On October 25th, 2004 we changed from the Rule of Six to Standardized Drips in the Pediatric Intensive Care Unit at the University of Maryland. Below we offer a report of our experience with and feelings about the change to Standardized Drips.

What were the reasons for our change?
i) Our hospital administration required it in order to be compliant with JCAHO (number one reason, obviously!)
ii) Having developed a customized software solution, the "Concentration Optimizer®" to manage the entire transition, we were confident that we could "have our cake and eat it too"! In other words the program would enable us to reap some of the benefits inherent in the use of standard concentrations, while at the same time it would allow us to overcome some of the drawbacks.

Some benefits of Standard Concentrations: For example, even the strongest opponents of Standard concentrations will agree that it just so much easier to pick up and hang a premixed bag of Dopamine than to go through all the calculations, compounding each drip, etc, etc.
Some drawbacks of Standard Concentrations: The use of Standard concentrations results in loss of the intuitive dose-rate relationship that nurses are so familiar and conversant with. We have repeatedly encountered this being cited as one of the major safety concerns in use of SCs leading many to believe that SCs can only be used in conjunction with "Smart" infusion pumps.  Additionally, many neonatologists express valid concerns about the possibility of excessive fluid load in their micropreemies when using SC.

The Concentration Optimizer solution:  The program enabled rapid and automatic  identification of 2 to 4 standard concentrations for any drug,  which is the first step or rather the first hurdle when deciding to change to standard concentrations. For any given drug, at any dose and for any patient weight (from 500 gm to 70 kg) the Concentration Optimizer could always identify one concentration that resulted in an clinically appropriate infusion rate (not too much or not too less, yes even for micropreemies!). Next the computerized ordering program made it a breeze for the physicians to order the drips in just 3 steps (enter weight, select drug, enter dose). Finally the computerized printout generated clear legible compounding instructions for the pharmacists and clear, unambiguous step by step instructions for the nurses to set up the pump. The printout included, patient weight-specific dosing chart allowing nurses instantaneous check of correct dose-infusion rate relationship. The printout, made the change seamless and transparent.

How easy/difficult was the transition?
"Implement it and forget about it",  was what we could say about our experience. Although a lot of careful and meticulous planning had gone into the process, surprisingly the final implementation was smoother than anticipated. In fact the process was so transparent to the physician, pharmacist and the nurse that unless specifically told about the change to standard concentrations, it appeared as if we had just changed from hand-written orders to computerized orders with some enhanced bells & whistles!

What benefits have we noted?
i)      It takes ONLY between 30 to 40 seconds for physicians to order as many as 3 to 4 drips. No phone calls from pharmacy, correct concentrations, complete orders, optimum fluid balance each and every time. Each patient gets the most optimized drips tailored to their weight, dose and fluid requirements effortlessly. Physicians are ecstatic
ii)     Pharmacists are enjoying dispensing premixed drips, as well as compounding the limited number of concentrations for each drip. No calculation errors! Compounding instructions are built into the order itself, no need to maintain hundreds of pages of individual drip compounding instructions.
iii)    Nurses are happy not having to deal with illegible handwriting, feel secure that the dose and rate are correct since there is a triple check (the order itself, the pump and the dosing chart, each independently corroborate the same dose-rate relationship). To keep up their skills, they do use their calculators once in a while! (In fact the printout even provides them with a formula to enter into their calculators). Premixed Dopamine, Dobutamine, Milrinone stocked in the unit can now be infusing within seconds during emergencies.

Have we noted any errors?  
No

Has the use of Standard Concentrations resulted in increased safety?
Perhaps the use of Standard concentrations alone cannot be credited with enhancing safety. Rather, the revamping our entire ordering process as described above to accommodate the use of Standard Concentrations has clearly added many more safety layers which were lacking in our previous paper-based rule of six method. We are pretty certain that using a similar approach for the Rule of Six method could result in similar benefits. In other words it would be unfair to compare our old paper-based rule of six method with our new computerized, feature-loaded standard concentration method and jump to the conclusion that all the benefits are simply due to the use of Standard Concentrations alone.