We are a small CSU of 9 beds. Our hospital was recently surveyed by JCAHO. Of course, they picked our most critical ECMO patient to hover around. When the patient's BP tanked, we were cited for practicing medicine without a license because we did not follow standard titration protocol. (We titrated pressors quickly to keep the patient alive.) Of course there was a big.. calling on the carpet.. meeting about this.. and JCAHO reps said Unless you have a Drs order to titrate that quickly, you may not!
Do your CCU's or CVICU's have any emergency titration protocols or IV sets to protect you?
Standard titration rates are ridiculous when BP is 44/20 and HR just dropped 20 pts and your CI is now 0.7. Just saying.
When I worked ICU I do not ever recall an emergent protocol. If they tanked and the med was on the profile we began or increased the drip and you notify the physician. The alternative is to call, wait and then you are coding the patient - so WTF.
The goal is to save the patient and prevent code. If you are starting a med without an order then...maybe, but most orders provide a starting rate and titrate for BP of xx/xx or MAP of XX
JCAHO has a lot of really old school people in the organization with really old school mindsets and that is where the this archaic "explicit orders for everything" BS comes from. They HATE the idea of nursing judgement. It is antithetical to JCAHO philosophy. They want cookbook care only, and even push that approach at the physicians.
They are so off in la la land that something like "Norepinephrine - titrate between X and Y to keep MAP>65" will not satisfy them. They literally want to see, "start at Z rate and titrate by steps of A every B minutes" added to the order... at a minimum. They really only get happy with "and notify physician after each titration step."
One of the major criticism of the JC is that they aren't very good about staying in their lane. Titration parameters are not a CMS regulatory issue, they are regulated by the State department of health hospital accreditation, same goes for covered drinks at the nursing station. This doesn't stop JC surveyors from making declarations on these issues, even though they have no authority over these issues. As far as titration parameters go, state regulatory agencies generally only require that there be a common understanding between the ordering provider and the RN as to how the medication will be titrated, I've actually worked at a place where the state required us to remove the strictly defined parameters on our insulin gtt orders since they considered the lack of flexibility to be unsafe.
TicTok411
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When I worked ICU I do not ever recall an emergent protocol. If they tanked and the med was on the profile we began or increased the drip and you notify the physician. The alternative is to call, wait and then you are coding the patient - so WTF.
The goal is to save the patient and prevent code. If you are starting a med without an order then...maybe, but most orders provide a starting rate and titrate for BP of xx/xx or MAP of XX