Proper Titration Orders Are Essential for Patient Safety

Medication errors are common and cause patient harm in approximately 5% of hospitalized patients.1 Titratable continuous infusions are particularly prone to error, and the consequences of these errors tend to be more severe than for other medication errors.2 Lack of titration limits or failure to adhere to limits are the most frequent type of error,3 and the subsequent overdosing most likely contributes to the greater severity of harm from infusion errors. Unpublished data from Joint Commission hospital surveys show that the vast majority of citations related to infusions occur because key components of orders are missing.To mitigate this risk, The Joint Commission has requirements that organizations have policies in place for continuous infusion orders. These must include the starting dose, the range for dose changes, the range for frequency of changing the infusion rate, the maximum dose, and the clinical goal of the titration (eg, mean arterial pressure or level of sedation).4 The requirements allow "double-range orders," which give nurses flexibility in both the frequency and the magnitude of dose adjustments. The Joint Commission's required elements for orders are consistent with accepted standards of practice in the United States.5Although the standards are intended to address well-documented safety problems and follow the recommendations of national experts, they have come under criticism. The first criticism is that they slow workflow for critical care nurses and delay achievement of clinical goals. This criticism is based on an uncontrolled, pre-post study by Chen and colleagues that examined time to hemodynamic stability for patients treated with titrated norepinephrine before and after implementation of formal titration instructions concordant with Joint Commission requirements.6 After implementing the detailed instruction template, the time to hemodynamic stability was more than 20 minutes longer than it was before implementation (32 minutes vs 10 minutes, P < .01). These findings raised concerns that the detailed instructions could have caused nurses to be more conservative, use their judgment less, and be more likely to make incremental changes in the lower end of the specified range. However, the study yielded no evidence that care was slowed. There were no significant differences in the maximum dose of norepinephrine, the time it took to achieve the maximum dose, or the maximum amplitude of change between norepinephrine doses. Most importantly, no significant differences were found in mortality or lengths of stay in the hospital or the intensive care unit. Much of the difference in time to hemodynamic stability may have been due to the higher severity of illness for patients in the postintervention period, and an accompanying editorial emphasized the need for more research on this topic.7Another possible explanation for the findings in the study by Chen and colleagues is longer time for documentation, which was not measured by the investigators. In discussions with the American Association of Critical-Care Nurses after the study came out, this was a major concern. In response to those discussions, additional changes in The Joint Commission's requirements were published in June 2020 to allow block charting to mitigate the possibility that the new requirements were causing excessive time for documentation.However, a recent survey of critical care nurses published in the September 2021 issue of this journal by Davidson and colleagues again raised concerns.8 Of the 781 respondents, 80% of respondents perceived that titration standards had caused delays in patient care, although the study did not assess the reasons for delays. However, the survey was conducted from January to September of 2020, meaning most of the nurses were reporting their experience before the revised Joint Commission standards were published in June 2020. Additional research is necessary to understand if the changes in the requirements, including allowing block charting, have affected perceptions.Another criticism by Davidson and colleagues was that the new requirements have decreased the autonomy of critical care nurses.8 What does autonomy mean in the modern ideal of team-based care? It is vitally important that nurses are able to use their clinical judgment, and we believe that our requirements do not inhibit nurses' ability to do so. For example, we have emphasized that our requirements allow "double-range orders" to allow nurses flexibility in both the frequency and the magnitude of dose adjustments. However, if a nurse's expert opinion is that an order needs to be modified, that should prompt a discussion with the prescribing licensed practitioner. The Joint Commission believes in team-based care and decision-making that respects the knowledge and experience of all team members. The idea that any member should be "autonomous" is problematic. In the study by Davidson and colleagues, 84% of respondents requested revisions in orders, which we believe is the appropriate way to handle disagreements. In contrast, 70% of respondents said they "deviated from orders." The context of the deviations is not known. However, deviating from orders during routine care because they are unclear or thought to be incorrect can harm patients and may have legal ramifications.In the study by Davidson and colleagues,8 33% of respondents said they could not comply with titration orders, and 68% reported suboptimal care resulting from pressure to comply with orders. We agree that this is concerning. But this problem appears to be due to incorrectly written or unclear orders rather than The Joint Commission's standards. The study's findings suggest that major efforts are needed to educate prescribing licensed practitioners further on how to write orders for titratable medications. In addition, critical care nurses must be fully empowered to question the orders and ask for modifications, if needed. Strengthening hospitals' culture of safety to make these conversations possible is crucial.Finally, Davidson and colleagues argue that objective, measurable clinical end points (as required in Joint Commission standards) are unnecessary.8 If that is the case, then how is a nurse to know whether a medication needs to be increased, decreased, or stopped? How do nurses know whether their opinion of the goal is concordant with what the prescribing licensed practitioner thinks the intended goal should be? The condition of critically ill patients is dynamic, and what may be the clinical end point for one patient may not be the same end point for another. It is essential to remain cognizant of the pharmacokinetics of medications when determining the dosing and administration of medications. There have been reported events of medications titrated too quickly, leading to adverse outcomes. This reinforces the need to have a comprehensive team of health care providers, including but not limited to nurses, physicians, and pharmacists, engaged when caring for individual patients and constructing titration order sets.The paper by Davidson and colleagues also shows the need for further education regarding The Joint Commission requirements for titrated medications and how they were developed. The article mentions that nurses were not at the table as The Joint Commission developed the titration requirements. However, bedside nurses across multiple care settings were involved in the development and review, including the Joint Commission staff who developed the standards and the public field review. The article also states that the changes to our standards were made because of high "variation" in implementation of titrated medications. This is incorrect. The changes were made to address published safety concerns and improve patient safety by ensuring that medication orders contain the necessary elements to guide medication administration.The basis for safe medication administration is ensuring a complete and accurate medication order. If such an order is lacking, patients can be harmed. Joint Commission surveyors continue to observe titration orders that are not in alignment with the care provided. This is the primary reason why The Joint Commission encourages organizations to begin their review of practices with staff working at the bedside. By doing so, they can observe firsthand how medications are titrated by nurses and then work backwards to construct elements of the titration order. Many of the challenges that organizations face today may be due to policies that that go beyond our requirements, including restrictive orders and not fully implementing allowances made through revisions. The Joint Commission hopes to continue the dialogue with nurses, physicians, pharmacists, and quality and safety leaders to increase understanding of the intent of our requirements and work together to find ways to implement them to improve safety without unintended consequences.