Abandoning the 30 minute window for Medication Administration

New and Improved Guidelines

Between the release of the first CMS guidance establishing the 30-minute rule and the revocation of that guidance, the ISMP was not idle. In fact, the organization has accomplished something we have needed for a very long time in nursing. With an expert clinical advisory group, they created the ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications, ^[10] a comprehensive document that collates best practices for the administration of scheduled medications. Although the issue is complex and detailed, the ISMP maintains that "timely medication administration is a multifaceted issue that cannot be managed appropriately with a single standard."

The ISMP realized that very few scheduled medications are truly time-critical. Scheduled medications are those that are administered according to a standard, repeated cycle of frequency (eg, every 4 hours, twice daily, or daily). Scheduled medications do not include the following:

• STAT and Now doses;
• First doses and loading doses;
• One-time doses;
• Specifically timed doses (eg, antibiotic for a surgical patient 10 minutes before incision, drug desensitization protocols);
• On-call doses (eg, preprocedure sedation);
• Time-sequenced or concomitant medications (eg, chemotherapy and rescue agents, N-acetylcysteine and iodinated contrast media);
• Drugs administered at specific times to ensure accurate peak/trough serum drug levels;
• Investigational drugs in clinical trials; or
• PRN medications.

Time-critical scheduled medications that should be on every hospital's list include:

• Medications with a dosing schedule more frequent than every 4 hours;
• Scheduled (not PRN) opioids used for chronic pain or palliative care (fluctuations in the dosing interval may result in unnecessary breakthrough pain);
• Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to treat myasthenia gravis;
• Medications that must be administered apart from other medications (eg, antacids and fluoroquinolones); and
• Medications that require administration within a specified interval before, after, or with meals -- for example, rapid-, short-, or ultra-short-acting insulins, certain oral antidiabetic agents (eg, acarbose, nateglinide, repaglinide, and glimepiride), alendronate, and pancrelipase.