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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 DisclosuresAll planners, presenters, reviewers, and ASHP staff of this session report nofinancial 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 Background 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 practice1. The Joint Commission e-edition. https://e-dition.jcrinc.com/MainContent.aspx. Accessed Sept 13, 20182. 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 scope3. California Board of Registered Nursing. An explanation of the Scope of RN Practice Including StandardizedProcedures. 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 Problems
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
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.
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:
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.
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