UCSF: 150 years in the making

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1 Securing Hospital Approval for Ketamine use on the Wards: Challenges, Outcomes and Lessons Learned Acknowledgements Mark Schumacher Ph.D.,M.D. Professor and Chief, Division of Pain Medicine Dept. of Anesthesia & Perioperative Care Medical Director, UCSF Pain Services University of California, San Francisco School of Pharmacy: S. VanOsdol Pharm.D. Clinical Pharmacy: H. Windham Pharm.D. PACU Nursing: S. Brynelson RN Unit Nursing: M. Eckhaus RN IP3 Drs. K. Sun, C. Kim, S. Wilson NPs Nicole Hodgeboom, M. Comstock Division Pain Medicine R. Naidu & Faculty Division of Palliative Care S. Pantilat UCSF: 150 years in the making UCSF: The Health Care System Parn Zion MB SFVA SF General Hospital MB Founded in

2 UCSF: Benioff Children s Hospital Feb 2015 Zion MB U UCSF nder C onstruction S ometimes F inished Challenges: The Institution - UCSF Challenges: Inpatient Pain Care UCSF is Too Large to: Innovate? Manage? Despite being a leader in Medicine, Pharmacy, Nursing, Dentistry Historically - UCSF inpatient clinical pain management was focused on primarily opioids. Provide Personalized Care? 2

3 Challenges: Inpatient Pain Care Challenges: The ideal analgesic does not yet exist What system level practices are at play driving opioid related unwanted side effects? Can we develop an institutional approach for reducing the burden of opioids to our patients? Is there a better way to manage pain that balances opioids with other modalities? - Acts selectively on the pain-sensing nerves -Does not depress CNS - respiration -Use over time maintains analgesia -Easy to administer -Is not addictive -Low Cost $$ Challenges: Ketamine: NMDA antagonist High dose (IV Bolus): Dissociative: 1-2 mg/kg Anesthetic: 2-5mg/kg What other strategies are in our tool box to reduce the opioid burden? Moderate dose (Analgesia): (IV bolus) mg/kg iv Low-dose Ketamine Low dose (Opioid sparing): 1-5 mcg/kg/min (IV Infusion) or mg/kg/hr 3

4 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., Anesth Analg 93 (1) p ) Low dose Ketamine Opioid tolerant Spinal fusions: placebo vs low dose ketamine (0.2mg/kg induction then 2 ug/kg/min x24hr) in opioid tolerant pts Both groups hydromorphone PCA Less pain in PACU, POD1 at rest and activity Decreased hydromorphone requirement Challenges: How to Start? Who is in charge?.. You are!.. and you ll need to find some interested partners Urban

5 Pain Management is interdisciplinary Need to link: Providers Nurses Pharmacy Patients Challenges: Critical Systems: Medical Director Pain Services Acute Pain Services Provider Champion(s) Pain Management Committee Clinical Nurse Specialist Pain Unit Nurse Manager Critical Systems Components Clinical Nurse Specialist (CNS) - Pain Co-Chair Nursing pain education Meets with Pain Resource Nurses Intended to assess and disseminate innovation around analgesic therapy Challenges: Where to Start? Focus on Opioid Safety > Quality Critical Events Incident Reports - Respiratory Depression -Increasing use of naloxone 5

6 P u bli shed : D ecem ber Editor: Adrienne Green, MD, SFHM Associate Chief Medical Officer Chair, Patient Safety Com mittee October 2011 Volume 1, Issue 3 Work of the Pain Management Committee SAN DIEGO PATIENT SAFETY TASKFORCE Challenges: Pain Management NEW Adult PCA Order Changes TOOL KI T For use in patients > 40 kg P atient Controlled Analgesia (PCA) Guidelines of What: Care For the Opioid Naïve P atient PCA 6 > 10 The Delay and One Hour Limit on the Adult PCA Orders form are being changed. The delay times (lock out times) are being increased from 6 minutes to 10 minutes. What: For OPIOID NAÏVE patients: It is recommended to select MORPHINE SULFATE as a first choice (unless history of allergy, unwanted side effects or renal dysfunction. ADULT PATIENT CONTROLLED ANALGESIA: Why: A longer delay time is a safer practice and a. Morphine Sulfate is the first choice for opioid naïve patients without renal dysfunction. matches community and national standards. b. Fentanyl is the first cho ice for opioid naïve patients with renal dysfunction. Why: When initiating an opioid analgesic, Mor phi ne Sulf at e c. Hydromorphone is an alternative for opioid tolerant patients or patients appears the safest choice in opioid naïve patients. unresponsive to Morphine Sulfate. Fen t anyl is the recommended choice in opioid To improve naïve patient safety, a revised Adult Patient Controlled Analgesia IV Opioid patients with renal dysfunction. Hyd ro m ororder ph one Form is will an be rolled out on Oct. 28th. alternative often used in opioid tolerant patients. When: New PCA order forms will be replacing the current forms on Oct ober 2 7t h & 28t h Questions: Pain Service: ; Pain Management Committee / M. Schumacher MD PhD schumacm@anesthesia.ucsf.edu A NEW ORDER FORM FOR ADULTS > 40 KGS The use of Patient Controlled Analgesia (PCA) is a high risk therapy frequently 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 patients at UCSF a review of Patient Controlled Analgesia prescribing practices has recently been completed and new guidelines for Adult PCA orders have been developed. Key safety improvements include: 1. The Delay and One Hour Limit have been changed to align with community and national standards. The delay time (lock-out time) has been increased from 6 minutes to 10 minutes. The one hour limit has thus been appropriately decreased for each medication choice. 2. New recommendations for Opioid Naïve Patients: A hard stop will be placed on orders submitted on the old order form on Monday November 14 th. Rationale: A longer delay time improves safety by preventing dose stacking. Using Hydromorphone in opioid naïve patients has been shown to increase adverse outcomes. Hydromorphone has been associated with increased rates of respiratory depression in early post-op patients. High risk patients include those with age >65, COPD, renal disease, CHF and OSA. Use caution in dosing opioids in patients with renal dysfunction. In general, dose reductions are required for morphine and hydromorphone when CrCl <=30. Please consult the Pain Service or Pharmacy for assistance with dosing. Questions: M/L Acute Pain Service: ; Mt. Zion Acute Pain Service: Pain Management Committee / M. Schumacher MD PhD schumacm@anesthesia.ucsf.edu First Do No Harm Is it really just simple (analgesic) economics? Supply vs Demand Supply How provider s order analgesics vs Demand What are patients analgesic requirements? Challenges: Decreasing Opioid Demand while Improving Quality Goal: Introduce non opioid strategies to improve the quality of analgesia while reducing opioid requirements Where to Start? Unit with high levels of post-operative pain, highest opioid use, greatest number of opioid-related critical events, variable patient satisfaction General Surgery NPO, Ortho Spine Opioid Tolerance Patient Related Potential Benefits Decreased opioid use / side effects Improved PT Early mobilization System Related Decreased Length of Stay (LOS) Reduced transfer to SNF Improved patient Satisfaction Cost Savings 6

7 Challenges: Critical Systems Challenges: Integration of Care Medical Director Pain Services Pain Management Committee No single protocol will change a hospital s culture P & T Committee Acute Pain Services IP3 Clinical Nurse Specialist Pain Unit Nurse Manager Outcomes: low-dose ketamine Outcomes: low-dose ketamine Approval Pilot ketamine (1-5 mcg/kg/min) Designated Providers / Service Controlled by Pain Services Palliative Care Services Initially 4 units: General Surgery Palliative Care Pediatric / Onc Zion Med/Surg Report back to P & T of Pilot (~ 30 pts) Approval for official use on Original 4 units plus expansion to 4 additional units (all with CPO) Finally: Approval for Medical Center use following completion of in-service, CPO, continued oversight by Pain Services Palliative Care. Retrospective review ongoing 7

8 Challenge: Case Mr. T 34yo M h/o rectal CA s/p APR Chronic pain Oxycontin 60mg BID, Intermittently on methadone Oxycodone 60mg q4h PRN, Escalating opioid dose, constipation, concerns for opioid-induced hyperalgesia Epidural placed, low-dose ketamine infusion started POD 15 with great improvement in pain Hospital discharge 1 week later Challenge: Patient VG 19 yo with h/o desmoplastic small blue round cell tumor dx 7 years ago s/p chemo, surgical resection, autologous transplant, radiation. Admitted in Jan 2013 due to 4 month history of abdominal fullness and abdominal pain. Found to have significant ascites and recurrence of her tumor. Admitted for worsening pain and bowel obstruction. Admitted for worsening pain and bowel obstruction. Increase in hydromorphone requirement ~300mg IV/day Constipation likely due to increased opioid requirement Increase in hydromorphone requirement ~300mg IV/day Constipation likely due to increased opioid requirement Ketamine started 3mcg/kg/min Reduced requirement of Hydromorphone use 300mg IV to 20mg IV within 4 days. Consider Transfer to Hospice Outpatient 8

9 Transferred to George Mark Children s House IV ketamine administration outpt Free standing pediatric hospice No previous experience with ketamine infusion Specialist back up resources at UCSF PNP- during the day M-F MD- at night and weekends Dream Foundation Hospice to Disneyland Lessons Learned: Hospice to Home!!! But no home nursing provided Bi-weekly phone checks- working An agent initially restricted to the ICU was transformed to fulfill a family wish and return pt comfortably to home Unexpected benefits that extend beyond the initial plan 9

10 Lessons Learned: Low-Dose Ketamine Patient Selection and Expectations Provider Expectations & Education Managing side effects (Few and dose dependent) Visual changes nystagmus Locked in feeling Illusions vivid dreams Ongoing review of data by whom? A Work in Progress Lessons Learned: We are expanding its use to Ortho-spine patients with significant opioid tolerance Sickle Cell Anemia patients with significant opioid tolerance May have a role in opioid naïve patients undergoing major abdominal surgery Palliative adult and pediatric patients Lessons Learned: Systems Broad Participation from Admin - House Staff / Chairs Improve non-pharmacy interventions Integrate multi-modal pain therapies Reassess approach / med rec for chronic pain patients Educate staff about who to contact to troubleshoot pain Improve / establish pain care resource network Lessons Learned: Communication Reinforce your innovation and message 10

11 Thank You 11