Titration Orders: Are you set for safe practice?

Titrating intravenous medications is the process of adjusting medication dosage for maximum benefit without inducing adverse side effects. It can be a fine line to walk, but when staff follow clearly defined parameters through well-crafted titration orders, it can be performed with a high degree of safety and ensure that your practice is aligned with regulatory standards.

The goals for aligning with regulatory standards governing titration of intravenous medications include:

• Staff following consistent medication administration practices that reduce/eliminate variation

• Focus that therapeutic response is achieved and maintained

• Nursing staff scope of practice not being compromised by relying on them to make dosage/administration decisions

• Ensuring that the pharmaceutical manufacturer’s Instructions for Use along with the Instructions for Use of any supplemental equipment is followed

• Documentation of care reflects the actual therapeutic changes and patient responses

Essential Elements of the Order:

Regulatory standards speak to the requirement that organizations follow safe medication administration practices. This process starts with a well-defined order from the practitioner to ensure that patients receive medication dosing that fosters achieving and maintaining a therapeutic endpoint safely. These orders must include the medication name, the route it’s going to be administered, the starting dose/rate, the titration dose/rate (the incremental amount of the medication that will be changed during titration), the time factor for titration (or time between dose/rate changes), the maximum allowed amount of medication to be administered and the clinical endpoint (objective physiological parameters that define the target to achieve for the patient). These elements ensure that health care professionals (specially, nursing staff) have the criteria necessary to execute administration of titration of intravenous medications.

An example of effective titration orders could be:

Start Dopamine drip at 10 mcg/kg/min. Titrate by 5 mcg/kg/min every 5 minutes to maintain Mean Arterial Pressure (MAP) at least 60mm/Hg. Maximum rate is 50 mcg/kg/min.

Clearly, this example addresses the required elements. Additionally, there could be information to provide for a range of Mean Arterial Pressure rather than a target threshold. This could be written as:

Start Dopamine drip at 10 mcg/kg/min. Titrate by 5 mcg/kg/min every 5 minutes to maintain Mean Arterial Pressure (MAP) between 60mm/Hg and 70mm/Hg. Maximum rate is 50 mcg/kg/min.

This would provide the nurse a clearer therapeutic target to maintain, while allowing a small degree of patient variation and responsiveness to the intervention especially if the patient’s MAP starts to rise higher. The order as written would allow the nurse to titrate the medication down, providing for better control of the MAP through use of a therapeutic target range.

Range Orders for Titration:

There has been some question as to whether the use of range orders for titration were permissible. The glossary of The Joint Commission Accreditation Manual describes a ‘range order’ as “Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or the individual’s status.” Although many organizations have steered clear of range orders to reduce the complexity of the titration process, there is no regulatory standard that prohibits its use. However, standards are clear in that it places the responsibility on the organization to develop policy that allows for range orders as well as determining the implementation of range order titration to ensure consistency by staff. The organization also needs to have policy that addresses the competency/training of staff, how the range orders should be interpreted and how range orders in titration are documented in the patient record.

An example of a titration range order could be:

Start Dopamine drip at 10 mcg/kg/min. Titrate by 5-10 mcg/kg/min every 5 minutes to maintain Mean Arterial Pressure (MAP) between 60mm/Hg and 70mm/Hg. Maximum rate is 50 mcg/kg/min.

Additionally, double-range orders are likewise permissible, providing that organizational policy supports it and defines how it would be implemented, interpreted, how staff are trained and documented.

Start Dopamine drip at 10 mcg/kg/min. Titrate by 5-10 mcg/kg/min every 5-10 minutes to maintain Mean Arterial Pressure (MAP) between 60mm/Hg and 70mm/Hg. Maximum rate is 50 mcg/kg/min.

Again, the organization should ensure that these single and double range orders are implemented safely, and that staff clearly understand how to safely administer these medications. It may be beneficial to create standard order sets and/or algorithms to guide safe and consistent practice. Organizations should bring practitioners, pharmacists and nurses together with leadership to create a collaborative partnership in developing these policies and tools to ensure that all stakeholders’ concerns and questions are answered and there is clear understanding of each role’s responsibilities.

Common Pitfalls:

There are a number of common pitfalls that seem to trip up organizations’ implementation of intravenous titration despite having robust policy in place. Do these seem familiar?

• Nursing staff not titrating according to orders – this would include titration of the medication below or above the ordered dose. Staff who are concerned that the dose may be too great for the patient or not adequate to provide expected therapeutic action should be communicating these concerns to the ordering provider as these titration practices may be outside of their scope of nursing practice.

• Not documenting the titration change to include dose or the therapeutic effect of the change – In the case where the patient’s condition necessitates emergent titration changes, it is permissible to utilize block charting to document up to 4 hours of titration provided your organization has adopted block charting and set forth expectations within policy. Block charting is defined as a documentation method used when rapid titration of medication is necessary in specific urgent/emergent situations.

• Titration orders do not include all required information – Provider orders must align with organizational policy which should follow regulatory standards. The use of order sets (predetermined by provider and pharmacy representatives) coupled with Computerized Provider Order Entry (CPOE) has reduced this issue; however, it is still imperative that the pharmacy reviews titration orders that are not part of the standard order sets to ensure all elements are met for the order to support safe practice. Organizations may want to consider designing an indicator on titration orders and including this as an indicator in their OPPE program for departments where this is pertinent.

Summary

Ensuring that your organization’s titration orders follow regulatory guidance for required elements and that providers and staff are trained and follow policy will support safe medication administration practice. Use of range and double-range orders are permissible but will require additional effort by the organization. Safe titration can help your patients achieve positive outcomes providing you are periodically observing for staff compliance. Are you set for safe practice?

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Maxwell S (2013). “Chapter 2: Therapeutics and Good Prescribing: Choosing a Dosing Regime”. In Walker BR, Colledge NR, Ralston SH, Penman ID (eds.). Davidson’s Principles and Practice of Medicine. Elsevier Health Sciences. p. 34. ISBN 978-0-7020-5103-6
Joint Commission (Oakbrook Terrace, Ill.), & Joint Commission Resources, Inc. (2021). Comprehensive accreditation manual: CAMH for hospitals.

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