Where’s the Evidence Guiding Updated Titration Standards?

In two recently published manuscripts, hundreds of nurses reported delays in care, suboptimal care, nursing moral distress, falsifying of nursing documentation, and loss of autonomy to use nursing clinical judgement after the introduction of new medication standards that directly impact how nurses manage continuous titratable drips in critical care environments. These new standards, introduced by the Joint Commission (TJC) on Jan. 1, 2018, created additional requirements for ordering and management of nurse titrated medication infusions. Although the new accreditation standards for titratable medications were intended to safeguard patients, these changes instead placed decision-making into the hands of team members who lack experience in managing moment-by-moment titrations, leading to safety concerns and leaving nurses in moral distress.

Backlash Against the Standards

On March 22, 2019, a nurse published a post on the Society of Critical Care Medicine (SCCM) Nursing Section Connect platform about her organization’s struggle to create medication titration guidelines and order sets for vasoactive medications that balanced TJC requirements with safe and appropriate nurse-driven titration. This set off a firestorm of online dialogue from nurses all over the country regarding how difficult it was to comply with their hospitals’ new orders and guidelines.

By April 11, 2019, Judy E. Davidson, DNP, RN, and I began to lead a campaign to write a strategic proposal to submit to SCCM leadership regarding the new TJC standards. We also began to organize the grassroots efforts that led to research recently published in the American Journal of Critical Care. Our 35-member strong Titratable Medication Task Force (TMTF) was composed of volunteers from academic and community-based hospital systems and teaching institutes from around the country, including staff nurses, advanced practice nurses, nurse managers and directors, pharmacists, clinical professors, researchers, and anesthesiologists.

TMTF members identified that, other than anesthesiologists and nurse anesthetists, most ordering providers have never physically titrated multiple continuous IV medications while managing numerous “in the moment” therapeutic interventions for a critically ill patient. For decades, nurses have used expert “nurse knowing” to recognize which therapeutic interventions, including but not limited to titration of continuous IV medications, need to be implemented when, at what amount, and at what frequency.

So, why was this job suddenly being handed to providers who lacked the proper expertise and experience to manage it?

TMTF members reviewed the literature related to clinical decision-making and ordering practices for administration of continuous IV medications. They also evaluated educational resources for titration of continuous titratable IV medications with the goal of identifying best practices in curriculum and instruction techniques.

All search efforts failed to identify controlled trials that would point to evidence to support this change or to be used to guide clinicians in the development of evidence-based protocols, guidelines, and order sets for titratable medications in the critical care setting. This lack of evidence increased the likelihood that the protocols, guidelines, and order sets had been and would continue to be developed based on preference. Without any evidence to motivate the change, the new TJC titration standard forced hospitals to move from nurse-managed practice patterns based on “nurse knowing” to a new practice pattern requiring nurses to follow detailed and prescriptive orders from providers with no experience managing this type of care.

What Is “Nurse Knowing”?

For decades, nurses have used situational awareness and pattern recognition to uncover early warning signs and to evaluate, analyze, and interpret patient adaptive responses to targeted therapeutic interventions that they execute on a moment-by-moment basis. Not only do they pass this form of “nurse knowing” down from generation to generation, they also pass down what they have learned in the moment from individual patient responses to the next shift of nurses. Nurse competency for this skill set is evaluated through direct supervision and proctoring. Before mandating a standard that changes current practice, it should be informed by strong evidence. This is especially important if it alters “scope of practice.”

Pushing for Change

Working with the American Association of Critical-Care Nurses (AACN), TJC did acknowledged the need for some policy updates, including the allowance of block charting and permitting nurses to select which medication to start first, in addition to clarification regarding range orders. These changes took effect January 1 of this year, almost a year after nurses participated in our study. Unfortunately, several key issues were not addressed by these changes and new problems, such as trying to operationalize and build block charting into the electronic health record, have emerged.

What can clinical nurses, nurse leaders, and professional nursing organizations do? For one, nurses need to manage nursing knowledge and articulate their practice more consistently. Every profession has its niche knowledge and expertise. Figuring out ways to improve how we support novice, and even proficient nurses, as they progress to expert is an important step in ensuring safe medication management practices. Innovations for the future include using tele-ICUs staffed with expert nurses to conducting research to learn the “cognitive gymnastics” of the expert nurse to creating machine learning powered algorithms to support clinical decision-making, nurses need to drive how nurses improve delivery of complex nurse practice therapeutic interventions like continuous titration of IV medications. A standardized national approach to teaching and proctoring the skill of medication titration and management of multiple therapeutic interventions is also needed.

What can hospitals do better? Until the TJC medication standards are successfully changed, hospitals should 1) use range orders within order sets that allow nurses to use clinical judgement to titrate continuous IV medications; 2) create a culture of open dialogue and trust with nurses so they feel free to speak up and participate in creation of order sets and guidelines that impact their practice; 3) use collaborative root cause analysis investigations that are focused on uncovering system issues before considering corrective actions aimed at individual behavior; and 4) speak up and stand up when regulatory requirements and standards don’t follow the science or are unrealistic. Report inability to safely comply with standards to the Centers for Medicare & Medicaid Services and TJC.

What can regulatory and accreditation agencies do better? We hope that the information in these publications lead to collaboration between regulatory and accreditation agencies and professional nursing organizations before any changes to standards and regulations occur. We recommend pilot-testing any future changes prior to wide-scale implementation to help prevent unintended consequences. Standards should be clear and understandable. This will reduce confusion and varying interpretations by TJC surveyors as well as the healthcare organizations seeking accreditation. Finally, any future changes to regulations and standards must be guided by strong evidence and knowledge of the unique roles and contributions of healthcare providers. Critical care is a team sport. There is no single role that has all of the knowledge and expertise necessary to meet all of the needs of critically ill and injured patients.

Teresa Rincon, PhD, RN, is an assistant professor in the Graduate School of Nursing at the University of Massachusetts Medical School and serves as a senior telehealth consultant at Blue Cirrus Consulting. She is an active member of the Society of Critical Care Medicine and the American Association of Critical-Care Nurses. She has served in multiple leadership positions within these and other professional organizations and is a fellow in the American College of Critical Care Medicine.