Week 2 dq 1

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❖ One 18-gauge, -inch (1.3 × 80 mm) epidural needle (pink)

❖ One 0.45 × 0.85–inch epidural catheter

• One introducer stabilizing catheter guide
• One screw-cap locking tip catheter
• One 0.2-μm screw-cap locking tip catheter connector
• One epidural flat filter
• Topical skin antiseptic, as prescribed
• Sterile towels
• Sterile forceps
• Sterile gauze, 4 × 4 pads
• Face masks with eye shields
• Sterile gloves and gowns
• 20 mL normal saline solution
• 5 to 10 mL local anesthetic as prescribed (e.g., 1% lidocaine; local infiltration)
• 5 mL local anesthetic as prescribed to establish the block
• Test dose (e.g., 3 mL 2% lidocaine with epinephrine, 1:200,000)
• Gauze or transparent dressing to cover the epidural catheter entry site
• Tape to secure the epidural catheter to the patient’s back and over the patient’s shoulder
• Labels stating “Epidural only” and “Not for intravenous injection”
• Pump for administering analgesia (e.g., volumetric pump, dedicated for epidural use with rate and volume

limited, which has the ability to be locked to prevent tampering and preferably is a color-coded [e.g., yellow] or
patient-controlled epidural analgesia pump)

• Dedicated yellow-lined, epidural portless administration set
• Prescribed medication analgesics and local anesthetic medications
• Equipment for monitoring blood pressure, heart rate, and pulse oximetry

Additional equipment, to have available as needed, includes the following:
• Ice or alcohol swabs for demonstrating level of block
• Capnography equipment
• Emergency medications (e.g., naloxone for respiratory depression, intravenous colloids, and a vasoconstrictor

such as ephedrine for hypotension and Intralipid, a 20% fat emulsion for local anesthetic toxicity)
• Bag-valve-mask device and oxygen
• Intubation equipment

Patient and Family Education
• Review the principles of epidural use with the patient and family members. If the patient’s pain needs are not

met, an assessment of the therapy will be completed and the physician, advanced nurse practitioner, or other
healthcare professional may change the dosage or therapy to meet those needs. If available, supply easy-to-
read written information. Rationale: This information prepares the patient and family for what to expect and may
reduce anxiety and preconceptions about epidural use.

• Explain to the patient and family that the insertion procedure can be uncomfortable but that a local anesthetic
will be used to facilitate comfort. Rationale: Explanation promotes patient cooperation and comfort, facilitates
insertion, and decreases anxiety and fear.

• During insertion and therapy, instruct the patient to immediately report adverse side effects, such as ringing in
the ears, a metallic taste in the mouth, or numbness or tingling around the mouth, because these are signs
indicative of local anesthetic toxicity.13,30,33 Rationale: Immediate reporting identifies side effects and
impending serious complications.

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• Review an appropriate pain rating scale with the patient. The physician, advanced practice nurse, or other
healthcare professional and the patient need to establish a mutually agreeable pain level goal. Rationale:
Review ensures that the patient understands the pain rating scale and enables the nurse to obtain a baseline
assessment. Establishing a pain level goal allows the physician, advanced practice nurse, or other healthcare
professional to know an acceptable goal for pain management.

• During insertion and therapy, instruct the patient to report changes in pain management (e.g., suboptimal
analgesia), numbness of extremities, loss of motor function of lower extremities, acute onset of back pain, loss
of bladder and bowel function, itching, and nausea and vomiting.4,13,14,17 Rationale: Education regarding adverse
side effects allows for more rapid assessment and management of potential complications.

• If the epidural infusion is patient-controlled, ensure that patient and family understand that only the patient is to
activate the medication release. Rationale: The patient should remain alert enough to administer his or her own
dose. A safeguard to oversedation is that a patient cannot administer additional medication doses if he or she is
sedated.

Patient Assessment and Preparation
P a ti e nt Asse ssm e nt
• Assess the patient for local infection and generalized sepsis. Rationale: Assessment decreases the risk for

epidural infection (e.g., epidural abscess).31 Septicemia and bacteremia are contraindications for epidural
catheter placement.4,8,23,27

• Assess the patient’s concurrent anticoagulation therapy. Rationale: Heparin (unfractionated) or heparinoids
(e.g., low-molecular-weight heparin) administered concurrently during epidural catheter placement increases
the risk for epidural hematoma and paralysis. Care must be taken with insertion and removal of the epidural
catheter when patients have received anticoagulation therapy. Anticoagulant and fibrinolytic medications may
increase the risk for epidural hematoma and spinal cord damage and paralysis. If used, anticoagulants must be
withheld before insertion and removal of the epidural catheter.21,25,26 Removal of the epidural catheter should be
directed by the physician. According to Kleinman and Mikhail,13 aspirin or nonsteroidal antiinflammatory
medications (NSAIDs) by themselves do not pose an increased risk for epidural hematoma, assuming the
patient’s coagulation profile is within normal limits. Therefore aspirin or NSAIDs may be administered while the
epidural catheter is in place.13 However, epidural hematomas have been associated with the concurrent
administration of the NSAIDs, ketorolac, and anticoagulants.12,21 Assessment of sensory and motor function
must be regularly performed during epidural analgesia for all patients.

• Obtain the patient’s vital signs. Rationale: Baseline data are provided.
• Assess the patient’s pain. Rationale: Baseline data are provided.
• Review the patient’s medication allergies. Rationale: This information may decrease the possibility of an allergic

reaction.

Patient Preparation
• Ensure that the patient and family understand preprocedural information. Answer questions as they arise, and

reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.

• Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the
nurse and team members should ensure the correct identification of the patient for the intended intervention.

• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient
and makes a competent decision possible for the patient.

• Perform a preprocedure verification and time out including all team members. Rationale: This action ensures
patient safety.

• Wash the patient’s back with soap and water and open the gown in the back. Rationale: This action cleanses
the skin and allows easy access to the patient’s back.

• Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be used. Rationale: NPO
status decreases the risk for vomiting and aspiration.

• Establish IV access, or ensure the patency of IV catheters, and administer IV fluids as prescribed before
epidural catheter insertion. Rationale: IV access ensures that medications can be given quickly if needed. The
administration of IV fluids may decrease hypotension that may occur during epidural infusions.4,13

• Reassure the patient. Rationale: Anxiety and fears may be reduced.

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Procedure for Pain Management: Epidural Catheters (Assisting
With Insertion and Initiating Continuous Infusion)

FIGURE 105-2 Patient positioned for catheter placement. This figure shows two positions
patients can assume for the epidural catheter placement procedure. (From Pasero C, McCaffery M:
Pain assessment and pharmacologic management, St. Louis, 2011, Elsevier.)

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FIGURE 105-3 Dermatomes. Segmental dermatome distribution of spinal nerves to the front,
back, and side of the body. Dermatomes are specific skin surface areas innervated by a
single spinal nerve or group of spinal nerves. Dermatome assessment is done to determine
the level of spinal anesthesia for surgical procedures and postoperative analgesia when
epidural local anesthetics are used. C, Cervical segments; T, thoracic segments; L, lumber
segments; S, sacral segments; CX, coccygeal segment. (From Patton KT, Thibodeau GA: Anatomy and
physiology, ed 9, St. Louis, 2016, Elsevier.)

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Steps Rationale Special Considerations

1.

2. Physicians, advanced practice nurses, and other
healthcare professionals should apply personal
protective equipment (e.g., face masks with eye
shields). All physicians, advanced practice
nurses, and other healthcare professionals
present during epidural insertion should wear a
hat and mask. The individual performing the
procedure should wear hat, mask, sterile gown,
and gloves.

3. Obtain the prescribed
epidural medication
infusion from the
pharmacy.

The medication
should be
prepared with
aseptic technique
by the pharmacy
with laminar flow
or prepared
commercially to
decrease the risk
for an epidural
infection.23,27,28

All epidural solutions are preservative-free to avoid
neuronal injury.30

4. Connect the epidural tubing
to the prepared epidural
medication infusion and
prime the tubing.

Removes air from the
infusion system.

5. Ensure that the patient is in
position for catheter
placement. Assist with
holding the patient in
position (lateral decubitus
knee-to-chest position or
leaning over bedside table)
and consider preprocedure
analgesia or sedation, if
necessary (Fig. 105-2).

Facilitates ease of
insertion of the
epidural catheter.
Both positions
open up the
interspinous
spaces, aiding in
epidural catheter
insertion (see Fig.
105-2).

Movement of the back may inhibit placement of the
catheter.

6. Assist as needed with the
antiseptic preparation of
the intended insertion site.
(Level C*)

Reduces the
transmission of
microorganisms
into the epidural
space.

The choice of povidone-iodine or chlorhexidine as
an antiseptic agent for neurological procedures
is controversial. Both should be allowed to dry
completely. Studies suggest chlorhexidine is
neurotoxic.10,18,24

7. Assist if needed with
draping the patient with
exposure only of the
insertion site.

Aids in maintaining
sterility.

8. Assist the physician or
advanced practice nurse
as needed as the epidural
catheter is placed.

Provides needed
assistance.

9. Monitor the patient as the
physician or advanced
practice nurse administers
2–3 mL of 1% lidocaine
containing 1:200,000
epinephrine as a test dose.

To confirm proper
placement of the
epidural catheter

An immediate increase in heart rate indicates the
catheter has inadvertently penetrated an
epidural vein. If this occurs the physician,
advanced practice nurse, or other healthcare
professional inserting the catheter should

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withdraw the catheter slightly or remove it and
insert a new catheter.29

10. After the epidural catheter
is inserted, assist as
needed with application of
a sterile, occlusive
dressing.

Reduces the
incidence of
infection.

Use of a transparent dressing allows for ongoing
assessment of the insertion site for infection,
leakage, or dislodgment.

11. Secure the epidural filter to
the patient’s shoulder with
gauze padding.

Avoids disconnection
between the
epidural catheter
and filter. Gauze
padding prevents
discomfort and
skin pressure
from the filter.

12. The physician or advanced
practice nurse administers
a bolus dose of
medication.

Facilitates a
therapeutic level
of analgesia and
confirms correct
catheter position.9

If a local anesthetic is used for the bolus, monitor
the blood pressure frequently, with assessment
for possible hypotension. Some analgesia
medications (e.g., morphine) may take up to 1
hour to be effective.13,14,30

13. Connect the prescribed
medication infusion
system.

Prepares the infusion
system.

14. Initiate therapy:

A. Place the system in the
epidural pump or PCEA
pump and set the rate and
volume to be infused.

No other solution or
medication (e.g.,
antibiotic or total
parenteral
nutrition) should
be given through
the epidural
catheter.33

Responses to epidural analgesia vary individually,
and epidural analgesia is tailored according to
individual responses.

B. Attach an “Epidural only”
label to the epidural tubing.
Use a portless system.4,33
(Level E*)

Inadvertent
intravenous
administration of
some epidural
solutions can
cause serious
adverse
reactions,
including
hypotension and
cardiovascular
collapse.11,28

C. Lock the key pad on the
epidural or PCEA pump.

This is an important
safety feature.

15. Assess the effectiveness
of the analgesia. Follow
institutional standards for
assessing pain.

Identifies the need
for additional pain
medication and
interventions.

A. Determine the pain score. Tolerable pain scores
should be
reported at rest,
and very little pain
should be

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experienced with
deep breathing,
coughing, and
movement.

B. Assess the level of the
epidural block with ice or an
alcohol swab.6

The ideal epidural
block should be
just above and
just below the
surgical incision
or the trauma site
(see the
dermatomes
described in Fig.
105-3).

16. Remove and sterile
equipment and discard
used supplies in an
appropriate receptacle.

Removes and safely
discards used
supplies.

17.
*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized
controlled trials with inconsistent results.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational
standards without clinical studies to support recommendations.

Procedure for Epidural Catheter (Bolus Dose Administration)
Without a Continuous Infusion

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Steps Rationale Special Considerations

1.

2.

3. Boldly label the epidural catheter
used for intermittent bolus dosing
(suggest color coding).4,33 (Level
E*)

Reduces the risk for administration of
medication into intravenous lines.

4. Verify the correct medication with
the five rights of medication
administration.

Before performing a procedure, the
nurse should ensure that the
correct medication is being
administered.

5. Prepare the bolus dose as
prescribed.

Use only preservative-free solution to
dilute assuring a decreased risk
of neuronal injury.4,13

Do not use multidose vials
because they increase
the risk for
contamination and the
risk for an epidural
infection.4,14

6. Prepare and cleanse the epidural
port with an antiseptic agent. (Level
C*)

Do not use an alcohol-based
preparation. Use aqueous
chlorhexidine or povidone-iodine.

Preparations with alcohol
are neurotoxic to the
epidural space. The
choice of povidone-
iodine or chlorhexidine
as an antiseptic agent
is controversial. Both
should be allowed to
dry completely. Studies
suggest chlorhexidine
is neurotoxic.10,18,14

7. Use aseptic technique to
administer the epidural bolus:

A. Connect an empty syringe to
the catheter port.

Administers the medication for
injection.

Follow state and
institutional guidelines
as to who is able to
provide bolus doses.

B. Aspirate the epidural catheter,
limited by the amount allowed by
institutional policy. If blood is
aspirated, do not reinject the
aspirate. Do not inject the
medication. Notify the physician or
advanced practice nurse. If clear
fluid is obtained, it may be CSF. Do
not reinject the aspirate. Do not
inject the medication. Notify the
physician or advanced practice
nurse.6,9,19,30

If blood is obtained, the epidural
catheter may have migrated
into an epidural vessel. An
amount of only 1–2 mL of
blood may be inconclusive
because any blood from an
epidural vein may have mixed
with blood from the trauma of
inserting the catheter. If more
than 3 mL is aspirated, the
catheter is most likely in an
epidural vein.30

If 5 mL or more of CSF is
obtained, the catheter may
have migrated into the
subarachnoid space.30

Administration of epidural
medications into the
epidural vein or into the
subarachnoid space
may result in increased
sedation, respiratory
depression,
hypotension, and
bradycardia.

C. Connect the syringe with the bolus
medication to the catheter port.

Prepares for the injection.

D. Administer the medication slowly.
Note: If excessive pressure occurs,
assess for kinks in the catheter or
reposition the patient.

Some resistance will be felt because
the diameter of the epidural space
is small and the epidural filter is in
place.

Excessive pressure
may be more
pronounced if the
epidural catheter is

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placed at the
lumbar dermatome
as opposed to the
thoracic
dermatome.

If resistance
continues to impair
administration of a
bolus dose,
contact the
physician or
advanced practice
nurse.

8. Assess the effectiveness of the
medication. Follow institutional
standards for assessing pain.

Identifies need for pain interventions.
Pain should be relieved or
decreased.

Report continued pain
despite pain
interventions.

9. Monitor vital signs. An epidural bolus may cause
hypotension, bradycardia,
respiratory depression, or
increased sedation.11,28

Report untoward
decreases in blood
pressure, heart rate,
respirations, oxygen
saturation, and
sedation.

10. Monitor for increased motor and or
sensory block, and signs and
symptoms of local toxicity related
to the epidural medications.

Allows for the early identification of
signs and symptoms of local
anesthetic toxicity which include
lightheadedness, tinnitus, metallic
taste, visual disturbances, perioral
numbness loss of
consciousness, seizure,
arrhythmia, and asystole.4

11. Remove and discard used
supplies.

12.
*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized
controlled trials with inconsistent results.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational
standards without clinical studies to support recommendations.

Procedure for Assisting With Removal of the Epidural Catheter

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Steps Rationale Special Considerations

1.

2. Physicians, advanced practice nurses, and other
healthcare professionals should apply
personal protective gear (e.g., face masks with
eye shields), and sterile gloves may be worn by
the physician, advanced practice nurse, or
other healthcare professional removing the
catheter.

3. Assist the
physician or
advanced practice
nurse as needed
with removal of the
catheter.

Facilitates catheter removal.

4. Assist if needed
with applying a
sterile occlusive
dressing.

Reduces contamination by
microorganisms.

5. Remove personal
protective
equipment and
discard used
supplies in an
appropriate
receptacle.

Removes and safely discards
used supplies.

6. Assess
neurological status,
pain, and insertion
site after removal
of the epidural
catheter.

Motor or sensory loss in
the extremities may be
an early warning sign
of an epidural abscess
or hematoma or may
indicate an excessive
dose of a local
anesthetic.26,27

An epidural hematoma is
a rare but serious
complication; if
undetected, it may
result in permanent
paralysis.14,16,22,32

Assess for a change in sensory or motor function
in extremities, sudden onset of back pain with
increasing motor weakness, and loss in
bladder and bowel function.

A. Monitor sensory
and motor status of
lower extremities
and ability to void up
to 24 hours after
removal of the
catheter (see Fig.
105-3).2,8,14,16

Identifies potential adverse
effects of epidural
analgesia.

B. Monitor insertion
site for drainage or
infection.

Identifies adverse effects of
epidural analgesia such as
infection.

C. Continue to assess
pain.

Identifies need for ongoing
interventions to manage
pain.

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7.

Expected Outcomes
• The epidural catheter is inserted into the epidural space
• Pain is decreased and maintained at a tolerable level
• The patient experiences minimal sedation
• The patient experiences minimal numbness and no motor loss in the limbs
• Hemodynamically stable
• No opioid-related respiratory depression or decreased respiratory blockade from local anesthetic affecting the

diaphragm or ancillary muscles required for inspiration and expiration

Unexpected Outcomes
• Inability to insert the epidural catheter
• Suboptimal pain relief13

• Oversedation or drowsiness11,28

• Opioid-induced respiratory depression or hypoxia11,28

• Hypotension14,19,30

• Motor blockade of limbs; lower extremity weakness13,19,30

• Sensory loss in the limbs13,19,30

• Patchy block (e.g., uneven pain relief)13

• Unilateral block (e.g., pain relief on the contralateral side of the body only)13

• Nausea and vomiting8,14,17,28

• Pruritus1,8,14,17,28

• Urinary retention1,8,14,16,28

• Accidental dural puncture into the subarachnoid space13,33

• Dural puncture headache13,33

• Epidural catheter tip migration into a vessel or adjacent structure13

• Redness or signs of skin breakdown at pressure area sites (e.g., sacrum, heels) from decreased sensation
• High epidural block— epidural local anesthetic block above the thoracic fourth vertebrae (T4)14

• Total spinal blockade13

• Occlusion of epidural catheter13

• Accidental epidural catheter dislodgment13

• Dressing disruption exposing insertion site
• Leakage from the epidural catheter insertion site13,33

• Cracked epidural filter
• Local anesthetic toxicity13

• Anaphylaxis14

• Epidural hematoma8,25,26,28

• Epidural abscess8,25,27,28

• Local erythema or drainage at insertion site32

• Nerve or spinal cord injury13

• Accidental connection of the epidural solution to the intravenous fluids33

• Accidental connection of intravenous fluids to the epidural catheter.
• Local anesthetic toxicity13,14

• Cardiopulmonary arrest13

Patient Monitoring and Care

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Steps Rationale Reportable
Conditions

These conditions
should be
reported if
they persist
despite
nursing
interventions.

1. Assess the patient’s level of pain with
use of a pain scale.9,14,30 The
frequency of assessments is
determined by institutional standards.
Record the patient’s subjective level of
pain, with use of the institution’s
standard pain assessment tool.

Describes patient response to pain
therapy. A low pain score is
expected both at rest and during
movement.

Analgesic goal is safe, steady pain
control at a low level that is
acceptable to the patient.

• Moderate to
severe pain
scores

2. Assess the patient’s level of
sedation9,14,30 with use of the
institution’s standard assessment
scale and frequency standard.

Sedation precedes opioid-related
respiratory depression. A sudden
change in sedation scale may indicate
that the epidural catheter has migrated
into an epidural blood vessel or the
intrathecal space.11

• Increasing
sedation and
drowsiness
or sudden
change in
sedation
scale

3. Assess respiratory rate the first 20
minutes after administration of the
epidural medication, and/or bolus then
every 1–2 hours and as needed
(prn).11,14,28 (Level D*)

Provides data for diagnosis of respiratory
depression.

• Increasing
respiratory
depression
or sudden
change in
respiratory
rate
combined
with
increasing
somnolence

4. Assess heart rate14,28 with vital signs
every 2 hours, then every 4 hours when
stable.

Tachycardia may indicate a condition such
as shock. Bradycardia may indicate
opioid overmedication and sympathetic
blockade by the local anesthetic.13,19

• Change in
heart rate

• Abnormal
heart rate

• Abnormal
cardiac
rhythm

5. Assess blood pressure with vital signs
every 2 hours, then every 4 hours when
stable. If hypotension occurs:

A. Turn off the epidural infusion;
notify the physician, advanced
practice nurse, pain relief
service.

B. Place the patient in a supine, flat
position.

C. Administer IV fluids as
prescribed or according to
protocol.

D. Administer vasopressor
medications as prescribed.14,28

Epidural solutions that contain a local
anesthetic may cause peripheral and
venous dilation, providing a
“sympathectomy.”14 The hypotensive
effect of a local anesthetic is most
common when a patient’s fluid status is
decreased. Epidural analgesia may not
be the sole cause of hypotension but
may reveal hypovolemia.

• Hypotension

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E. Use caution when raising patient
from lying to sitting or sitting to
standing positions.31

6. Monitor the infusion rate with vital
signs. Ensure that the control panel is
locked if using the volumetric infuser
or ensure that the PCEA program is
locked in via key or code access.

Ensures that the medication is
administered safely.

7. Monitor oxygen saturation and end-
tidal carbon dioxide if prescribed or
continuously as per institutional
policy.11,14 (Level E*)

Assesses oxygenation. A decrease in
oxygen saturation is a late sign of opioid
oversedation and should not be solely
relied on to detect oversedation.

• Oxygen
saturation
<93% or a
decreasing
trend in
oxygenation

• Note:
Decreased
oxygen
saturation is
a late sign of
opioid
oversedation
and should
not be solely
relied on to
detect
oversedation
.

8. Obtain the patient’s temperature11,14
every 4 hours; assess more often if
febrile. (Level E*)

Fever may signify an epidural space
infection or systemic infection that is a
potential risk when an epidural catheter
is in place.14,17,27,32

• Temperature
>101.3°F
(38.5°C)

9. Assess the epidural catheter site every
4 hours or according to established
institutional standards.14,32

Identifies site complications and infection.
An epidural abscess is a rare but
serious complication. Patient recovery
without neurological injury depends
largely on early recognition.14,17,27,32

• Redness
• Tenderness

or increasing
diffuse back
pain

• Pain or
paresthesia
during
epidural
injection
induration

• Swelling or
presence of
exudate

10. Monitor ability to void and ability to
completely empty bladder.1,8,14 (Level
E*)

Provides data regarding urinary retention
and possible early signs of epidural
abscess or epidural
hematoma.8,14,26,27,32

• Urinary
retention

• Change in
bladder
function

• Lack of
urination for
>6–8 hours

11. Monitor for sensory and or motor loss
(e.g., leg numbness or inability to bend
knees) at least every 4 hours and prn
(see Fig. 105-3).2,8,14,16 (Level E*)

Motor or sensory loss in the extremities
may be an early warning sign of an
epidural abscess or hematoma or may
indicate an excessive dose of a local

• Change in
sensory or
motor

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anesthetic.26,27 An epidural hematoma
is a rare but serious complication; if
undetected, it may result in permanent
paralysis.14,16,17,32

function in
extremities

• Sudden
onset of
back pain
with
decreasing
motor
weakness

• Loss in
bladder and
bowel
function
(e.g.,
incontinence
)

12. Assess for ringing in the ears, tingling
around lips, or a metallic taste.5,13,14
(Level E*)

If a local anesthetic is used in the epidural
solution, ringing in the ears, tingling
around the lips, or a metallic taste may
indicate impending local anesthetic
toxicity.5,13,14

• Ringing in
the ears,
tingling
around the
lips, or a
metallic
taste

13. Monitor and check skin integrity of the
sacrum and the heels every 2 hours
and as needed. Change the patient’s
position as needed.

If a local anesthetic is used in the epidural
solution, check for pressure points and
decubitus ulceration (patient may have
sensory loss in lower limbs).13,19,30

• Altered skin
integrity

• Increasing
redness or
blistering of
the skin on
the sacrum
or heels

14. Change the epidural catheter insertion
site dressing as prescribed or if soiled,
wet, or loose. Call physician or
advanced practice nurse if catheter
site is exposed. Follow institutional
standards.

Provides an opportunity to cleanse the area
around the catheter and to assess for
signs and symptoms of infection that
may indicate early signs of an epidural
abscess.14,27

• Swelling
• Site pain
• Redness
• Leakage of

epidural
solution or
drainage

15. Assess for the presence of nausea or
vomiting.8

Antiemetics may need to be administered;
the medication may need adjustment
(e.g., opiates may need to be decreased
or stopped if nausea and vomiting are
not well controlled).

• Unrelieved
nausea and
vomiting

• Note:
Nausea and
vomiting
may be a
sign of
severe
hypotension.

16. Assess for the presence of pruritus.2,8 Epidural opiates may cause itching.
Medications such as antihistamines

may cause sedation and are
ineffective for spinally mediated
itching. Low-dose opioid
antagonists may be necessary to
relieve pruritus. Small doses of
naloxone (e.g., 0.04 mg) are

• Itching
• Redness
• Rashes

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effective for pruritus without
reversing the analgesia.13,19

Diphenhydramine or hydroxyzine can
also be effective for itching
associated with dehydration but
may cause increased sedation.13,19

17. Label the epidural pump and tubing33
and consider placing the epidural
pump on one side of the patient’s bed
and all other pumps on the other side
of the bed. Consider the use of a
different colored label for the epidural
pump and the tubing to differentiate it
from pumps and tubing for
intravenous fluids and medications.

May aid in minimizing the risk for mistaking
the epidural infusion for an IV infusion
system. Cardiopulmonary arrest and
seizures may occur if the epidural
solution is infused intravenously.13

• Infusion of
IV fluid into
the epidural
space

• Infusion of
epidural
solution into
the IV

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational
standards without clinical studies to support recommendations.

Documentation
Documentation should include the following:
• Patient and family education
• Completion of informed consent
• Preprocedure verifications and time out
• Any difficulties associated with insertion
• Type of dressing used
• Confirmation of epidural catheter placement (e.g., decrease in blood pressure, demonstrable block to ice; see

Fig. 105-3)
• Site assessment
• Preintervention and serial pain assessment, including levels of motor and sensory blockade (documented on an

appropriate flow chart at regular intervals; see Fig. 105-3) and effectiveness of interventions30

• Sedation score assessment
• Vital signs and oxygen saturation11

• Epidural analgesic medication and medication concentration being infused and infusion rate per hour
• Bolus dose administration and patient response after bolus dose, including effectiveness of pain relief
• Occurrence of unexpected outcomes or side effects
• Nursing interventions taken
• Pump settings when programmed for PCEA
• Medication concentrations, continuous infusion rate, bolus dose, lockout interval, limit for 1 or more hours

according to institutional standards
• Pain assessment, interventions, and effectiveness

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P R O C E D U R E 1 0 7

Peripheral Nerve Blocks

Assisting with Insertion and Pain Management

Kimberly Williams

P U R P O S E :

Peripheral nerve blocks are administered as single local anesthetic injections or continuously through a
catheter placed into a precise anatomical area to provide site-specific analgesia or anesthesia.

Prerequisite Nursing Knowledge
• State boards of nursing may have detailed guidelines involving peripheral nerve blockade. Each institution that

provides this therapy also has policies and guidelines pertaining to peripheral nerve blockade. It is important
that the nurse is aware of state guidelines and institutional policies.15

• The nurse must have an understanding of the principles of aseptic technique.9,12,19,23,39

• The nurse assisting with the insertion of peripheral nerve blocks requires specific skills and knowledge.15

• Catheter placement and management of the patient should be under the direct supervision of an
anesthesiologist, nurse anesthetist, or the acute pain service.24,26,39 Peripheral nerve blocks are used as part of
a preemptive and multimodal analgesic technique to provide safe and effective postoperative pain
management with minimal side effects.10,12,14,18,21

• Peripheral nerve blocks are site specific (e.g., femoral, brachial plexus, axillary, intrapleural, extrapleural,
paravertebral, tibial, sciatic, lumbar plexus) and provide prolonged anesthesia or analgesia for postoperative and
trauma pain management.4,26

• Peripheral nerve blocks in the outpatient setting have facilitated early patient ambulation and discharge by
decreasing side effects, such as drowsiness, nausea, and vomiting.3,11,13,18 In addition, unlike general
anesthesia, peripheral nerve blocks do not directly alter the level of consciousness. By preserving the patient’s
level of consciousness, the patient’s protective airway reflexes (e.g., cough and gag) are maintained and the
need for airway manipulation and intubation is negated. Furthermore, with the use of peripheral nerve blockade,
the complications of general anesthesia are avoided.3 Continuous peripheral nerve blockade improves
postoperative analgesia, patient satisfaction, and rehabilitation compared with intravenous (IV) opioids for
upper- and lower-extremity procedures.11,13,18,26,31

• The anatomical position of the specific catheter should be clearly defined and documented after insertion by the
physician or advanced practice nurse (e.g., femoral, axillary [Figs. 107-1 and 107-2], brachial plexus [Fig. 107-3],
intrapleural, extrapleural, paravertebral, tibial, sciatic, lumbar plexus).5,32 Radiological confirmation6 of the
catheter position may be necessary to avoid suboptimal outcomes (e.g., pneumothorax). Catheters may be
placed by the surgeon, anesthesiologist, or certified nurse anesthetist under direct vision, via ultrasound scan–
guided techniques or with the use of a peripheral nerve stimulator, either adjacent to or directly into the nerve

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sheath (e.g., sciatic or tibial nerve during surgery for lower-limb amputation).16,19,21,23,29,31 Catheters may also be
placed after surgery (e.g., intercostal, intrapleural, axillary, brachial plexus, femoral, paravertebral; Table 107-1).

FIGURE 107-1 Location for needle insertion for an axillary block. (From Sinatra RS: Acute pain:
Mechanisms & management, St Louis, 1992, Mosby.)

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FIGURE 107-2 Needle insertion for an axillary block. (From Sinatra RS: Acute pain: Mechanisms &
management, St Louis, 1992, Mosby.)

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FIGURE 107-3 Landmarks for interscalene brachial plexus block. (From Sinatra RS: Acute pain:
Mechanisms & management, St Louis, 1992, Mosby.)

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TABLE 107-1
Single-Shot (One-Time, Single Injection) and Continuous Peripheral Nerve Blocks

Block Indications Practical Problems

Interscalene Shoulder/arm pain (e.g., shoulder dislocation/fractures, humeral
fracture)

• Horner’s
syndrome
may obscure
neurological
assessment

• Block of
ipsilateral
phrenic nerve

• Close
proximity to
tracheostomy
and jugular
vein line sites

Cervical
paravertebral
(continuous
catheter
only)

Shoulder/elbow/wrist pain (e.g., shoulder fractures, humeral fracture,
elbow fractures, wrist fractures)

• Horner’s
syndrome
may obscure
neurological
assessment

• Block of
ipsilateral
phrenic nerve

• Patient
positioning

Infraclavicular Arm/hand pain (e.g., elbow fractures, wrist fractures) • Pneumothorax
risk

• Steep angle
for catheter
placement

• Interference
with
subclavian
lines

Axillary Arm/hand pain (e.g., elbow fractures, wrist fractures) • Arm
positioning

• Catheter
maintenance

Intercostal Blockade used for management of pain due to traumatic rib fractures.
Commonly an elastomeric infusion pump, which is a balloon filled
with local anesthetic attached to a catheter placed at the site of
injury. This delivery system results in slow infusion of local
anesthetic for pain control. This provides pain relief so that
patients are able to ventilate more effectively.

• Catheter
malposition

• Risk of
pneumothorax

Paravertebral Unilateral chest or abdominal pain restricted to a few dermatomes
(e.g., rib fractures)

• Patient
positioning

• Stimulation
success
sometimes
hard to
visualize

Combination of
femoral and

Unilateral leg pain (e.g., femoral neck fracture [femoral], tibial and
ankle fractures [sciatic])*

• Patient
positioning

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sciatic block • Interference
of femoral
nerve
catheters with
femoral lines

*Caution: Compartment syndrome.
Modified from Schulz-Stubner S: The critically ill patient and regional anesthesia, Curr Opin Anaesthesiol 19:538–544, 2006.

• A three-in-one peripheral nerve block can be used for analgesia after proximal lower-limb orthopedic surgery. A
three-in-one peripheral nerve block provides analgesia to block three nerves, including the lateral femoral
cutaneous, femoral, and obturator nerves.4,26 This block is as effective as epidural analgesia, with fewer side
effects than epidural analgesia (e.g., urinary retention, nausea, risk for epidural hemorrhage in patients with
anticoagulation).6,7,16,26,27 Some forms of plexus analgesia (e.g., brachial plexus analgesia) in the postoperative
setting may serve two purposes: pain relief and sympathetic blockade, the latter of which increases blood flow
and may improve outcomes in some cases (i.e., digit reimplantation).5,16,23,34

• Analgesia via a catheter may be administered as a continuous infusion with the use of a volumetric pump
system, a patient-controlled regional infusion system, or a disposable pump device (e.g., elastomeric). An
elastomeric pump is one type of disposable infusion pump designed to provide a constant rate of infusion from
a filled reservoir. The infusion rates may or may not be adjustable (Fig. 107-4).21,30,34 Medication administered is
usually a local anesthetic (e.g., bupivacaine, ropivacaine). Other agents have been used on an adjunctive basis
as a bolus, including opioids, clonidine, epinephrine,16,17 and neostigmine.18

FIGURE 107-4 An elastomeric infusion pump. Parts include 1, filling port; 2, elastomeric
balloon (drug-containing reservoir); and 3, outer protective shell. (Originally published in Skryabina
E, Dunn TS: Disposable infusion pumps, Am J Health Syst Pharm 63:1260-1268, 2006.) © 2006, American Society
of Health-System Pharmacists, Inc. All rights reserved. Reprinted with permission (R1002).

• The pharmacokinetics and pharmacodynamics of local anesthetics and other agents used, including side
effects and duration of action, should be clearly understood. Local anesthetic medications used for peripheral
nerve blocks provide surgical analgesia (i.e., loss of pain sensation) and anesthesia (i.e., loss of all sensation).
The duration of action for each anesthetic medication depends on several factors, including the volume
injected, concentration of the medication, site of injection, and absorption. The addition of a vasoconstrictor,
such as epinephrine, constricts blood vessels and reduces vascular uptake, which further prolongs the duration
of action of the local anesthetic.16,17 Epinephrine is not recommended with peripheral nerve blocks in areas with
end arteries, such as ear lobes, the nose, digits, and the penis.39 Vasoconstrictor medications may cause
spasm of blood vessels, resulting in necrosis.9 Knowledge of signs and symptoms of profound motor and
sensory blockade, or overmedication, is essential.5,9,10,17

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• Sensory and motor blockade may be acceptable or desirable, depending on the goals and preferences of the
interdisciplinary team. The loss of sensation at the site is often the primary goal of blocks, and although motor
loss is often acceptable, it is not desirable.3

• Relative contraindications to peripheral nerve blockade include a history of coagulopathy, preexisting
neuropathies, anatomical or pathological deviations at the injection site, and systemic disease or
infection.5,7,10,22,26,27,39

• Local anesthetic toxicity can result from inadvertent injection of local anesthetic into the vascular system or
rapid absorption of the agent from the tissue into the vascular system. Intralipids/20% fat emulsion should be
immediately available for IV infusion, to help restore cardiovascular stability.8

Equipment
• One peripheral nerve catheter kit
• Infusion set for continuous plexus anesthesia with or without an adaptor for a nerve stimulator
• Peripheral nerve stimulator
• Topical skin antiseptic, as prescribed
• Sterile towels
• Sterile forceps
• Sterile gauze 4 × 4 pads
• Sterile gloves and gowns
• Fluid shield face masks
• 20-mL normal saline solution
• 5- to 10-mL local anesthetic as prescribed (1% lidocaine) for local infiltration
• Local anesthetic as prescribed (to establish the block)
• Occlusive dressing supplies to cover the catheter entry site
• Gauze and tape to secure the catheter to the patient’s body
• Labels stating “Local anesthetic only” and “Not for intravenous injection”
• Pump for administration of analgesia (e.g., volumetric pump, dedicated for peripheral nerve block infusion with

rate and volume limited, and preferably a different color from the epidural and IV infusion pumps; patient-
controlled analgesic pump or a portable infusion device such as a disposable elastomeric continuous infusion
pump

• Specific observation chart for patient monitoring of the peripheral nerve block infusion
• Prescribed analgesics and local anesthetics
• Equipment for monitoring blood pressure, heart rate, and pulse oximetry

Additional equipment, to have available as needed, includes the following:
• Ice or alcohol swabs for demonstrating sensory block
• Emergency medications (e.g., 20% fat emulsion/intralipids for local anesthetic toxicity)
• Bag-valve-mask device and oxygen
• Equipment for end-tidal carbon dioxide monitoring
• Intubation equipment
• Peripheral nerve stimulator and/or ultrasound to facilitate placement

Patient and Family Education
• Explain the reason and purpose of the catheter. If available, supply easy-to-read patient information. Rationale:

The patient and the family know what to expect; anxiety may be reduced.
• Explain to the patient and family that the procedure can be uncomfortable but that a local anesthetic will be

used to facilitate comfort. Rationale: Explanation elicits the patient’s cooperation and comfort, and facilitates
insertion; anxiety and fear may be decreased.

• During therapy, instruct the patient to report side effects or changes in pain or sensation. Observe for
suboptimal analgesia, profound numbness of extremities (beyond the goal of therapy), patient report of
lightheadedness, metallic taste, circumoral numbness, dizziness, blurred vision, tinnitus, loss of hearing, and
seizures.5,9,17,23 Rationale: Reporting of pain aids the patient’s comfort level and identifies side effects.

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Recognition of early signs and symptoms of local anesthetic toxicity can prevent cardiac arrhythmias, arrest,
and death.

• Teach the patient to protect the affected extremity from injury and trauma (e.g., burns).3,5,23 Rationale: Patient
safety is increased, and the limb is protected from injury and trauma.

• If a volumetric pump for patient-controlled regional analgesia (PCA) is used, educate the patient and family on
its use. Reinforce this education throughout the duration of regional PCA therapy. Rationale: This may decrease
anxiety and assists the patient in effectively using the infusion system.

Patient Assessment and Preparation
P a ti e nt Asse ssm e nt
• Observe the patient for signs and symptoms of local infection or generalized sepsis. Rationale: This decreases

the risk for infection at the site of catheter insertion. Septicemia and bacteremia are contraindications for
peripheral nerve block catheter placement or continuation of therapy.10,12

• Assess the patient’s concurrent anticoagulant and fibrinolytic therapy.6,7,39 Rationale: Heparin (unfractionated
and low–molecular-weight heparin), heparinoids, and fibrinolytic agents administered concurrently increase the
risk for vessel trauma (e.g., hematoma). Care must be taken with insertion and removal of the peripheral nerve
block catheter when patients are on anticoagulant and fibrinolytic therapy.9,27 Special institutional guidelines
must be observed.3,5–7,19,25,27 Insertion and removal of the peripheral nerve catheter should be directed by the
physician or advanced practice nurse.5–7,27

• Obtain the patient’s vital signs. Rationale: This provides baseline data.
• Assess the patient’s pain and anxiety. Rationale: This provides baseline data and helps determine whether

premedication is required.
• Reassure the patient. Rationale: Anxiety and fears may be reduced.
• Review the patient’s medication allergies. Rationale: Review of medication allergies before administration of a

new medication decreases allergic reactions.
• Consider instructions for nothing by mouth, especially if sedation or general anesthesia is to be used. Rationale:

The risk for vomiting and aspiration is decreased.

Patient Preparation
• Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the

nurse should ensure the correct identification of the patient for the intended intervention.
• Ensure that the patient and family understand the planned procedure. Answer questions as they arise, and

reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.

• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient
and makes a competent decision possible for the patient.

• Perform a preprocedure verification and time out, if nonemergent. Rationale: This ensures patient safety.
• Wash the specific anatomical area of the patient’s body with soap and water, and open the gown to expose the

site for injection while maintaining the patient’s privacy and dignity. Rationale: This action cleanses the skin and
allows easy access to the specific anatomical area of the patient’s body.

• Establish IV access or ensure the patency of IV catheters. Rationale: Medications may be needed if side
effects occur (i.e., hypotension).

• Position the patient as appropriate, according to which anatomical area of the body is to be blocked. Rationale:
This prepares the patient for the procedure.

Procedure for Peripheral Nerve Blocks

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Steps Rationale Special Considerations

1.

2. Physicians, advanced practice nurses, and
other healthcare professionals should
apply personal protective gear (e.g., face
masks with eye shields) and sterile
attire (e.g., sterile gowns, sterile gloves).

3. Obtain the
prescribed
peripheral nerve
block medication.

The medication should be prepared
with aseptic technique by the
pharmacy with laminar flow or
prepared commercially.

All peripheral nerve block solutions are
preservative free to avoid neuronal
injury.7

4. Connect the correct
tubing to the
prepared infusion
and prime the
tubing.

Removes air from the infusion
system.

5. Ensure that the
patient is in position
for catheter
placement.

Facilitates ease of insertion of the
peripheral nerve block catheter.

Assist with holding the patient in position or
consider sedation, if necessary.

6. Assist as needed
with the antiseptic
preparation of the
intended insertion
site. (Level C*)

Reduces the transmission of
microorganisms into the nerve
sheath or plexus space.12,23

The choice of povidone-iodine or
chlorhexidine as an antiseptic agent for
neurological procedures is controversial.
Both should be allowed to dry
completely. Chlorhexidine may be
neurotoxic.20

7. Assist if needed
with draping the
patient with
exposure of the
insertion site.

Aids in maintaining sterility.

8. Assist the physician
or advanced
practice nurse as
needed with the
catheter placement
and manipulation of
the controls on the
peripheral nerve
stimulator if
used).3,23 (Level C*)

Facilitates catheter insertion. Use
of a peripheral nerve stimulator
assists with identification of the
nerve.23,28

Ultrasound guidance may be used to place
the continuous peripheral nerve block
catheter. If ultrasound has print
capability, print a reading and include it in
the chart for documentation.

9. After the peripheral
nerve catheter is
inserted, assist as
needed with the
application of a
sterile, occlusive
dressing.

Reduces the incidence of
infection.12,23

10. Secure the filter to
the patient’s body
with a gauze
padding and tape.

Avoids disconnection between the
peripheral nerve catheter and
the filter. The gauze padding
prevents discomfort and skin
pressure from the filter.

11. The physician or Facilitates a therapeutic level of An initial test dose of local anesthetic agent

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advanced practice
nurse will
administer a bolus
dose of medication
via the catheter.

analgesia and ensures correct
catheter placement.39

with or without epinephrine may be
administered, then a bolus dose. Monitor
vital signs and symptoms of local
anesthetic toxicity and assess the
patient’s pain. Emergency medications
and equipment must be available.7,25

12. Connect the
prescribed
medication infusion
system.

Prepares the infusion system.

13. Initiate therapy:

A. Place the system
in a volumetric
pump or
elastomeric
continuous
infusion pump and
set the rate and
volume to be
infused as
prescribed.

Prepares the infusion system. Responses to peripheral nerve block
analgesia vary individually, and analgesia
is tailored according to individual
responses. Note: Peripheral nerve
catheters may also be attached to a
portable disposable infusion device (e.g.,
elastomeric pump)16,21,30,35 that may not
have an adjustable rate or volume.30,35

B. Attach a label:
“Local anesthetic
only—Not for
intravenous
injection” to the
tubing and use a
portless system.5
(Level D*)

Do not give any other solution
or medication via this
catheter.

Inadvertent administration of
some IV medications into
the peripheral nerve block
catheter may cause nerve or
tissue damage. Inadvertent
administration of local IV
anesthetic can cause
hypotension and
cardiovascular collapse or
arrest.17,21,23

C. Lock the key pad
on the volumetric
pump.

Prevents inadvertent or accidental
changes in therapy.

14. Continue to assess
the quality of the
analgesia.

Identifies patient comfort level and
is an indicator to clinicians
regarding the effectiveness of
the therapy.

A. Determine the
patient’s pain
based on a
consistent and
reliable pain-
assessment tool
according to
institutional
policy.33

The amount of pain experienced by
the patient should be no more
than the amount of what is
acceptable to the patient.1,2,9

B. Assist as needed
with testing the
corresponding
dermatome level
of the peripheral
nerve block with

The ideal peripheral nerve block
should be just above and just
below the (anticipated) surgical
incision or the trauma site (see
the dermatomes described in
Fig. 107-3).9,23

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ice or an alcohol
swab.

15. Remove and
discard used
supplies in an
appropriate
receptacle.

Removes and safely discards used
supplies.

16.
*Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized
controlled trials with inconsistent results.
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Expected Outcomes
• Regional analgesic catheter inserted; accurate catheter placement confirmed with use of ultrasound scan,

nerve stimulator, or radiological imaging when appropriate5,6,18,22,29,31

• Pain minimized or relieved3,31,32

• No patient oversedation or respiratory depression5,17,39

• Reduced need for parenteral opioids, thereby also reducing opioid side effects18,23

• Potential for reduction in neuropathic pain states, especially after limb amputation14

• Temporary numbness and loss of motor control23

Unexpected Outcomes
• Inability to insert the catheter
• Untimely or erroneous medication administration5,9

• Suboptimal analgesia
• Adverse medication reactions not recognized
• Altered skin integrity from decreased sensory and motor loss6,9,16,37,38

• Accidental dislodgment of the catheter delivery system
• Leakage from the catheter insertion site
• Cracked filter on the delivery system
• Inadvertent injection into a blood vessel3,5,39

• Ipsilateral Horner’s syndrome—symptoms that arise when a group of nerves known as the sympathetic trunk is
damaged or blocked by anesthetic during stellate ganglion block.26,36 Horner’s syndrome may also develop due
to inadvertent vascular puncture and hematoma formation in the neck.4,26 The signs and symptoms occur on
the same side as the affected sympathetic trunk (ipsilateral). Miosis (a constricted pupil), ptosis (drooping
eyelid), and anhidrosis (decreased sweating) can occur. Enophthalmos (inset eyeball) may also be present, as
may hoarseness5,26,36,39

• Nerve or vessel trauma3,5,39

• Hemorrhage or hematoma6

• Respiratory distress related to phrenic nerve paralysis, pneumothorax, or medication effect3,16,23,32

• Local infection at the peripheral nerve block catheter insertion site
• Sepsis12

• Anaphylaxis5,17

• Permanent neurological injuries and damage from insertion26,39

• Systemic toxicity from local anesthetics (e.g., tachycardia, hypotension, metallic taste, blurred vision, circumoral
numbness, tinnitus, decreased hearing, dizziness, confusion progressing to seizures, cardiac arrest, or even
death)5,17,23

Patient Monitoring and Care

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Steps Rationale Reportable Conditions

These conditions
should be reported
if they persist
despite nursing
interventions.

1. Assess the patient’s level of pain with a
valid and reliable pain scale. Follow
institutional standards for assessing pain.
Administer analgesia as prescribed.
Continue to assess frequently, especially
during the first 12–24 hours of
therapy.2,9,23,33

Identifies the need for pain
interventions. Describes the
patient’s response to pain
therapy. A lower pain score is
expected. Assessing and
reassessing pain in an
objective manner helps
determine appropriate
treatment measures.

• Continued pain
despite pain
interventions

2. Assess the patient’s vital signs,
oxygenation and ventilatory status, and
level of sedation with a valid and reliable
sedation scale.15,33 Monitoring the patient
every 15 minutes has been recommended
in the immediate period after initiation of
therapy.23

Hypotension and sedation may
reflect IV infusion, systemic
toxicity, or the residual effects
of sedation administered for
catheter placement.21,23

• Change in
respiratory status
or other vital
signs (e.g.,
respiratory rate,
oxygenation via
pulse oximetry,
blood pressure)

• Altered level of
consciousness

3. Assess the levels of motor and sensory
blockade. Follow institutional standards for
these assessments (see Fig. 107-3).1–3,9,23

Ensures effectiveness of
analgesia and maintenance of
the block at the correct level.

• Signs and
symptoms of
overmedication:
• Decreased

ability to feel or
to move area of
the body where
the peripheral
nerve block is
infusing4

• Excessive
sensory or
motor blockade
in the lower
extremities may
result in signs
of pressure and
skin breakdown
on the heels4

4. Monitor the infusion rate according to
institutional policy. Ensure that the control
panel is locked if using a volumetric
infuser or ensure that the PCA program is
locked via a key or code access.
Disposable infusion devices (e.g.,
elastomeric pumps) have been shown to
be less accurate than volumetric
pumps.30,35

Ensures that medication is
administered safely and
securely.

5. Monitor oxygen saturation and
capnography (if available) continuously,
especially if parenteral opioids are

Assesses ventilation and
oxygenation.

• Oxygen saturation
<93% or

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administered for pain or mild sedation
before, during, or after the procedure.4,11

decreasing trend
in oxygenation

6. Assess temperature regularly; assess
more frequently if febrile.

Increasing hyperpyrexia could
signify infection.12

• Temperature
>101.3 °F (38.5 
°C)

7. Assess the catheter site every 4–8 hours
and as needed.

Identifies site complications. • A change in the
integrity of the
peripheral nerve
block insertion
site (e.g.,
redness,
tenderness, or
swelling or the
presence of
exudate on the
dressing)

8. Observe for signs and symptoms of
peripheral nerve catheter migration into a
blood vessel.

The catheter is no longer in the
correct position.

• Unexpected
change in
sedation scale

• Drowsiness
• Dizziness
• Blurred vision
• Slurred speech
• Poor balance
• Circumoral

numbness
• Hypotension
• Cardiovascular

collapse

9. Monitor sensory or motor loss according to
the defined goal of therapy. (Level D*)

Motor or sensory loss may result
from the local anesthetic
infusion. Note: With peripheral
nerve blockade, sensory loss
is usually acceptable and often
desirable. Motor loss is not
desirable but often
acceptable.3,5,18,23,39

• Unexpected
change in
sensory or motor
function beyond
the defined goal
of therapy

• Interference with
respiration or
excessive spread
of local
anesthetic
beyond the
defined area of
recommendation

10. Assess for systemic toxicity from the local
anesthetic administered through the
catheter.

Local anesthetic is used in the
solution, and symptoms
indicative of systemic toxicity
from the agent used to induce
anesthesia may occur.

• Metallic taste
• Blurred vision
• Circumoral

numbness
• Tinnitus
• Decreased

hearing
• Dizziness
• Confusion

progressing to
seizures

11. Monitor and check the skin integrity of the
pressure points relating to the location of
the peripheral nerve block (e.g., elbow,

If a local anesthetic is used in the
solution, check for pressure
ulceration (patient may have

• Increasing
redness or
blistering of the

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sacrum, and heels). Change patient’s
position as needed. Provide protective
positioning.3,23

sensory loss in areas adjacent
to the area of the peripheral
nerve block).3,23

skin on pressure
points

12. Change the peripheral nerve block catheter
insertion site dressing as prescribed or if
soiled, wet, or loose.7 Note: Usually the
dressing is left intact for the duration of
therapy unless wet or loose.6

Provides an opportunity to cleanse
the area around the catheter
and to assess for signs and
symptoms of infection.12,23

• Signs of site
infection (e.g.,
swelling, pain,
redness, or
presence of
drainage)

• Leakage of the
peripheral nerve
block solution

13. Label the peripheral nerve block pump and
consider placing the pump on one side of
the patient’s bed and all other pumps on
the other side of the bed.6

Aids in minimizing the risk for
mistaking the local anesthetic
infusion for an IV infusion
system.7

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Documentation
Documentation should include the following:
• Patient and family education
• Patient tolerance of procedure
• Completion of informed consent
• Completion of a preprocedure verification and time out
• Catheter location
• Type of dressing used
• Confirmation of peripheral nerve block catheter placement (e.g., radiological confirmation, stimulating peripheral

nerve catheter, ultrasound scan)
• Site assessment
• Assessment of pain and levels of motor and sensory blockade documented on an appropriate flow chart (see

Fig. 107-3).
• If PCA is used, document medication concentration, PCA bolus dose, continuous infusion, lockout interval,

hourly limits, and total dosage
• Regional analgesic medication and the medication concentration being infused and infusion rate; remaining

volume of medication in a disposable infusion device
• Bolus dose administration (if appropriate) and patient response after a bolus dose, including quality of pain

relief
• Vital signs and oxygenation saturation.
• Occurrence of unexpected outcomes
• Nursing interventions taken
• Date and time of discontinuation of treatment
• Pain assessment, interventions, and effectiveness

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CHAPTER 11
Practical Considerations of Incorporating

Evidence into Clinical Practice

J. Richard Pittman, Jr., MD

Mikhail Akbashev, MD

INTRODUCTION
With over 21.5 million unique articles and more than 1 million randomized controlled trials
indexed in MEDLINE as of 2014 and more than 1 million new publications published and
indexed annually, clinicians now must process a vast volume of medical literature. Many
clinicians feel like they are drowning in information. Hospitalists must balance the need to
find relevant and accurate answers to their clinical questions with the need for efficiency in
finding those answers to immediately guide high-quality care to multiple acutely ill
patients. Formulating and answering questions efficiently and effectively will improve care
and reduce the rates of consultation, testing, and potential errors.

The volume of data and limited time for searching for answers compound each other.
A recent systematic review examining clinical questions raised by clinicians at the point of
care found approximately one clinical question arises for every two patient encounters.
Clinicians only pursued 51% of the questions raised and found answers to only 78% of
those questions pursued. Studies reported the main barriers to seeking information
included a clinician’s lack of time and a doubt that a useful answer existed. The state of
relying on information already known prevails when the energy required to get a new

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answer outweighs the perceived benefit. Clinical inertia may be illustrated by considering
the gap between the potential benefits of evidenced-based care and actual rates of
implementation as in the treatment of heart failure with reduced ejection fraction (HFrEF).
Optimal implementation of strong evidence-based therapies for HFrEF could save an
estimated 35,000 to 117,000 thousand lives per year. See Chapter 129 (Heart Failure).

In an ideal practice setting, the majority of clinical questions would have a readily
accessible, evidence-based answer. Clinicians would have current knowledge of guideline-
based therapy and could apply pertinent point-of-care reminders from the electronic
medical record for best practice for every patient under their care. As a result, patients
would yield maximal benefit from clinical trials and guideline-driven information. This
ideal state may not be attainable; however, clinicians may take steps toward better
utilizing the evidence-based answers currently available to meaningfully impact clinical
practice.

CURRENT CONSEQUENCES AND MOTIVATORS FOR CHANGE
PRACTICING WITH OUTDATED INFORMATION

Relying on outdated information for patient care (ie, clinical inertia) may limit potential
benefits of current therapies and expose patients to risks of disproven therapies. An
example would be practicing based off outdated guidelines for the treatment of blood
cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults where
a clinician tailors treatment and statin dosing based solely on the low-density lipoprotein
cholesterol (LDL-C) levels rather than selecting a moderate- or high-intensity statin
strategy based on ASCVD risk, an LDL-C ≥ 190 mg/dL, and/or the presence of diabetes as
recommended in the current updated guidelines.

UTILIZING UNVERIFIED INFORMATION SOURCES

Clinicians may utilize unverified information sources. Examples of possible unverified
information sources include seemingly more informed colleagues, television
programming/advertisements, popular media, drug company representatives, and
searching for “evidence” or answers to clinical questions using search engines that may
provide information from unverified sources (eg, “Googling”). Heavy reliance on unverified
information sources can significantly limit the quality of information with which a
clinician practices and should be avoided if possible.

SEARCH SATISFACTION BIAS

Depending on a clinician’s comfort level with evidence-based medicine and available
search tools and time, a clinician may only read article summaries or conclusions from
abstracts. This represents a form of search satisfaction bias. When an answer is found to
a clinical question that is frequently encountered in a clinician’s scope of practice, the
clinician might jump to apply this answer to all subsequent patients without fully
assessing the validity and quality of the source or considering the applicability of this
information to the individual patient.

EVIDENCE-BASED PRACTICE IMPROVES PATIENT OUTCOMES

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Perhaps the strongest and most important motivator for change should be the fact that
evidence- or guideline-based practice has been shown to improve patient outcomes across
a wide spectrum of illnesses.

SOLUTIONS TO INCORPORATE EVIDENCE INTO CLINICAL PRACTICE
Solutions should take into consideration how a clinician might encounter information
during the flow of practice. “Keeping up” with the literature is increasingly difficult, and
staying abreast of important developments that may not directly relate to patients that the
clinician is actively managing. “Keeping up” single-source publications from an area of
clinical focus are useful, but they may narrow a clinician’s awareness of broader advances
across different disciplines. There are numerous methods to “keep up” with the literature
that transcend traditional postal mail by utilizing e-mail or designated applications for
mobile devices. Users sign up for these “keeping up” resources as reputable and reliable
evidence sent to them from trusted sources. These tools may help clinicians keep up with
a particular field or topic by organizing information by discipline, relevance to that
discipline, and newsworthiness or impact level. This information may be delivered to an e-
mail inbox, a website, or to a discrete mobile application. The focus below will be on free
resources available or those included with professional society memberships common for
most hospital medicine providers.

Advantages of push resources available for most hospital medicine providers include:

Preset, reliable stream of information lowers the energy required to incorporate new
information into clinical practice, leaving a clinicianless subject to clinical inertia or
anchoring.
Many of the tools are free and can focus on a specific discipline or a topic.
The volume of information presented can be adjusted based on clinician desire or
tolerance.
The frequency of the delivery of this information can be customized.
Article summaries by colleagues trained in evidence-based analysis can be accessed
and can raise awareness of potential inclusion biases.

Disadvantages include:

These streams may become overwhelming if the amount and frequency of content
is not properly customized to the individual clinician preferences. There is a risk of
attending a conference or reading a publication on mobile resources that may be
tempting to clinicians to sign up for too many resources at one time.
Selection methodology for choosing the articles presented may not always be clear.

Suggestions

1. Setting up digital resources. It may be helpful for a clinician to initially take
consider what information he or she needs and the areas of knowledge deficiencies
(eg, original research manuscripts, clinical updates, and guidelines). Any individual
clinician may not be aware of each of her or his personal deficiencies, especially
since “blind spots” are by definition not seen. Thoughtful attention to one’s
knowledge base, deficiencies, and practice gaps may lead to crucial first digital

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steps for change. In addition, a comparison of professional needs and knowledge
gaps should be made with regards to any resources a clinician is actively
subscribed. A busy clinician should pay careful attention to cutting down on
infrequently used resources prior to subscribing to new ones.

Consideration should be made for an individual clinician’s preferred method of
receiving information. Some like information to come straight to their e-mail with a
link to a website while others prefer opening a designated application on their
device(s). E-mails clutter e-mail inboxes, but most people regularly check e-mail.
Mobile applications clutter your devices while also continuing to collect new
material unnoticed to the clinician. This can be corrected by removing unused
applications that clutter mobile devices while also taking steps to become familiar
with how applications work and aggregate information. Most tools discussed in this
chapter strive to deliver information in a way that best fits the workflow of different
clinicians (Table 11-1). The key is for any individual practitioner to identify
resources most convenient and reliable for that individual clinician.

TABLE 11-1 Example Digital Resources for “Keeping Up”

E-mail/Website-Based Website Link
BMJ Evidence Updates https://plus.mcmaster.ca/evidenceupdates/
ACP Journal Club http://annals.org/journalclub.aspx
NEJM Journal Watch www.jwatch.org
PubMed—My NCBI http://www.ncbi.nlm.nih.gov/pubmed/
Application-Based (App) Website Link
Docphin https://www.docphin.com/
Read by QXMD http://www.qxmd.com/apps/read-by-qxmd-

app
Doximity https://www.doximity.com/

Once an account is setup for the any of the resources, the next step is to select
specialty and topic preferences. Once these steps are completed, the information
will then be sent either via e-mail or to a mobile application depending on which
resource is selected (Figure 11-1).

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Figure 11-1 Screenshot of BMJ evidence updates. This is an example of a free online
“keeping up” resource which allows users filter paper alerts by topic, relevance and
newsworthiness, to narrow to a manageable amount.

A critical step is to then monitor the usefulness of information and then after a
period of time (eg, a couple of weeks or a month) go back into the tool and adjust
the settings or unsubscribe from the resource based on its helpfulness or not.

2. Schedule time for new reading. A seemingly simple step, but one that can make a
large difference in “keeping up” is to schedule time for new reading. Carrying a
paper or virtual file with articles, presentations, and/or books may make a half an
hour before rounds, between appointments, or while sitting in carpool lines a lot
more productive.

3. Attend institutional conferences. Attending institutional conferences (eg, Grand
Rounds, noon conferences) is an excellent way for a clinician to acquire new
information while also providing the opportunity to spark conversations and clinical
questions with colleagues. Volunteering to present a topic at conference promotes
expertise acquisition of new and updated clinical knowledge.

4. Participate in professional societies and their scientific meetings. Scientific
meetings hosted by medical professional societies are designed to help clinicians
stay abreast of the ever-changing information and also to offer credit for Continuing
Medical Education.

5. Encourage a culture of learning. Activities such as journal club, case conference,
and clinical updates in hospital medicine at hospitalists’ sites of practice can be an
effective way to promote a culture of learning, which can help providers further keep
up with the flow of new information.

6. Utilize the electronic health record. Perhaps the most pertinent time to receive
updated information on any treatment or diagnostic test is at the time of ordering
the treatment or test. Recent advances and expansions in electronic health records
(EHR) offer a limited opportunity for “just-in time” learning about specific medical
concepts. Many EHRs incorporate evidence-based recommendations into order sets,
as well as linking users to literature regarding updated recommendations. A recent
meta-analysis showed improvement in both efficiency and adherence to guidelines

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through use of EHR. Similarly, a study of an older computer support tool for
antibiotic management found a dramatic decrease in pharmacy antibiotic
expenditures and mortality rates over a 6-year period. A systematic review of 68
controlled trials of computer decision support systems found the majority of the
trials demonstrated benefit in physician performance and patient outcomes.
Multiple health systems have implemented quality improvement projects to adhere
to core measures using order sets within the EHRs with great success.

QUICK QUESTION

The context is essential for any clinical question. The ideal “quick question” resource
would be readily available at the point of care, pertinent to the patient, with specific,
actionable information that is quickly and reliably accessed. Unlike the “keeping up”
resources previously discussed, these “quick questions” need to be answered for a real
patient right now. That is why using these types of resources is essential in day-to-day
patient care. Fortunately, multiple resources exist including current textbooks, database
search tools such as Trip Database, popular portable resources such as UpToDate or
Dynamed, and large databases like PubMed. These resources have been developed to
answer specific, patient-related questions. Hospitalists should check with their institutional
subscriptions first and utilize these before personally enrolling in subscriptions that may
be expensive.

Developing “quick questions” require clinicians to stop their flow of work and look for
an answer. Cumbersome retrieval of information may lead to clinical inertia. Initial
searching using summary resources, such as textbooks or review articles, can be efficient
and more likely to yield pertinent answers. However, these resources are subject to
authorship biases. Important articles could potentially be omitted while smaller studies
maybe overly emphasized in recommendations. Summary resources can also be delayed
in incorporating the most recent study results, even sometimes those of large pivotal
studies. Many clinicians start with a Google search with Wikipedia as the top listed initial
resource. This may often be a quick and satisfying way to answer simple medical
definition questions such as “what is an antimitochondrial antibody.” Mainstream publicly
available search engines such as Google or Yahoo can offer fast and free searches but
often are less reliable and may not provide a robust and accurate answer to clinical
questions as would more rigorously vetted medical resources, such as AccessMedicine,
ClincialKey (formerly MD Consult), DynaMed, Medscape (a.k.a. eMedicine), UpToDate and
a growing list of other compiled medical summary resources and reviews (Table 11-2).
These resources have made incorporation of new information a priority.

TABLE 11-2 Example Digital Resources for Answering Clinical Questions

Resource (Publisher) Description CME
AccessMedicine

McGraw-Hill

Compendium of rapidly searchable medical
textbooks

Yes

Clinical Key (a.k.a.
MDConsult)

Automated evidence search engine, allow users to
search the primary medical literature, guidelines and
standard textbooks

Yes

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Elsevier
Dynamed

EBSCO Health

Collection of evidence-based summary reviews on
common clinical topics; presented in bulleted format
with specific citations and assessment of evidence
quality for recommendations. Systematic rapid
inclusion of newly published high-quality evidence,
including systematic reviews

Yes

Essential
Evidence Plus

Wiley

Search engine to browse guidelines and systematic
reviews; integrated with other resources such as
calculators, coding helper, or decision support tools

Yes

Medscape
(a.k.a. eMedicine)

WebMD

Compilation of summaries by specialists in the field;
includes new article formats

Yes

PubMed Clinical Queries

NIH

Indexed database of articles from a multitude of
medical journals

No

TRIP Database
(Translating Research
Into Practice)

TRIP

Automated evidence search engine of primary
studies, guidelines, textbooks and other clinical
resources with filters available; scores articles based
on how recent, pertinence, and publication source

No

Up-To-Date

Wolters Kluwer

Evidence-based online textbook. Compendium of
expert written invited reviews on a broad array of
topics; evidenced based and graded
recommendations, primarily prose and directive in
nature

Yes

Suggestions

Despite the apparent limitations, actively and efficiently searching for answers to clinical
queries is an essential part of patient care. Overcoming clinical inertia to identify and
explore questions is the first step. This may be as simple as an index card with questions
for the day or lunches with colleagues to discuss cases. Having identified questions, a
clinician needs to formulate the question as specifically as possible and identify an
efficient search strategy (Figure 11-2).

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Figure 11-2 An effective search strategy for answering clinical questions.

Many hold to dogma and use PubMed as an initial search. This often yields a time-
consuming search, with many published articles to sift through, and challenges finding
relevant studies efficiently. This also has been shown to take 41% longer (29 vs 17
minutes) than UpToDate searches in a cohort of resident physicians. Furthermore, a study
of 54 medical students, residents, and faculty searching multiple methodologies to answer
critical-care-related questions showed that users most frequently searched Google first
(45% of the time), with Google and UpToDate providing faster answers than PubMed (3.8
vs 3.3 vs 4.4 minutes, respectively). Importantly, Google and UpToDate were more likely to
lead to a correct answer than PubMed (60% vs 70% vs 36%, respectively). The highest
value first resource is often a compiled resource such as Dynamed or UpToDate, but
multiple resources are available from various publishing organizations (Table 11-2).

Regardless of the initial search strategy, there are often clinical situations that require
more nuanced answers and specific expertise. These questions should be very concrete
and specific. A standard “PICO” (Patient, Intervention, Comparison, Outcome) format
identifies the pertinent parts of a question (eg, “What is the effect of 23-valent
pneumococcal polysaccharide vaccine versus placebo on mortality in patients with
systolic heart failure exacerbations?” or “What is the relative risk of bleeding with
rivaroxaban versus warfarin in patients with venous thromboembolism?”). For questions
too specific or narrow to be found in summarized resources, a primary literature search
may be preferred. PubMed offers free access to users, and its “Clinical Queries” search
option quickly filters results for clinical and systematic review articles. Other electronic
resources like TRIP (Translating Research into Practice) database can quickly filter studies
indexed in MEDLINE, guidelines and other resources, and it also ranks them on quality and
type of study. Guideline searches may be completed through the National Guideline
Clearinghouse (http://www.guideline.gov), which is a resource maintained by the U.S.
Department of Health and Human Services. This resource facilitates comparison of
guidelines on topics published from different societies (eg, breast cancer screening
guidelines from American College of Physicians versus American College of Obstetrics

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and Gynecology). Although somewhat cumbersome to use initially, it is readily updated.
Actively recruiting clinical trials are indexed in the registry ClinicalTrials.gov
(https://clinicaltrials.gov), provided by the U.S. National Institutes of Health.

Although there are advantages and disadvantages to the different resources, the least
useful resource is the unavailable resource. For this reason, clinicians should find the
resources available at their home institutions. Clinicians should identify clinical questions
and explore the available resources to find answers. Ideally, a query should obtain a high-
quality answer in less than 5 minutes.

STORAGE FOR FUTURE REFERENCE

A challenge of the digital and increasingly paperless work environment is how to keep up
with the materials that an individual clinician would like to save for future reference.
Mobile technology can really help take busy clinicians far beyond the traditional physical
file cabinet into a system that can travel on mobile devices with certain ones that can even
help create bibliographies if needed.

Many digital storage solutions follow the “freemium” model. “Freemium” is a pricing
strategy that refers to an initial free price for the limited use of an application that then
tiers to paid subscriptions for heavier use. The real advantage of the digital storage
solutions is their use of storing files virtually in the “cloud.” The “cloud” refers to the
storage of files in a server (ie, high-capacity computer) that is connected to a clinician’s
personal computer or mobile device via the Internet. The advantages of this include an
online backup and the ability to synchronize files across multiple devices with very little
effort. Many of these services allow a clinician to keep a copy of the files on a computer or
mobile devices so these files can be accessed even when not connected to the Internet.
These systems retrieve information by storing text documents that can be searched using
terms that obtain results based not just on the title of the file but also from the text of the
document. This allows use of these resources with almost no organization necessary.

With a digital storage solution, the important tactile experience of touching and
annotating the original article is lost. The clinician must convert from paper to digital files,
name folders, and move documents to the folders that have been created. A similar effort
would be required to set up a new file cabinet, but many struggle to invest the time into a
similar digital system. Theoretically, this digital storage solution is still a mechanical
system that could fail.

Suggestions

1. Understand the cloud Many clinicians already have user accounts for cloud-based
storage solutions but are simply unaware that they do. Programs such as Dropbox,
Google Drive, Box, Evernote, OneDrive, and iCloud all meet the definition for cloud-
based storage solutions. If a clinician already has one of these accounts, then it
may be best for that clinician to first explore all the features of that solution, before
considering others (Table 11-3).

TABLE 11-3 Example Cloud-Based Storage Solutions

Platform Cost/Memory Pros Cons
Box.com Free up to 10 Gb, then Only solution that Web editing,

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$10/mo for 100 Gb advertises HIPAA
complaint for enterprise
clients; great amount free;
can edit documents on
web, make comments,
and assign tasks to
documents

commenting,
and tagging
have some flaws
that limit their
usefulness

Dropbox Free up to 2 Gb, $10/mo
1 Terabyte of storage

Established company;
cross platform with easy
sharing and well-
integrated into mobile
devices

Small amount of
data free

Evernote Free up to 60 Mb data
transfer per mo, then
$45/per y for heavier use

Accepts multiple types of
inputs including audio,
photos, scanned
documents, and web
clips; advanced
organization with
notebooks and tagging

Best use
requires some
organization

Google drive 15 Gb free, paid plans for
100 Gb per mo

Best for working on files
with other users, even
simultaneously; great if
you use Android mobile
device(s)

Navigation of
the drive is
somewhat
nonintuitive

Microsoft
Onedrive

Free up to 7 Gb Ideal if heavy user of
Microsoft® Office,
especially on a windows
platform computer

While the solutions can be accessed through websites using a web browser,
most also offer applications that can be downloaded and placed on personal
computers and mobile devices that allow for more convenient access of their stored
files. The applications work by turning files and folders meant for storage into ones
that are automatically synchronized and immediately uploaded to the cloud, which
allows them to thereby be available from anywhere.

2. Use cloud-based storage After gaining an understanding of the “cloud,” clinicians
should strongly consider using cloud-based storage in their practice.

In general, any of these cloud-based storage solutions will work to get started, so
once a choice is made regarding which one to use then time must be invested by
users in order to learn how to use all of the features. Many have “getting started”
videos which can be viewed on their respective websites. Once a clinician is familiar
with the tool, time should be set aside for at least an hour or two to allow for some
files or articles to be moved over to the cloud folders. Investing time up front will
allow a busy clinician to get the most of out of the system and generally be better
organized moving forward in clinical practice. Choosing a system-based

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organization (eg, cardiology, gastroenterology, infectious diseases, and so on.)
versus by more specific topic areas (eg, heart failure, cirrhosis, pneumonia, and so
on.) depends on the file contents and personal preferences of the individual
clinician.

The next time a clinical question comes up about the topic previously searched
and saved in this storage system, the clinician can simply check the system rather
than doing another search.

3. Comply with patient confidentiality As with any new developments or advances in
technology that affects or modifies a clinician’s practice, care should be taken to
assure the safety and protection of a patient’s confidentiality. Most cloud resources
are not compliant with the Health Insurance Portability and Accountability Act
(HIPAA). As such, patient or personal health information should not be stored on
these digital and cloud-based drives. The notable exception is “enterprise services”
provided by the digital platform Box, but it should be noted the “personal service” of
Box is not HIPAA compliant.

4. Annotate articles Some clinicians prefer to read paper articles, which then allows
for highlighting or annotating. Digital versions of these articles often allow of
highlighting or annotating as well depending on the viewer used on a computer or
mobile device. This latter way of reviewing articles allows the clinician to more
easily save notes taken right inside the cloud-based storage solution being used. For
those who still prefer the paper version to initially review an article, clinicians should
consider document scanner to convert the annotated paper version of the article
into a digital one which can then be stored in these cloud-based storage platforms.
The scanner that uses “Optical Character Recognition” or OCR to turn the
documents scanned into a text searchable document after storage provides optimal
functionality. At the time of this chapter being drafted, Evernote is the only one of
the cloud-based solutions that has annotation (eg, highlighting) or drawing built into
its system. Many of these other platforms can integrate easily with
software/application viewers or readers (eg, “Portable Document Format” or PDF)
which are available on most mobile devices.

CULTURAL CHANGE

Fostering a culture of education, accountability for actions, and support for evidence-
based, high-quality care can encourage all clinicians to keep learning for better patient
care. Although intangible personal attributes contribute greatly to culture, leadership can
adjust policy to achieve desired outcomes by nurturing a workplace of collaboration,
learning, open feedback, and accountability. A supportive, collaborative environment
encourages clinicians to discuss individual studies or publications, treatment decisions on
complicated cases, and even to work together on quality improvement and system-based
projects. Impediments to collaboration among hospitalist groups include provider
scheduling and workload. Seven-day-cycled schedules may isolate providers to those
other providers on for the same shifts only. Potential interventions to improve
collaboration could include standardized work schedules, physician lounges, physician
cafeterias, grouped offices, and consideration of patient census caps.

Open feedback also plays an important role in incorporating evidence and improving
patient care. Increasing isolation of physicians and high workload limits the available time
to discuss the management of individual patients and/or to follow up on subsequent care

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while off-service. Handoffs could be an opportunity for colleagues to review care and
potentially notify providers of updates in hospital medicine or new literature. In order to be
successful, this should be done in a collegial manner with adequate time allotted.
Hospitalists should be encouraged to both give and request feedback regularly. Morbidity
and mortality conferences may also offer an opportunity to discuss updates in new
literature using a pertinent clinical case. “Word of mouth” spread of information is a
pertinent and powerful way to share medical information and encourage a culture that
strives to keep up with the literature.

CONCLUSION
The volumes of literature and increasing demands on physician time have complicated
the process of finding and incorporating evidence into clinical practice. Multiple new
methods exist to receive new evidence on pertinent topics in manageable volumes.
Compiled review resources are significantly quicker and more reliable initial resources than
primary literature searches for most clinical questions. Cloud-based storage options offer
the advantages of better search-ability and portability over filing cabinets and stacks of
printed manuscripts and journals; most cloud storage options are not HIPAA compliant but
are good for storing medical references. Simple steps can be taken to foster a positive
learning culture at a hospitalist’s respective institution (eg, starting a journal club or
scheduling lunchtime discussions of current topics). Some hospitalists may pursue
resources to better keep up, while others may inquire at their institution for “quick
question” resources. Some clinicians may already be inundated with what they have
collected and need to invest in a cloud-based resource to decrease the stress every time
they ask, “Where is that article?” Encouraging a work culture shift toward addressing gaps
may help clinician scope with information overload. Even the most current or seemingly
up-to-date clinicians started one step at a time and invested continued effort.

SUGGESTED READINGS
Banzi R, et al. Speed of updating online evidence based point of care summaries:

prospective cohort analysis. BMJ. 2011;343:d5856.
Campanella P, et al. The impact of electronic health records on healthcare quality: a

systematic review and meta-analysis. Eur J Public Health. pii:ckv122 [Epub]; Jun 30,
2015.

Del Fiol G, et al. Clinical questions raised by clinicians at the point of care: a systematic
review. JAMA Intern Med. 2014;74:710-718.

Elliott DJ, et al. Effect of hospitalist workload on quality and efficiency of care. JAMA
Intern Med. 2014;174:786-793.

Hunt DL, et al. Effects of computer-based clinical decision support systems