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Color Coding Kids: The Broselow-Luten System.

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Presentation on theme: "Color Coding Kids: The Broselow-Luten System."— Presentation transcript:

1 Color Coding Kids: The Broselow-Luten System

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6 Institute of Medicine Report Deaths: 44,000 to 98,000 Cost: 17 to 29 Billion Dollars

7 Lesar study Medication error rate in tertiary care center –Greatest areas Pediatrics Emergency Department –Pediatrics: reliance on dosage equations was major cause of error

8 Kaushal JAMA Study 4/01 Included major Children’s Hospital 5.7% of orders had medication errors Dosing error most prevalent category

9 Institute for Safe Medication Practices (ISMP) Pediatric Pharmacy Advocacy Group (PPAG) –“Pediatric patients need more protection from medication errors, survey shows”

10 Two Key Pediatric Error Issues 1) Dependence upon calculations 2) Lack of familiarity with normal vs. abnormal

11 Number3430 Greater than 1 error199 Ten fold errors34

12 Didn’t recognize errors ICU Patients 10 drugs orders per day. Could translate to one 10-fold error for each 10 infants

13 Recognizing normal

14 Even The Cleaning lady would know!! “Too many amps in the trash”

15 Which dose is 10 times error?

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17 ADJUSTED BROSELOW- LUTEN ZONES ZoneCM LengthWt in KgAge in months 1 Pink Red Purple Yellow White Blue Orange Green

18 Mathematical Accuracy of New Zones Average variation from “rounded” Kg dosing for each zone or practical difference between per Kg and zone dosing: 4%

19 RED PURPLE YELLOW WHITE ORANGE GREEN BLUE PINK 6-7KG 8-9KG 10-11KG 12-14KG 15-18KG 19-23KG 24-29KG 30-36KG Standard Pediatric system Gray 3kg Gray 4kg Gray 5kg Gray Zones Round to the nearest whole kilogram

20 RAINBOW TAPE YELLOW DRUGS and EQUIPMENT

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22 “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

23 Rainbow Page Format

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31 Rainbow Stripe Format TIDAL VOLUME mL mL mL mL mL mL mL mL VENTILATION FREQUENCY(BPM) Parameters: F i O 2 100%, PEEP 3 cm H 2 O, Inspiratory Time >0.6 sec, PIP 2030 cm H 2 O, Tidal Volume mL/kg—Start low and increase to PIP cm H 2 O BOLUS ( mL) FLUIDS MAINTENANCE ( mL/hr) ZONE PINKREDPURPLEYELLOWWHITEBLUEORANGEGREEN ZONE PINKREDPURPLEYELLOWWHITEBLUEORANGEGREEN MINIMUM HOURLY URINE OUTPUT (mL/hr) 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.

32 Drug administration by protocol 1) Standardized Dosing 2) Medication ordering by Protocol … Guide or “Key Word” 3) Dose in mLs 4) Information organized by Point of care “Flow Guides”

33 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

34 Protocol dosing in Guide Book Format

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37 HYPERKALEMIA FLOW CHART Give Calcium Chloride IV over 3-5 minutes, may repeat in 10 minutes Albuterol neb Initial Stabilzation Initial Stabilzation First Line Drugs First Line Drugs Ancillary Measure Ancillary Measure Long term Preventive Long term Preventive Give Sodium Bicarbonate IV over 5-10 minutes Give Glucose and Insulin IV over 30 minutes, may repeat immediately Kayexalate PO,NG, or PR

38 YELLOW kg

39 ZONE 3.5 uncff F 50 MM 4.5 uncff F 6F 60 MM 5.0 uncff F 6F 60 MM 4.0 uncff F 6F 60 MM 5.5 uncff F 14F 70 MM 6.0 cuff F 14F 80 MM 6.5 cuff F 14F 80 MM 3.5 uncff F 6F 50 MM PINKREDPURPLEYELLOWWHITEBLUEORANGEGREEN 1 straight 2 straight/ curved 2 straight/ curved 1 straight 2 straight/ curved 2-3 straight/ curved 2-3straight/ curved 1 straight 6F ET Tube(mm) Lip-Tip (cm) Suction L-Scope blade Stylet Oral Airway PEDIATRIC/ DETECTOR CHILD PEDIATRIC/ DETECTOR CHILD ADULT/ DETECTOR CHILD PEDIATRIC/ DETECTOR CHILD ADULT/ DECTECTOR CHILD/ ADULT ADULT/ DETECTOR ADULT ADULT/ DETECTOR INFANT PEDIATRIC/ DETECTOR 14F20F22F18F24F26F30F14F INFANT NP Airway BVM ETCO 2 EQUIPMENT Defib (1 st dose) 13j17j20j26j33j42j53j66j Cardioversion 26j34j40j52j66j84j106j132j ZONE PINKREDPURPLEYELLOWWHITEBLUEORANGEGREEN 7j8j10j13j17j21j27j33j DEFIBRILLATION - CARDIOVERSION Defib ( 2+ doses) 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.

40 DRUG PINKRED PURPLEYELLOW WHITEBLUE ORANGE GREEN Amoxicillin ( HIGH DOSE) 400mg/5mL Acetamin suspension Amoxicillin 125mg/5mL Amoxicillin 250mg/5mL COMMON ORAL MEDICATIONS ( mLs) Acetamin drops cefdinir 125mg/5mL Ibuprofen suspension

41 RSI FLOW CHART(Medications) Lidocaine-RSI IV Fentanyl-RSI IV Atropine-RSI IV Pan/vecuronium-Defasiculation IV 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 Maintenance Pan/Vec/Rocuronium-maintenance IV Sedation Maintenance Lorazepam IV, or other Preparation Preoxygenation Preparation Preoxygenation Pretreatment Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management

42 Atropine-RSI/RESUS IV Preparation Preoxygenation Preparation Preoxygenation Pretreatment Zero minus 5-10min Zero minus 3min Zero plus 45sec Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV Paralysis/ Induction Paralysis/ Induction Placement Post Intubation Management Post Intubation Management K + Risk+ICP Poor Perfusion Asthma Gen Sequence RSI FLOW CHART

43 Preparation Preoxygenation Preparation Preoxygenation Pretreatment Zero minus 5-10min Zero minus 3min Zero plus 45sec Paralysis/ Induction Paralysis/ Induction Placement Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV +ICP Poor Perfusion Asthma Gen Sequence RSI FLOW CHART K + Risk

44 Preparation Preoxygenation Preparation Preoxygenation Pretreatment* Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV K + Risk Poor Perfusion Asthma Gen Sequence RSI FLOW CHART +ICP

45 Atropine-RSI/RESUS IV Preparation Preoxygenation Preparation Preoxygenation Pretreatment Zero minus 5-10min Zero minus 3min Zero plus 45 sec Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV Paralysis/ Induction Paralysis/ Induction Placement Post Intubation Management Post Intubation Management Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV K + Risk+ICPAsthma Gen Sequence RSI FLOW CHART Poor Perfusion

46 Atropine-RSI/RESUS IV Preparation Preoxygenation Preparation Preoxygenation Pretreatment Zero minus 5-10min Zero minus 3min Zero plus 45sec Paralytics Succinylcholine IV, or Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV or Ketamine Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV Paralysis/ Induction Paralysis/ Induction Placement Post Intubation Management Post Intubation Management K + Risk+ICP Poor Perfusion Asthma Gen Sequence RSI FLOW CHART

47 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

48 Preparation Preoxygenation Preparation Preoxygenation Pretreatment* Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV K + Risk Poor Perfusion Asthma Gen Sequence RSI FLOW CHART +ICP

49 Preparation Preoxygenation Preparation Preoxygenation Pretreatment* Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV K + Risk Poor Perfusion Asthma Gen Sequence RSI FLOW CHART +ICP

50 Blue KGS Pretreatment Medications

51 Preparation Preoxygenation Preparation Preoxygenation Pretreatment* Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV K + Risk Poor Perfusion Asthma Gen Sequence RSI FLOW CHART +ICP

52 Blue KGS

53 Preparation Preoxygenation Preparation Preoxygenation Pretreatment* Paralysis/ Induction Paralysis/ Induction Placement Zero minus 5-10min Zero minus 3min Zero plus 45sec Post Intubation Management Post Intubation Management Atropine-RSI/RESUS IV Lidocaine-RSI IV Paralytics Rocuronium-Paralysis IV Induction Agent Etomidate-Induction IV Paralysis Maintenance Vecuronium maintenance IV Sedation Maintenance Lorazepam IV K + Risk Poor Perfusion Asthma Gen Sequence RSI FLOW CHART +ICP

54 Blue KGS Post Intubation Agents

55 Are We " Dumbyfying" Medicine? Math free algorithms enhance “critical thinking “ “Transparency” of critical decisions promotes team approach to error reduction

56 Point of Care functional units ALS RSI Anaphylaxis Pain and Sedation Fluids and burns Weapons of Mass destruction Seizures, electrolytes, etc

57 BURNS PINK Body Surface Area Percentages for PINK zone 7% 4% 7% 3% 1)Determine % BSA of patient’s burn 2) Refer to fluid charts for hourly rate for patient’s burn FrontBack Minimum Urine output7-13 mL/hr Morphine IV, IM mg Demerol IV, IM6.5mg

58 10% % Burn 12mL/hr Rate For 7 hrs 30%36mL/hr 40%50mL/hr 50%60mL/hr 20%25mL/hr 60%70mL/hr 80%96mL/hr 90%107mL/hr 70%86mL/hr Presentation 1 hr post burn 2) Piggy Back Fluid ( Maintenance D 5 W+1/4 NS) Presentation 1hr Post Burn Presentation 2hr Post Burn Presentation 3hr Post Burn Presentation 4hr Post Burn 50mL/hr For 7hrs 58mL/hr for6hrs 70mL/hr For 5hrs 88mL/hr for4hrs 1) Resuscitation Fluid (LR) 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 Presentation 2hr post burn Presentation 3 hr post burn Presentation 4 hr post burn % Burn Rate For 6 hrs % Burn Rate For 4 hrs % Burn Rate For 5 hrs 100%120mL/hr Rate for 7hrsRate for 6 hrsRate for 5 hrsRate for 4 hrs 10%21mL/hr 30%63mL/hr 40%88mL/hr 50%106mL/hr 20%44mL/hr 60%125mL/hr 80%170mL/hr 90%188mL/hr 70%150mL/hr 100%213mL/hr 10%17mL/hr 30%50mL/hr 40%70mL/hr 50%85mL/hr 20%35mL/hr 60%100mL/hr 80%135mL/hr 90%150mL/hr 70%120mL/hr 100%170mL/hr 10%14mL/hr 30%42mL/hr 40%58mL/hr 50%70mL/hr 20%29mL/hr 60%83mL/hr 80%113mL/hr 90%125mL/hr 70%100mL/hr 100%142mL/hr

59 Emergency infusions Standard Pediatric System Neonates

60 RED PURPLE YELLOW WHITE ORANGE GREEN BLUE PINK 6-7KG 8-9KG 10-11KG 12-14KG 15-18KG 19-23KG 24-29KG 30-36KG Standard Pediatric system Gray 3kg Gray 4kg Gray 5kg Gray Zones

61 RED PURPLE YELLOW WHITE ORANGE GREEN BLUE PINK 6-7KG 8-9KG 10-11KG 12-14KG 15-18KG 19-23KG 24-29KG 30-36KG Standard Pediatric system Gray 3kg Gray 4kg Gray 5kg Gray Zones

62 RAINBOW TAPE Purple DRUGS and EQUIPMENT

63 mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg 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 PURPLE 10-11KG mLs/hour Maintenance Fluids 42 mLs/hr #1 Dopamine 1600 micrograms/mL B-L Concentration Infusion bag label applied by pharmacist

64 # 1 B-L Concentration Dopamine 6400 Micrograms/mL Infusion bag label from pharmacy or manufacturer

65 mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg 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 PURPLE 10-11KG mLs/hour Maintenance Fluids 42 mLs/hr #1 Dopamine 1600 micrograms/mL B-L Concentration Infusion bag label applied by pharmacist

66 Newborn System Pink Miceronates (up to 1 Kg) RedBlue Purple Orange White YellowGreen Pink Red Blue Purple yellow White Green Orange Elefants (1Kg to 4.5 Kg)

67 Pink GMS Red GMS Blue GMS Purple GMS Yellow GMS White GMS Green GMS Orange Elefants

68 mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg 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 mLs/hour Maintenance Fluids 12 mLs/hr #1 Dopamine 1600 micrograms/mL B-L Concentration Blue GMS Newborn infusion sticker

69 Miceronates Pink GMS Red GMS Blue GMS Purple GMS Yellow GMS White GMS Orange GMS Green GMs

70 # 2 B-L Concentration Dopamine 6400 Micrograms/mL Infusion bag label from pharmacy or manufacturer

71 mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg 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 mLs/hour Maintenance Fluids 2 mLs/hr #2 Dopamine 6400 micrograms/mL B-L Concentration Pink GMS Newborn infusion sticker

72 mcg/kg/min 2 mcg 4 mcg 6 mcg 8 mcg 10 mcg 12 mcg 14 mcg 16 mcg 18 mcg 20 mcg 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 mLs/hour Maintenance Fluids 12 mLs/hr #1 Dopamine 1600 micrograms/mL B-L Concentration Blue Newborn infusion sticker

73 Purple 10-11KG 8 % Broselow-Luten color Per Cent of maintenance Fluid requirements Scroll bar 4 mLs/Hour Standard Pediatric Scroll may be used to set infusion to maintenance, twice maintenance, etc Scroll may be used to set infusion To Broselow-Luten color Select BL System Infusion pump window To be used in coordination with infusion label

74 10 % Broselow-Luten color Per Cent of maintenance Fluid requirements Scroll bar 2 mLs/Hour Standard Pediatric Scroll may be used to set infusion to maintenance, twice maintenance, etc Scroll may be used to set infusion To Broselow-Luten color Blue GMS Select BL System Infusion pump window To be used in coordination with infusion label

75 15% Broselow-Luten color Per Cent of maintenance Fluid requirements Scroll bar 1.5 mLs/Hour Standard Pediatric Scroll may be used to set infusion to maintenance, twice maintenance, etc Pink GMS Scroll may be used to set infusion To Broselow-Luten color Select BL System Infusion pump window To be used in coordination with infusion label

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78 Computer Based Computer Based Approach

79 DRUG NAME

80 Pancuronium

81 PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Paralyzing Defasiculation Maintenance 1mg/mL concentration 2mg/mL concentration COLOR INDICATION CONCENTRATION Pancuronium

82 PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Paralyzing Defasiculation Maintenance 1mg/mL concentration 2mg/mL concentration COLOR INDICATION CONCENTRATION Pancuronium

83 PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Paralyzing Defasiculation Maintenance 1mg/mL concentration 2mg/mL concentration COLOR INDICATION CONCENTRATION Pancuronium

84 PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN Paralyzing Defasiculation Maintenance 1mg/mL concentration 2mg/mL concentration COLOR INDICATION CONCENTRATION Pancuronium

85 PURPLE 2mg Paralyzing Defasiculation Maintenance Pancuronium 1mg/mL concentration 2mL

86 RED 1.7mL1.7mg Paralyzing Defasiculation Maintenance Pancuronium 1mg/mL concentration

87 BLUE 4.2mL4.2mg Paralyzing Defasiculation Maintenance Pancuronium 1mg/mL concentration

88 ORANGE 5.3mL5.3mg Paralyzing Defasiculation Maintenance Pancuronium mg/mL concentration

89 Setting a New Standard

90 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.

91 Jerome Medical Addressing pediatric issues of airways management and spinal alignment

92 P1 Collar (Ages 0-2 yrs.) P2 Collar (Ages 2-6 yrs.) P3 Collar (Ages 6-12 yrs.) Adult (Ages > 12 yrs.) Kids vs. Adults Occipital Angle

93 P1 Collar (Ages 0-2 yrs.) P2 Collar (Ages 2-6 yrs.) P3 Collar (Ages 6-12 yrs.) Adult (Ages > 12 yrs.) Kids vs. Adults Neck Length

94 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.

95 Potential for color- coding Unit dosing and packaging of Pediatric drugs (associated cost savings) Defibrillator settings Infusion Pumps Respirators Computer order entry Car Restraints

96 Error Prevention for the Public OTC Medications

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99 Color “A Universal Language”

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