A Software Program to Safely, Quickly, and Accurately Standardize Pediatric Infusions

THE COMMONLY USED “RULE-OF-SIX” METHOD OF
ordering continuous infusions (a weight-based equation used to determine medication concentrations for pediatric patients) results in a customized solution for each patient, but also requires complex calculations. On the other hand, if predetermined standard concentrations are used for pediatric patients, compounding tasks can be simplified and there is less potential for mathematical error.

The Joint Commission National Patient Safety Goal 3b, published in July 2002, states that hospitals should “standardize and limit the number of drug concentrations available in the organization.” This mandate concerned pediatric practitioners greatly, because there was little literature to support the safety of standard concentrations. Switching from “Rule-of-Six” prescribing to standard concentrations can be quite complex, and may involve new ordering patterns and forms, the reassessment of pump capabilities, titration charts, and developing a plan for emergency situations. Retraining of physicians, pharmacists, and nurses would be required. Also, there is a necessity to make standard concentrations work in different clinical environments (PICU, NICU, ER, transport, OR). In addition, the need for new equipment (pumps, forms, and computers) needs to be assessed. Institutions would also need to determine how many concentrations should be allowed for each drug, what those concentrations should be, and how a concentration should be selected for a specific patient.

At the University of Maryland Medical Center, a multidisciplinary group, including a PICU attending and fellow, a pediatric pharmacist, and a pediatric nurse, came together to address these issues. We developed a website (www.icudrips.org) to detail our work and to provide a forum for discussion, and we developed an Excel-based program to calculate standard concentrations based on the drug, the patient population, and the capabilities of the infusion pump. The program was successful in determining standard concentrations for approximately 40 drugs most commonly used as continuous infusions in pediatrics, and it allowed our group to feel comfortable using standard concentrations for the entire pediatric population. We have published that list of standard concentrations on our website for other institutions to use as a guide.

After determining the best standard concentrations, we created a CPOE program, which allows physicians to order these drips at the point of care. The program assists the clinician by selecting the best concentration based on the patient’s fluid maintenance. We built several safety checks into the program, including:

• Confirmation alerts that allow the clinician to verify that the right patient information and medication have been selected
• Two signature requests and hard stops to prevent overdoses
• Instruction screens to guide the prescriber through each step of the ordering process

The program generates printed order sheets with separate sections for the physician or nurse practitioner ordering the drip, the pharmacist who compounds the drip, and the bedside nurse who administers the drip. In the prescriber’s section, the basic elements of the prescription are displayed, eliminating the prescriber’s need to perform calculations. The pharmacist’s section contains a mnemonic to assist in the selection of the right standard concentration, and lists compounding instructions to guide accurate preparation. Finally, the nursing section provides detailed pump-programming instructions, a double-check calculation equation, and a titration chart for dosage changes.

Auditing the Program
This program was implemented in our PICU in October 2004. After evaluating 200 pre-implementation and post-implementation orders, we found that 40.5% of our handwritten, “Rule-ofSix” orders were missing important elements such as the patient’s weight, dose, and rate, and 6.5% contained calculation errors. In comparison, the computerized, standardized orders were errorfree, complete, and legible, and the average time to generate a post-implementation order was 71 seconds. To further evaluate the process, a bedside audit, which revealed no problems, and a pharmacist’s feedback form were used. The feedback form revealed some suggestions for minor program changes, which were implemented.

After the success of the PICU implementation, the program was implemented in the NICU and the pediatric OR and ER. The program has been issued an international patent and licensed for public sale by Healthprolink. We feel that through a rigorous, scientific, standardized approach, we have worked hard to exceed JCAHO expectations to provide safe pediatric continuous infusions.

Authors:
Elora Hilmas, PharmD, BCPS, Pediatric
Pharmacy Clinical Manager Jason Topolski, PharmD, Pharmacy Practice
Resident University of Maryland Medical Center,
Baltimore, Maryland Vinay Vaidya, MD, Director, Pediatric Critical
Care Fellowship Program and Assistant
Professor of Pediatrics Mohamed I. Gaffoor MD, Fellow, Division of
Pediatric Care University of Maryland Hospital for Children,
Baltimore, Maryland