A study in the September American Journal of Critical Care evaluating the experience of critical care nurses in implementing the 2018 changes to the Joint Commission's medication management standards for titration of continuous medication infusions found significant negative consequences for nursing practice. Survey responses from nearly 800 critical care nurses with experience titrating IV medications raised issues of patient safety, documentation burden, professional autonomy, and moral dilemma when adherence to standards conflicted with patients' clinical needs. For example, before the 2018 update, nurses could use their clinical judgment to select the rate and increments of the titrated medication to achieve a prescribed physiological goal. After the update, which tightened standards, nurses were required to document additional information, such as the rate of the initial dose, the incremental units for increasing or decreasing the dose, and the frequency of the dose titration, and to do so as each change occurred.

Major themes emerging from nurses' responses to the survey centered on harm and professionalism. Regarding harm, nurses reported stress from overly rigid titration standards that made prompt intervention more difficult. In some instances, nurses said they chose to falsify documentation rather than follow standards that went against their clinical judgment. As to professionalism, nurses said the standards undermined their ability to apply expertise and critical thinking skills to manage ongoing changes in their patients' conditions.

The American Association of Critical Care Nurses (AACN) brought preliminary findings of the study to the Joint Commission team responsible for medication titration standards. The standards were subsequently updated in June and September 2020 in response to the study's findings, but these updates "inadequately address the issues," according to the study's authors, who recommend repeating the survey after incremental changes to the standards are complete. They also stressed the long-held position of the AACN that nurses be included in standard-setting deliberations to ensure safe patient care.-Gail M. Pfeifer, MA, RN