Recently, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) issued a policy statement recommending that rebolus of an epidural catheter be performed only by a qualified anesthesia provider. Particularly in the community setting, many anesthesia groups utilize labor and delivery nurses whom they have trained, to assist them with this task. What follows is one practitioners experience with this approach and information from AWHONN on how and why they arrived at this decision. If you have personal experience or feelings on this matter, please let other SOAP members know how you feel via the SOAP Box.
Valerie Arkoosh, M.D.
Chair, Education Committee
ISSUE: ROLE OF THE REGISTERED NURSE (RN) IN THE MANAGEMENT OF THE PATIENT RECEIVING ANALGESIA BY CATHETER TECHNIQUES (EPIDURAL, INTRATHECAL, INTRAPLEURAL, OR PERIPHERAL NERVE CATHETERS)
A registered nurse (RN) manages the care of nonpregnant patients with catheters or devices for analgesia to alleviate acute postsurgical pain, pathological pain, or chronic pain. The RN may monitor the care of the pregnant patient receiving epidural analgesia following stabilization of vital signs after either bolus injection or establishment of continuous pump infusion. The RN may remove the catheter from either the pregnant or nonpregnant patient when educational criteria have been met and institutional policy and state laws allow. The registered nurse may remove the catheter that has been used for analgesia upon receipt of a specific order from a qualified anesthesia or physician provider.
For the Pregnant Women:
The insertion, initial injection, or initiation of a continuous infusion of epidural catheters for analgesia should be performed only by a qualified and credentialed, licensed anesthesia care provider as described by the American Society of Anesthesiology, Guidelines For Practice, Oct. 1994, and the American Association of Nurse Anesthetists, Guidelines for Obstetrical Anesthesia and Conduction Analgesia, 1991.
Rebolus of an epidural catheter includes injection of the catheter by syringe or increasing the rate of a continuous infusion. Rebolus should be performed only by a qualified and credentialed, licensed anesthesia care provider.
A qualified and credentialed licensed anesthesia care provider must be readily available as defined by institutional policy.
The RN may monitor the mother and fetus, replace empty infusion syringes or infusion bags with new pre-prepared solutions, stop the infusion, initiate emergency therapeutic measures under protocol if complications arise, and remove the catheter.
For the Nonpregnant Women:
It is within the scope of practice of the registered nurse to manage the care of nonpregnant patients receiving analgesia by catheter as defined above only when the following criteria are met:
The registered nurse managing the care of the patient does not assume responsibility for the catheter until the provider who placed the catheter/infusion device has verified correct catheter placement and the patient's vital signs have stabilized.
Management and monitoring of analgesia by catheter techniques, including reinjection and/or alteration of infusion rate by nonanesthetist RNS are allowed by state laws and institutional policy, procedure, and protocol.
Consistent with the law, the attending physician or the qualified anesthesia provider placing the catheter or infusion device selects and orders the drugs, dosage, and concentrations of opioids, local anesthetics, steroids, alpha-agonists, or other documented safe medications or combinations thereof.
Guidelines for patient monitoring and drug administration and protocols for dealing with potential complications or emergency situations are available and have been developed in conjunction with the anesthesia or physician provider.
Replaces 1991 statement of same title.
I am writing in reference to the AWHONN statement noted above. Your revised statement was sent to the American Society of Anesthesiologists' Committee on Obstetrical Anesthesia last year for possible endorsement. We chose not to endorse the statement because of the following concerns: 1) there was no morbidity or mortality data to support this change in policy, 2) there are too many practice styles around the country to mandate a single policy for every hospital on this issue, and 3) there is no basis for separating gynecology patients from obstetric patients as the complications of epidural analgesia are the same.
Since your statement has been released, our committee has received numerous calls from around the country from anesthesiologists, nurses, hospital administrators, etc. who have concerns about the impact this statement is having on their labor and delivery practice. Our committee recently reviewed your document again with these practice concerns in mind, and we wish to raise the following issues against your change in policy:
1. To our knowledge, there is no morbidity or mortality data available to support or necessitate a change in policy on a national level. We endorse policies made at individual institutions depending upon nursing education and training.
2. Changes in nurse practice mandated by the AWHONN statement may impact obstetric patients' pain relief and satisfaction in some practices if this document is adopted as policy without prior arrangements for alternate personnel who can adjust infusion rates or administer additional doses. In some units epidural analgesia may be denied or delayed because of a lack of personnel.
3. The policy does not allow for variations in nursing education and training at different institutions. If the protocols, credentialling, and educational support systems are in place, there are institutions where nurses can safely manage epidural analgesia. This is supported by the fact that AWHONN allows such practices in gynecology patients. In many practices around the country, L&D nurses have been safely managing epidural infusions and bolus doses with such protocols in place.
4. The guidelines should allow hospitals to develop their own nursing policies based on their nurses' education and training. Anesthesiologists value their relationships with L&D nurses and should be involved in this type of education and credentialling.
5. Nurses administer other potentially dangerous medications to obstetric patients such as magnesium and intravenous narcotics with training and credentialling. Care of epidural catheters should not be treated differently.
6. Another example of the safe practice of non-anesthesia personnel providing epidural bolusing is patient-controlled epidural analgesia (PCEA). With this technique, the patient administers a preset dose of anesthetic, a dose similar to one administered by a trained RN. Nursing protocols which allow nurses to change the rate on an infusion pump or bolus from a pump or prefilled syringe by protocol and with training is a similar practice.
We hope you will respond to these concerns and consider revising your statement to reflect the need for appropriate training and credentialling of nurses rather than simply a restriction in their practice without supporting data.
Joy L. Hawkins, M.D.
Chairman, ASA Committee on Obstetrical Anesthesia
The current position statement is a revision of a document that originated from a multi-association effort in 1990. It appears that a number of state nurses associations asked the American Nurses Association (ANA) for guidance in the nurses role with epidural analgesia and conscious sedation. The National Federation of State Nursing Organizations collaborated with the ANA to address these issues. The ANA sponsored an issues-focused discussion group for interested nursing specialty organizations at the 1990 Nursing Organizations Liaison Forum. A series of meetings to develop the written document occurred over the next several months. The result was a two-part position statement signed by 22 participating nursing specialty groups, which was distributed in 1991.
In 1995 concerns began to surface across our membership regarding the lack of clarity for the nurses role in supporting epidural analgesia for the pregnant woman. During the next several months the committee on practice entertained discussion and review of this issue. In the summer of 1996 the Executive Board of AWHONN accepted the committee's recommendation to revise this position statement based on these factors:
(1) The fetus is the second patient for whom the nurse is responsible.
(2) The fetus is dependent on maternal physiology. If the mother is compromised, the fetus suffers that compromise first.
(3) The pregnant woman differs physiologically from the nonpregnant woman. Her increased sensitivity to local anesthetics like the "caine" drugs,, the engorgement of the epidural vein which increases the potential for catheter migrations, and her obliterated response to supine hypotension are the basis for viewing her epidural management in a different context than the nonpregnant woman.
(4) Finally, we do not believe that the staff nurse, in most hospitals, is educated or trained to intervene independently and manage the patient should there be a negative response to the analgesia. The data from our member survey highlights the latter point. Almost one third of the nurses who do provided an intervention to the epidural, through a bolus or increase in infusion rate, indicate they have received no education or training for this responsibility. Of the 1000 members who responded to the survey 76.5% do not provide the intervention. All of the 24.5% who provide this intervention indicted they do so because "anesthesia is unavailable."
We do believe we should make a distinction between the pregnant woman and the nonpregnant woman in relationship to epidural analgesia. And because there are no data to support the safety of staff nurses providing a bolus of increasing an infusion, AWHONN altered its 1991 position statement.
Your letter also suggests that epidural analgesia should not be viewed differently than other medications nurses administer to obstetric patients, such as magnesium sulfate and intravenous narcotics. The technical function is not in dispute, but the management of potential complications is the issue. Other interventions are considered part of core curriculum in nursing programs, and they are found in the major nursing texts as well as nursing literature. This is not the case with increasing infusion rates or providing a bolus with epidural analgesia for the pregnant woman. We agree with Terry Walman, M.D., J.D. who comments in the February 1997 OB-GYN Malpractice Prevention newsletter, "An RN who gives a bolus injection to the epidural or removes the catheter assumes the same liability as the anesthetist who inserted the catheter.
Judith H. Poole, RNC, MN
Chair, Committee on Practice
The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has been striving to have their position incorporated into the various state regulations governing the practice of the Registered Nurse (RN). If successful, this needlessly would disrupt approximately 25 percent of the current obstetrical anesthesia services.
In a letter to The American Society of Anesthesiology (ASA), Gail Kincaide, Executive Director of AWHONN, asked the ASA to endorse AWHONN's Position Statement. The first paragraph reads: (in entirety)
"Our Executive Board has withdrawn the position statement titled Role of the Registered Nurse in the Management of Analgesia by Catheter Techniques, reaffirmed June 1994. This decision was based on the Committee on Practice recommendation that the staff nurse providing re-injection of epidural analgesia to the pregnant woman poses a risk-management concern. If the mother has an adverse reaction to epidural medication there can be serious consequences if the reaction is not managed effectively: the fetus is the second patient dependent on maternal physiology. Anesthesia personnel are educated and trained in the management of these complications."
Correctly, the ASA has declined endorsement. AWHONN has not furnished the data necessary to justify support.
AWHONN must explicate the "risk-management concern" they perceive.
Accurate assessment, and thorough analysis, come before policy endorsement.
Prior to asking for endorsement, AWHONN must determine that the "risk-management concern" referred to, is a tenable adverse event, and not simply a "windmill".
To authenticate their position, they need to present data which:
1. Establishes the existence and frequency of the identified adverse event.
2. Determines whether the event is, as they imply, confined to the pregnant patient.
3. Documents the morbidity and mortality experienced by mother and baby.
4. Elucidates the factor(s) causing the event, as opposed to those that simply might be associated with the event.
5. Demonstrates that their proposed policy mandate, if enacted, would eliminate the perceived adverse event.
6. Discusses the possible negative effects the proposed mandate would have on the availability of labor analgesia.
7. Suggests viable alternatives to the current, experience proven practice.
AWHONN has proposed an encompassing, restrictive policy, that markedly conflicts with current practice.
For many years, anesthesiologists at my institution and others have delegated to trained RN's the adjustment of epidural infusion rates and the administration of small bolus injection, in established labor epidurals without compromising patient safety. This has been by physician order following standardized protocol with the anesthesiologist immediately available.
In a communiqué from AWHONN to the ASA Judith H. Poole, RNC, MN, Chair, Committee on Practice makes reference to a survey of 1,000 AWHONN members. Ms. Poole states that 24.5 percent of the members reported that they "provide an intervention to the epidural, through a bolus or increase in infusion rate". Although she alludes to "potential complications", there is no mention of any specific adverse event(s).
The SOAP membership has confirmed AWHONN's findings. At the last SOAP meeting (Bermuda, April 1997) a Workshop was devoted to discussing existing labor analgesia practices. 1 Of the 80 participants responding: 26 percent reported in their practices RNS adjust epidural infusion rates according to written instructions. In 11 percent of the practices, "top up" doses were administered by RNS. In response to the specific question: "Is anyone aware of an adverse outcome caused by a RN adjusting the epidural infusion rate of, or administering a bolus to, an established labor epidural?" no one responded in the affirmative.
Although perhaps not conclusive, such data at least shows that - and agrees with AWHONN's survey that - in approximately 25 percent of existing practice settings the RN safely adjusts labor epidurals.
At the same SOAP meeting Eli Alon, M.D. presented data concerning the labor analgesia practices in his native Switzerland. He reported that over 90 percent of labor epidurals, once established, are managed by non-anesthesia personnel.
For the past 21 years the group with whom I am associated, (at Tucson Medical Center, Tucson, Arizona) has maintained a 24 hour obstetric anesthesia service. The anesthesiologist is in-house and has no responsibility other than labor and delivery. We have performed more than 60,000 epidurals. All epidurals were established by an anesthesiologist. For most of the years we utilized a patient-request rebolus method for continuing the epidurals. The vast majority of the repeat boluses were administered by trained RNs according to the anesthesiologist's orders per written protocol. We experienced no adverse outcomes to either mother or baby as a result of a bolus administered by a RN. In recent years, we have converted to the continuous infusion technique. After training, RNs are permitted to adjust the infusion rate and administer bolus injections within written confines. In approximately 25 percent of the epidurals the RN either adjusts the infusion rate or administers a bolus injection. Again, we have had no adverse outcomes to either the mother or the baby as a result of rate adjustment or bolus injection by the RN.
While we are very comfortable with our practice protocol, in no way would we suggest that our preferences be adopted as a national mandate.
Our experiences at Tucson Medical Center, while extensive, is by no means unique. Others report similar experience. A SOAP colleague from Virginia Beach, Virginia reports their 30 year experience with approximately 50,000 labor epidurals. They also utilize the expertise of RNS and recount "no problems or bad results". Similar information is reported from a member in the San Francisco area. Following this Newsletter I'm sure we will hear from others with even greater experience.
AWHONN's position statement is not consistent with the acknowledged responsibilities of the labor RN.
Labor RNs administer many potent medications including oxytocin, magnesium sulfate, terbutaline, and narcotics; all of which have well-documented, potentially adverse effects for both mother and baby. Each medication has minor complications that easily can be detected and corrected by the RN. However, each medication has recognized but fortunately very rare complications, the management of which requires personnel whose training is beyond that of the RN. It is the protocol of administering the medication that assures safety. Properly, the details of the protocol are the prerogative of the individual institution.
As an example, oxytocin is recognized as one cause of uterine rupture, the
management of which requires an obstetrician. However, it would be inefficient,
inappropriate, and unnecessarily disruptive to require that the obstetrician
personally make all adjustments of an intravenous oxytocin infusion. The RN
is able to
function within individual institutional protocol guidelines to safely and efficiently manage the infusion.
Changing the infusion rate of an existing epidural or bolusing an existing epidural should be considered the analogous to adjusting an infusion of oxytocin.
AWHONN's position statement, if enacted, would result in less effective pain relief with no evidence of increased safety for mother or baby.
Anesthesia and nursing personnel must blend their expertise and availability to maximize the safety and comfort of every mother and baby. Individual institutional prerogative is the cornerstone to this achievement.
A factor, unique to the safety of medications administered by the labor room RN, is the virtually constant observation the RN can offer following administration.
While we expect each surgical patient to be attended by their exclusive anesthesia and surgical personnel, no such expectations exists for the labor patient - nor can it be provided - nor is it necessary. In obstetrics, it is the RN who offers the parturient constant vigilance. Both the obstetrical provider and the anesthesia provider must be able to engage the expertise of the RN to assure the safest, most efficient, and most effective patient care.
There is no need to deny the adjustment of an existing labor epidural while the anesthesia provider is establishing another labor epidural. There is ample evidence that the trained RN currently assists effectively and safely. There is no evidence to the contrary.
There is no morbidity data to support AWHONN's proposal for differentiating the pregnant from the non-pregnant patient.
At least, I am not aware of any data; and, as AWHONN has not presented any, I assume they have none.
Ms. Kincaide's statement: "If the mother has an adverse reaction to epidural medication there can be serious consequences if the reaction is not managed effectively: the fetus is the second patient dependent on maternal physiology." while a truism, in no way validates AWHONN's position of arbitrarily allowing the RN to alter the rate of infusion for non-pregnant patients while prohibiting adjustment for pregnant patients.
AWHONN's position statement is in conflict with the extensive experience from patient controlled epidural analgesia (PCEA).
Certainly, the trained RN is as competent to administer a bolus injection as the medically untrained parturient is to administer her own bolus injection.
At the previously referenced SOAP Workshop Session, 26 percent of respondents said they use PCEA in their practices.
Numerous articles confirm the safety and efficacy of PCEA. (See the excellent review article and extensive bibliography by M.J. Paech.) 2
The mechanical act of administering the bolus injection has been done by anesthesia providers, obstetrical providers, nursing personnel, and even the patient herself. No one has reported an adverse outcome attributed to who is doing the injection. The safety of PCEA is achieved by adhering to the individual institutional protocol.
The safety experience with PCEA is convincing that in an established, functioning epidural, the bolus injection can be done with equal safety by the anesthesiologist, the nurse anesthetist, the RN, or the patient.
Are there factors other than a "risk-management concern" that compel AWHONN to propose their policy statement?
Perhaps. However, I have elected to confine my response to the stated phrase "risk-management concern" rather than speculate as to the existence of other factors.
AWHONN's proposal for a national mandate should be rejected.
Emotive statements must be separated from observed experience.
The members of both AWHONN and SOAP are committed to the safety and comfort of all mothers and babies. Existing health care market forces necessitate that we unite to maximize the efficient deployment of our individual expertise and availability. While the anesthesiologist always remains responsible for the labor epidural, she (he) must be permitted to delegate certain specifically defined functions to the trained RN. Together, we can question, investigate, resolve, and provide.
1. Interactive audience responses from the Annual SOAP Meeting (Bermuda, April, 1997). Responses are in publication (so says, David Birnbach). They were to be available in late April (also, per David Birnbach). However, Gerry Burger confirms the accuracy of the statistics.
2. Paech, M.J. Patient-controlled epidural analgesia in obstetrics. International Journal of Obstetric Anesthesia, 1996; 5:115-125.
James R. Farina, M.D.