This section contains recommendations concerning the Excited Delirium Syndrome diagnosis that is often used to support ketamine administration, mitigation of the role that explicit and implicit bias can play in prehospital ketamine administration, and the limited circumstances in which ketamine can be appropriately administered in the prehospital setting.
A.1 Panel Recommendation: Rejection of Excited Delirium Syndrome Diagnosis
The diagnosis of Excited Delirium Syndrome has come under scrutiny for a number of years (predating the deaths of Elijah McClain and George Floyd) for the potential of bias. This is in part because descriptors such as “hyper aggression,” “increased strength,” and “police noncompliance” are listed as criteria for this assessment and have been associated with racial bias against African American men.
Besides the fact that the Excited Delirium Syndrome diagnosis lends itself to discriminatory practices that result in systemic bias against communities of color, its lack of a uniform definition and specific, validated medical criteria allows for the possibility of inaccurate assessments and the inappropriate administration of ketamine to patients for non-medical reasons.
Consequently, the panel recommends that Excited Delirium Syndrome no longer be used as a condition that warrants waivers for the administration of ketamine. While making this recommendation, the panel acknowledges that in the prehospital setting a patient’s agitation and disorientation can present a direct threat to the patient’s safety as well as to the safety of the public and first responders. (See Recommendation A.3)
A.2 Panel Recommendation: Findings of Implicit and Explicit Racism
The panel affirms that patient care and the administration of ketamine in the prehospital setting are strictly within the purview of the paramedic. Paramedics must not administer ketamine for law enforcement restraint and/or custodial purposes.
CDPHE should analyze whether there is disproportionate use of ketamine for marginalized persons and communities of color in Colorado. CDPHE’s data collection processes should facilitate this analysis by capturing accurate race/ethnicity and zip code information in order to perform this analysis. The panel further recommends that paramedics be trained on assigning a race/ethnicity element.
CDPHE and the Emergency Medical Practice Advisory Council (EMPAC) should develop and implement ketamine waiver policies, procedures, and guidance that incorporate objective criteria and promote racial equity.
CDPHE and EMPAC should incorporate a Racial Equity Impact Assessment in the ketamine waiver process that requires community stakeholder participation from different racial and ethnic groups that have been or may be affected by the disparate use of ketamine in the prehospital setting, in line with national best practices. In doing so, CDPHE should utilize its existing resources, including the Equity, Diversity and Inclusion Officer as well as the Office of Health Equity.
CDPHE should engage with the national organizations that develop paramedic education standards and advocate that the standards include education in the areas of racial equity, explicit/implicit bias, verbal de-escalation and law enforcement-to-EMS hand-off protocols. In the meantime, the panel recommends that CDPHE develop training programs in these areas and make them available to all EMS medical directors for the purpose of providing training to EMS medical directors and their providers. Completion of these training programs should be required of EMS medical directors and their paramedics as a condition of obtaining a ketamine waiver.
CDPHE should revise its regulations on continuing education requirements for the certification/licensure of EMS providers to include minimum hours in the areas of racial equity and explicit/implicit bias in the field of health care.
A.3 Panel Recommendation: Appropriate Administration of Ketamine
The panel concludes that paramedics should only administer ketamine in the prehospital setting when there are no other means available to safely assess, treat, and transport a patient. These circumstances are limited to patients presenting a serious, probable, imminent threat of bodily harm to self or others.
CDPHE should therefore only issue waivers that allow paramedics to use ketamine when patients whose serious, probable, and imminent threat of harm to self or others prevents EMS providers from safely assessing, treating, and transporting the patient to a hospital.*
The panel acknowledges that if ketamine is administered for this purpose, the safeguards set forth in the “Protection of Persons from Restraint'' law (Sections 26-20-101 et seq., C.R.S.) must be followed. However, EMS providers often respond to a chaotic scene in the prehospital setting that requires their undivided attention and immediate intervention. In those situations, EMS providers may lack the time necessary to make a telephone call to a physician to receive a verbal order to administer ketamine. The panel therefore recommends that the General Assembly amend the chemical restraint statute to allow EMS providers to administer ketamine as a chemical restraint in these situations under the authority of an EMS medical director’s standing order, rather than a verbal order as the law currently requires.**
*Note: This recommendation is only associated with waivers for excited delirium and/or extreme or profound agitation and does not impact waivers for ketamine use for pain management or RSI.
**Note: The panel understands that HB 21-1251 requires the paramedic to attempt to obtain a verbal order while the existing restraint law requires that paramedics engage in telephone consultation with a physician and receive a verbal order to administer ketamine after determination that chemical restraint by ketamine is the least restrictive and most appropriate alternative available.