Ensure Safe Titration of Infused Medications

There’s a push to ensure the use of complete medication orders and to clarify and improve processes with administration and documentation of titratable med infusions.4 The following is a checklist of important points regarding The Joint Commission’s requirements for ordering, charting, and selecting titratable meds.2 Keep in mind that your hospital may need to comply with additional requirements, such as those included in state laws or practice acts.

Topic/Issue

Suggestions/Pertinent Information

Elements of a complete titratable med order

  • Ensure titratable med orders have the following elements, in order to be considered complete:1,3
    • Med name
    • Administration route
    • Initial infusion rate
    • Increments by which the rate can be increased or decreased
    • How often the rate can be changed
    • Max rate
    • Endpoint (e.g., Critical Care Pain Observation Tool [CPOT], Richmond Agitation-Sedation Scale [RASS] score)
  • Note that this will be a requirement of The Joint Commission as of January 1, 2021.1,3

Block charting

  • Be aware of the option for block charting, also referred to in some cases as abbreviated charting. It’s a mechanism for summarizing charting, for “blocks” of no longer than four hours, to allow nurses to focus on patient care in urgent situations when medications require rapid titration.2
  • For each block, require documentation of the following:1
    • Med name
    • Starting and ending time of block
    • Starting and ending infusion rate
    • Max infusion rate
    • Parameters that were used for titration
  • Ensure your organization defines, in policy, the urgent situations where block charting is acceptable.1,2
    • For example, mean arterial pressure (MAP) dropping below 50 may be considered urgent per policy.
  • Restrict use of block charting to critical or procedural settings.1
    • Keep in mind this may occur outside of an ICU or procedural location. For example, block charting may be appropriate in an unstable floor patient when an ICU bed isn’t yet available or for a trauma patient in the emergency department.6
  • Only allow/use block charting for infusions that are being rapidly titrated including vasoactive meds, sedatives, and analgesics.2,6
    • Meds whose doses are not rapidly changing should follow standard practice. These meds generally don’t require frequent documentation and should not require the use of block charting.6
  • If a time period of longer than four hours is needed, require starting another block.1
  • Explain that block charting can be documented anywhere in the patient’s permanent record. Clarify where to document, especially if separate from charting of other medications.6
  • Keep in mind that block charting may not be necessary if pump integration is in place (i.e., when information about rate changes is automatically transmitted to the patient’s electronic medication administration record [eMAR]).

Titrating multiple meds with the same goal

  • Keep in mind that nurses are well-positioned in certain cases to select between multiple titratable meds ordered to meet the same goal based on their familiarity with a patient’s individual response to the meds.2 For infusions of vasoactive meds, sedatives, and analgesics, The Joint Commission will now allow nurses to select between ordered agents in critical care or procedural areas only.1
    • For example, if a patient with orders for norepinephrine and phenylephrine to maintain blood pressure becomes tachycardic, the nurse may choose to increase phenylephrine and decrease norepinephrine.
  • Require that nurses continue to stay within parameters of individual med orders when titrating.1
  • Ensure that nurses have completed an organizational competency, and that completion of the competency is documented.1
    • Consider how pharmacists can get involved with creating the competency and/or educating nurses about Joint Commission requirements, hospital policy, pharmacology, med safety, etc.
    • Be aware, competency should go beyond providing education. Nurses should be able to demonstrate application of knowledge.6

Range orders

  • Be aware that range orders for all meds, including titratable meds, are allowed according to The Joint Commission. “Range” can apply to dose (e.g., 10 to 20 mg) and/or frequency (e.g., every 15 to 30 minutes).2,3
    • For example, an order that includes titrating IV fentanyl by 25 to 50 mcg/hr Q30 minutes is a range order.5
  • Ensure that hospital policy specifies if and when range orders are acceptable.3
  • Verify that range orders will be interpreted consistently.3 This is a responsibility of leadership and medical staff.5
    • Consider a scenario where multiple nurses are asked independently how they would interpret a range order. They should all give the same answer. In the above example, titrating 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.

Pausing and restarting

  • Be aware of when a med may need to be paused, such if the patient no longer meets criteria for administration based on assessed physiological parameters (e.g., upon stabilization of blood pressure).1,2
  • Keep in mind that pausing differs from discontinuing a med. Discontinuing a med should only be done in response to a prescriber’s order or criteria described in hospital policy (e.g., a med that’s been paused for more than 24 hours).1
  • Ensure that if an infusion is paused, there is an order or a policy indicating how to restart.1 Options may include:
    • Restarting at the last infusion rate
    • Restarting at the original infusion rate
    • Restarting at a new rate, as ordered by the provider

Project Leader in preparation of this clinical resource (360918): Stacy A. Hester, R.Ph., BCPS, Associate Editor

References

  1. The Joint Commission. Joint Commission Perspectives. June 2020, Volume 40, Issue 6.
  2. Barden C, Campbell R. Interview transcript. June 29, 2020. American Association of Critical Care Nurses.
  3. Joyce MC. Your annual Joint Commission update. APhA Annual Meeting. Seattle, WA. March 22-25 2019.
  4. The Joint Commission. Medication administration – titration orders. December 12, 2019. https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/medication-management-mm/000002114/. (Accessed August 18, 2020).
  5. The Joint Commission. Medication administration – range orders. April 16, 2020. https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medication-management-mm/000002153/. (Accessed August 18, 2020).
  6. Personal communication (verbal). Robert Campbell, PharmD. Clinical Director, Standards Interpretation Group for Hospital/Ambulatory Programs. The Joint Commission. August 27, 2020.

Cite this document as follows: Clinical Resource, Ensure Safe Titration of Infused Medications. Hospital Pharmacist’s Letter/Pharmacy Technician’s Letter. September 2020.

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