PAIN MANAGEMENT
Ziconotide: last resort?
Recently we admitted a patient with low back pain refractory to other treatment for intrathecal ziconotide infusion therapy. What do I need to know about this drug?-H.D., OHIO
Ziconotide is a nonopioid and non-NSAID analgesic agent classified as an N-type calcium channel antagonist. It's the synthetic equivalent of a conopeptide found in the marine snail Conus magus. The drug is indicated for the management of severe chronic pain in patients for whom intrathecal therapy is warranted, and who are intolerant of or refractory to other treatment, such as systemic analgesics, adjunctive therapies, or intrathecal morphine used to manage severe and chronic pain.1 Ziconotide is administered using a programmable implanted variable-rate microinfusion device or an external microinfusion device and catheter. It shouldn't be administered I.V.1
This drug isn't a first-line option for intrathecal therapy because it can cause serious adverse reactions. The most frequently reported adverse reactions in clinical trials were dizziness, nausea, confusional state, and nystagmus.1
Patients should be informed about possible adverse reactions before treatment begins. It has a boxed warning for severe psychiatric symptoms and neurologic impairment, including depression, cognitive impairment, depressed levels of consciousness, and hallucinations. Patients with a preexisting history of psychosis shouldn't be treated with ziconotide. Patients using this medication must be willing and able to communicate that these effects have occurred and seek help from healthcare providers when appropriate.1
REFERENCE
1. PRIALT (ziconotide solution, intrathecal infusion). Prescribing information. http://www.prialt.com. [Context Link]
The drug information presented here applies to adults, not children. Consult a pharmacist or the package insert for information on drug safety during pregnancy and breastfeeding. Consult a pharmacist, the package insert, or a comprehensive and current drug reference for more details on precautions, drug interactions, and adverse reactions for this drug.
23-HOUR OBSERVATION
One hour short of a day
How did the concept of 23-hour observation in the hospital develop?-B.B., N.C.
An observational admission (OA) is between 8 and 48 hours per Centers for Medicare and Medicaid services,1 but deciding whether the course of treatment will end in discharge or conversion to inpatient status should be made in 24 hours.
The 23-hour OA was originally created for patients diagnosed with disorders such as asthma and cellulitis with well-established treatment protocols requiring a short hospital course.2 During this short OA, healthcare providers (HCPs) determine whether hospital admission is necessary or if these patients could be treated as outpatients.
The OA provides safety and improved satisfaction for these patients in light of ED capacity and boarding issues.2 OA patients can be housed on a single unit or occupy beds on inpatient units throughout a facility. The unit can be under emergency services, hospitalist groups, or all admitting HCPs. Most importantly, observation status is a designation that may have little or no connection to the actual care that the patient requires.
In one hospital, the OA unit is located behind the ED and accepts patients from only the ED and the trauma service. The unit is staffed 24/7 by advanced practice nurses (APNs) in collaboration with physicians. The APN and nursing staff receive HCP and nursing report at the patient's bedside and "pull" the patient to the OA unit. The patient is evaluated, has orders placed, and receives a plan of care with goals communicated at the time of transfer to the OA unit. The discharge decision is made by the APN with consultation when appropriate. Discharge takes place when goals are reached regardless of the time of day or whether HCPs are present.
Nationwide, 25% of OA patients do become inpatients, but the length of stay is shorter and cost of care is less for those who remain on the OA unit.3
REFERENCES
1. Medicare Benefit Policy Manual. Chapter 6: 20.6 section A. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06. [Context Link]
2. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation units: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37. [Context Link]
3. Runy LA.Clinical observation units: building a bridge between outpatient and inpatient services. Hosp Health Netw. 2006;80(3):59-65. [Context Link]