9/19/2014 Securing Hospital Approval for Ketamine use on the Wards: Acknowledgements Challenges, Outcomes and Lessons Learned School of Pharmacy: S. VanOsdol Pharm.D. Clinical Pharmacy: H. Windham Pharm.D. PACU Nursing: S. Brynelson RN Mark Schumacher Ph.D.,M.D. Unit Nursing: M. Eckhaus RN IP3 Drs. K. Sun, C. Kim, S. Wilson Professor and Chief, Division of Pain Medicine NPs Nicole Hodgeboom, M. Comstock Dept. of Anesthesia & Perioperative Care Division Pain Medicine – R. Naidu & Faculty Medical Director, UCSF Pain Services Division of Palliative Care – S. Pantilat University of California, San Francisco UCSF: 150 years UCSF: The Health Care ‘System’ … in the making Parn Zion MB SFVA SF General Hospital MB Founded in 1864 1
9/19/2014 UCSF: Benioff Children’s Hospital UCSF Feb 2015 Zion U nder C MB onstruction S ometimes F inished Challenges: The Institution - UCSF Challenges: Inpatient Pain Care UCSF is Too Large to: Manage? Despite being a leader in Medicine, Pharmacy, Nursing , Dentistry… Innovate? Historically - UCSF inpatient clinical pain management was focused on primarily opioids . Provide Personalized Care ? 2
9/19/2014 Challenges: The ‘ ideal ’ analgesic does not yet exist Challenges: Inpatient Pain Care - Acts selectively on the “ pain-sensing ” nerves What system level practices are at play driving opioid – related unwanted side effects ? - Does not depress CNS - respiration - Use over time maintains analgesia Can we develop an institutional approach for - Easy to administer reducing the burden of opioids to our patients? - Is not addictive Is there a better way to manage pain that -Low Cost $$ balances opioids with other modalities? Ketamine : NMDA antagonist Challenges: High dose (IV Bolus): Dissociative: 1-2 mg/kg Anesthetic: 2-5mg/kg What other strategies are in our tool box to Moderate dose (Analgesia): 0.1-0.3 mg/kg reduce the opioid burden? (IV bolus) Low dose (Opioid sparing): 1-5 mcg/kg/min iv Low-dose Ketamine (IV Infusion) or 0.1-2 mg/kg/hr 3
9/19/2014 Challenges: Where we started Outcomes: Low dose Ketamine (3 ug/kg/min ) Consult – “We have a 27 yo F in the ICU on…” Fentanyl ( 7000ug/hr ) 3.4 L /day ! “ Reversal of Fentanyl-Induced Tolerance by administration of Small-Dose Ketamine ” (Eilers et al., 2001. Anesth Analg 93 (1) p213-214) Low dose Ketamine Opioid tolerant Challenges: How to Start? � Spinal fusions: placebo vs low dose ketamine (0.2mg/kg induction then 2 ug/kg/min x24hr) in opioid tolerant pts Who is in charge? .. � Both groups hydromorphone PCA � Less pain in PACU, POD1 at rest and “You are!” activity � Decreased hydromorphone requirement .. and you’ll need to find some interested partners Urban 2007 4
9/19/2014 Challenges: Critical Systems: Pain Management is interdisciplinary � Pain Management � Medical Director Need to link: Committee Pain Services � Providers � Provider � Nurses Champion(s) � Pharmacy � Clinical Nurse � Patients � Acute Pain Specialist – Pain Services � Unit Nurse Manager Critical Systems Components Challenges: Where to Start? � Clinical Nurse Specialist (CNS) - Pain Co-Chair Nursing – pain education Focus on Opioid Safety > Quality Meets Critical Events with Incident Reports Pain Resource Nurses Intended to assess and disseminate innovation - Respiratory Depression around analgesic therapy -Increasing use of naloxone 5
9/19/2014 Work of the Pain Management Committee Challenges: Pain Management SAN DIEGO PATIENT SAFETY TASKFORCE NEW Adult PCA Order Changes For use in patients > 40 kg T OOL K IT Patient Controlled Analgesia (PCA) Guidelines of Care What: The “Delay” and “One Hour Limit” on the Adult PCA Orders For the Opioid Naïve P atient form are being changed. The delay times (lock� out times) are being increased from 6 minutes to 10 minutes. O ctober 2011 Volume 1, Issue 3 What: P u bli shed : D ecem ber 2 0 08 Editor: For OPIOID NAÏVE patients: It is recommended to select Adrienne Green, MD, SFHM Associate Chief Medical Offic er MORPHINE SULFATE as a first choice (unless history of Chair, Patient Safety Com mittee allergy, unwanted side effects or renal dysfunction. Is it really just simple (analgesic) economics? Rationale: ADULT PATIENT CONTROLLED ANALGESIA: A longer delay time improves A NEW O RDER FORM FOR ADULTS > 40 KGS safety by preventing dose stacking. The use of Patient Controlled Analgesia (PCA) is a high risk therapy frequently Using Hydromorphone in used in post-operative care. At UCSF and nationally it has been associated with significant adverse events and death. In response to trends in post-operative opioid naïve patients patients at UCSF a review of Patient Controlled Analgesia prescribing practices has been shown to increase has recently been completed and new guidelines for Adult PCA orders have been adverse outcomes. developed. Key safety improvements include: Supply vs Demand Hydromorphone has been 1. The “Delay” and “One Hour Limit” have been changed to align with associated with increased rates of community and national standards. The delay time (lock-out time) has been respiratory depression in early increased from 6 minutes to 10 minutes. The one hour limit has thus been post-op patients. High risk patients include those with age appropriately decreased for each medication choice. >65, COPD, renal disease, CHF 2. New recommendations for Opioid Naïve Patients: and OSA. a. Morphine Sulfate is the first choice for opioid naïve patients without Why: A longer delay time is a safer practice and Use caution in dosing opioids in renal dysfunction. Supply How provider’s order analgesics matches community and national standards. patients with renal dysfunction. In b. Fentanyl is the first choice for opioid naïve patients with renal general, dose reductions are dysfunction. required for morphine and Why: When initiating an opioid analgesic, Morphine Sulfate hydromorphone when CrCl <=30. c. Hydromorphone is an alternative for opioid tolerant patients or patients Please consult the Pain Service appears the safest choice in opioid naïve patients. unresponsive to Morphine Sulfate. Fentanyl is the recommended choice in opioid naïve or Pharmacy for assistance with vs To improve patient safety, a revised “Adult Patient Controlled Analgesia IV Opioid dosing. patients with renal dysfunction. Hydromorphone is an Order Form” will be rolled out on Oct. 28th. alternative often used in opioid tolerant patients. Demand What are patients analgesic requirements? When: New PCA order forms will be replacing the current forms on October 27th & 28th Questions: Pain Service: 443-2398; Pain Management Committee / M. Schumacher MD PhD schumacm@anesthesia.ucsf.edu Questions: M/L Acute Pain Service: 443-2398; Mt. Zion Acute Pain Service: 443-2676 Pain Management Committee / PCA 6’ > 10’ M. Schumacher MD PhD schumacm@anesthesia.ucsf.edu A hard stop will be placed on orders submitted on the old order form on Monday November 14 th . First Do No Harm Challenges: Potential Benefits Decreasing Opioid Demand while Improving Quality � System – Related � Patient – Related � Decreased Length Goal: Introduce non–opioid strategies to � Decreased opioid of Stay (LOS) improve the quality of analgesia while reducing use / side effects opioid requirements � Reduced transfer � Improved PT to SNF � Early mobilization Where to Start? Unit with high levels of post-operative � Improved patient pain, highest opioid use, greatest number of opioid-related critical events, variable patient satisfaction Satisfaction � Cost Savings General Surgery – NPO, Ortho Spine – Opioid Tolerance 6
9/19/2014 Challenges: Critical Systems Challenges: Integration of Care � Pain Management � Medical Director Committee Pain Services � P & T No single protocol Committee will change a hospital’s culture � Clinical Nurse � Acute Pain Specialist – Pain Services � Unit Nurse � IP3 Manager Outcomes: low-dose ketamine Outcomes: low-dose ketamine � Approval ‘Pilot’ ketamine (1-5 mcg/kg/min) � Report back to P & T of Pilot (~ 30 pts) � Designated Providers / Service � Approval for “official” use on Original 4 units plus � Controlled by Pain Services – Palliative Care Services expansion to 4 additional units (all with CPO) � Initially 4 units: � Finally: Approval for Medical Center use � General Surgery following completion of in-service, CPO, � Palliative Care continued oversight by Pain Services – Palliative � Pediatric / Onc Care. � Zion – Med/Surg � Retrospective review – ongoing 7
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