Center for Improvement in Healthcare Quality Newsletter
April 2022

CIHQ-ARS Blog

The Right To Titrate

By: Gina Miller
Titration is increasing or decreasing a drug infusion to maintain therapeutic effect. What nurse wants to call the attending every 30 minutes to notify them that the medication is not having the desired effect? On the flip side, what provider wants to be notified every 30 minutes that the patient on Propofol is at a RASS of 0 instead of the desired -2? Managed correctly, a titratable infusion is a beautiful timesaver and safe way to manage a patient’s response to medication.
On the backside, you can count on surveyors to closely scrutinize your management of titratable infusions. Titratable infusions are considered a high-risk area and a prime target for surveyor’s eyes. Let’s examine how the guidelines at §482.25 (pharmaceutical services), §482.24 (medical record documentation) and §482.23 (nursing services) apply to the management of titratable infusions. It’s as simple as ABCDE…

Accurate, Complete Order

Just as any order for medications requires an order that is considered complete, titrations must include the following to be considered complete:
  • Medication name
  • Medication route
  • Initial or starting rate of infusion (dose/minute or hour)
  • Incremental units the rate can be increased or decreased
  • Frequency for incremental doses (how often dose(rate) can be increased or decreased)
  • Maximum rate (dose) of infusion
  • Objective clinical endpoint (RASS score, mean arterial pressure, blood pressure, train of four, etc.)

Background Information

There are times that organizations will use protocols to guide the administration of titratable infusions. The provider will order the “sedation protocol” or “Oxytocin per protocol”. Remember, the protocols driving the care must be either manually added to or electronically attached to the medical record and validated by the provider. An entire blog has previously been dedicated to the requirements around protocols if additional information is desired on the topic.
If the infusion is held/stopped for a period of time, then restarted, the starting rate must be based on a provider order or defined by procedure or protocol. Again, if a procedure/protocol is used to guide the care provided, the organization must determine how that order will be entered into the medical record.

Clinical Monitoring

Monitoring of the patient on a titratable infusion is determined by the organization’s policy or by the provider order. Assessment policies should define the expectations for types and frequency of monitoring and be consistent with accepted standards of practice based on guidelines or recommendations issued by nationally recognized organizations as well as Federal and State law.

Documentation

As always, documentation is very important. The adage applies – if it wasn’t documented, it wasn’t done. This is the area most frequently cited during a regulatory survey. Your documentation should show that an increase (or decrease) of the infusion rate was made in accordance with the provider order or protocol, and that an assessment of the patient drove the change in the rate. Most citations involve not starting at the ordered rate, not titrating according to the order, and not being able to see the correlation between the patient’s response and the reason for titration. For example: the provider ordered an infusion and the parameter being monitored is the mean arterial pressure (MAP); any increase in the infusion should be associated with documentation of the MAP (not the blood pressure), showing it was below the desired goal. Likewise, if the MAP falls within the desired parameter, then the infusion should not be increased.
If the infusion is not titrated according to the order, a clarification is received from the provider and a written order should support the outlier change. The order is to titrate a propofol infusion by 5mcg/kg/min every 10 minutes to maintain a RASS score of -2. If it is titrated by 10mcg/kg/min because the patient is at +1; a provider would need to be contacted and an order entered to support titrating the infusion outside of the original order. Granted, this is easy to say and very difficult to do in real time if managing multiple infusion parameters in critical situations; perhaps receiving verbal orders bedside. Some accreditors do allow four-hour timeframes of “block charting” to manage multiple titrated infusions in emergent situations. Documentation of starting/ending rates as well as medications included and parameters during the timeframe must be clearly evidenced.

Evaluation

Monitoring of titratable medication falls into a high-risk area and must be included in the organization’s QAPI program. This includes the appropriate use of protocols as well evaluation of the timeliness of medication administration and any adverse outcomes when a titratable infusion is involved.

References

American Society for Health-System Pharmacists, Mid-Year Conference. (2018). Titrating to safety and compliance; Management of titration orders in the ICU. Retrieved from American Society for Health-System Pharmacists, Mid-Year Conference. (2018)
Centers for Medicare and Medicaid Services, (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from Centers for Medicare and Medicaid Services, (2020)
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