Advocacy Correspondence: Pennsylvania Department of Health, Administration of Low-dose Ketamine
March 12, 2024
The Honorable Dr. Debra L. Bogen
Acting Secretary of Health
Pennsylvania Department of Health
Health and Welfare Building
625 Forster Street, 8th Floor West
Harrisburg, PA 17129
Dear Secretary Bogen
I’m writing on behalf of The Hospital and Health System Association of Pennsylvania (HAP) to request clarification from the Department of Health on the regulatory parameters in place to guide the administration of ketamine by registered nurses under the supervision of a physician or certified registered nurse anesthetist. Reports from the hospital community indicate that compliance enforcement efforts and discussions with Department staff do not align with the most recent guidance available.
Below is our summary of the issue and our request from the hospital community.
The Department’s guidance states that registered nurses can administer low-dose ketamine in certain circumstances.
In 2020, the Department of Health released its administration guidelines for low-dose ketamine. This guidance outlines safe use practices in any treatment setting. This is seemingly the only piece of written guidance available on the topic. Low doses of ketamine are defined as those that are not intended to induce moderate to deep sedation or general anesthesia. The guidelines indicate that IV ketamine may be delivered in inpatient, outpatient, emergency department, and office-based settings with appropriate equipment and staffing. Most importantly, the guidance states that:
Ketamine administration (infusion initiation and infusion dose changes) may be provided by any licensed practitioner, such as a registered nurse who has competence in administration of low-dose ketamine, under supervision of a physician or a CRNA. Patient monitoring during infusion is to be completed by a licensed practitioner who is trained and credentialed to provide this care, including immediate treatment of emerging adverse effects. There must be adequately trained health care providers immediately available to monitor and respond to adverse events.
Current compliance enforcement efforts are not aligned with the above guidance.
Despite the current guidelines, members of the hospital community report hearing from the Division of Acute and Ambulatory Care (DAAC) surveyors and leadership that registered nurses are not permitted to administer low-dose ketamine.
The regulated community acknowledges the distinction between low-dose ketamine for pain management and ketamine for anesthetic purposes or procedural sedation and understands the guidance speaks only to the former. However, the same distinction is reportedly not being made by DAAC.
Across the U.S., registered nurses can administer low-dose ketamine with proper supervision.
As written, Pennsylvania’s guidance matches the standard of care in states nationwide.
In New York, RNs, meeting certain conditions, can administer drugs classified as anesthetic agents (most specifically ketamine) to patients experiencing pain in recovery rooms, critical care, hospice, step-down, or palliative care areas. Once 24 hours has passed from the time of initiation, patients on a ketamine regimen can be cared for by RNs with demonstrated competence on general patient units.
In Maryland, the administration of medication classified as an anesthetic agent is within the scope of practice of the registered nurse in an acute care setting when administered for purposes other than anesthesia or non-procedural sedation, such as clinical circumstances requiring sedation, and/or rapid sequence intubation.
In Rhode Island, the Department of Health updated its guidance to allow for administration of subanesthetic/low-dose ketamine under an order from an appropriate physician or other independent licensed provider (LIP) by a trained and competency-verified registered nurse (RN) in doses intended for relief of pain/analgesia or palliative care.
In South Carolina, it is within the scope of practice for an RN to administer and monitor low dose ketamine via continuous infusion and intravenous push in the ED and PACU with physician orders for specific cases of acute pain management in patients who with opioid-tolerance, intractable post-operative pain, poorly controlled chronic pain, palliative care, or patients suffering from extreme opioid side effects in an acute care setting.
In Arizona, it is within the Scope of Practice of a Registered Nurse (RN) to administer low-dose (sub-anesthetic) continuous IV Ketamine for the purposes of pain control (analgesia) and antidepressive effects when certain criteria is met.
Considering the current workforce challenges and the very clear support of administration of low-dose ketamine by registered nurses, HAP respectfully requests clarification on the Department’s regulatory parameters around the issue and that consideration is given to the role that registered nurses could play, especially in critical care units and emergency departments.
In addition, we ask that you provide your clarification in writing. This helps hospitals that may have interpreted the guidance differently and may unknowingly be operating in a way that would not be considered compliant with DOH regulations to correct course. The preference of the regulated community is to have this information delivered via a guidance document or notice of policy but in the interest of time, a message board might suffice.
Thank you for your consideration and collaboration on this matter.
Nicole Stallings
President & CEO
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Topics: State Advocacy
Revision Date: 3/12/2024
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