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

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.