Experiential Learning with Ketamine: A Mixed-Methods Exploratory Study on Prescription and Perception.

Intensivists at a tertiary academic ICU felt ongoing discomfort using ketamine for analgosedation, even after a large increase in its use during the COVID-19 pandemic. Among 446 mechanically ventilated medical ICU patients, ketamine prescriptions rose from 4 (2.1%) pre-COVID to 81 (32.3%) during the COVID-19 surge. Focus groups with 13 attending intensivists revealed three key themes behind their discomfort: a lack of evidence about ketamine, a lack of personal experience, and a desire for more education and protocols. The increase in hands-on experience alone did not reduce provider discomfort, suggesting that continuing education and process improvements are needed to support adoption of unfamiliar therapies.

Study at a glance

Abstract

Incorporating unfamiliar therapies into practice requires effective longitudinal learning and the optimal way to achieve this is debated. Though not a novel therapy, ketamine in critical care has a paucity of data and variable acceptance, with limited research describing intensivist perceptions and utilization. The Coronavirus-19 pandemic presented a particular crisis where providers rapidly adapted analgosedation strategies to achieve prolonged, deep sedation due to a surge of severe acute respiratory distress syndrome (ARDS). How does clinical experience with ketamine impact the perception and attitude of clinicians toward this therapy? We conducted a mixed-methods study using quantitative ketamine prescription data and qualitative focus group data. We analyzed prescription patterns of ketamine in a tertiary academic ICU during two different time points: pre-COVID-19 (March 1-June 30, 2019) and during the COVID-19 surge (March 1-June 30, 2020). Two focus groups (FG) of critical care attendings were held, and data were analyzed using the Framework Method for content analysis. Four-hundred forty-six medical ICU patients were mechanically ventilated (195 pre-COVID-19 and 251 during COVID-19). The COVID-19 population was more likely to receive ketamine (81[32.3%] vs 4 [2.1%], p < 0.001). Thirteen respondents participated across two FG sessions (Pre-COVID = 8, Post-COVID=5). The most prevalent attitude among our respondents was discomfort, with three key themes identified as follows: 1) lack of evidence regarding ketamine, 2) lack of personal experience, and 3) desire for more education and protocols. Despite a substantial increase in ketamine prescription during COVID-19, intensivists continued to feel discomfort with utilization. Factors contributing to this discomfort include a lack of evidence, a lack of experience, and a desire for more education and protocols. Increase in experience with ketamine alone was not sufficient to minimize provider discomfort. These findings should inform future curricula and call for process improvement to optimize continuing education.