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orders
TJC: Titrated Medications a Common Challenge
By David Wild
Many health systems still struggle to fully comply with a number of the Joint Commission’s medication management standards, particularly creating and following titration orders, according to the organization’s most recent survey results.
“If you look at many of the top-scored standards [in terms of noncompliance], you will see that a lot of these revolve around medication orders,” Jeannell Mansur, RPh, PharmD, a principal consultant for Joint Commission Resources, said during a session at the ASHP 2021 Midyear Clinical Meeting and Exhibition, held virtually. “Creation of proper medication orders, as well as their interpretation and review, always comes up.”
Dr. Mansur presented results from Joint Commission surveys of 1,355 institutions performed between January 2020 and September 2021. The most common area of noncompliance noted in the surveys involved administering a medication according to the prescriber order (49%; MM.06.01.01 Element of Performance [EP]3), the results showed. Following complex titration orders was a common cause of disparity between orders and administration, Dr. Mansur said.
In addition, 15% of institutions did not have written policies defining minimal elements of a medication order, including medication titration orders (MM.04.01.01 EP2). The Joint Commission requires organizational policies to define which medications can be titrated, what the starting and maximum rates of infusion should be, incremental units by which the rate can be increased and decreased, the maximum frequency of infusion rate changes, the maximum infusion dose, and objective clinical and physiologic measures to guide changes.
Although the onus is on nurses to follow orders as written, “organizations might want to make sure their titration orders reflect how specific medications are typically titrated and that they align with their own written policies,” Dr. Mansur said.
“Titration of medications is a complex process in critically ill patients, and often the provider will provide the details of how much and how often dosing changes are made,” Dr. Mansur added. “But surveyors have found that nurses make changes to titrated medications that are not consistent with the order because the orders don’t reflect the needs of a patient care situation.”
Balancing Order Requirements With Patient Needs
Don Janczak, PharmD, a consultant with Joint Commission Resources, told session attendees there is a particular challenge for nurses, who have to juggle “managing these complex therapies, documenting changes and, at the same time, focusing on the care of the patient.”
To provide nurses with the latitude to balance order requirements with patient care, the Joint Commission permits institutions to add certain features to titration orders, he said. For example, block charting allows nurses to document multiple dosing changes made during a defined period. (The Joint Commission specifies a maximum four-hour block.)
Block charting can help nurses focus on making rapid infusion changes and choosing medications “in those critical moments when a patient may be hemodynamically unstable,” Dr. Janczak said.
Organizations that allow block charting need to define the maximum charting period, the settings in which it can be done (critical care or procedural, as defined by the Joint Commission) and the allowable medications (limited to titrated vasoactive, titrated pain and titrated sedative medication infusions, as per the Joint Commission), he said.
Written organizational policy should also specify the minimum elements required for each block-charting episode, Dr. Janczak said.
As laid out by the Joint Commission, that includes: • the time of chart-blocking initiation and completion; • the name of the medications administered during the block; • the starting and ending rates of these medications; • the maximum rate and dose of these medications; and • physiologic parameters evaluated to determine the administration of titratable drugs during the charting block.
“Organizational policies should also specify where to document the charting episode, whether it’s in the medication administration record, in progress notes or through other EHR [electronic health record] options,” Dr. Janczak said. “Importantly, make sure not only that your policies have these key requirements but that you take this information from your policies and implement them in your medication-use process,” he stressed, noting that surveyors compare
organizational titration order policy with what is in electronic order sets.
Written policy should also specify what to do if a titrated IV infusion is paused and then requires restarting, Dr. Janczak said, adding that “it’s OK for the nurse to pause an infusion, but if it needs to be restarted based on assessment of a set of physiological parameters, the physician order must specify how to restart that infusion, including the starting dose and rate.”
Titration orders present yet another challenge: Creating and implementing them—and ensuring nurses comply— requires multidisciplinary buy-in from physicians, pharmacists and nurses, Jessalynn White, PharmD, the network medication safety director at Community Health Network, a health system based in Indianapolis, told Pharmacy Practice News.
“You have to make sure providers agree with the titration parameters you’ve chosen, then make sure pharmacy is familiar with the policy, so when they verify the order, it makes sense to them. Then you need to provide nurse education on the new protocols,” said Dr. White, who was not involved in the ASHP presentation. “It can be difficult to get everyone in the same room to work this out, and at times it feels like it is easier to work within their silo. But a team effort is really necessary to successfully implement complex orders.”
Including titration parameters directly in her organization’s EHR order sets has helped ensure nurse practice is in compliance with organizational policy, particularly during the
COVID-19 pandemic, Dr. White said.
“We have more nurses float between hospitals in the community to meet changing staffing needs during the pandemic, and titration parameters can be completely different from one hospital to the next,” she noted. “Building everything into the EHR as clearly and concisely as possible has made it so that it doesn’t matter whether it’s your first day on the job; you have clear instructions for what to do with that drug.”
Dr. White cited another challenge she has faced when implementing these measures: the sense among employees that Joint Commission standards are “an annoyance.” To combat this, she routinely ties standards implementation to “our shared goal of patient safety,” she said.
“Every single Joint Commission standard addresses a safety necessity and focuses on how to prevent errors, particularly in scenarios such as administration of complex orders and high-risk medications where an error can cause significant patient harm,” she said.
