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The Broselow-Luten System
Color Coding Kids: The Broselow-Luten System
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Institute of Medicine Report
Deaths: 44,000 to 98,000 Cost: 17 to 29 Billion Dollars “Wake up Call” Can argue with statistics; hard to argue that we should decrease medical errors or that it is a significant problem. Over half of general public followed the story closely. Leapfrog group. Interest in buyers of health care. This problem is costing them money.
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Lesar study Medication error rate in tertiary care center
Greatest areas Pediatrics Emergency Department Pediatrics: reliance on dosage equations was major cause of error Out of 200 consecutive medication prescribing errors, nearly 70% occurred in Pediatric Patients. More striking: these mistakes represented a serious error rate that was nearly 6 fold higher for pediatric services.
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Kaushal JAMA Study 4/01 Included major Children’s Hospital
5.7% of orders had medication errors Dosing error most prevalent category test
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Institute for Safe Medication Practices (ISMP)
Pediatric Pharmacy Advocacy Group (PPAG) “Pediatric patients need more protection from medication errors, survey shows”
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Two Key Pediatric Error Issues
1) Dependence upon calculations 2) Lack of familiarity with normal vs. abnormal
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Number 34 30 Greater than 1 error 19 9 Ten fold errors 3 4
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Didn’t recognize errors
ICU Patients 10 drugs orders per day. Could translate to one 10-fold error for each 10 infants
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Recognizing normal
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Even The Cleaning lady would know!! “Too many amps in the trash”
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Which dose is 10 times error?
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ADJUSTED BROSELOW-LUTEN ZONES
Zone CM Length Wt in Kg Age in months 1 Pink Red Purple Yellow White Blue Orange Green
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Mathematical Accuracy of New Zones
Average variation from “rounded” Kg dosing for each zone or practical difference between per Kg and zone dosing: 4%
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Standard Pediatric system
PINK 6-7KG Gray Zones Gray 3kg RED 8-9KG Gray 4kg Gray 5kg PURPLE 10-11KG YELLOW 12-14KG Round to the nearest whole kilogram WHITE 15-18KG BLUE 19-23KG ORANGE 24-29KG GREEN 30-36KG
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RAINBOW TAPE DRUGS and EQUIPMENT YELLOW
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“Prescribing system” A standardized pre-calculated color-coding dosing system May be used in all therapeutic environments (not protocol driven) Two formats: 1) rainbow pages 2) rainbow stripes
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Rainbow Page Format
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VENTILATION FLUIDS Rainbow Stripe Format ZONE ZONE TIDAL VOLUME
Parameters: FiO2 100%, PEEP 3 cm H2O, Inspiratory Time >0.6 sec, PIP cm H2O, Tidal Volume mL/kg—Start low and increase to PIP cm H2O ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN TIDAL VOLUME 60-100mL mL mL mL mL mL mL mL FREQUENCY(BPM) FLUIDS ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN BOLUS ( mL) 130 170 210 260 325 420 530 660 MAINTENANCE (mL/hr) 28 35 40 45 55 65 70 75 MINIMUM HOURLY URINE OUTPUT (mL/hr) 7-14 9--18 10-20 13-25 16-32 20-40 25-50 35-65 NOTE: The 3, 4, 5 kg weights are not part of the color coded system.The following applies to these Patients : VENTILATION Rate same as pink and red, Tidal Volume, Fluid- 3kg 1/2 (50%) pink zone, 4kg 2/3(67%) pink zone, 5kg 3/4(75%) pink zone values.
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Drug administration by protocol
Standardized Dosing Medication ordering by Protocol … Guide or “Key Word” 3) Dose in mLs 4) Information organized by Point of care “Flow Guides”
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Dosing by “Key word” Midazolam Induction Midazolam Sedation
Diazepam- sedation IV Diazepam-Seizure IV* Diazepam-seizure-RECTAL Diphenhydramine IV Pancuronium Defasciculation Pancuronium Induction Pancuronium Maintenance Vancomycin IV Vancomycin
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Protocol dosing in Guide Book Format
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HYPERKALEMIA FLOW CHART
Initial Stabilzation Give Calcium Chloride IV over 3-5 minutes, may repeat in 10 minutes Give Sodium Bicarbonate IV over minutes First Line Drugs Give Glucose and Insulin IV over 30 minutes, may repeat immediately Ancillary Measure Albuterol neb Long term Preventive Kayexalate PO,NG, or PR
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12-14 kg YELLOW
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DEFIBRILLATION - CARDIOVERSION
EQUIPMENT ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN ET Tube(mm) 3.5 uncff 3.5 uncff 4.0 uncff 4.5 uncff 5.0 uncff 5.5 uncff 6.0 cuff 6.5 cuff Lip-Tip (cm) 14- 5 17-18 Suction 8F 8F 8 - 10F 10F 10F 10F 10F 12F L-Scope blade 1 straight 1 straight 1 straight 2 straight/ curved 2 straight/ curved 2 straight/ curved 2-3 straight/ curved 2-3straight/ curved Stylet 6F 6F 6F 6F 6F 14F 14F 14F Oral Airway 50 MM 50 MM 60 MM 60 MM 60 MM 70 MM 80 MM 80 MM NP Airway 14F 14F 18F 20F 22F 24F 26F 30F BVM INFANT INFANT CHILD CHILD CHILD CHILD CHILD/ ADULT ADULT ETCO2 PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR PEDIATRIC/ DETECTOR ADULT/ DETECTOR ADULT/ DECTECTOR ADULT/ DETECTOR ADULT/ DETECTOR DEFIBRILLATION - CARDIOVERSION ZONE PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Defib (1stdose) 13j 17j 20j 26j 33j 42j 53j 66j Defib ( 2+ doses) 26j 34j 40j 52j 66j 84j 106j 132j Cardioversion 7j 8j 10j 13j 17j 21j 27j 33j NOTE: The 3, 4, 5 kg weights are not part of the color coded system.The following applies to these Patients : EQUIPMENT- same as pink and red. Defibrillation,Cardioversion 3kg 1/2 (50%) pink zone, 4kg 2/3(67%) pink zone, 5kg 3/4(75%) pink zone values.
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Amoxicillin (HIGH DOSE) 400mg/5mL
COMMON ORAL MEDICATIONS (mLs) DRUG PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Acetamin suspension 3.1 4 5 6.2 8 10 12.5 15 Acetamin drops 1 1.3 1.6 2 2.5 3.2 4 5 Ibuprofen suspension 3 4 5 6.5 8 10 13 16.5 Amoxicillin 125mg/5mL 3 4 5 6 8 10 13 16 Amoxicillin 250mg/5mL 1.5 2 2.5 3 4 5 6.5 8 Amoxicillin (HIGH DOSE) 400mg/5mL 5.6 7.2 9.5 11 15 19 24 30 cefdinir 125mg/5mL 1.8 2.5 3 3.6 4.6 6 7.5 9.2
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RSI FLOW CHART(Medications)
Preparation Preoxygenation Zero minus 5-10min 3min plus 45sec Lidocaine-RSI IV Fentanyl-RSI IV Atropine-RSI IV Pan/vecuronium-Defasiculation IV Pretreatment Paralytics Succinylcholine IV Rocuronium-Paralysis IV Pan/vecuronium-Paralysis IV Induction Agents Etomidate-Induction IV Ketamine Induction IV Midazolam-Induction IV Thiopental-Induction IV Propofol-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Pan/Vec/Rocuronium-maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV, or other
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis/ Induction Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45 sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV Paralysis/ Induction Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment Atropine-RSI/RESUS IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV Paralysis/ Induction Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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Putting it together 5 year old “Broselow Tape Red Zone”
Hit on head with baseball bat Glasgow Coma score is 6 BP 130/100 pulse 90 Respirations 20 Needs airway management and is at risk for elevated ICP
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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Pretreatment Medications
Blue KGS Pretreatment Medications
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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Blue KGS
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RSI FLOW CHART K+ Risk +ICP Asthma Preparation Preoxygenation
Gen Sequence K+ Risk +ICP Poor Perfusion Asthma Zero minus 5-10min 3min plus 45sec Preparation Preoxygenation Pretreatment* Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralysis/ Induction Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Placement Paralysis Maintenance Vecuronium maintenance IV Post Intubation Management Sedation Maintenance Lorazepam IV
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Post Intubation Agents
Blue KGS Post Intubation Agents
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Are We " Dumbyfying" Medicine?
Math free algorithms enhance “critical thinking “ “Transparency” of critical decisions promotes team approach to error reduction
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Point of Care functional units
ALS RSI Anaphylaxis Pain and Sedation Fluids and burns Weapons of Mass destruction Seizures, electrolytes, etc
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BURNS--------PINK Determine % BSA of patient’s burn
2) Refer to fluid charts for hourly rate for patient’s burn Body Surface Area Percentages for PINK zone 7% 7% 4% 3% Front Back Minimum Urine output 7-13 mL/hr Morphine IV, IM mg Demerol IV, IM 6.5mg
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1) Resuscitation Fluid (LR)
Presentation 1 hr post burn Presentation 2hr post burn Presentation 3 hr post burn Presentation 4 hr post burn % Burn Rate For 7 hrs % Burn Rate For 6 hrs % Burn Rate For 5 hrs % Burn Rate For 4 hrs 10% 12mL/hr 10% 14mL/hr 10% 17mL/hr 10% 21mL/hr 20% 25mL/hr 20% 29mL/hr 20% 35mL/hr 20% 44mL/hr 30% 36mL/hr 30% 42mL/hr 30% 50mL/hr 30% 63mL/hr 40% 50mL/hr 40% 58mL/hr 40% 70mL/hr 40% 88mL/hr 50% 60mL/hr 50% 70mL/hr 50% 85mL/hr 50% 106mL/hr 60% 70mL/hr 60% 83mL/hr 60% 100mL/hr 60% 125mL/hr 70% 86mL/hr 70% 100mL/hr 70% 120mL/hr 70% 150mL/hr 80% 96mL/hr 80% 113mL/hr 80% 135mL/hr 80% 170mL/hr 90% 107mL/hr 90% 125mL/hr 90% 150mL/hr 90% 188mL/hr 100% 120mL/hr 100% 142mL/hr 100% 170mL/hr 100% 213mL/hr 2) Piggy Back Fluid (Maintenance D5W+1/4 NS) Presentation 1hr Post Burn Presentation 2hr Post Burn Presentation 3hr Post Burn Presentation 4hr Post Burn Rate for 7hrs Rate for 6 hrs Rate for 5 hrs Rate for 4 hrs 50mL/hr For 7hrs 58mL/hr for6hrs 70mL/hr For 5hrs 88mL/hr for4hrs Presentation > 4hr Post Burn *If > 4 hr.s post burn, start fluids at 4hr post burn rate, treat shock with 20mL/kg fluid boluses, and consult burn center for further fluid guidelines
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Emergency infusions Standard Pediatric System Neonates
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Standard Pediatric system
PINK 6-7KG Gray Zones Gray 3kg RED 8-9KG Gray 4kg Gray 5kg PURPLE 10-11KG YELLOW 12-14KG WHITE 15-18KG BLUE 19-23KG ORANGE 24-29KG GREEN 30-36KG
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Standard Pediatric system
PINK 6-7KG Gray Zones Gray 3kg RED 8-9KG Gray 4kg Gray 5kg PURPLE 10-11KG YELLOW 12-14KG WHITE 15-18KG BLUE 19-23KG ORANGE 24-29KG GREEN 30-36KG
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RAINBOW TAPE DRUGS and EQUIPMENT Purple
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#1 PURPLE 10-11KG 42 mLs/hr 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14
Infusion bag label applied by pharmacist #1 PURPLE 10-11KG Maintenance Fluids 42 mLs/hr B-L Concentration Dopamine 1600 micrograms/mL mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg mLs/hour 0.8 mL 1.6 mL 2.4 mL 3.2 mL 4 mL 4.7 mL 5.5 mL 6.3 mL 7 mL 8 mL
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# 1 Infusion bag label from pharmacy or manufacturer
B-L Concentration Dopamine 6400 Micrograms/mL
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#1 PURPLE 10-11KG 42 mLs/hr 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14
Infusion bag label applied by pharmacist #1 PURPLE 10-11KG Maintenance Fluids 42 mLs/hr B-L Concentration Dopamine 1600 micrograms/mL mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg mLs/hour 0.8 mL 1.6 mL 2.4 mL 3.2 mL 4 mL 4.7 mL 5.5 mL 6.3 mL 7 mL 8 mL
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Miceronates Elefants (up to 1 Kg) (1Kg to 4.5 Kg) Newborn System Pink
White Pink White Red Blue Red Blue Purple Purple Orange Orange Yellow Green yellow Green
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Elefants Pink 1001-1250 GMS White 2001-2500 GMS Red 1251-1500 GMS Blue
Purple GMS Orange Yellow GMS Green GMS
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Newborn infusion sticker
#1 Maintenance Fluids 12 mLs/hr B-L Concentration Blue GMS Dopamine 1600 micrograms/mL mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg mLs/hour 0.2 mL 0.4 mL 0.8 mL 1 mL 1.4 mL 1.8 mL 2.2 mL 2.6 mL 3 mL 3.6 mL
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Miceronates White 701-750 GMS Blue Red 751-800 GMS 551-600 GMS Orange
Pink GMS Blue GMS Red GMS Orange GMS Purple GMS Green GMs Yellow GMS
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# 2 Infusion bag label from pharmacy or manufacturer
B-L Concentration Dopamine 6400 Micrograms/mL
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Newborn infusion sticker
#2 Maintenance Fluids 2 mLs/hr B-L Concentration Pink GMS Dopamine 6400 micrograms/mL mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg mLs/hour 0.2 mL 0.4 mL 0.8 mL 1 mL 1.4 mL 1.8 mL 2.2 mL 2.6 mL 3 mL 3.6 mL
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Newborn infusion sticker
#1 Maintenance Fluids 12 mLs/hr B-L Concentration Blue Dopamine 1600 micrograms/mL mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg mLs/hour 0.2 mL 0.4 mL 0.8 mL 1 mL 1.4 mL 1.8 mL 2.2 mL 2.6 mL 3 mL 3.6 mL
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Infusion pump window To be used in coordination with infusion label
Standard Pediatric Select BL System Broselow-Luten color mLs/Hour Per Cent of maintenance Fluid requirements Purple 10-11KG 4 8 % Scroll bar Scroll bar Scroll may be used to set infusion To Broselow-Luten color Scroll may be used to set infusion to maintenance, twice maintenance, etc
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Infusion pump window To be used in coordination with infusion label
Standard Pediatric Select BL System Broselow-Luten color mLs/Hour Per Cent of maintenance Fluid requirements Blue GMS 2 10 % Scroll bar Scroll bar Scroll may be used to set infusion To Broselow-Luten color Scroll may be used to set infusion to maintenance, twice maintenance, etc
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Infusion pump window To be used in coordination with infusion label
Standard Pediatric Select BL System Broselow-Luten color mLs/Hour Per Cent of maintenance Fluid requirements 1.5 15% Pink GMS Scroll bar Scroll bar Scroll may be used to set infusion To Broselow-Luten color Scroll may be used to set infusion to maintenance, twice maintenance, etc
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Computer Based Computer Based Approach
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DRUG NAME
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DRUG NAME Pancuronium
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1mg/mL 2mg/mL COLOR PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
INDICATION CONCENTRATION PINK Defasiculation 1mg/mL concentration RED Paralyzing PURPLE Maintenance 2mg/mL concentration YELLOW WHITE BLUE Pancuronium ORANGE GREEN
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1mg/mL 2mg/mL COLOR PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
INDICATION CONCENTRATION PINK Defasiculation 1mg/mL concentration RED Paralyzing PURPLE Maintenance 2mg/mL concentration YELLOW WHITE BLUE Pancuronium ORANGE GREEN
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1mg/mL 2mg/mL COLOR PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
INDICATION CONCENTRATION PINK Defasiculation 1mg/mL concentration RED Paralyzing PURPLE Maintenance 2mg/mL concentration YELLOW WHITE BLUE Pancuronium ORANGE GREEN
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1mg/mL 2mg/mL COLOR PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
INDICATION CONCENTRATION PINK Defasiculation 1mg/mL concentration RED Paralyzing PURPLE Maintenance 2mg/mL concentration YELLOW WHITE BLUE Pancuronium ORANGE GREEN
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PURPLE 2mL 2mg 1mg/mL Defasiculation Paralyzing Maintenance
Pancuronium 1mg/mL concentration
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RED 1.7mL 1.7mg 1mg/mL Defasiculation Paralyzing Maintenance
Pancuronium 1mg/mL concentration
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BLUE 4.2mL 4.2mg 1mg/mL Defasiculation Paralyzing Maintenance
Pancuronium 1mg/mL concentration
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ORANGE 5.3mL 5.3mg mg/mL Defasiculation Paralyzing Maintenance
Pancuronium mg/mL concentration
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Setting a New Standard
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November 26, :03:00 PM ET CHICAGO--(BW HealthWire)--Nov. 26, Color Coding for Kids to Provide Easy Reference Guidelines for Hospitals and Help Reduce CT Radiation for Children GE Medical Systems, a unit of the General Electric Corporation (GE: NYSE), has signed an agreement that will allow GE to apply the Broselow-Luten Pediatric System, commonly known as Color Coding for Kids, to all of its medical imaging and patient information systems. The results of this agreement could positively impact millions of pediatric patients in the years to come.
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Jerome Medical Addressing pediatric issues of airways management and spinal alignment
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Kids vs. Adults Occipital Angle
P1 Collar (Ages 0-2 yrs.) P2 Collar (Ages 2-6 yrs.) P3 Collar (Ages 6-12 yrs.) Adult (Ages > 12 yrs.)
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Kids vs. Adults Neck Length
P1 Collar (Ages 0-2 yrs.) P2 Collar (Ages 2-6 yrs.) P3 Collar (Ages 6-12 yrs.) Adult (Ages > 12 yrs.)
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Importance of Alignment:
Always raise the child's thorax with the appropriate height padding to accommodate the occipital prominence and to maintain c-spine alignment and open airway with or without collar.
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Potential for color-coding
Unit dosing and packaging of Pediatric drugs (associated cost savings) Defibrillator settings Infusion Pumps Respirators Computer order entry Car Restraints
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Error Prevention for the Public
OTC Medications
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Color “A Universal Language”
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