kind of funny....a fat, old guy, getting has *** tossed out on the street by a kid who came to the practice after him.....still looking for a job......I guess that production pressure thing is keeping the man down.

 

[militarymd]

I think you bring up a good point. Lawyers will blow up this thread on a powerpoint in the courtroom. For the record, I will never rush an epidural. If I don't feel a good loss, or I keep hitting bone, I take my time, reposition the needle/patient, etc. The OR's can wait a few minutes to start a case, or one of my partners covers.

I think the stakes are too high to just randomly keep poking a pregnant woman's back because you are in a rush to get back to the OR, plus it's not good for the patient. However, I do think that if the epidural is straightforward, 20 minutes is not an unreasonable amount of time to provide quality patient care.

On a side note, if you are in the middle of driving your Tuohy and the woman decides to have a contraction, do you pause until it's done or keep driving? Personally, I pause if I can. I don't want them moving at all when I am close. I just tell them to breathe through it and that this will likely be their last painful contraction.

uhhh....where in my post did I say "rush"? Maybe you should read it again....I said it was important for me to know approximately how long I was going to be away.....and I'm trying to find ways in my routine to minimize that time.....

I would say that not reading carefully is worse.....which apparently a lot of readers in this forum do not do.

As for contractions....I used to wait when I was a resident and wasn't skilled at placing epidurals, but now I just keep going....the distracting pain makes the needle stick less painful.

 

[zippy2u]

Wow, ONE QOD! Pops, where I come from, that's Shut-er-Down numbers with a lil' "muscled leverage" sprinkled with some badboy attitude. What I mean... had a Boss man gas dude I worked for with prolly similar numbers. Cost vs. monetary benefit wasn't up to par for him so he talked to bean counters and hatched a plan to shut down the OB dept. without the single OB doc knowing. So they shut er down when he was away on vacation. He came back and a nurse on the floor told him that the OB dept. was no more. OB doc went apeshiit, cursing at administrators but stood their ground. They tried to appease him by telling him he could still do GYN surgery at the hospital but not OB, as it was financially unrewarding. Talk about gettin' owned---rather brutal. Regards, ----Zippy

 

[jwk]

I'm new in my group - they have told me to chart that we were in the room for at least 30 minutes for insurance purposes. I get in the room, talk/consent to the patient while they are getting positioned by the nurse, perform the epidural, and then chart as I am dosing it/setting up infusion with the patient now supine again, all in about 15-20 minutes. I do sit around in the room for another 10 minutes if I can, but not always possible. Since I am a new attending, I probably write a lot more detail than others, including a full procedure note.

Labor epidurals get charged as a procedure plus management time as I recall - there is no 30 minute rule. If our guys took 30 minutes for each epidural, they'd never make it through the day.

I'd guess ours are in the 10-15 minute range max. When we go in the room, the patient has already filled out their part of the anesthesia evaluation, labs are out for us to see, gotten some fluid on board, and the anesthesia cart is in the room. The L&D nurses handle all the pump stuff - absolutely no reason not to. We use pre-printed orders for everything and have a separate OB anesthesia record with lots of check boxes that takes about 30 seconds to fill out.

 

[Gas]

uhhh....where in my post did I say "rush"? Maybe you should read it again....I said it was important for me to know approximately how long I was going to be away.....and I'm trying to find ways in my routine to minimize that time.....

I would say that not reading carefully is worse.....which apparently a lot of readers in this forum do not do.

As for contractions....I used to wait when I was a resident and wasn't skilled at placing epidurals, but now I just keep going....the distracting pain makes the needle stick less painful.

uhhh....where in my post did I even mention you??? Chill, I'm just making a general statement.

 

[militarymd]

uhhh....where in my post did I even mention you??? Chill, I'm just making a general statement.

solly

 

[Laryngospasm]

i didnt say i ever "rushed" as you stated, for an average (easy) epidural the procedural part should be able to be done in 5-10 minutes by a skilled individual....period. If it takes longer it takes longer. You guys can stand around and take 30min if you want.

 

[coprolalia]

Some of yous guys are worried about lawyers reading this?

This thread is what is known as "hearsay". No lawyer would ever try to use this as "evidence" in a case, unless that particular lawyer's face was hanging on the back of the bus and he wanted to get laughed outta the courtroom.

-copro

 

[swpm]

one of the dudes that I fired called me a child too.......kind of funny....a fat, old guy, getting has *** tossed out on the street by a kid who came to the practice after him.....still looking for a job......I guess that production pressure thing is keeping the man down.

I thought the primary litmus test when you cleaned house was that the guys to be fired were in the neither board-certified nor board-eligible category. Just sort of curious to hear what other criteria you used.

I'd guess ours are in the 10-15 minute range max. When we go in the room, the patient has already filled out their part of the anesthesia evaluation, labs are out for us to see, gotten some fluid on board, and the anesthesia cart is in the room. The L&D nurses handle all the pump stuff - absolutely no reason not to. We use pre-printed orders for everything and have a separate OB anesthesia record with lots of check boxes that takes about 30 seconds to fill out.

This is the way my hospital works too, except we have to program the pumps (<1 minute). Everyone gets an anesthesia H&P/consent when they check in (the OB CRNA typically does this, then pulls labs when they're done). Nurses prime the tubing, get her positioned, and start the fluid bolus. By the time we get called for an epidural, everything short of painting and poking her back is done. I'm a slow/cautious CA-2 but I can get out of the room in under 15 minutes if she's a cooperative non-fattie.

My last call, I felt goooood about getting one done in under 10 ... and had my ego hauled back down to earth immediately afterwards with a chunky scoliotic freaked out teenager (4 sticks, 2 levels, 45 minutes in the room ... even had to open a 2nd kit when the freakazoid leaned back and put her hand in the tray).

 

[Gas]

I'm not a fan of the obese patients. Sometimes they go easily, but sometimes I struggle with them, and then they ask "What is taking you so long?" I politely say "I'm making my way down there, I have to make my way through extra layers of tissue."

Back in residency, I once had to use ultrasound just to find the midline.

 

[coprolalia]

I'm not a fan of the obese patients.

No one is.

I'm a little more direct and upfront, yet PC, when I walk in the room and see a fattie. I tell them straight-up before we even get into position that it's going to be more difficult because of the "extra weight they are carrying" and that it is a higher-risk procedure. Usually when you put it that way, they understand that it isn't going to be a slam dunk.

You don't have to tell them directly that they are fat. They already know this (and are probably embarrassed by it). But, you do have to tell them that their fatness may affect your ability to effectively do your job. That's part of the informed consent process. It still is an elective procedure, after all.

-copro

 

[militarymd]

I thought the primary litmus test when you cleaned house was that the guys to be fired were in the neither board-certified nor board-eligible category. Just sort of curious to hear what other criteria you used.
.

he fit into that category too.

 

[CanGas]

15 min on average (19 min from call room door to call room door) and no that is not rushing, that's being efficient. Glancing at chart for labs while getting patient positioned. Taking history and consent while opening tray and preparing drugs. 1/2 loading/test dose through needle with 1st bp and FHR check and leg movement after cath fixed and patient lying down. 2nd half of loading dose through cath with 2nd BP and FHR while finishing documenting. 3rd BP by nurse as I'm heading down the hallway.

In my opinion, being forced to stay in the room for 30 min if you are done is just stupid.

My record/worst night is 12 epidurals midnight-8am with 8 in 2 hrs. I would have the nurses have the next patient sitting up while I was finishing the last one. The $$$ signs in my staff's eyes when I dropped of the sheaf of anesthetic sheets in the am were something to see (labor epidural ~$150 normally and 200% ($300) after midnight).

Fortunately pharmacy makes all our epidural infusions so we just have to hook up the tubing and put it in a pump and we have an "epidural cart" with all the equipment on it that we just need to wheel into the room so that does speed things up.

 

[joshmir]

what are the barriers to getting the nurses to set stuff up for you? it sounds like if the admin understood that other hospitals do it, and it makes things much more efficient, they should want to go aong, right? can you get some ranking surgeon to tell the nurse manager or admin that things need to change for pt safety?

i would love to hear how people have tried to address these challenges, and what the responses have been, how they were negotiated, etc

thanks for all replies

 

[pd4emergence]

We do an average of about 4 epidurals a day. Pharmacy mixes our bags,nurses set up our pumps but we program them. Nurses also have the epidural cart in the room and will have the patient sitting for us if we tell them that we are on our way. We also have a nice video that goes over the procedure and the R/B/I. Every patient watches and it and then signs a statement saying that she watched it and agrees to have her epidural. My consent is basically to go in and say "did you watch the video?, do you have any questions?" (we also have them sign our preop form). The process usually works out pretty well.

 

[militarymd]

what are the barriers to getting the nurses to set stuff up for you? it sounds like if the admin understood that other hospitals do it, and it makes things much more efficient, they should want to go aong, right? can you get some ranking surgeon to tell the nurse manager or admin that things need to change for pt safety?

i would love to hear how people have tried to address these challenges, and what the responses have been, how they were negotiated, etc

thanks for all replies

the barrier?..............the nurses....

and as I mentioned....we don't do that many....and we're all fast enough that it hasn't been an issue...just a pain.