Of Titration Orders In The Intensive Care Unit Titrating To

Of titration orders in the intensive care unit titrating to

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(Management Case Study)
Titrating to Safety and Compliance: Management
of Titration Orders in the Intensive Care Unit
Kimberly Snodgrass, Pharm.D., BCPS
Manager, Critical Care
Cedars-Sinai Medical Center
Los Angeles, CA
All planners, presenters, reviewers, and ASHP staff of this session report no
financial relationships relevant to this activity

Learning Objectives
• Identify key regulatory requirements related to titrated medications
• Describe an approach to medication order build in the electronic health
record (EHR) to ensure regulatory compliance with orders
• Explain how a titration policy can be used to improve consistency in
documentation and communication among providers
Self-Assessment Questions
• Titration medication orders must include dose range, start dose, titration
parameters, goal (True or False)
• Use of specific order questions related to required order elements may
improve regulatory compliance with orders in the electronic health record
(True or False)
• Documentation of patient parameters is not necessary as medications are
titrated (True or False)
Cedars-Sinai Medical Center
• Non-profit, acute, tertiary teaching hospital
• 886 licensed beds
• 120 intensive care unit beds including medical, surgical, cardiothoracic,
neuroscience, cardiac, pediatric and neonatal units
• Level I Trauma Center
• Comprehensive Stroke Center
• Decentralized clinical pharmacy services include intensive care, medicine,
surgery, pediatrics, oncology, solid organ transplant, emergency
department and operating room services
Medication Titration
• Titration orders allow the critical care nurse to adjust medications in
patients with a rapidly changing clinical status
• Implementation of electronic health records (EHR) and smart infusion
pumps in many institutions makes data more readily retrievable
• Process for management of titrations should include careful consideration
of safety and regulatory risk
• Pharmacists are uniquely positioned for
– Development of safe titration practices
– Real-time assessment of titration orders and administration
Regulatory Requirements for Titrations
• The Joint Commission standard MM 04.01.01 mandates that medication
orders are clear and accurate1
• Required elements of titration orders2
– Medication name and route
– Dose range including start dose
– Incremental units for dose changes and frequency
– Objective goal
• Goals to ensure safe administration
– Achieving and sustaining patient response
– Consistent administration and documentation that reflects changes
– Nursing activity within scope of practice
1. The Joint Commission e-edition. https://e-dition.jcrinc.com/MainContent.aspx. Accessed Sept 13, 2018
2. The Joint Commission Standards FAQs Medication Administration – Titration Orders

https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=1432&ProgramId=46.. Accessed Sept 13, 2018

Nursing Scope of Practice
• California Board of Registered Nursing recently clarified nursing scope3
– Nurses authorized for “administration of medications and therapeutic
agents necessary to implement a treatment, disease prevention, or
rehabilitative regimen ordered by and within the scope of licensure of
a physician, dentist, podiatrist, or clinical psychologist.”
– Physicians may diagnose and use drugs
• Vague or unclear titration orders may leave room for varied interpretation
or broad decision making which is outside nursing scope
3. California Board of Registered Nursing. An explanation of the Scope of RN Practice Including Standardized
Procedures. https://www.rn.ca.gov/pdfs/regulations/npr-b-03.pdf. Accessed 9.20.18
Historical Management of Titrations at CSMC
• Titration guidelines in place
– Used to educate nurses and guide practice
– Per approved policy, pharmacists could clarify orders with missing
titration parameters
EHR Orders
• With implementation of computerized prescriber order entry (CPOE),
standardization of orders did improve
• Order questions created to define how to titrate for each patient

Nursing Scope of Practice • California Board of Registered Nursing recently clarified nursing scope3 –Nurses authorized for “administration of medications and therapeutic agents necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of

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Frequently Asked Questions

What is an example of a titration order?

Objective clinical endpoint (RASS score, CAM score, etc) For example, a titrated medication order would say: Start [medication name] drip at 10 mcg/kg/min. Titrate by 5 mcg/kg/min every 5 minutes until desired patient response and/or numeric target (e.g. RASS =3) is achieved. Maximum rate of 60 mcg/kg/min.

Who is responsible for medication titration?

Three healthcare workers play critical roles in medication titration: the provider, the pharmacist, and the critical care nurse. The Joint Commission Medication Management Standard requires that each medication order include the following information:

What drips should be titrated in the critical care unit?

Jennifer has been a preceptor/mentor and has a doctorate's degree in nursing. Follow along as we look at how to titrate medications in the critical care unit. Insulin drips, sedation infusions, and cardiac drips will be highlighted. Updated: 09/11/2020 Sharon is a nurse and her critical care patient is on a few drips that she must titrate.

What is the appropriate titration for a central venous drip?

1 Titrate the drip to 75mcg/kg/min 2 Titrate the drip to 65mcg/kg/min 3 Stop the drip and call the physician 4 Continue vital signs every five minutes