Abstract: National Online Survey of Rule of Six versus Standardized Concentrations

National Online Survey of Rule of Six versus Standardized Concentrations Gaffoor, MI, MD, Hilmas, E, PharmD, Mathews, L, RN, Morrison, W, MD, and Vaidya, VU, MD Division of Pediatric Critical Care, University of Maryland School of Medicine, Baltimore, MD Introduction: There has been a significant ongoing debate among pediatric and neonatal critical care providers regarding the method of choice for ordering continuous infusions; the rule of six (ROS) versus standardized concentrations (SC) method. The debate has intensified since the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandated that all institutions use the SC method by January 2005. To-date there are no studies comparing the two methods. We conducted a national online survey to assess provider experiences and opinions comparing the two methods. Method: A 60 question web-based survey was posted on multiple internet listservs aimed at pediatric and neonatal critical care providers. A total of 1483 responses were received of which 1150 were complete and used in the data analysis. Data analysis was performed using logistic regression except where otherwise noted to control for confounding factors. Results: Our sample consisted of 494 (43%) nurses, 406 (35%) physicians, 155 (14%) pharmacists, and 81 (7%) nurse practitioners with the majority (60%) having greater than 10 years of clinical experience. Surprisingly, 32% of respondents were not aware of the JCAHO mandate. Of our sample, 59% of respondents are currently using ROS while 41% are using SC. Most respondents preferred the method they were currently using with 53% preferring ROS and 42% preferring SC (OR:28, p<0.001, 95% CI: 18.0-41.4) When looking at respondents opinions regarding the strengths and weaknesses of SC and ROS we found their results to be dichotomized based on their overall preference of method. For example, 85% of those who prefer ROS disagree with the JCAHO mandate while only 10% of those who prefer SC disagree with the JCAHO mandate (p<0.001). Regarding respondents opinion about the loss of intuitive relationship between dose and infusion rate when using the SC method, 85% of ROS users feel that the lack of this relationship will lead to more nursing errors if SC method is used as opposed to 15% of SC users (p<0.001). This statistically significant trend was seen in almost every other question of opinion such as applicability of SC in the NICU as well as ease of use and safety of both methods for physicians, nurses and pharmacists. We also noted that more respondents recalled sentinel (adverse) events with SC (67%) than with ROS (51%), (p<0.001 via two-sample test of proportion). However, respondents who preferred rule of six were more likely to report sentinel events with SC (OR: 1.9, p<0.001, 95% CI: 1.3-2.8) and respondents who preferred SC were more likely to report sentinel events with ROS (OR: 2.0, p<0.001, 95%CI: 1.4-2.9). A reanalysis was performed only looking at users’ recollection of sentinel events for their preferred method. Even when controlling for user bias in this fashion we noted that 64% recalled sentinel events with SC while 45% recalled sentinel events with ROS (p<0.001 via two-sample test of proportion) Conclusions: Respondent’s opinions about the strengths and weaknesses of both methods were heavily weighted based on their individual preference for a particular method. In addition, despite this bias, respondents do recall more adverse events related to SC than to RO6. Based on this data, from a group of multidisciplinary and experienced respondents, and the lack of true scientific studies, it appears that we cannot categorically identify one method as being superior and safer than the other. A mandate to use only one method may be premature at this time.

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