Oct 01, 2013
Ketamine for acute-on-chronic pain
Introducing and sustaining a new ketamine protocol at Foothills Medical Centre
Successfully implementing a new protocol and then sustaining it is a common challenge in health-care facilities. Among the many resources that can assist nurses with knowledge translation initiatives is the knowledge-to-action process (Graham et al., 2006), a conceptual framework for creating and tailoring knowledge, applying it and sustaining its use. The Acute Pain Service (APS) team in the Calgary Zone of Alberta Health Services (AHS) used this framework to guide the implementation of a low-dose ketamine continuous intravenous infusion (LDKCII) protocol for analgesia in surgery patients.
Ketamine is an N-methyl-d-aspartate receptor antagonist that blocks transmission of painful stimuli and can reduce opioid need (Pasero & McCaffery, 2005). It is used as an adjunct to both anesthesia and analgesia (Pasero & McCaffery). APS at Foothills Medical Centre wanted to use ketamine as an adjunct for treating acute-on-chronic pain in opioid-tolerant individuals following spinal surgery. However, proposals to administer ketamine on AHS medical-surgical units had been met with substantial resistance in the past, primarily because of the AHS drug monograph, which called for a level of bedside monitoring that was not feasible on these units.
In July 2011, APS revisited the possibility of providing ketamine for analgesia to medical-surgical patients. The APS nurse conducted a literature review and examined ketamine-related documents from other areas of AHS (including palliative care, pediatrics and critical care) as well as policies and protocols from health-care centres across Canada and from the U.K. She determined that the monograph was outdated and proceeded to have it amended, with input from anesthesiologists, chronic pain physicians and pharmacists. This activity represented a major turning point in the LDKCII initiative.
With these first steps completed, the APS nurse drafted a learning module for staff education, a new protocol and a physician order set and presented these to the APS medical director for review. LDKCII would be administered at 0.05-0.2 mg/kg/h over a few days postoperatively to opioid-tolerant individuals, in addition to standard postoperative analgesia regimes.
A team was assembled consisting of the medical leads (anesthesiologist, chronic pain physician and spinal surgeon), pharmacists, the APS nurse, a clinical nurse educator (CNE), a charge nurse clinician and managers. The evidence for using ketamine with the spinal surgery population and the feasibility of the initiative were discussed. Potential barriers were identified, including human factors issues such as choice of pump, mixing of the ketamine infusion bag and the number of RNs on the units (only RNs would be allowed to administer LDKCII).
Strategies for implementing the protocol successfully and safely were developed, taking into consideration the challenge of in-servicing and certifying RNs. The certification process would involve attending an in-service, completing the learning module and passing an exam. The APS nurse collaborated with the spinal surgery CNE to tailor the protocol and the learning module to meet unit needs. Once the documents were finalized, they were signed off by the APS medical director and sent to professional practice and legal for final approval.
The learning module and the protocol were posted on the intranet and circulated to staff on the two pilot units. The APS nurse developed the in-service, which included pain theory, ketamine pharmacology, a case study and hands-on low-fidelity simulated programming pump practice. The in-service was offered at various times to accommodate the schedules of staff on late shift. A date to roll out the initiative was chosen, based on the number of certified staff on each unit needed to cover every shift. On the implementation date, 94 per cent of RNs on the unit with a mix of RNs and licensed practical nurses and 67 per cent of RNs on the unit with mostly RN staff were certified.
LDKCII was first administered to a patient post spinal surgery in April 2012. The APS nurse and the CNE were at the bedside, to ensure that the patient was safe and that nurses were comfortable with the new protocol. A member of APS was available 24/7 for any concerns or questions.
EVALUATION AND EXPANSION
A few months later, APS reviewed patients’ responses, adverse events and staff feedback. No critical incidents had occurred. Some patients had experienced hallucinations that were not tolerated well, but these resolved once the infusion was turned off. Responses to a questionnaire sent to all certified RNs on the pilot units showed that 57 per cent of respondents had cared for a patient receiving ketamine. Overall, staff reported feeling supported by APS, the CNE and managers during the implementation; most reported they were prepared (62%) and well educated (77%) before having to care for these patients. The documents on the intranet were perceived as useful (77%). According to most respondents, LDKCII was not as complicated as they initially thought it might be.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13-24. doi:10.1002/chp.47
Pasero, C., & McCaffery, M. (2005). Ketamine: Low doses may provide relief for some painful conditions. American Journal of Nursing, 105(4), 60.
APS expanded the use of the protocol in 2013 to include abdominal surgery patients and trauma patients. The next targets for expansion are the medical-surgical units of the South Health Campus hospital. APS continues to be directly involved in the care of the individuals receiving LDKCII and in supporting nurses. Evaluation is ongoing through various quality assurance initiatives, and a retrospective chart review has begun.
This particular initiative was launched because the information on a single piece of paper was questioned. What’s standing in the way of your knowledge transfer initiative?
The author acknowledges Julie Reader (CNE of unit 101) and the RNs on units 101 and 112 at Foothills Medical Centre for their hard work during the implementation and their continued dedication to pain management.