Multidisciplinary Task Force Improves Epidural Procedures
The Epidural Task Force, which included members from Anesthesia, Nursing, Pharmacy, Surgery, Risk Management and the Patient Safety Team, was established in 2004 by Andy Whittemore, MD, BWH's CMO, to review postoperative, non-ICU management of epidural anesthesia.
"We convened this multidisciplinary task force to review unexplained complications in patients who underwent epidural anesthesia," said Tejal Gandhi, MD, director of Patient Safety.
After reviewing patient cases, relevant literature and safety reports, the task force recommended and implemented several changes. Specifically, the task force created new guidelines on the use of anticoagulants in the management of patients receiving epidural anesthesia and guidelines for recognizing and treating hypotension in patients receiving epidural anesthesia. These guidelines were shared with clinical staff in Surgery, Medicine, Pharmacy and Nursing and are available on the intranet and the Partners Handbook.
The task force also developed detailed guidelines for monitoring patients, including how often to monitor patients at initiation of epidurals, during the infusion and after the epidural is discontinued. In addition, monitoring guidelines for high risk patients, such as patients with sleep apnea, were created. These monitoring guidelines were incorporated into the epidural ordering templates in order entry (OE). The epidural templates also underwent major revisions to ensure more accurate and clear ordering.
The task force implemented additional key changes to enhance the safety of epidural ordering:
1. Implemented several Bupivacaine drug-drug interaction (DDI) notifications within the OE System, including a hard stop in the Pharmacy System for certain interactions. These DDIs were also added Partners-wide.
2. Linked epidural OE and Pharmacy systems to prevent duplicate orders.
3. Changed the dose field within the Pharmacy system to automatically fill in the dose of the epidural expressed as ml/hour.
4. Implemented a 24-hour expiration date for epidural orders.
5. Standardized the description of epidural mixes across all of the clinical systems (OE, Pharmacy, Omnicell, eMAR); this entailed eliminating the fractions or fractional percentages and using decimals.
6. Prohibited physicians from adding ingredients in the "special instructions" section of OE because it will not be translated to Pharmacy with eMAR.
7. Added "Infuse at cap" option in OE.
8. Prevented patients from being deleted from the epidural worksheet at the time of transfer so the Pain Service can continue to follow those patients .
9. Prevented patients from being removed from the epidural worksheet after the epidural order has been discontinued, so the Pain Service can continue to follow those patients.