UCSF: 150 years UCSF: The Health Care System in the making Parn - - PowerPoint PPT Presentation

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UCSF: 150 years UCSF: The Health Care System in the making Parn - - PowerPoint PPT Presentation

Nov 30, 2023 113 likes •225 views

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

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9/19/2014 1

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

Securing Hospital Approval for Ketamine use

  • n the Wards:

Challenges, Outcomes and Lessons Learned

Acknowledgements

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

Founded in 1864

UCSF: The Health Care ‘System’

SFVA MB Zion Parn SF General Hospital MB

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9/19/2014 2

UCSF: Benioff Children’s Hospital

Feb 2015 MB Zion

UCSF

U C S F

nder

  • nstruction
  • metimes

inished

Challenges: The Institution - UCSF

UCSF is Too Large to: Manage? Innovate? Provide Personalized Care ?

Challenges: Inpatient Pain Care

Despite being a leader in Medicine, Pharmacy, Nursing , Dentistry… Historically - UCSF inpatient clinical pain management was focused on primarily opioids.

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9/19/2014 3

Challenges: Inpatient Pain Care

What system level practices are at play driving

  • pioid – 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?

Challenges: The ‘ideal’ analgesic

does not yet exist

  • 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 $$

iv Low-dose Ketamine

Challenges:

What other strategies are in our tool box to reduce the opioid burden?

Ketamine: NMDA antagonist

High dose (IV Bolus): Dissociative: 1-2 mg/kg Anesthetic: 2-5mg/kg Moderate dose (Analgesia): 0.1-0.3 mg/kg (IV bolus) Low dose (Opioid sparing): 1-5 mcg/kg/min (IV Infusion)

  • r 0.1-2 mg/kg/hr
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9/19/2014 4

Challenges:

Consult – “We have a 27 yo F in the ICU on…” Fentanyl (7000ug/hr) Where we started

3.4 L /day !

Outcomes: Low dose Ketamine (3 ug/kg/min )

“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

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

Urban 2007

Challenges: How to Start?

Who is in charge? ..

“You are!”

.. and you’ll need to find some interested partners

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9/19/2014 5

Pain Management is interdisciplinary

Providers Nurses Pharmacy Patients

Need to link:

Challenges: Critical Systems:

Acute Pain

Services

Pain Management

Committee

Medical Director

Pain Services

Clinical Nurse

Specialist – Pain

Unit Nurse

Manager

Provider

Champion(s)

Critical Systems Components

Clinical Nurse Specialist (CNS) - Pain

Meets with Pain Resource Nurses

Intended to assess and disseminate innovation around analgesic therapy Co-Chair Nursing – pain education

Challenges: Where to Start?

Focus on Opioid Safety > Quality

Critical Events Incident Reports

  • Respiratory Depression
  • Increasing use of naloxone
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SLIDE 6

9/19/2014 6

SAN DIEGO PATIENT SAFETY TASKFORCE

TOOL KIT Patient Controlled Analgesia (PCA) Guidelines of Care

For the Opioid Naïve P atient

P u bli shed : D ecem ber 2 0 08

Adult PCA Order Changes For use in patients > 40 kg NEW

What: The “Delay” and “One Hour Limit” on the Adult PCA Orders form are being changed. The delay times (lock

  • ut 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. Why: A longer delay time is a safer practice and matches community and national standards. Why: When initiating an opioid analgesic, Morphine Sulfate appears the safest choice in opioid naïve patients. Fentanyl is the recommended choice in opioid naïve patients with renal dysfunction. Hydromorphone is an alternative often used in opioid tolerant patients. 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
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. Morphine Sulfate is the first choice for opioid naïve patients without
renal dysfunction.
  • b. Fentanyl is the first choice for opioid naïve patients with renal
dysfunction.
  • c. Hydromorphone is an alternative for opioid tolerant patients or patients
unresponsive to Morphine Sulfate. To improve patient safety, a revised “Adult Patient Controlled Analgesia IV Opioid Order Form” will be rolled out on Oct. 28th.

ADULT PATIENT CONTROLLED ANALGESIA: A NEW O RDER FORM FOR ADULTS > 40 KGS

O ctober 2011 Volume 1, Issue 3

First Do No Harm

Editor: Adrienne Green, MD, SFHM Associate Chief Medical Offic er Chair, Patient Safety Com mittee Rationale: A longer delay time improves safety by preventing dose stacking. Using Hydromorphone in
  • pioid 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
  • r Pharmacy for assistance with
dosing. Questions: M/L Acute Pain Service: 443-2398; Mt. Zion Acute Pain Service: 443-2676 Pain Management Committee /
  • 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 14th.

Work of the Pain Management Committee

PCA 6’ > 10’

Challenges: Pain Management

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

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 Goal: Introduce non–opioid strategies to improve the quality of analgesia while reducing

  • pioid requirements

Potential Benefits

Patient – Related

Decreased opioid

use / side effects

Improved PT Early mobilization

System – Related

Decreased Length

  • f Stay (LOS)

Reduced transfer

to SNF

Improved patient

Satisfaction

Cost Savings

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9/19/2014 7

Challenges: Integration of Care

No single protocol will change a hospital’s culture

Challenges: Critical Systems

Acute Pain

Services

IP3 Pain Management

Committee

Medical Director

Pain Services

Clinical Nurse

Specialist – Pain

Unit Nurse

Manager

P & T

Committee

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

Outcomes: low-dose ketamine

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

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9/19/2014 8

34yo M h/o rectal CA s/p APR Chronic pain – Oxycontin 60mg BID,

Oxycodone 60mg q4H PRN,

Intermittently on methadone

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: Case Mr. T 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.

Increase in hydromorphone requirement

~300mg IV/day

Constipation likely due to increased opioid

requirement Admitted for worsening pain and bowel

  • bstruction.

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

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9/19/2014 9

Transferred to George Mark Children’s House

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

IV ketamine administration

  • utpt

Hospice to Disneyland…

Dream Foundation

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

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9/19/2014 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

  • pioid tolerance

May have a role in opioid naïve patients undergoing major abdominal surgery Palliative adult and pediatric patients

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: Systems Lessons Learned: Communication

Reinforce your innovation and message

http://pain.ucsf.edu/#

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9/19/2014 11

Thank You