LAUSR

Learning Objectives: The Joint Commission mandates that intravenous (IV) medication orders should contain specific titration parameters to guide nurse administration of continuous IV medications. Many centers have received citations for having IV titration orders without complete instructions for initiation, adjustments, dose limits and goal parameters. To our knowledge, no studies have evaluated the safety and efficacy of titratable medications that include titration instructions. Methods: Single center, retrospective cohort study of patients who received at least 24 hours of norepinephrine (NE) as their first vasopressor in 1/2016 through 6/2016 (pre-group) and 1/2017 through 1/2017 (post-group). Patients were classified based on whether they were receiving NE before or after titration instructions were added to the medication order in 10/2016. The instructions require user entry of mean arterial pressure target and starting dose, instructions to titrate by 2–5 mcg/min every 1–2 minutes and for the nurse to contact the ordering provider if dose is adjusted by more than 20 mcg/min in any 30-minute period. Primary outcome evaluated was time to hemodynamic stability (reaching blood pressure goal), which was evaluated using Mann-Whitney U-test and multivariable linear regression to account for baseline differences between groups. Results: 1303 patients were included with 616 in the pre-group (47%) and 687 in the post-group (53%). The average age was 64 years and 60% of patients were male. Median systolic blood pressure (SBP) was significantly higher in the pre-group prior to initiation of NE (106 mmHg [88, 127] vs. 100 mmHg [85, 116]; p<0.01). On univariate analysis, time to hemodynamic stability was significantly longer in the post-group (32 min [12, 65] vs. 10 min [0, 26]; p<0.01). Initial and maximum dose of NE, time to maximum dose, maximum NE dose change and heart rate or central venous pressure were not significantly different between groups. On multivariate analysis, after accounting for baseline differences in baseline SBP, fluid bolus given before NE, presence of baseline arrhythmia, number of other vasopressors and other titratable infusions, the addition of titration instructions increased time to hemodynamic stability by 24 minutes (95% CI = 3.3–45.6, p=0.02). Conclusions: In this evaluation, time to hemodynamic stability was significantly longer after addition of norepinephrine titration instructions even after accounting for differences in baseline characteristics. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MD CCM