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Rule of Six vs.
Standardized Drips
| Current News at ICUdrips.org (updated
7/18/05) Dear colleagues,
This past year and a half has been a very productive
one since the inception of the icudrips.org website in March 2004,
aimed at providing solutions for transitioning to standardized drips.
During this period, we developed
software to automate the generation of
standard concentrations,
collaborated with national leaders with the aim of developing
consensus, and conducted a large national
survey on this subject.
We also developed a software
CPOE module, that enabled us to successfully and rapidly
implement standardized drips at our
institution. We have presented our research findings at
several national meetings and
most of all enjoyed interacting with many of you through hundreds of
emails, phone calls, site visits and subscription to our email lists.
In response to the numerous requests for the
Concentration Optimizer software, it has become evident that we would
not be able to provide support to its many potential users. To enable
organized distribution of the program through established vendor
networks and further its development, the University of Maryland
licensed the software to
Healthprolink, a pharmacy software company based in Seattle. The
company plans to market the software in the upcoming months.
Thanks once again for your support, questions, and
ideas.
Sincerely,
Mohamed Gaffoor, M.D.
& Vinay Vaidya, M.D. |
Welcome:
In recent years, perhaps no other issue has intrigued the pediatric
and neonatal ICU community more than how to order continuous medication
infusions such as Dopamine, Epinephrine, etc. For years, centers have used the
"rule of six" (weight-based) method to order and
compound continuous medication infusions. Rule of six method uses
the following formula; six times the body weight is the amount of drug
to be added to 100 ml of carrier fluid. The
resulting concentration of infusion is such that 1 mcg/kg/min
(dose) = 1 ml/hour (rate). This intuitive relation between dose and rate
makes it easy and convenient to initiate the infusion at the correct rate and
to titrate the dose. (e.g. since 1mcg/kg/min = 1ml/hour, it
follows that 5 mcg/kg/min = 5 ml/hr, and 7.5 mcg/kg/min = 7.5
ml/hour, and so on) This intuitive relation between dose and rate, which
does not require any complex calculations or for that matter, does not
even require a simple calculator, is the key feature which has made this
method attractive to healthcare workers. This explains why the 'rule
of six' method has ruled for so long!
Recently, the "standardized
concentration method" has been introduced as a viable alternative
to the rule of six method. In this method, unlike the rule of six method,
the concentrations of drips do not vary with the patient's weight .
Instead, just two to four pre-determined concentrations are used for
patients of all weights. While the rule of six method results in
potentially limitless concentrations (a different concentration for each
patient with a different weight), the standard concentration method limits
the concentrations to a few (two to four) fixed, pre-determined
concentrations.
Limiting and standardizing concentrations of high alert
drugs has been the "National patient safety goal, # 3b"
as put forth by JCAHO (Joint Commission on Accreditation of
Healthcare Organizations). JCAHO has mandated that organizations switch to standard
concentrations to keep in compliance with goal 3b. While some
organizations have been using the standardized concentration method even
prior to the JCAHO mandate, an estimated 20 to 30% of hospitals have
recently changed to the new method. The vast majority of pediatric
hospitals around the country are either scrambling to change to
standardized drips as per the JCAHO requirement or expressing
their opinion against the JCAHO mandate in various forums. At the
same time, many of the hospitals that have changed to standardized drips
are reporting user satisfaction, reduced errors, reduce costs as
benefits of the standardized drips. They also report and demonstrate the feasibility
of using standard concentrations across a wide range of patient weights
typically seen in the pediatric population.
In November 2004 JCAHO has changed their
stance on the mandate. They have stated that institutions may continue
to use the rule of six as long as they show a written plan with adequate
safety precautions.
Are standardized drips safer? Is the rule of six outdated? How smart are
"smart pumps"? What concentrations are the "best" standard? These are some
of the questions that have surfaced and are posing a national
challenge.
Our goals:
The current website, www.icudrips.org
is created by a multidisciplinary team of
professionals at the University of Maryland Medical Center to
specifically answer some of these questions in a scientific manner
without preconceived bias towards either method. Our team is composed of representatives
from medicine, nursing, pharmacy, medical informatics and Human
Factors researchers, all aligning together with the aim of providing answers
to some of the recent
controversies surrounding continuous infusions. As more information
evolves on this topic, we will update our site on a regular basis.
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