(Management Case Study) Don't Be Strangled by the Epidural Tubing Shortage: Switching Epidural Administration to a Large Volume Intravenous Pump

Purpose: The medical center received short notice that tubing used on the epidural pumps was on national shortage and the current supply on hand will be exhausted in two days. Two key populations affected include patients with acute/chronic pain undergoing surgery and Labor and Delivery. Epidural medications affected include opioids with or without bupivacaine, and ropivacaine. The decision to use the hospital’s large volume intravenous pump prompted the critical need to develop safety strategies with this pump change as incorrect route errors can have lethal consequences. Bupivacaine epidural infusion incorrectly given intravenously can trigger cardiotoxicity that is refractory to resuscitative measures.

Methods: A multidisciplinary committee was created to address the topics of concern including the following: (1) Update the pump drug library to include rate limits for the epidural medications with clinical advisory; (2) Update the impacted order sets; (3) Procure new tubing with yellow strip and prepare kits that include 0.2 micron filter, tubing, and sticker; (4) Create a yellow sticker to be affixed to the pump channel and tubing to visibly identify epidurals; (5) Create a nursing educational plan that includes written and video materials about management of these pumps such that it is a dedicated pump with no additional medications attached, and pump and pole is physically separate from other intravenous medications preferably on the other side of the bed; (6) Develop a nursing checklist that includes the strategies to safely initiate epidural administration; (7) Devise an ongoing observation process to ensure safe use of epidurals with just-in-time training and audit of set up and monitoring for deviations and best practices; and (8) Report back to key committees the opportunities identified and errors discovered.

Pharmacy and Therapeutics approved order set revisions and drug library updates. Education was provided multiple times to hospital-wide huddles. Nurse-led observations were completed weekdays in the first month then three times a week in the next month and then twice a week in the subsequent month.

Results: Data was collected after implementation and 364 observations were completed between 1/21/2022 and 4/30/2022 to be reported here. Data continues to be collected currently. The following safety strategies were implemented and observation compliance is reported here:

• 99.7% dedicated pump use (363/364)


• 97% use of yellow strip tubing w 0.2 micron filter (354/364)


• 97% pump physically located opposite other intravenous medications (354/364)


• 99.7% correct epidural connectivity (363/364)


• 98% drug library use with safety software (357/364)

Several opportunities were identified during observations such as the need to clearly label the epidural catheter as it may not be visible if near other IV catheters and underneath patient clothing. Empty modules were attached to the pump which increases the likelihood of initiation of an intravenous medication. Nurses were provided education about removing the extra pump module attachments. Stickers missing from the tubing or from the channel were immediately corrected. Regular tubing without the yellow strip was also observed. The patient-controlled dose may be ordered even though the pump does not all patient-controlled dosing and Pharmacy and Therapeutics emergently approved the revision and the electronic health record was updated to “zero” out the dose field. Opportunities were shared with nursing leadership committee.

Conclusion: Due to a national shortage of epidural tubing requiring a hospital-wide change in the pump used to administer epidural medications, a multidisciplinary team was assembled to quickly create a plan to safely implement epidural administration via the intravenous pump. Strong actions such as standardized processes, ongoing observations by nurse educators, technology order set updates and pump clinical advisories as well as initiation checklists for epidural administrations resulted in the successful implementation with strong compliance data. No wrong route errors with administering an epidural medication intravenous have occurred.