APS GUIDELINES

 

 

       Welcome to the APS ( Anesthesiology Pain Service).  There are four residents assigned to this rotation. Two will be rotating through the block room and the OR for two weeks each. The other two will rotate through the PACU or the Pre Op Anesthesiology Clinic for one month.  Check the OR schedule on Sunday for your Monday assignment. Your call schedule is posted in the Anesthesia Library. Any call changes must go through the chiefs and Ellyn. Call schedules are posted for house wide access on the Shands Intranet.

 

Monday through Friday the APS is also covered by a registered nurse during the day (0730-1600).

APS has a cell phone #; 494-1496.  The extra battery is kept in a charger in the clinical office, back corner cubical. Please be sure to check the battery status before you leave and change if needed. DO NOT TAKE THE CHARGER WITH YOU.

 

Block Room resident responsibilities:

 

Report to the Block Room at 0630 ready to work. Review the OR schedule the previous day and prepare by reading and reviewing anticipated block procedures. Inpatients scheduled on the OR schedule for the block room should be seen by the resident the night before. Be sure to hold any medication, eg. Lovenox or early am heparin that might interfere with the block. Also assess for positioning issues, eg. External fixators, fractured hips etc. Being prepared to deal with these issues facilitates your work. If the block room resident schedules a patient for a regional procedure, they need to call the resident who is providing the operating room anesthesia and inform them of this.  This way they may discuss regional as part of the overall patient care plan with their attending.

       Review the patient’s chart, pre op if done and all labs, specifically the PT/INR and platelet count for all central axis blocks and deep peripheral nerve blocks.

       Question the patient about any antiplatelet medications such as Plavix and low molecular weight heparins like Lovenox. These are contraindicated for central axis and deep peripheral blocks – See ASRA guidelines.

       Obtain a permit for general/regional anesthesia and have witnessed.

       Gather equipment for the desired block and as soon as confirmed, start setting up. You may position and prep the patient while waiting for the attending.

       The block procedure form and post op orders are to be completed by the resident.

The appropriate order form will be placed with the patient’s paperwork on the bedside table. When complete give both forms to the clerk. The orders will be faxed to the OR pharmacy.  Our new standard (commercially prepared and readily available) epidural solution is Ropivacaine 0.2% and fentanyl 3mcg/ml. Ropivacaine 0.3% and 0.2% are also available for use with peripheral catheters or can have whatever fentanyl concentration you wish added for use with epidurals.  It is strongly recommended that you use the commercially prepared solutions.

 

New guidelines for prevention of infections have been suggested. Therefore all blocks will require you to remove your watch and hand jewelry, wash your hands before gloving and wear a mask.

 

The block room resident is responsible for seeing acute pain consults Monday through Thursday. The Pain Fellow should perform consults on Friday.

 

The regional resident should remain in house until the on call person has the book and beeper. Exceptions to this must be discussed with the regional attending of the day.

 

**APS Pager# is: 413-7900. The phone and beeper are carried by Ellyn during the day Monday thru Friday. The beeper is to be transferred to the block resident by Ellyn at 1600 and to the call resident when they are free to take over the call duties.

 

It is our responsibility to be available to address pain management issues. The nurse or resident must be available at all times during the day and night to answer pages and address problems in a timely manner.

 

APS Nurse Pager # 413-7901

 

Ellyn Radson is the nurse on the APS.  Her role is to pre round with the Pre OP and PACU residents in the AM to assess patients and address any overnight problems, to admit patients to the service and address pain management problems throughout the day. She will provide a full report to the block room resident at 1530 and hand over the book and beeper. She is also the liaison to the nursing staff as well as an educator for nursing staff. She is able to take verbal orders for changes in epidural and perineural infusions and to bolus catheters via the pump with the infusion solution. She can also manipulate the connections/repair connections and dressings and remove catheters.

Nurses in Florida are not permitted to bolus dose any epidural or perineural catheter with local anesthetic to test function unless they are a CRNA.

 

Staff nurses at Shands UF DO NOT remove catheters or redress or repair disconnects.

 

Staff nurses at Shands UF are not permitted to bolus dose any epidural or perineural catheter via the pump. Only APS may give an additional bolus dose. Nurses may take verbal orders to change the infusion prescription up or down and they can reprogram the pumps.

 

APS Paper Work:

 

A patient log book is maintained for all patients on the service. Attached to the book is a key to the epidural pumps. Please be careful about returning the key to the book.

When a patient is admitted to the APS service, a yellow card is completed and placed in the book. The card should be updated each day on rounds or with adjustments. This is your communication tool. You will be very happy to have it at 0300 when you are called about a patient you may not have seen before. THE BOOK MUST BE KEPT UP TO DATE FOR OPTIMAL PATIENT CARE.

When a patient is discharged from the service, turn the card over and complete the back QA portion. Please make note of problems such as disconnects, dressings that have fallen off, tape burns, blisters etc. Leave the card in the front of the book or place it in Ellyn’s mailbox (RADSON) in the library.

 

A daily visit note is created for every patient who is seen on the APS. This is our chart documentation, communication with the primary service and our billing documentation.

These are preprinted forms that are to be filled out on rounds. IT IS CRITICAL THAT THE FOLLOWING ELEMENTS ARE INCLUDED ON EACH APS DAILY VISIT NOTE:

       Patient name, medical record number and date.  WRITTEN LEGIBLY

       ICD-9 Diagnosis checked in bottom left column

       CPT code and modifiers checked

       Attending signature (only if the attending actually saw the patient)

The top copy of this form is placed in the patient chart in the progress note section when completed. The bottom two copies can be left in the clip board box or placed in Ellyn’s mailbox in the library. These are then submitted for billing.

*  Vital signs for patients on units 75, 54 and 10 trauma are available online in the LCR.

 

Pain Management Consults:

 

We are an ACUTE pain service. However, we are frequently consulted for chronic pain medication management and cancer pain management. We do not have the resources to do interventional procedures at this time. Please check with your attending regarding their willingness to staff a chronic or cancer pain consult. Sometimes a conversation with the intern or resident can solve their question. They all need help converting from PO to IV and from drug to drug. Please see the Shands Pain Treatment Guidelines for assistance with this. Chronic pain, addiction and detox issues can be referred to the Department of Psychiatry Consult Service (265-6902) or to Clinical and Health Psychology (265-0294, Out patient Services only.)

If you are assisting with conversions, please ask an attending to review with you for accuracy if you are at all unsure.

 

CATHETER REPAIR KITS – There is a large baggie and a blue fanny pack with the items needed to repair/test dose an epidural or PNC on 75 in a four drawer lateral file at the back of the nurses’ station near the exit to the hallway.  If you use this equipment, please return the bag to Ellyn’s mailbox in the library to be restocked.

 

You may also obtain all the things you need in the anesthesia workroom.

 

 

OVERVIEW OF RESPONSIBILITIES:

1.   Morning rounds/ Evening rounds

2.   Admission of new patients/care of existing patients

3.   Consults

4.   Call

 

Rounds:  The block room/pre op and PACU resident are all expected to participate in rounds.  Proper attire for rounds is a clean lab coat over scrubs or street clothes. No OR hats, masks, or shoe covers are permitted.

 

Weekday morning rounds will take place as soon as the regional attending and resident are available. The PACU/Pre Op residents should attend AM conference as usual then contact Ellyn (413-7901) to begin pre rounding while the block resident and attending are finishing first case blocks. Patients will be divided to be seen and assessed. The resident will then present the patients they have seen on teaching rounds and do the in room assessment and write orders for any changes. Ellyn will present her patients and the block room resident will write orders. Patient visits should include a review of the primary service progress note and any orders regarding our services.

If the block room is extremely busy and there will be no time for AM rounds, the Pre op and PACU resident will return to their individual assignments after pre rounding. Ellyn will round at a later time with the attending.

 

Block and PACU residents need to return to their primary assignment if paged.

 

On the weekend, the on call resident should consult the OR on call attending prior to rounding as to whether the attending desires to round with you. If they do not wish to round, you should still contact them to discuss any problems prior to leaving the hospital. The on call attending DOES NOT SIGN THE DAILY VISIT NOTE IF HE/SHE DOES NOT ROUND WITH YOU AND ACTUALLY SEE THE PATIENTS.

Weekend rounds may be made slightly later than daily rounds as surgical services do not round as early on the weekends. They should be no later than 10am.

 

The purpose of AM rounds is to:

 

1.               Assess adequacy of pain control

2.               Check presence and severity of side effects

3.               Establish a continued pain management plan

 

Assessment:

 

1.               Review current medications to assure that there are no inappropriate medications ordered. This includes sedative, analgesics or anticoagulants that are not appropriate with epidurals or PNC.

2.               Talk with the patient. Determine a verbal numeric pain rating, both at rest and dynamic pain.

3.               Inquire about side effects

4.               Assess function by requesting patient to use Incentive spirometer or turn in bed.

5.               Perform a sensory motor exam on extremities affected by the particular block. eg. Thoracic epidurals and upper extremity blocks should have an upper extremity assessment as well.

6.               Examine the catheter site for:

Status of dressing

Bleeding

Skin integrity

Infection

Assure that the connection is secure.*

 

Catheter disconnects – Please read the article included in your packet.

The APS nurse or resident must fix catheter disconnects.  Only witnessed disconnects should be repaired. If you have questions, contact the APS or OR attending for advise. If the catheter is not grossly contaminated, it is acceptable to cover it with a sterile dressing and leave it in place until the morning. Service will have to resume pain management. In order to expedite pain control, you may write for interim meds until the service is contacted.

NB-ONLY PERIPHERAL NERVE CATHETHERS THAT ARE CONTIPLEX[LOOK LIKE AN EPIDURAL CATHETER] CAN BE STERILIZED AND CUT.  STIMCATH CATHETERS HAVE A WIRE INSIDE AND CANNOT BE STERILIZED AND CUT.  YOU MUST PULL THESE.

 

      

Address any issues related to the above assessment and formulate a plan. Document the assessment and plan on the daily note and write any necessary orders.*  For epidurals ONLY: If continuing the epidural- place a “red” sticker in the progress notes and in the Physician order section. This reminds everyone that the patient SHOULD NOT be given any Lovenox or other low molecular weight heparin or antiplatelet drugs. If the epidural is being discontinued- place a “black” sticker in the progress notes and the orders. On the sticker, note that anticoagulants may be resumed or started after – 2hours from the time the catheter was removed or if within the first 24 hours, the time is 24hours from the time the back was instrumented. (See the block room procedure note or the OR anesthesia record.)**

 

**You should review the ASRA Guidelines for the use of anticoagulation with epidurals and spinals. This can be found by accessing the ASRA website on the internet: www.asra.com or in our Departmental Core Educational Materials for Regional Anesthesia. 

 

 

The Plan:   Pain scores below 3 are acceptable and do not require any changes. Pain scores greater than 3 or any interference with function require that we make changes to the plan.

 

1.               Address inadequate pain control/side effects  (see separate pain treatment algorithm)

 

Is the catheter working? – At the bedside, a bolus of the current infusion can be helpful in telling you if the catheter is working. If no response to this, consider a more aggressive test dose.* This should be done with monitoring of BP and Pulse OX  and only after a negative CSF check..

 

Adjust the epidural/perineural infusion up or down to improve pain control or relieve side effects. It may be necessary to change the infusion medication .

 

If the epidural/perineural catheter is clearly not working, contact the service and let them know. They will provide IV medication orders.

 

Please advise the nursing staff of changes made to infusions at the bedside. If you bolus the patient through the pump, you should write an order to check vital signs, including LOC in 30min..  If you wish to change a solution to improve pain control or decrease side effect, please write STAT or ASAP on the order sheet and request the clerk to fax immediately. We have been assured that this will facilitate turn around time in pharmacy.

 

Epidural Catheter Test Dose:   A bolus of 5-10 mL of 1% lidocaine with epinephrine is sufficient to make sure that the epidural is still properly placed. The use of more concentrated local anesthetics is unnecessary and increases the risk of complications such as hypotension. When performing a test dose, the vital signs should be taken at 5 minute intervals until it is certain that the patient is hemodynamically stable.* Please check with individual attendings for additional approaches.* Resuscitation equipment, including thiopental to treat local anesthetic toxicity seizures, should be readily available. If you are doing this on the nursing unit, you must stay with the patient for a minimum of 20 minutes and check VS q5. There are crash carts on all nursing units.  A note should be written in the chart.

 

For test dosing or redosing of perineural catheters, please check with your daily attending.

 

 2.  Check the chart or with the service regarding their plan for the patient.

 

Most services will write orders to DC the catheters when they are ready.

 

Most epidural/perineural catheters for orthopedic procedures are left in until POD 2 to facilitate rehab.

 

Gastric Bypass patients usually keep epidurals until POD 3.

 

Thoracic procedure epidurals are usually left in place until the chest tubes are removed.

 

Peds Surgery wants their pectus patients’ epidurals to come out on the 3rd POD. Dr. Kays does not like opiates in his epidurals for pectus.

 

General surgery is variable.

 

Note: Currently we DO NOT offer epidurals to the GYN patients. If the patient is adamant about having an epidural, you MUST check with the surgeon before consenting the patient. These patients will have to be off service and this is not usually acceptable to the GYN group.

 

If you feel that the patient is benefiting and that a change in analgesic technique is not forward progress, then please advocate with the pain  attending for continuing the epidural.

 

APS CALL

 

The regional resident assigned to the block room holds the beeper until the resident who is on call is free to take it and be available to see patients if needed. Ellyn only works until 4 PM.

 

Evening rounds are to be made by the on call resident prior to leaving the hospital. Any new patients who require adjustments, test dosing etc should be taken care of prior to leaving. APS problems must be dealt with in a timely fashion to prevent patient suffering. Acute pain crises are always an emergency to patients and families. It is acceptable to have the call team in the OR or the MOLE team, assess and address an acute problem if they are willing and able to do so. If not, the resident on call will have to return to the hospital to address the problem. Should the APS resident encounter an after  hours problem that requires discussion or assistance, contact the OR on call attending by beeper or phone for guidance. Some APS attendings will accept phone calls. Check before you leave.

 

Please leave the book and beeper in the block room BEFORE YOU GO TO CONFERENCE. Be sure that you have updated the cards.

 

Apsguidelines.doc      rev 09/06