SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY

Transcription

1 PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: ACUTE AND POST OPERATIVE EPIDURAL/INTRATHECAL PAIN Job Title of Responsible Owner: Acute Pain Coordinator EFFECTIVE DATE: REVISED DATE: POLICY TYPE: (Patient Care) 07/88 11/17 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 17 PURPOSE: POLICY STATEMENT: To establish plans of care and protocols for the management of patients receiving intermittent or continuous epidural or intrathecal therapy. Only qualified Registered Nurses will directly provide care for patients having intermittent and continuous epidural/intrathecal therapy as outlined in this document. Patients may receive epidural analgesia in the following areas: Labor and Delivery; Mother/Baby Unit, PACU, Critical Care, Cardiovascular Thoracic Step-Down Unit (7 Courtyard Tower), General Surgical (6ET), and Orthopedics. Patients may receive or be assessed for the effects of intrathecal analgesia in the following areas: Labor & Delivery, Mother/Baby Unit, PACU, Critical Care, and Orthopedics. The RN who is caring for a patient who has received a continuous epidural infusion or intermittent epidural dose will follow the criteria below for additional patients under their care: Mother/Baby Units: For the first 24 hours post epidural/intrathecal bolus dose, an RN may care for no more than two post-epidural/intrathecal bolus dose patients and their infants if, at the same time, the RN is assigned to two other non high risk patients and their infants. (8:1 ratio). High risk patients are defined as any patient who: is on a Heparin drip multiple antibiotic therapy hematology patient who is having blood/blood components administered is deemed by their physician (or consultant) to be high-risk.

2 2 of 17 Note: Patients receiving magnesium sulfate infusions have their own patient ratio requirements. For the first 24 hours post epidural/intrathecal bolus dose, an RN may care for up to three (3) post epidural/intrathecal dose patients and their infants (6:1 ratio). None of these patients should be considered High risk as identified above. Orthopedics/7 Courtyard Tower/General Surgical Unit: a Registered Nurse who is directly caring for the patient with a continuous infusion via an epidural catheter will have no more than four (4) patients under his/her direct care. NOTE: Orthopedics will be the only nursing unit (other than critical care) that has patients with continuous intrathecal infusions. The RN caring for a patient with an intrathecal infusion will have no more than four (4) patients under their direct care. EXCEPTIONS: DEFINITIONS: Labor and Delivery will follow Nursing Department Policy # Continuous Epidural Analgesia in the Labor and Delivery Suite. Epidural Catheter A catheter placed in the epidural space. Epidural Injection Analgesic and/or anesthetic administered intermittently by an anesthesiologist or CRNA. Monitors Pulse oximeter Continuous Epidural Infusion Analgesic administered via a hospital approved locked infusion pump into an epidural catheter at rate/quantity specified by an anesthesiologist directly cared for by a qualified Registered Nurse (RN). Continuous intrathecal infusion- Analgesic administered via a hospital-approved infusion pump into a catheter placed into the intrathecal space by a qualified physician. Certified Registered Nurse Anesthetist (CRNA) The certified registered nurse anesthetist, may administer epidural/intrathecal analgesia/ anesthesia under the medical direction of an anesthesiologist.

3 3 of 17 Qualified Registered Nurse A RN who has completed an approved educational offering relevant to the care of epidural catheters, and has knowledge of the medications administered through the catheters and shall ONLY ADMINISTER EPIDURAL/INTRATHECAL THERAPY under the anesthesiologist s medical direction. Pain Resource RN- An RN who is chosen by her clinical manager, coordinator, and educator to participate on an advanced pain management team. The team is given pain management education on a regular basis. Acute Pain Service RN- An RN who serves as a member of the interdisciplinary hospital based Acute Pain Service, under the direction of the Acute Pain Program Coordinator/CNS and Pharmacy Director. Independent Verification-A process whereby a second licensed nurse verifies the pump programming (pain pump settings) performed by the first person while standing away from that person (i.e., the check should not be done looking over the programmer s shoulder). The second check should then be compared to the original physician order. Pain Pump Settings- Refers to the concentration of the opioid in the Epidural/intrathecal solution, the volume of the solution (usually a combination of opioid and local anesthetic), and the continuous basal rate. Pain Programming Pump Changes- Refers to performing pump operations to demonstrate the hanging of a new bag of the prescribed solution, administering of bolus doses or changing a continuous basal rate. Unusual numbness-any numbness or loss of sensation greater than that commonly associated with epidural analgesia (mild tingling, loss of temperature sensation). Initial Epidural/intrathecal Bolus Any introduction of a new medication into the epidural/intrathecal space that the patient has not previously received during this hospitalization. Initial bolus to be administered only by the anesthesiologist or CRNA. Start The initiation of an epidural infusion.

4 4 of 17 Epidural Flowsheet Documentation Refers to the use of the Epidural Parameter which may be found either on the Pain Management flowsheet or on the Assessment/ Reassessment Flowsheet in SCM. This is where the Pain Pump settings, two nurse verifications, LOS, RR and VAS (pain ratings) will be recorded. PROCEDURE: INITIATION 1. The anesthesiologist/crna will be responsible for placement and subsequent physician orders regarding pain and side effects associated with epidural/intrathecal analgesic therapy (nausea, vomiting, itching, respiratory depression). No OPIOIDS (PO, IM, IV), or other analgesics, anticoagulants (except subcutaneous heparin 5000 units or less), or sedatives should be transcribed or given without approval from the anesthesiologist during epidural/intrathecal therapy. The following exceptions for anticoagulants will be made for the trauma service: a) Enoxaparin 40 mg daily will be allowed for anticoagulant selection. b) Patients with CrCl<30 ml/min will have enoxaparin adjusted to 30mg daily. Patients with a CrCl < 15 ml/min will receive heparin (enoxaparin contraindicated). The administration of enoxaparin in trauma patients will follow the following timeframe stipulations: 1. Prior to epidural catheter insertion a. Enoxaparin dose should be held at least 12 hours prior to epidural catheter insertion 2. During epidural catheter insertion a. DO NOT give enoxaparin dose until 12 hours after catheter insertion b. If the epidural becomes dislodged during treatment, the nurse shall contact the anesthesiologist and trauma surgeon on-call and follow the instructions as listed below in the Catheter and Dressing Care section of this policy. 3. Prior to epidural catheter removal a. MUST WAIT at least 12 hours after last enoxaparin dose before removing catheter

5 5 of Post-epidural anticoagulation a. Time between catheter removal and next dose of enoxaparin is a minimum of 4 hours. 2. The anesthesiologist/crna will confirm placement of the catheter and administer the initial bolus of analgesic. This will be documented in the narrative physician progress notes of the medical record or on the Anesthesia record. The anesthesiologist/crna will place a label marked Epidural on the epidural catheter. 3. Continuous epidural therapy solutions will be handled as all other controlled substances. Epidural solution will be stocked in the PACU Pyxis for surgical patients only. PACU RN will confirm orders for Epidural medication that has been verified by pharmacy. Epidural medications may not be removed from Pyxis without an order that has been checked by pharmacy. PACU RN will program the yellow epidural pain pump using the prescribed settings per MD order. The nurse will prime tubing using pump programming. Patient ID label will be affixed to the epidural bag Pump programming will be independently verified by a second PACU nurse. PACU nurse will deliver programmed epidural pump to operating room and programming will be confirmed by CRNA. CRNA will connect epidural tubing to patient and start infusion when it is appropriate to do so. PACU RN will record epidural information on SCM flowsheet. Upon patient s arrival in PACU, RN will recheck the epidural pump and confirm with a second RN PACU RN will record updated information in SCM flowsheet Note: This process guarantees chain of custody concurrent with SMH policy and federal DEA laws. 4. Epidural pump keys are to be securely stored in the Pyxis when not in use. Exception: Acute Pain RNs and a select group of designated providers may possess his/her own Epidural pump key. 5. The Epidural key must be secured at all times, within the

6 6 of 17 Pyxis or in the nurse s eyesight when in use. The key is never to be left on a counter or unattended. 6. Keys to Epidural pumps are considered controlled substances. Epidural keys require accurate accounting of their removal and return from the Pyxis. 7. Keys must be removed and returned under the patient for whom the key is being used. The key must be returned promptly after each use to the Pyxis it was removed from. NOTE: Epidural keys cannot be handed off between nurses. 8. A lost or missing Epidural key is to be treated as a missing controlled substance. Every effort should be made to locate the missing Epidural key in a timely manner. 9. If unable to locate a missing Epidural key: Report to immediate supervisor Notify Pyxis Administrator via Complete an occurrence report Occurrence Report Tip Sheet Note: If a replacement Epidural key is needed urgently after hours, contact Pharmacy. 10. Epidural solutions may be delivered to the nursing unit by Pharmacy or a licensed nurse may pick up the solution directly from the Pharmacy. He/she will sign the Controlled Drug administration record after receiving the epidural bag. Any wasted epidural solution must be recorded in the Pyxis Medstation. EXCEPTION: Labor & Delivery and Cardiovascular Thoracic Step-Down Unit (7 Courtyard Tower) will stock epidural solutions in the Pyxis Med Stations. 11. For Epidurals, an anesthesiologist or a CRNA must administer the initial dose. The RN shall not administer the initial dose per the Florida State Board of Nursing. The initial dose is defined as the introduction of any new medication into the epidural space that the patient has not previously received during this hospitalization. 12. The RN may start a maintenance epidural infusion of the same medication subsequent to the initial dose being administered by the anesthesiologist. If no initial dose has been administered, the RN shall not start an epidural

7 7 of 17 infusion. For increased pain, the RN may titrate an increased infusion rate via pump programming once the infusion has been in place for 15 minutes according to the order set. In the PACU, the nurse will contact Anesthesia. 13. A qualified registered nurse and a second registered nurse will independently verify the solutions with the physician s order and the patient s identification band prior to hanging the bag in the pump. (They will both initiate and electronically sign the Epidural Flowsheet Documentation). 14. All Epidural bags administered will be documented and cosigned on the EMAR by a qualified RN. 15. The patient will have patent IV access prior to and during epidural/intrathecal therapy for the administration of emergency drugs. 16. Upon initiation, a qualified RN along with a second RN, will independently verify that the epidural tubing has been traced from the origin site in the patient to the pump to ensure the tubing is connected to the epidural catheter. Both RN s will electronically sign the Epidural Flowsheet in the appropriate box. 17. Continuous respiratory monitoring will consist of a minimum of a pulse oximeter. The pulse oximeter alarm will be set at 92%. 18. Upon assuming care of the patient with a continuous epidural analgesic infusion, the receiving nurse will check the pump programming against the physician s order and the Epidural Flowsheet Documentation in SCM. 19. All pump programming changes need to be independently verified by another nurse prior to initiation. 20. Once the motor strength, ability to move and lack of numbness has been assessed and validated (by the RN or Physical therapist) the patient may ambulate unless contraindicated by the surgeon or anesthesiologist. QUALIFIED REGISTERED NURSE S RESPONSIBILITIES- Continuous Epidural Infusions 1. Epidural Therapy Solution: a. Only a qualified RN may care for patients who have

8 8 of 17 PROCEDURE (cont d): continuous epidural infusions. b. Solutions will be run using the appropriate pump and tubing. Never inject or flush into an epidural catheter. c. The appropriate tubing, the solution and the filter will be changed every 96 hours using sterile technique. d. Complete pump readings should be done every four (4) hours for the duration of the therapy. e. Every shift, trace epidural tubing from origin site in patient to pump and back to ensure that tubing is connected to epidural catheter. Document electronically in the appropriate box on the Epidural Flowsheet. A label, marked Epidural, must be on the filter of the epidural catheter. In addition, hang a yellow Epidural Catheter sign above the head of the patient bed. f. All epidural pain pump programming settings need to be independently verified by another RN. g. All epidural pain pump concentration changes need to be done by a validated Pain Resource Nurse or an Acute Pain Service Nurse. h. When a continuous drip is discontinued and the catheter is left in place, a red cap can be applied to the filter by the qualified RN. i. After the anesthesiologist administers the initial bolus and the initial dosage period is complete (15 minutes), the RN may activate a prescribed increase in infusion rate and/or bolus via pump programming once the infusion has been in place for 15 minutes. 2. Catheter and Dressing Care: a. A sterile dressing will be applied to the epidural catheter site by the anesthesiologist/crna on insertion. The RN will inspect the dressing every shift, and report any evidence of infection, redness, pain, swelling or leakage to the anesthesiologist. If the dressing is loose, reinforce it with tape. DO NOT change the tape over the catheter. DO NOT change the dressing. b. If the epidural catheter becomes dislodged from the patient, the nurse will stop the infusion, and apply a band-aid to the site. The nurse will check the tip of the catheter for the presence of a colored tip (usually blue or black) indicating that the catheter is intact. If the colored tip is absent, notify the anesthesiologist or Acute Pain Service Nurse immediately. The catheter

9 9 of 17 should be saved for inspection by the anesthesiologist or Acute Pain Service Nurse. c. If the epidural catheter is disconnected, immediately stop the infusion and wrap the tip of the catheter in a sterile 2x2 and notify the anesthesiologist. d. If the surgeon orders the epidural catheter to be replaced, follow procedure as outlined at the end of this policy. e. With the anesthesiologist s order, the qualified RN may remove the epidural catheter and should document that the tip of the catheter was black/blue. f. Patient may not shower. g. The RN shall not adjust the position of the catheter for any reason. 3. Initial and ongoing Patient Assessment/Monitoring: This includes level of sedation, respiratory rate and pain scale: a. Upon initiation of Epidural therapy, Vital signs, Level of Sedation, and Pain Level per PACU standards. b. Then Patient Assessment (level of sedation, respiratory rate and pain scale) : Every 1 hour x 12 hours Then every 2 hours for a total of 24 hours After 24 hours, post initiation of therapy, do patient assessment with vitals every 4 hours. c. If any bolus doses are administered, or the infusion rate is increased or the epidural solution is changed, vital signs with level of sedation and pain scale every 30 minutes x2, then as above. 4. Sedation Levels: a. Document the levels of sedation (LOS) on the Epidural Flowsheet Documentation in SCM as directed above. 1) Level 1 alert; easy to rouse 2) Level 2 occasionally drowsy; easy to arouse 3) Level 3 frequently drowsy 4) Level 4 somnolent; difficult to arouse; 5) S sleeping; easy to arouse. 5. Pain Rating: a. After the above assessments outlined in 3b, assess for pain Q2H for the first 24 hours of therapy and whenever the patient complains of Pain by asking the patient to rate their pain on a scale of 0 to 10. Record this on the

10 10 of 17 Epidural Flowsheet documentation in SCM. Wong-Baker FACES Pain Rating Scale. From Wong, D.L., Hockenberry-Eaton M., Wilson D., Winkelstein, M.L., Schwartz, P.: Wong s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p Copyrighted by Mosby, Inc. Reprinted by permission. PROCEDURE (cont d): 6. Assess every 12 hours: a. The epidural catheter for security, and the infusion tubing for patency and security. b. Signs and symptoms of infection (redness, swelling, fever, purulent drainage, new back pain, neck stiffness, or pain which is increasing). c. Integrity of dressing. d. Sensory/motor deficits, such as numbness or weakness. 7.Side Effects Management: a. Side effects are managed by following the protocols in the Epidural Analgesia Order Set. 8. Intrathecal infusions: All of the previous procedures for epidural therapy include intrathecal therapy except for: An RN may decrease the rate and stop the infusion without the prescribing physician being physically present. The prescribing physician must be physically present at the bedside to initiate the infusion; administer a bolus; change an infusion bag; increase infusion rate; or perform any other pump programming changes. The prescribing physician must remove the intrathecal catheter. 9. Notification of the Anesthesiologist: a. The RN will notify the anesthesiologist: 1) When the patient experiences unusual numbness. 2) When the patient s respiratory rate is less than 8. 3) When the patient exhibits unexplained signs of central nervous system depression (reduced level of consciousness), or numbness. In this situation, the qualified RN will stop the epidural

11 11 of 17 infusion and then notify the physician. 4) When the patient s urinary output falls below the parameters established by the physician. 5) When the patient develops a temperature over 101 degrees. 6) When the patient is no longer receiving adequate pain relief. 7) When measures/medications to relieve side effects are ineffective. 8) When there is pain, redness, drainage, swelling, or leakage at the catheter site or when the catheter is occluded. 9) When the catheter becomes dislodged. 10) When the dressing is disrupted or damp. 11) When anticoagulation therapy is ordered. (Except subcutaneous heparin 5000 units or less). 12) In any situation the RN determines that signs and symptoms mentioned above are not present or 10. If the anesthesiologist orders an IV PCA, along with the epidural, the patient must be in critical care. Both pumps and their respective tubings must be labeled appropriately. 11. If the anesthesiologist orders the epidural to be stopped and capped and no other pain pump (ie IV PCA) is to be initiated, the locked pump may stay at the bedside. Disconnect the tubing from the filter and place a red cap on the end of the tubing. 12. If the anesthesiologist orders the epidural to be stopped and capped AND orders an IV PCA, the epidural infusion pump, bag and tubing must be removed from the patient s bedside. Any amount of opioid that has not been used by the patient should be appropriately wasted as soon as possible (waste procedure to follow) Disconnect the tubing from the catheter and apply a red cap to the filter. 13. Removal of the epidural catheter(may be removed by a qualified RN with documented competency): a. Ensure the anesthesiologist has ordered the removal of the epidural catheter and check to see that the Discontinue Epidural Catheter order set has been placed in SCM. b. Check the patient s most recent platelet count and INR.

12 12 of 17 Contact the anesthesiologist if the platelet count is below 100,000 or if the INR is abnormal. c. Check to make sure that the patient has not received any anti-coagulants except for subcutaneous heparin during this hospitalization. If so, contact the anesthesiologist before removing the catheter. d. Ask the patient to assume a sitting or a side-lying position with their back exposed and arched out toward the nurse. e. Before removing the catheter, turn off the infusion pump if it is still infusing. f. Remove the tape from the patient s back and shoulder to expose the catheter site. g. Apply gloves. h. Apply gentle, steady traction to remove the catheter. Do not pull on the catheter vigorously; if resistance is met, stop and notify the anesthesiologist. (Note: These catheters are usually not sutured in and should slide out easily.) i. Cleanse the patient s back of any blood or secretions. Cleanse the epidural site with an alcohol prep and cover with a band-aid. j. Waste the unused medication in the infusion bag and record the waste in Pyxis (see waste procedure below). k. Return the infusion pump to Central Service. l. Notify the anesthesiologist for any of the following: * Difficulty or inability to remove the catheter. * Patient experiences pain or tingling during removal. * Absence of the colored tip on the catheter. (Save the Catheter) * Epidural site is painful, red, swollen, or draining purulent material. m. Document the removal of the catheter in the Nursing Reassessment Flowsheet and that the tip of the catheter is black/blue. 14. Waste Procedure for Epidural Medication a. To waste the unused medication, two nurses must be present when Epidural pump is opened to remove the solution bag. b. Two nurses must visualize the physical waste of the medication. c. One nurse removes the tubing from the bag and empties the medication into a measuring cup. The nurse then empties the medication into a sink drain. These two steps must be witnessed by the second

13 13 of 17 RN. d. After performing the waste, the Epidural waste must be documented in Pyxis with the nurse who witnessed the waste. The RN who removes the epidural pump from the patient is responsible for the medication and should serve as the initiator for the waste (as opposed to the witness for the waste). To initiate an epidural waste in Pyxis: a. Log in to Pyxis b. Select the patient. c. Select Waste. d. Select the epidural medication Note: There are two possible ways to locate the medication in Pyxis. If it was removed from that Pyxis station, the medication will appear under Meds to Waste. Type the medication name in the search field. After selecting the medication, select Waste. If it was removed from another Pyxis station or delivered by pharmacy to the unit, the medication will appear under Search All Meds. Select Search All meds and type the drug name in the search field to find the Epidural medication. After selecting the medication, select Waste. e. Enter the Waste amount in the ml field. f. After the correct Waste amount is shown, select Accept. g. Witness then enters ID/ biometrics Note: The amount recorded should be the amount physically wasted, not the volume displayed on the epidural pump. RESPONSIBILITY: 1. It will be the responsibility of the anesthesiologist/crnas mentioned in this document to be aware of, and adhere to, this policy. 2. It will be the responsibility of the Department Managers/ Directors to see that nursing personnel are aware of, and adhere to, this policy.

14 14 of 17 REFERENCES: Sarasota Memorial Hospital Corporate Policy. Pain Management (00.PAT.44). Sarasota, FL. Author. McCaffery and Pasero. (2011). Pain Assessment and Pharmacologic Management. Horlocker, Wedel et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy ; American Society of Regional Anesthesia and Pain Medicine Evidence- Based Guidelines (Third Edition) Regional Anesthesia and Pain Medicine; January/February Volume 35 Issue 1 pp American Society for Pain Management Nursing (2011 June) Procedural Pain Management. A position statement with clinical practice recommendations. Pain Management Nursing 12 (2), American Society of Anesthesiologists (2010- April) Practice Guidelines for Chronic pain management. An updated report by the ASA task force and the American Society of Regional Anesthesia and Pain Medicine Anesthesiology 112(4) AUTHOR(S): ATTACHMENT(S): D. Scheb, RN, Acute Pain Coordinator/CNS Dave Jungst, Director, Pharmacy Dr. Sean Daley, Medical Director, Anesthesia Acute Pain Service Nurse Protocols for Epidurals The Acute Pain Service RN may implement the following attached protocols approved by Anesthesia. The Anesthesiologist assigned to the Acute Pain Service for that day will be informed of the implementation and result. Epidural Re-insertion Check List

15 15 of 17 ACUTE PAIN SERVICE NURSE PROTOCOLS FOR EPIDURALS May increase infusion rate every one hour x 2 if analgesia inadequate and LOS= 1-2, and RR>12/min. May decrease or stop infusion for excessive sedation, nausea, or decreased respiratory rate. May administer epidural bolus via pump if analgesia is inadequate and proper patient assessment/labwork review present. May enter electronically, verbal order to discontinue epidural and start IV or oral analgesics (as ordered by Surgeon). May enter electronically, verbal order for Tylenol 650 mgs po/pr every 6 hours while on Epidural therapy (no allergy to Tylenol). All verbal orders will be written per the anesthesiologist collaborating with the Acute Pain Service that day. Epidural Re-insertion Check List Please follow these steps when an epidural catheter falls out of a patient or becomes dislodged or contaminated. Notify Anesthesia and the Surgeon and the Acute Pain Service (weekdays only) Obtain order for reinsertion of Epidural from Surgeon. (Remove pump and medication from patient and waste epidural solution appropriately. Send yellow epidural pump to central service) If patient is anti-coagulated, perform neuro check every hour and observe patient for signs and symptoms of epidural hematoma (Constant diffuse back pain, sensory and/or motor deficit, bowel bladder dysfunction) Initiate IV PCA, standard settings under surgeon s name per order on the Anesthesia order. Notify anesthesiologist or the Acute Pain Service of need for reinsertion of epidural Anesthesia to book the procedure as a case. Complete a detailed incident report that spells out what happened and what part of the catheter became contaminated and your opinion as to why it occurred (if you know) If epidural to be replaced, assess patient for eligibility for reinsertion. (Make sure the

16 16 of 17 patient is not anti-coagulated, running a temperature or has an abnormal white count.) Send patient to Pre-Op when patient is called for. Approved by Anesthesia: April 2017 Medical Director, Anesthesia: Dr. Sean Daley Acute Pain Program Coordinator: Diane Scheb

17 17 of 17 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Signature: Title: Diane Scheb, MSN, RN, Acute Pain Coordinator Signature: Title: Signature: 11/3/17 Title: Dave Jungst, Director, Pharmacy Signature: Title: Committee/Sections (if applicable): Clinical Practice Council 11/2/17 Vice President/Administrative Director (if applicable): Signature: Name and Title: Signature: 11/14/17 Name and Title: Connie Andersen, Vice President, Chief Nursing Officer