Deficiencies in the Implementation and Leadership Oversight of Ketamine at the Eastern Oklahoma VA Health Care System in Muskogee

Report Information

Issue Date
Report Number
21-01836-66
VISN
19
State
Oklahoma
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Mental Health
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) assessed allegations and reviewed processes at the Eastern Oklahoma VA Health Care System in Muskogee (facility) related to the provision of ketamine for patients with treatment-resistant depression. The OIG did not substantiate an anesthesiologist self-referred facility patients to a private practice. The anesthesiologist provided intravenous ketamine to one patient at the private practice but did not self-refer the patient. The OIG substantiated that the anesthesiologist prescribed sublingual ketamine to treat a patient with depression and found the anesthesiologist prescribed sublingual ketamine for two patients for pain; however, VHA does not prohibit prescribing sublingual ketamine. The OIG determined there were inconsistencies with pharmacy staff’s approval of non-formulary requests for sublingual ketamine. The OIG substantiated that behavior medicine and psychiatry leaders did little to respond to a concern regarding the anesthesiologist’s prescribing practices and facility leaders did not resolve the disagreement between prescribers and pharmacists concerning ketamine prescribing. The OIG determined that the ketamine team’s informal process to review and approve patients for intravenous ketamine was not maintained after members changed and the team did not discuss or decide on approval for ketamine for four patients. Not formalizing a review process may have contributed to a nurse approving a community care consult for ketamine without the team’s approval. The OIG found that scientific opinions on the selection of patients for ketamine treatment differ from VA’s national ketamine guidance regarding the acceptable number of prior treatment failures in a current episode of depression. The OIG made one recommendation to the VHA Under Secretary for Health regarding determining whether the national protocol guidance should be modified, and four to the Facility Director related to non-formulary medication processes; informed consents; the ketamine standard operating procedure; and development of positive working relations among Anesthesiology, Pharmacy, and Psychiatry Services.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Eastern Oklahoma VA Health Care System Director evaluates the Eastern Oklahoma VA Health Care System’s non-formulary medication request and appeal processes for ketamine and antipsychotic medication, implements necessary changes, and educates prescribing providers and pharmacists on the processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Eastern Oklahoma VA Health Care System Director ensures that the Eastern Oklahoma VA Health Care System staff document informed consents for stellate ganglion blocks and intravenous ketamine treatment in accordance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Eastern Oklahoma VA Health Care System Director evaluates the standard operating procedure, Psychiatric Use of IV Ketamine, Eastern Oklahoma VA Healthcare System, and specifically delineates the mechanisms for referral and evaluation of patients, to include documentation of criteria for patients to receive ketamine treatment and ensures staff are educated and compliant with the procedure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Eastern Oklahoma VA Health Care System Director takes action to ensure Eastern Oklahoma VA Health Care System leaders continue to resolve disagreements between prescribers and pharmacists and foster the development of positive working relations among Anesthesiology, Pharmacy, and Psychiatry Services.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates the VA Ketamine Infusion for Treatment-Resistant Depression and Severe Suicidal Ideation National Protocol Guidance to determine whether the acceptable number of previous treatment failures in a current episode of depression should be modified to align with current scientific recommendations.