The Joint Commission Titration Guidelines and the Death of Nursing Clinical Judgment in the Intensive Care Unit

As a practicing intensive care unit (ICU) nurse and an adjunct faculty member in an undergraduate nursing program, I have observed with grave concern a decline in nursing practice grounded in clinical judgment as a result of The Joint Commission’s (TJC’s) latest changes to titration order requirements. According to the American Association of Colleges of Nursing,1 clinical judgment is As a faculty member, I emphasize the importance of clinical judgment to my students and expect them to demonstrate an appropriate level of competency in this area in order to progress within the program. However, as a bedside ICU nurse, I am witnessing a steady erosion of nursing clinical judgment in medication titration as a direct result of the implementation of the TJC standards. As hospitals implement strict titration controls for continuous intravenous medication infusions in the ICU, nurses are being placed in increasingly difficult situations in which they are required to use a “one size fits all” approach to patient care that negatively affects the quality of care delivered.2 The moral distress experienced by ICU nurses as a result of these TJC changes has also been documented.3Although moral distress among bedside nurses and declining quality of care are serious concerns, they are not the primary focus of this letter. Instead, I would like to highlight the interesting paradox these changes create for nurse educators across the continuum, from academic faculty to bedside nurse preceptors. During their training, student nurses are repeatedly urged to think critically and apply clinical judgment in practice so they can provide personalized, appropriate care for their patients. Yet, following graduation, some of these students transition into bedside practice in the ICU only to be told that they must suspend their clinical judgment during the administration of titratable medications because the medication order specifies every detail of the titration parameters, including the exact dose by which the nurse must titrate the medication when the clinical end point falls outside of the specified goal range.2In my experience, the greatest moral distress for nurses, and the greatest risk to patients, results from titrations of vasopressors under the new TJC order requirements. For example, a norepinephrine titration order may state to titrate by 0.01 µg/kg/min every minute to maintain a mean arterial pressure (MAP) goal of 65 to 75 mm Hg. This order may be adequate for approximately 95% of clinical situations, but it is the remaining 5% in which nursing moral distress and patient harm become significant concerns. In critically ill patients, sudden decreases (or increases) in blood pressure can occur within seconds and may indicate a life-threatening emergency. To continue this example, perhaps the patient is intubated and receiving multiple vasopressors when their MAP decreases from 65 to 36 mm Hg immediately after being turned in bed for necessary care. In this case, critical thinking and the application of clinical judgment would demand a response greater than a titration of 0.01 µg/kg/min, given the acuity and life-threatening nature of the situation. No clinically competent ICU nurse would expect a patient receiving moderate to high doses of vasopressors to respond adequately to such a minimal titration under these circumstances. Yet, the medication order mandates titration only by that fixed increment (or, in some facilities, within a narrowly defined dose range with detailed requirements for each dosage level). Intensive care unit nurses are now required, by TJC and subsequently their facility’s policies, to emergently call for a provider to come to the bedside and issue a new medication order while dutifully titrating norepinephrine by 0.01 µg/kg/min for a patient with a MAP near 30 mm Hg. The nurse is aware that imminent circulatory collapse can be prevented only by a significant and timely increase of vasopressor support, yet they are not allowed to exercise clinical judgment to rapidly adjust dosing in this situation. These untenable situations are not the fault of ICU nurses, nor are they necessarily the fault of health care facilities struggling to comply with TJC’s titration requirements while maintaining their accreditation. Rather, these situations are a system-level problem that require system-level changes to allow ICU nurses to practice with clinical judgment in all aspects of patient care, including medication titration, while remaining safely within the confines of their professional scope of practice.