For decades, critical care nurses have practiced and shared their knowledge related to titration of continuous I.V. medications. These lifesaving medications primarily affect cardiac function and blood pressure, and, therefore, blood flow, which can be significantly altered during critical illness. Titration—the process of adjusting the dose of an I.V. continuous infusion of medication for maximum benefit—has long been within the nurse’s purview.
In 2017, The Joint Commission, a nonprofit organization that reviews and accredits healthcare organizations to ensure and advance patient safety and quality of care, issued revised standards on the management of titrated medications. The changes were made in a well-intentioned attempt to optimize patient safety. (Read more about the standards at jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medication-management-mm/000002114/.)
The revised standards shifted autonomy away from nurses by requiring orders from licensed providers (physicians, credentialed nurse practitioners and physicians assistants) for practices once decided upon by educated and trained nurses. Titrations had previously been determined on a case-by-case basis by the nurse at the bedside, based on assessment of the patient’s individual needs and response to medications. (Immediate adjustments are frequently required to ensure patient safety and preserve blood flow.)
Faced with little choice, bedside nurses now often have to make immediate decisions to adhere to the restrictive guidelines or save their patients’ blood flow, organs, and, in some cases, lives. This decision is frequently mired in moral distress and fear of loss of job and license, which creates significant emotional conflict. All this comes at a time of crisis, with the COVID-19 pandemic already prompting an exodus of nurses from the profession, leading to nursing shortages and excessive stress on the remaining workforce. It’s essential that we take action to reduce unnecessary moral burden on nurses.
The need for action is reinforced by two articles published in the September 2021 issue of the American Journal of Critical Care that present nurses’ input on this topic obtained from a survey and testimonials. Nurses report that the changes in titration management standards reduce their ability to provide timely adjustments to medications, resulting in adverse consequences and harming patients. The respondents make it clear that when nurses are able to use their extensive training and critical thinking skills to function at the top of their scope of practice, everyone benefits—patients, staff, faculty, and health systems.
In the article presenting the survey results (https://doi.org/10.4037/ajcc2021716) from 781 nurses, 80% said the revised titration standards caused delays in patient care. Most (93%) experienced moral distress by being prevented from doing what they felt was the right thing to do for patients.
These articles highlight the harm that over-regulation can cause for patients and professionals. The articles’ authors suggest that the current practice of issuing a call for comments on new standards is insufficient. Moreover, regulations affecting nursing practice and patient safety should be tested and include nursing input before publication.
What nurses can do now is to work with their critical care teams, pharmacists, patient safety staff, and compliance officers to develop orders that are compliant with current standards while providing protection and support for both patients and staff. Nurses need to make their voices heard; case studies that illustrate the problems with the guidelines (while maintaining patient privacy) can be effective in illustrating the challenges.
Nurses also need to work with their professional organizations, unions, and shared governance groups to make changing the titration guidelines a top priority, and participate in polls, letter writing, and research regarding this topic. Start by submitting a patient concern on The Joint Commission’s website.
Nurses must act now to protect nursing scope of practice—and our patients’ safety.
Barbara McLean is a critical care program specialist at Grady Health Systems in Atlanta, and Laura Chechel is manager of the cardiovascular ICU, Sulpizio Cardiovascular Center, at the University of California San Diego Health in La Jolla, California.
Davidson J, Doran N, Arellano DL, et al. Survey of nurses’ experiences applying The Joint Commission’s medication management titration standards. Am J Crit Care. 2021;30(5):365-74. doi:10.4037/ajcc2021716
Davidson J, Chechel L, Chavez J, Olff C, Rincon T. Thematic analysis of nurses’ experiences with The Joint Commission’s medication management titration standards. Am J Crit Care. 2021;30(5):375-84. doi:0.4037/ajcc2021280