Nurses: Bring color-coded equipment to your ED
When a child comes to your ED with severe trauma, color-coding systems can help ensure correct dosages and equipment sizes. Now that same concept has been expanded to treatment sheets, acute sheets, and discharge information.
"Drug dosages tend to be looked up in emergencies, and the calculations of dosages and infusions are done during the actual resuscitation," says James Broselow, MD, FACEP, a co-developer of the system and an emergency physician at Catawba Memorial Hospital in Hickory, NC. He explains that the new products are designed to reduce errors by using a color-coded system.
The new products were recently tested at four North Carolina EDs: the pediatric ED at Duke School of Medicine in Durham, the pediatric ED at Wake Forest School of Medicine in Winston Salem, Womack Army Hospital at Fort Bragg, Fayetteville, and Northern Hospital of Surrey County in Mount Airy.
Products available in 2000
The items studied were color-coded acute and treatment care sheets for reference and color-coded discharge materials. The products are the only materials for pediatric patients based on color-coding and are scheduled to be commercially available in 2000, reports Broselow. Prices are not yet determined, since the products are still in the development phase.
The advantage to clinicians is a set of materials that are designed to simplify the emergent care of children, says Susan McDaniel Hohenhaus, RN, CEN, TNS, FNE, coordinator of emergency medical services for children at the North Carolina State Office of EMS in Raleigh, NC. "The benefit to children is it reduces the inappropriate use of equipment and hopefully will reduce medication errors."
The idea was to look at the tools of color-coding to see if they are easy and worthwhile for clinicians to use, says Hohenhaus. "The goal is to reduce medication errors, inappropriate use of equipment, improve provider comfort with acutely ill children, and to improve the ED experience for children," she explains. "This program overall has a tremendous opportunity to truly impact the emergent care of children."
Every child who came to the ED was measured using the tape and assigned a color based on length. A corresponding color sticker was placed on the chart, and in some cases an arm bracelet was used. The color was used for dosing medicines, procuring equipment, and giving discharge instructions.
Here is information about the new products:
• Color-coded forms.
Two groups of color-coded forms were developed as quick references for clinicians. Each color corresponds to a child’s weight and length. For example, red stands for children with an average weight of 8.5 kilograms and 66.5 cm to 74 cm tall. The acute sheets include the following information:
— medication dosing, equipment, and fluid administration;
— the medication dosages for rapid-sequence intubation, ventilator settings, and selected emergencies that require medications (overdose and anaphylaxis);
— fluid calculation for burns and cardiopulmonary resuscitation instructions.
The treatment form includes sections on equipment, oral analgesics and anti-pyretics, fluids, oral antibiotics, reactive airway disease, croup, allergic reaction, IV antibiotics, and conscious sedation.
Broselow says the idea is to use the color-coded Rainbow tape, then go directly to these forms for a quick reference. To reduce the chance of making a calculation error, drugs are given not only by their milligram dosages, but also in cubic centimeters. The acute and treatment sheets include information based on length and weight.
Discharge sheets are age-adjusted
• Discharge sheets.
The color-coded discharge instructions include medical conditions most likely to occur in children, such as reactive airway disease, head injuries, diarrhea, and ear infections. (See sample discharge instructions inserted in this issue.) They also include common non-prescription medications and growth and development stepping stones.
Discharge instructions tend to be developed at individual EDs and are frequently not age-adjusted, says Broselow.
"They are often based on adult instructions. For example, a head trauma sheet appropriate for an adult might be given to the mother of a 6month-old who hit his head. Or an adult gastroenteritis sheet might be given to a parent who is breast-feeding an infant," he explains. "Injury prevention tips are included on discharge sheets, such as advising parents not to refer to medicine as candy, and never to give medicine in the dark. I am unaware of any systems which address incorporating injury prevention into every day emergency medicine."
• Future plans.
Future plans include discharge sheets in Spanish, color-coded videos, and CD-ROMs to demonstrate size-related interventions such as proper child restraint fitting and airway interventions in emergencies.
The color-coding concept will eventually be expanded to include over-the-counter medicines. "We are going to do studies to see if accuracy of dosages can be increased in the general public," reports Broselow.
Tape added for 3-6 months
• Revised Rainbow tape.
The color-coded Rainbow tape, used to calculate dosages in many EDs, now has one additional color: a pink zone that includes children from 6 kg to 7 kg, ages 3 months to 6 months.
"Any child below this weight needs individual calculation by weight, since there is too much room for error in very small infants," says Hohenhaus.
The added pink zone reduces the possibility of adverse outcomes, according to Broselow. "We found that the zones were too wide to give all kids in that range the same dose of medicine," he explains. "If you are off by one zone, which represents 3 kg, and the other zone represents 4 kg, that’s 1/4 of a difference, which is a pretty big error. Zones were made smaller so variation isn’t too wide if you’re off one zone."
• Community education.
At the Children’s Museum in Durham, NC, there is a display of a community ED for children to explore, which includes the Broselow color-coded system. "Children and their caregivers are introduced to the color-coding system even prior to entering the medical setting. It gives us a chance to explain what the system can do," says Hohenhaus.
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