This tool helps you standardize infusions

May 22, 2006

For many years, doses and rates of administration for continuousinfusions in pediatric patients have been based upon the "rule ofsix." This weight-based method relies on the following formula: sixtimes body weight is the amount of drug to be added to 100 ml ofcarrier fluid.

For many years, doses and rates of administration for continuous infusions in pediatric patients have been based upon the "rule of six." This weight-based method relies on the following formula: six times 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/hr (rate). The intuitive relationship and simplicity between rate and dose is the reason this method has been attractive to healthcare workers for so long.

To address the "standardization" mandate, a group of healthcare professionals including two physicians, a nurse, and a pharmacist (Hilmas) at the University of Maryland developed a software program to calculate standard concentrations based upon drug, patient populations, and capabilities of infusion pumps. This program successfully identified standard concentrations for approximately 40 drugs commonly used as continuous infusions in pediatrics.

After determining the best standard concentrations, Hilmas' group created a computerized physician order entry (CPOE) program that allows physicians to order these drips at the point of care. The program assists clinicians by selecting the best concentration based upon the patient's fluid maintenance.

After order completion, the program generates order sheets with separate sections for physicians, pharmacists, and nurses. In the prescriber's section, the basic elements of the prescription are displayed, including dose, rate, and drip concentration. The pharmacist's section contains detailed compounding instructions. According to Hilmas, "Pharmacists have never before seen physician orders with this much detail."

For physicians, pharmacists, and nurses, this technology, implemented at the University of Maryland in October 2004, has reaped many benefits. Physicians can rapidly complete orders for drips in a matter of seconds with no phone calls back and forth to the pharmacy, and optimal fluid balance is maintained each and every time. Pharmacists appreciate the compounding instructions that are built into each order and enjoy dispensing pre-made drips. Nurses are assured that the dose and rate are correct and are thrilled that they no longer have to deal with illegible hand-writing.

After implementation, Hilmas compared pre- and poststandardization orders, "We found that 40.5% of our handwritten rule-of-six 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 error-free, complete, and legible.

Standardized infusions were initially implemented in the Pediatric Intensive Care Unit at the University of Maryland's Hospital for Children, but Hilmas thinks "the biggest achievement is that it has been implemented housewide."

For hospitals around the country that are still unsure how to comply with JCAHO's mandate, Pharmacy OneSource, in Bellevue, Wash., said that it has licensed the "concentration optimizing" technology. The CPOE module is available commercially to facilitate widespread distribution, and it can be purchased under the name Accupedia.

Pharmacists charged with implementing dosage standardization at their own hospitals can visit either or for additional information. Those who have used this new technology claim it not only meets, but actually exceeds, the JCAHO mandate, and contains multiple safety checkpoints at the physician, pharmacy, and nursing levels.

THE AUTHOR is a writer based in the Philadelphia area.