Week 2 dq 2

1578185 – Elsevier Health Sciences ©

❖ 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 l

1578185 – Elsevier Health Sciences ©

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 ane

1578185 – McGraw-Hill Professional ©

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

1578185 – McGraw-Hill Professional ©

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.

1578185 – McGraw-Hill Professional ©

CHAPTER 49
Role of the Medical Consultant

Steven L. Cohn, MD, FACP, SFHM

INTRODUCTION
Medical consultation has become an important component of Hospital Medicine. These
consultations include preoperative evaluation, perioperative management, and medical
care of patients on various nonmedical services. Previous surveys found that many
primary care physicians and hospitalists felt inadequately trained in perioperative
medicine, and as a result, this area received additional emphasis as part of the core
competencies for Hospital Medicine. With the growth of the hospitalist movement, the role
of the consultant has evolved from providing evaluation and advice to include
comanagement of the patient in certain settings. The goal of this chapter is to review the
role and responsibilities of the medical consultant, focusing on the principles of
consultation and techniques to improve effectiveness.

GENERAL PRINCIPLES OF CONSULTATION

More than 25 years ago, Goldman and colleagues described the concepts for performing
medical consultations. His “Ten Commandments” for effective consultation included the
following:

1. Determine the question.
2. Establish urgency.
3. Look for yourself.

1578185 – McGraw-Hill Professional ©

4. Be as brief as appropriate.
5. Be specific and concise.
6. Provide contingency plans.
7. Honor thy turf.
8. Teach with tact.
9. Talk is cheap and effective.

10. Follow-up.

These concepts, which incorporated many of the ethical principles described by the
American Medical Association (AMA), are important and remain valid for the traditional
consultation. However, some modifications are necessary to cover the new role of
hospitalists as comanagers.

TYPES OF CONSULTATION

The traditional or standard medical consultation consisted of a formal request from the
requesting physician to evaluate a patient and answer a specific question (Table 49-1).
The consultant was expected to address the question and to provide advice and
recommendations, but not to write orders or bring in other consultants; the requesting
physician remained in control and responsible for the patient’s overall care and treatment.
The consultant also focused on the specific problem rather than looking for and
addressing other issues. Consultations were requested only when necessary and not for
routine management. The follow-up period was usually brief and did not involve daily
visits for the duration of hospitalization.

TABLE 49-1 Roles and Responsibilities of Different Types on Consultations

  Traditional Comanagement Curbside
MD in charge overall Requesting

physician
Shared responsibility Requesting physician

Primary care of
medical problems

Requesting
physician

Medical consultant
Surgical—requesting
physician

Requestin

1578185 – McGraw-Hill Professional ©

CHAPTER 49
Role of the Medical Consultant

Steven L. Cohn, MD, FACP, SFHM

INTRODUCTION
Medical consultation has become an important component of Hospital Medicine. These
consultations include preoperative evaluation, perioperative management, and medical
care of patients on various nonmedical services. Previous surveys found that many
primary care physicians and hospitalists felt inadequately trained in perioperative
medicine, and as a result, this area received additional emphasis as part of the core
competencies for Hospital Medicine. With the growth of the hospitalist movement, the role
of the consultant has evolved from providing evaluation and advice to include
comanagement of the patient in certain settings. The goal of this chapter is to review the
role and responsibilities of the medical consultant, focusing on the principles of
consultation and techniques to improve effectiveness.

GENERAL PRINCIPLES OF CONSULTATION

More than 25 years ago, Goldman and colleagues described the concepts for performing
medical consultations. His “Ten Commandments” for effective consultation included the
following:

1. Determine the question.
2. Establish urgency.
3. Look for yourself.

1578185 – McGraw-Hill Professional ©

4. Be as brief as appropriate.
5. Be specific and concise.
6. Provide contingency plans.
7. Honor thy turf.
8. Teach with tact.
9. Talk is cheap and effective.

10. Follow-up.

These concepts, which incorporated many of the ethical principles described by the
American Medical Association (AMA), are important and remain valid for the traditional
consultation. However, some modifications are necessary to cover the new role of
hospitalists as comanagers.

TYPES OF CONSULTATION

The traditional or standard medical consultation consisted of a formal request from the
requesting physician to evaluate a patient and answer a specific question (Table 49-1).
The consultant was expected to address the question and to provide advice and
recommendations, but not to write orders or bring in other consultants; the requesting
physician remained in control and responsible for the patient’s overall care and treatment.
The consultant also focused on the specific problem rather than looking for and
addressing other issues. Consultations were requested only when necessary and not for
routine management. The follow-up period was usually brief and did not involve daily
visits for the duration of hospitalization.

TABLE 49-1 Roles and Responsibilities of Different Types on Consultations

  Traditional Comanagement Curbside
MD in charge overall Requesting

physician
Shared responsibility Requesting physician

Primary care of
medical problems

Requesting
physician

Medical consultant
Surgical—requesting
physician

Requestin

1578185 – Elsevier Health Sciences ©

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 ane

1578185 – McGraw-Hill Professional ©

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

1578185 – McGraw-Hill Professional ©

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.

1578185 – Elsevier Health Sciences ©

❖ 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 l

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