Title:  Management of Patients Receiving Analgesia by Catheter Technique

Advisory Ruling Number: 1001

Authority:

The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education.  In addition, M.G.L. c.30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board.  Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency.  The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.

Date Issued: July 14, 2010

Date Revised:  March 11, 2015

Scope of Practice: Registered Nurse (RN)

Purpose:

To guide the practice of the Registered Nurse (RN) whose clinical responsibilities include the administration and management of analgesic medication by catheter technique in order to alleviate acute or chronic pain, regardless of patient age or setting, by epidural, intrathecal, intrapleural, peripheral nerve routes. 

Analgesia by catheter techniques refers to all non-intravenous catheters used to provide analgesia, including but not limited to, analgesia administered by the epidural, intrathecal, interpleural, and perineural routes of administration.  An external or implanted pump is used to administer the medication for analgesia.

Advisory:

For the purpose of this Advisory Ruling, the term "duly authorized anesthesia provider" means an anesthesiologist licensed by the Board of Registration in Medicine or Advance Practice Registered Nurse authorized by the Board of Registration in Nursing as a Certified Registered Nurse Anesthetist.

Management of the patient receiving analgesia by catheter technique may be performed in accordance with accepted professional standards and only under the following provisions:

  1. In the context of the care of the patient requiring analgesia by catheter technique, the nurse is responsible and accountable for: 
  • Completing education that includes, but is not limited to, advanced knowledge in:
    • Anatomy
    • Patient assessment/screening
    • Safe equipment use
    • Catheter management strategies
  • Verifying that orders are written by a duly authorized prescriber that include, at a minimum the;
    • Drug name
    • Diluent type
    • Concentration
    • Dosing parameters
  • Anticipating and recognizing potential complications
  • Recognizing and appropriately reacting to emergency situations
  1. The RN will assume responsibility for the patient only after the duly authorized anesthesia provider has:
    • Obtained consent for the procedure
    • Placed and verified the correct placement of the catheter/infusion device
    • Provided the initial dosing and established the desired level of analgesia
    • Determined that the patient's vital signs are stable
  1. The RN will practice according to accepted standards including communication with a duly authorized anesthesia provider and other providers in attendance regarding patient status or changes in status during therapy
  2. The RN will adhere to standard precautions, principles of asepsis and infection control and will not place self, patient or others at risk for infectious disease transmission
  3. The RN will document handling, administration and destruction of controlled substances in accordance with all federal and state laws and regulations and in a manner consistent with accepted standards of nursing practice
  4. The RN will ensure documentation is complete, accurate and legible in all records required by federal and state law
  5. The following are NOT considered to be within the scope of practice of a RN who is not a duly authorized anesthesia provider for the management of the patient receiving analgesia by catheter technique:
    • Inserting the catheter for analgesia
    • Verifying catheter position
    • Advancing or repositioning the catheter
    • Administering the first dose of medication or initiating the continuous infusion
  1. Caring for the NON-PREGNANT patient receiving analgesia by catheter technique

In addition to 1 – 7 above, there must be established employer policy and procedure before the RN can perform the following:

    • Preparing the medication for administration with an infusion device
    • Replacing empty infusion drug reservoirs with new, pre-prepared solutions with the same medication and concentration prescribed by a duly authorized prescriber
    • Adjusting the drug dose or infusion rate per prescription of a duly authorized prescriber
    • Administering a prescribed medication re-bolus by continuous infusion by syringe or pump, when the patient has received a previous bolus dose by a duly authorized anesthesia provider
    • Troubleshooting the infusion device
    • Changing infusion device batteries, dressing and tubing
    • Stopping the infusion
    • Removing the catheter, after receipt of a specific order and verifying the patient's anticoagulation status
  1. Caring for the PREGNANT patient receiving analgesia by catheter technique

In addition to 1 – 7 above, there must be established employer policy and procedure that includes RN access to a readily available duly authorized anesthesia provider, before the RN can perform the following:

    • Preparing the medication for administration with an infusion device
    • Assisting to maintain a continuous epidural infusion by replacing empty infusion drug reservoirs with new, pre-prepared solutions containing the same medication and concentration prescribed by a duly authorized prescribe
    • Troubleshooting the infusion device
    • Changing infusion device batteries, dressing and tubing;
    • Stopping the infusion if there is a safety concern or the woman has given birth
    • Removing the catheter, after receipt of a specific order and verifying the patient's anticoagulation status

Nursing care of the PREGNANT patient receiving analgesia by catheter technique does NOT include:

    • Administering the initial dose of medication
    • Adjusting the dose or infusion rate of the medication
    • Administering a bolus or re-bolus of medication
    • Re-starting the infusion once it has been stopped

The nurse in a management role must ensure the availability of sufficient resources to provide for safe implementation, including, but not limited to organizational policies that provide for:

  • Protocols for assessing and documenting the education and validation for RN initial and continued competency for each activity
  • Nursing care responsibilities, including, but not limited to patient assessment, monitoring, medication administration, potential complications, and documentation criteria
  • Emergency protocols including, but not limited to, immediate, on site availability of emergency equipment, medications and personnel

 

References

This information is provided by the Division of Health Professions Licensure within the Department of Public Health.