![[ Visit Client Website ]](images/banner.gif)
Opioid-tolerant patients have complex pain management needs, and untreated acute pain may lead to the development of persistent pain. Ketamine, as a low-dose analgesic, may benefit opioid-tolerant patients undergoing surgery by re-setting opioid receptors, decreasing opioid requirements post-operatively, and therefore decreasing opioid side effects. The purpose of this EBP project was to improve post-operative pain for opioid-tolerant orthopedic spine surgery patients by implementing the use of low-dose Ketamine infusions. Although the benefits of Ketamine for opioid-tolerant patients have been well demonstrated, side effects, such as unusual dreams and dysphoria, warrant special consideration.
Ketamine has successfully been used as an option for post-operative acute pain management in some patients at the University of Iowa Hospitals and Clinics, thereby creating an opportunity or trigger to improve practice in other populations. An interdisciplinary team, led by a staff nurse, used the 2001 Iowa Model as a guide for the EBP process. The pilot step in the Iowa Model involved creation of a policy (in lieu of a guideline) for Ketamine for post-operative management in the opioid-tolerant population. Piloting the policy and practice change required development of an implementation plan along with systematic use of multiple interactive and reinforcing strategies based on the four-phased Implementation Guide. As part of implementation, the interdisciplinary acute pain service created a consistent referral process for opioid-tolerant patients undergoing spine surgery. Pre-operatively, the pharmacist and patient collaborate to develop a surgical pain treatment plan, to guide intra-operative and post-operative interventions, based on current medications, dosages, duration of use, etc. Pilot evaluation components included both pre- and post-implementation patient questionnaires regarding Ketamine and pain management along with knowledge and attitudes of staff (nurses and licensed independent practitioners). Staff knowledge results indicated 72% correct (pre; n=50) improved to 77% correct (post; n=22). Staff perceptions demonstrated staff believe Ketamine controls pain (2.7 pre & post; 1-4 Likert scale); are knowledgeable about Ketamine administration (2.4 pre; 2.6 post) and Ketamine side effects (2.6 pre & post); and believe potential patients, who may be candidates for Ketamine, were easy to identify (2.3 pre; 2.2 post). The next step in the Iowa Model includes a decision about the appropriateness of the practice based on the pilot results. For the Ketamine project, the decision was actually a question about whether the practice change and implementation plan worked as intended to guide direction about moving to integration, the subsequent step in the Iowa Model. The Iowa Model then proceeds to monitoring and analyzing structure, process, and outcomes. As learned in this project and other projects, in reality, integration is quite complex and additional planning and internal reporting were deemed important next steps after the pilot.
This EBP project led to improved staff knowledge regarding Ketamine for pain; proactive identification of opioid-tolerant orthopedic spine surgery patients who may benefit from Ketamine; development of pain treatment plans; and interdisciplinary communication and collaboration. However, steps outlined in the 2001 Iowa Model produced gaps, so adaptations were made to better meet project needs. This project provides an example of one impetus for updating the Iowa Model.