Look for The Joint Commission to Add Leeway for Titrations

You'll play a key role in ensuring that orders for titratable infusions are appropriate...based on updates from The Joint Commission.

Continue to check that these orders include initial and max rates...how much and how often to titrate...and objective goals.

For example, propofol may start at 5 mcg/kg/min, and titrate up or down by 5 mcg/kg/min Q5 minutes, with a max of 50 mcg/kg/min...to maintain a Richmond Agitation-Sedation Scale score of -1 to 0.

But it gets complicated in patients requiring MULTIPLE titratable infusions to achieve ONE goal...BP, sedation score, etc.

In this situation, The Joint Commission will now give nurses leeway to titrate based on their patient's condition.

For example, a patient may be receiving several pressors to maintain BP. If they develop tachycardia, a nurse could choose to decrease norepinephrine and increase phenylephrine.

Explain this leeway is only given to critical care or procedural settings...and is only for vasoactive, sedative, or pain med infusions.

Ensure it's limited to patients receiving multiple infusions for the same goal. For example, it doesn't apply if a patient is on fentanyl for pain and propofol for sedation.

Clarify that nurses still have to stay within the parameters of each ordered drip. Also hospitals must document nursing competency.

And this doesn't override state laws or practice acts.

Be aware that nurses can now use "block charting." This is a one-time summary for a 4-hour period used in an URGENT situation when RAPIDLY titrating vasoactive, sedative, or pain med infusions.

Point out that your policy must define what is considered urgent. For example, a hospital might include a MAP below 50 mmHg.

Verify block charting includes start and stop times...plus starting, ending, and max rates for each med.

Dispel the myth that The Joint Commission doesn't allow range orders. It's okay...if your policy is clear and consistently applied.

For instance, an order to titrate IV fentanyl by 25 to 50 mcg/hr Q30 minutes may mean to go up by 25 mcg/hr if the Critical-Care Pain Observation Tool (CPOT) score is 3 to 5...or by 50 mcg/hr if it's 6 to 8.

See our checklist, Ensure Safe Titration of Infused Medications, for more information, such as guidance on pausing and restarting titratable meds.

Key References

  • Jt Comm Perspect 2020;40(6):7-9
  • www.jointcommission.org/en/standards/prepublication-standards/revisions-related-to-medication-titration-orders/ (8-26-20)
  • www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medication-management-mm/000002153/ (8-26-20)
Hospital Pharmacist's Letter. September 2020, No. 360918

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