Daniel Arellano, ACNP, CCRN, PhD, RN
Advanced Practice Nurse
University of Texas MD Anderson Cancer Center
Houston
Disclosure information not submitted.
Judy Davidson, DNP, RN, FAAN, MCCM (she/her/hers)
Nurse Scientist
University of California San Diego
San Diego, California
Disclosure information not submitted.
Neal Doran, PhD
Professor
University of California San Diego School of Medicin
La Jolla, California, United States
Disclosure information not submitted.
Amber Petty, MSN, RN, CCRN, ACNPC-AG
Advanced Practice Nurse
IU Health Ball Memorial Hospital
Muncie, Indiana, United States
Disclosure information not submitted.
Elizabeth Henneman, PhD, RN, CCNS, FAAN
Professor
University of Massachusetts Amherst
Amherst, Massachusetts, United States
Disclosure information not submitted.
Hanneman Sandra, PhD, RN, FAAN
Jerold B. Katz Distinguished Professor for Nursing Research
University of Texas Health Science Center at Houston Cizik School of Nursing
Houston, Texas, United States
Disclosure information not submitted.
Hildy Schell-Chaple, CCNS, CCRN-K, CNS
Director of Clinical Practice & Research
University of Califonia San Francisco Medical Center
Burlingame, California
Disclosure information not submitted.
Glann Judy, DNP, RN, ACNP-BC
Advanced Practice Nurse
HarborView Medical Center
Harbor City, California, United States
Disclosure information not submitted.
Smith Lisa, MSN, RN-BC, NPD, CCRN-K
Nursing Professional Development Specialist
Veterans Health Administration
Buffalo, New York, United States
Disclosure information not submitted.
Katrina Derry, BCCCP, BCPS, PharmD
Director Clinical Pharmacy Programs
University of California, Health, California, United States
Disclosure information not submitted.
Marigene McNicholl, MSN, RN, AGACNP-BC
Nurse Practitioner
Vanderbilt University Medical Center
Nashville, Tennessee, United States
Disclosure information not submitted.
Mary Lou Warren, DNP, RN, APRN, CNS-CC, FCCM
Clinical Effectiveness Specialist
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
Disclosure information not submitted.
Sue Scott, PhD RN CCRN
Assistant Professor
Westfield State University
Westfield, Massachusetts, United States
Disclosure information not submitted.
Theresa Slazinski, MN, RN, CCRN, CNRN, SCRN, CCNS
Critical Care Clinical Nurse Specialist
Cedars-Sinai Medical Center
Los Angeles, California, United States
Disclosure information not submitted.
Thomas Ahrens, PhD, RN, FAAN
Research Scientist
Viven Health
St Louis, Missouri, United States
Disclosure information not submitted.
Barbara McLean, APRN, CCNS, (she/her/hers)
Critical Care Program Specialist, Emergency and Critical Care Division
Grady Memorial Hospital
Atlanta, Georgia
Disclosure information not submitted.
Laura Chechel, MSN, RN
RN Manager
University of California San Diego Health
La Jolla, California, United States
Disclosure information not submitted.
.jpg "Teresa Rincon, CCRN-K, PhD, RN photo")
Teresa Rincon, CCRN-K, PhD, RN
Assistant Professor, Tan Chingfen Graduate School of Nursing
University of Massachusetts School of Medicine
Rochdale, Massachusetts
Disclosure information not submitted.
Title: Unintended Consequences When Applying the Joint Commission Titration Standards into Practice
Introduction: Critical care nurses have independently titrated continuous infusions of medications to achieve clinical endpoints for decades. In 2018, The Joint Commission (TJC) restricted standards on titration practice decreasing autonomous decision-making by nurses. We sought to describe the practice and perceptions of nurses regarding the 2018 The Joint Commission accreditation standards for titration of continuous medication infusions.
Methods: A survey was designed and validated by the research team and pilot-tested prior to use. The study was conducted in a cross-sectional design using an electronic survey made available passively to members of the American Association of Critical Care Nurses on their website. Anonymous data were collected through the Qualtrics survey platform.
Results: Content validity index for the Medication Titration survey was 1.0 for relevance, and .95 for clarity. 781 nurses completed the survey; 625 (80%) perceived that the titration standards caused delays in patient care and 726 (93%) experienced moral distress (mean 4.97, SD 2.67, scale 0-10). 33% could not comply with titration orders, 68% reported suboptimal care from pressure to comply with orders, 70% deviated from the orders to meet patient needs, and 84% requested revised orders for compliance. Number of infusions titrated, batch documentation, and moral distress significantly, but weakly (regression coefficients ≤ 0.20), predicted desired autonomy with titration practice. Suboptimal care and delays in care significantly and strongly predicted moral distress (regression coefficients ≥ .69).
Conclusion: Critical care nurses perceive the medication titration standards as adversely impacting patient care and contributing to moral distress. The recent 2020 TJC updates attempted to address reported concerns, yet they do not address the delays in care and moral distress associated with inability to comply with orders that do not match the individual patient’s response to these titrated medications. Ongoing collaboration with The Joint Commission is indicated to share these findings and identify modifications to the standards that meet the patient’s clinical needs, optimizes patient safety, and prevents moral distress amongst nurses on the front line.