Obstetric Anesthesia/analgesia can Work in a Small Hospital: the Key Principles are Commitment, Flexibility, and Planning
James S. Hicks MD, MM
The ability to offer obstetric (OB) conduction anesthesia to laboring patients in a small hospital where 24-hour in-house anesthesia coverage is not available or feasible is both a challenge and an opportunity to provide excellent service both to patients and obstetric colleagues. To be successful, interposing obstetric conduction anesthesia services within a surgical schedule and managing the same service after usual operating room hours require careful planning, interdisciplinary cooperation, and ongoing continuous quality improvement.
Among the challenges that must be addressed to provide satisfactory small hospital OB services are the following:
Recognize and minimize the potential delay in the elective surgical schedule required to perform epidurals
Recognize and minimize the delay in responding to requests for epidural anesthesia due to the unavailability or on-call status of the anesthesia provider
Manage the potential inability to provide timely emergency cesarean section anesthesia
Recognize the need for obstetric nurses to assist with management of epidural infusions and provide them with appropriate education and experience
Meet regulatory requirements
Surmounting these obstacles requires a commitment on the part of the anesthesiology service that obstetric anesthesia is no less of a priority than surgical anesthesia. This does not imply that obstetric anesthesia will take priority on the surgical schedule, but simply that the efforts to meet the needs of obstetric patients are genuine, compassionate, and equivalent to our efforts to provide excellent surgical anesthesia.
Successful rural OB service is achievable. The American Society of Anesthesiologists’ (ASA) Consultation Program has provided hospitals with the expertise of board-certified anesthesiologists who are specially trained in assessing anesthesia practices and in providing recommendations for
improvement. The program also provides ASA with a multiple-exposure snapshot of many anesthesia practices, many of which involve rural anesthesia coverage. The following recommendations are the result of experiences drawn from observations gained from this program throughout the United States:
improvement. The program also provides ASA with a multiple-exposure snapshot of many anesthesia practices, many of which involve rural anesthesia coverage. The following recommendations are the result of experiences drawn from observations gained from this program throughout the United States:
Convene a “council of stakeholders” composed of anesthesia providers, obstetricians (and, if applicable, family practitioner and certified nursemidwife obstetric providers), surgeons, emergency physicians, obstetric nurses, pharmacy, and hospital administration. Obtain consensus from this group that labor epidural analgesia for all patients desiring such is a worthwhile and desirable goal. To gain this consensus, council members must acknowledge that the needs of the patients may require customization of policies that would, if otherwise applied, preclude the ability to have labor analgesia coverage. For example, pharmacists need to acknowledge the need to maintain adequate supplies of premixed epidural solutions, even if this results in occasional outdates of solutions. Obstetric nurses must be willing to titrate epidural anesthesia infusions (given clear parameters and orders) in the face of a national organization’s recommendations to the contrary. Surgeons must acknowledge the occasional delay between cases for the anesthesia provider to place an epidural catheter. None of these roadblocks has proven to be an obstruction to the small hospital and anesthesia service that are determined to offer comprehensive OB anesthesia, however.Related posts:
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