1. There will be an Anesthesiologist available, in house, twenty-four hours a day, seven days a week.
2. Nurses will not administer a bolus of opioids via epidural/intrathecal catheter.
3. When the Anesthesiologist administers subsequent bolus injections, they will enter an order in the electronic medical record, EMR, indicating that the medication was given.
4. When the opioids are administered by continuous infusion, only pumps from the Pharmacy Department will be used, utilizing sets without injection ports.
5. For further information, see the Protocol for the Nursing Management of the Patient receiving temporary Epidural/Intrathecal Analgesia. Nursing Protocol #7
6. All epidural drugs and intrathecal drugs must be double checked by two licensed personnel and documented in the patient record with the physician order.
7. All epidural pump settings must be double checked by two licensed personnel together at the bedside at the initiation of treatment and anytime the settings are changed and documented in the patient record.

Procedure For IV Line Labeling

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