Cracking the Code: Emergency Drug Cart Stocking Practices in North Carolina Hospitals

By:

Dr. Meghan E. Peterson

Dr. Greene Shepherd

Abstract

Background Emergency drug carts (EDC) have become a cornerstone in hospitals throughout the world. An EDC is a self-contained mobile unit that houses essential medications and equipment most frequently used in various emergency situations. Although the role of EDCs is well established, medication stocking trends and practices are less defined.

Objective To increase knowledge surrounding EDC medication stocking trends and practices in hospitals throughout North Carolina.

Methods This observational cohort study was conducted utilizing telephone and electronic surveys with key pharmacy team members at 97 health systems throughout North Carolina from August 2020 to February 2021. All hospitals in North Carolina were eligible for participation, and there were no exclusion criteria. Descriptive statistics were utilized for the analysis of demographics and stocked medication. Data from each hospital were compared to determine similarities and differences in medication contents and stocking practices.

Results A 77% (97/126) response rate was achieved, and 84 of 97 hospitals surveyed provided adult EDC content lists. On average EDCs contained 17 medications. A total of 33 different medications were stocked across hospitals with varying concentrations. Results also indicate that medication stocking aligned with evidence-based practice guidelines for Advanced Cardiovascular Life Support (ACLS), as 100% of hospitals stocked amiodarone and epinephrine in their adult EDCs. Restocking practices were wide-ranging, with numerous methods deployed for cart security, monitoring, expiration dates, and replenishing times.

Conclusion These results indicate that EDC medication stocking varies greatly between hospitals in North Carolina; however, evidenced-based guidelines are upheld at all surveyed hospitals.

Introduction

In 2018 there were an estimated 200,000 cases of in-hospital cardiac arrest, with successful resuscitation dependent on high-quality cardiopulmonary resuscitation, team speed, and medication administration.1,2 Survival to discharge following in-hospital cardiac arrest ranges between 15-20%.3,4 When a patient is in cardiac arrest, each minute resuscitation is delayed can lead to a 7%-10% reduction in survival.5 In an effort to increase rapid access to medications and equipment needed in cardiac arrest, Emergency Drug Carts (EDCs) have become a cornerstone in hospitals throughout the world. An EDC is a self-contained, mobile, multi-draw- ered unit that houses essential medications and equipment most frequently used in a wide array of emergency situations.2 Such contents are easily deployed to the location of the emergency to allow for rapid response and treatment. As emergency situations can occur throughout the hospital at any time, responders’ ability to rapidly access vital equipment and medications is important. Because medications can be stored in EDCs, automated dispensing cabinets, or within the pharmacy, responders need to know where the needed medications are located. As variability increases, medication retrieval time and incidence of errors rise, which may ultimately result in decreased patient survival.6

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) states that the pharmacy should control all emergency medication supplies.7 Additionally, JCAHO states that “hospital leaders, in conjunction with members of the medical staff and licensed independent practitioners, decide which emergency medications and their associated supplies will be readily accessible in patient care areas based on the population served.” 7 From this, it is evident that medication stocking responsibility lies in the department of pharmacy in conjunction with hospital administrators and practitioners, but little is known about how this is achieved.

Limited reports are published on EDC stocking practices, with only four articles published since 1972. The first report describing an EDC was published by Inquiry in 1972 and narrated how the trolley has been in use since 1963 “to over- come the difficulties and delays which often arise when a seriously ill or injured patient is admitted to the hospital, and the appropriate resuscitation equipment is not ready to hand.” 8 The second was published in 1995 and described a “pediatric care and resuscitation cart” used in a community hospital in Massachusetts.9 The article briefly discussed medication contents; however, no additional comments were made regarding medication use, stocking practices, or cart layout.

Nearly 20 years later, the W21C Research and Innovation Centre at the University of Calgary, Canada, published a two-phase study of EDC medication use in the Emergency Department (ED) with goals to develop a comprehensive list of EDC medications and observe stocking processes. Three hospital EDs were enrolled in the study, and multiple live visits were conducted in order to obtain drug inventories, workflow practices, and photographs. While contents varied between hospitals, 16 medications were present at all three sites2. Although commonalities were seen, the article noted that variability was still evident and that fundamental differences in the hospital patient population may have contributed to the large variability.

Finally, Jaquet et al published a systematic review where four articles were detailed, including two described above.5 Additionally, emphasis was placed on the disparity of research surrounding EDCs, even though they play a vital role in our hospitals. In addition to the review, suggested EDC contents were recommended by Jaquet; however, a rationale was not provided. It was suggested that medications to treat emergency situations such as cardiac arrest, tachyarrhythmia with a pulse, hypertensive emergencies, allergic reactions, acute exacerbations of respiratory diseases, overdoses, and seizures be included within the first two drawers of the EDC. Overall, 36 medications were suggested, with detailed locations present for each medication within the mock EDC.

Lack of standardization and literature to support EDC stocking practices may lead to variability in stocked medications. JCAHO provides little guidance on EDC stocking, with only reference regarding developing a standard stock of medications and supplies for EDCs which should be re-evaluated periodically. As a result, hospitals must use a variety of practice guidelines in combination with clinical judgment in order to determine their facility’s EDC stocking practices.

The 2020 American Heart Association Update for Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Neonatal Life Support (ACLS/PALS/NLS) Guidelines highlight a wide range of medications that can be administered during cardiac arrest. While use varies based on patient presentation, all medications should be easily accessible when needed.10 Recommended medications include: epinephrine, amiodarone, lidocaine, atropine, adenosine, dextrose, calcium, and magnesium.11-13 Post-arrest medications include epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, or milrinone.11-13 Medications for rapid sequence intubation, such as sedatives and neuromuscular blocking agents, should also be included.12

EDC variability amongst hospitals is likely as emergency scenarios to vary based on hospital type; however, overall trends in ACLS medications should be present. In order to describe what variability is present, it was necessary to gather data on current hospital practices. An inclusive survey of hospitals in North Carolina was undertaken to identify current medication contents and stocking practices. Through this quality improvement project, we aimed to greatly increase the knowledge surrounding EDC stocking practices to describe common medication trends and establish replenishing practices.

Methods

This study underwent application, review, and approval by the pharmacy school educational research committee and also received an IRB exemption.

Survey Development

Survey creation began by performing a systematic literature search via Pubmed (https://www. ncbi.nlm.nih.gov/pubmed/) and Embase (http://www.embase. com) in order to obtain literature surrounding current trends in hospital EDC stocking practices. Search terms utilized for Pubmed and Embase can be found in Table S1. Our search revealed that no new literature has been published about hospital EDCs since Jacquet et al. published a systematic review in 2018.

edge and survey development. Survey questions were developed based on previous literature and adapted for use in this study. The survey was reviewed by four hospital pharmacists for completion, answerability, and question clarity prior to dissemination. The survey consisted of 24 questions and was estimated to take 15 minutes to complete.

Survey Dissemination and Descriptive Statistics

In order to obtain a large representative sample size, a list of hospitals compiled by the North Carolina Department of Health and Human Services was utilized.14 This list included hospitals in North Carolina and key descriptors such as the county and the total bed count. Veterans Affairs hospitals operating in North Carolina were not included in this initial list but were added to the dataset for completeness. The United States Office of Management and Budget delineation of metropolitan and micropolitan designations guided the classification of rural and urban counties, which was compiled in a reference document by the North Carolina Department of Health and Human Services.15 All hospitals in North Carolina were eligible for participation, and there were no exclusion criteria.

complete the survey. The remaining hospitals were not contacted if EDC stocking practices were standardized throughout the system. However, if EDC stocking was not standardized throughout the hospital system, each hospital was contacted individually.

Hospitals were contacted by phone and connected to an inpatient pharmacy via a hospital operator. The surveyor was then connected to a pharmacy technician, pharmacy administrator, or pharmacist who was most knowledgeable of EDC stocking practices. The preferred survey completion method was telephone; however, due to employee schedule and availability, surveys were also sent via email and completed via QualtricsÒ. While this increased the risk of partial responses, it was decided that all completed questions would be taken into consideration for final data analysis. Hospitals were also asked to submit a photo of their EDC layout to allow for a more complete picture of practices; however, this was not required for survey completion.

The literature review provided a foundation for baseline knowl-

For this project, 126 hospitals were invited to participate. The flagship hospital was contacted first to obtain survey information for hospitals that were part of a hospital system. However, if the flagship hospital was unable to be contacted or denied participation, an alternative hospital within the hospital system was contacted to

In order to achieve a 5% margin of error with a 95% confidence interval, 94 hospitals were needed to participate in this study. Data analysis included descriptive statistics for demographic and medication content analysis, while nominal data were reviewed for trends.

Results Survey Response

Data collection was performed between August 2020 and February 2021, and all hospitals in North Carolina were attempted to be contacted. After survey completion, the number of hospitals participating was N = 97, yielding a 77% response rate. Medication lists for adult/universal EDCs were unable to be obtained from 13 hospitals. Nineteen hospitals did not provide pediatric medication lists, and 35 hospitals did not provide neonatal EDC medication contents even though they reported utilizing two or more EDC layouts. All other survey questions were answered in full. No respondents were excluded from this study. utilizing a pediatric-specific EDC and/or neonatal EDC or code bag. The pediatric and neonatal EDC medications stocked regardless of concentration can be found in the supplemental appendix as Figure S1 (pediatric) and Figure S2 (neonatal). Independent of concentration, 100% of hospitals stocked epinephrine and lidocaine in their pediatric EDC. More than 75% of hospitals stocked adenosine (98%), amiodarone (96%), atropine (98%), calcium chloride (93%), dextrose (98%), naloxone (81%), and sodium bicarbonate (98%). No medications were consistent in all surveyed neonatal EDCs. Ninety-seven percent of hospitals stocked epinephrine, while the remaining 13 medications were stocked in fewer than 75% of neonatal EDCs. The average number of stocked medications in the pediatric EDC was 20 ± 9, while neonatal EDCs stocked on average 5 ± 3 medications. A full list of stocked medications in surveyed pediatric and neonatal hospitals can be found in the supplemental appendix as Table S2.

Demographics of participating hospitals can be found in Table 1. Most respondents were located in urban areas and were members of a hospital system. Hospital bed count varied greatly (6 to 979 beds, with a median of 114 beds). The majority of hospitals (87.6%) were not a designated trauma center (Level 1, Level 2, or Level 3). There are no freestanding children’s hospitals in North Carolina.

The adult/universal EDC medications stocked regardless of concentration can be found in Figure 1. Independent of concentration, 100% of surveyed hospitals stocked amiodarone, epinephrine, and sodium bicarbonate in their adult/ universal EDCs. More than 75% of hospitals stocked adenosine (97.6%), atropine (98.8%), dextrose (85.7%), dopamine (88.1%), lidocaine (88.1%), magnesium sulfate (85.7%), and norepinephrine (83.3%). The remaining 23 stocked medications were found in less than 75% of the hospital’s EDCs. The average number of stocked medications was 17± 6.

Hospitals kept, on average, seven emergency drug carts or trays in reserve for backup use when a cart is used. Nearly all hospitals reported utilizing some form of EDC content security, such as breakaway locks, RFID technology, or plastic-wrapped trays. At the same time, half of the hospitals reported using a combination of locking strategies.

Once carts have left the pharmacy, there is evidence of interdisciplinary monitoring by materials management, pharmacy, and nursing staff with a variety of daily, weekly, and monthly inspection strategies deployed. Following a code, an EDC was able to be replenished within 15-120 minutes, with the majority of hospitals replacing an EDC within 60 minutes of cart return to pharmacy or materials management.

Pediatric and neonatal EDC data was collected with 73 hospitals

Of note, concentrations of stocked medications varied greatly in adult/universal, pediatric, and neonatal EDCs, with some hospitals stocking multiple concentrations of a medication within the EDC. Medication breakdown by concentration can be found in the supplemental appendix as Table S2. EDC stocking practices by facility are described in Table 2. Threefourths of hospitals report utilizing two or more EDC layouts, most commonly being adult and pediatric. Selected images of EDCs can be found in the supplemental information. The median EDC count was 30 carts per hospital, with a range of 3-297 carts per hospital.

Every hospital reported that the pharmacy managed EDC medication restocking. The majority of hospitals have built EDC management into normal workflow and utilize pharmacy technicians to perform EDC tray restocking, which is then checked by a pharmacist. The average expiration date utilized is three months in the future; however, all hospitals reported a desire to have longer expiration dates to reduce work demand. Additionally, medication shortage management was reported by most hospitals as a barrier to maintaining a three-month advanced expiration date.

Furthermore, 51.5% of hospitals reported pharmacist involvement during code blue resuscitation efforts. All hospitals utilize stakeholder input and guideline changes to update and revise EDC contents, with reviews occurring as often as quarterly or on an as needed basis.

Discussion

EDCs are used in emergent situations in order to allow rapid access to life-saving equipment and therapies. The results of this survey indicate significant variability in EDC medication contents and stocking procedures in hospitals throughout North Carolina. Furthermore, the extremely outdated and limited literature describing medication contents and stocking practices of EDCs indicates a need for further studies.

The 2020 American Heart Association Update for ACLS/PALS Guidelines highlights a wide range of medications that can be administered during cardiac arrest. Of the recommended ACLS medications stocked in adult/universal EDCs, our study found that 100% of hospitals stocked epinephrine and amiodarone, 98.8% stocked atropine, 88.1% of hospitals stocked lidocaine and dopamine, and 97.6% of hospitals stocked adenosine. PALS guidelines recommend the use of epinephrine, amiodarone, or lidocaine for use in pediatric cardiac arrest. Our study found that in pediatric EDCs, 100% of surveyed hospitals stocked epinephrine and lidocaine, and 96% of hospitals stocked amiodarone. Additional medications recommended for PALS include atropine and adenosine, with 98% of hospitals surveyed stocking adenosine and atropine, respectively, within their pediatric EDC. It is noteworthy that about 10% of surveyed hospitals stocked vasopressin which is no longer included in the ACLS algorithm.

Based on these medication stocking practices, it is evident that essential medications that are rapidly accessible in an emergent situation are most often stocked in EDCs. Current ACLS/PALS guidelines have multiple agents recommended for the treatment of certain conditions. For example, the algorithm for ventricular fibrillation or pulseless ventricular tachycardia recommends the administration of either lidocaine or amiodarone following three rounds of CPR.10-12

While there are guidelines indicating essential medications for use during a code, other medical emergencies have less straightforward guidelines. For example, the World Allergy Association highlights the importance of epinephrine for the treatment of anaphylaxis as it is the only medication that reduces hospitalization and death.16 When used for anaphylaxis, it is typically administered via the intramuscular route, which may lead to carts including multiple concentrations or dosage forms of epinephrine. The Neurocritical Care Society Guidelines for the Evaluation and Management of Status Epilepticus recommends the use of valproate, phenytoin/fosphenytoin, levetiracetam, or phenobarbital for the urgent treatment of status epilepticus.17 Hydrocortisone is often included for use in refractory hypotension and suspected adrenal crisis.18 These treatment guidelines do not specifically recommend whether or not such medications should be included in EDCs or made available through other mechanisms such as automated dispensing cabinets or STAT pharmacy orders. As such, clinical judgment and individual hospital policy are often utilized, thus leading to variability between hospitals.

Numerous concentrations of medications were notably present in EDCs. Guidelines, however, only recommend a specific dose; therefore, any vial size may be used as long as the appropriate dose can be administered. The Institute of Safe Medication Practices (ISMP) reports that about one-forth of medication errors that occur during a code situation originate from the dispensing and preparation process; therefore, great care and attention to detail need to be taken to ensure proper dose administration.19 Recommended mitigation strategies include using barcode scanning when possible, utilizing prospective verification of a compounded product, and including one medication strength per cart to reduce the risk of dose miscalculation.19

Literature published in 2012 surveyed three hospitals regarding their EDC medication stocking practices and found that 19 medications and concentrations were consistent amongst all three hospitals.2 While this study’s result differed from ours, they utilized a much smaller sample size. Their study, however, does indicate that relative standardization among three separate hospitals outside of a hospital system is obtainable. One review recommends a list of suggested medications for an EDC based on the review of resuscitation guidelines, with 36 medications identified to be included.5 While 23 recommended medications were stocked in at least one hospital in our study, 13 medications were not stocked in any surveyed adult/universal

EDC. Medications suggested that were not stocked include albuterol, dexamethasone, hydralazine, ipratropium, isoproterenol, labetalol, levetiracetam, oxytocin, pyridoxine, racemic epinephrine, thiamine, valproate, and vecuronium. Furthermore, of the medications suggested by Jaquet, many were only stocked by one hospital. Thus, it is evident that this broad list has not been widely implemented by North Carolina hospitals. It should be noted that none of the omitted medications are recommended for use in ACLS/BLS, and therefore not stocking them in EDCs may be reasonable if they can be quickly accessed by other methods.

EDC restocking practices were also variable throughout North Carolina hospitals; however, it was evident that pharmacy involvement was extensive at all hospitals. Furthermore, we found evidence of interdisciplinary stakeholder involvement in determining medication stocking practices. Finally, only 1% of hospitals surveyed used no locking mechanism for their EDCs. Most of these findings align with JCAHO policies for EDC medication restocking, management, and locking procedures.7

The sparsity of literature and regulations surrounding EDC stocking practices presents a true need for further research in this area. Opportunities may focus on the frequency of EDC medication use, retrieval times, and sources of errors. There is also a need for studies comparing the accessibility of other stocking and delivery methods. In particular, the role of automated dispensing cabinets in medical emergencies needs to be better explored since they were not available when EDCs deployed during the 1960s. Once additional data is obtained, trends and best practice guidelines may be developed to better inform EDC stocking practices.

While our study represents the largest sample of EDC stocking practices published to date, the sample size is still relatively small. Not all hospitals in our sample reported their adult/universal, pediatric, and/or neonatal EDC medication contents information, further decreasing this sample size. Furthermore, our findings represent less than 10% of the 6147 hospitals in the USA, and EDC practices in other regions are likely also to increase considerably so it limits the generalizability of our findings. 20 It is important to note that the 2020 update for Basic and ACLS was published in November 2020, midway through data collection. As a result of the update and the Coronavirus 2019 pandemic, it is probable that hospitals had not yet met to update their stocking practices in accordance with this guideline update. Additionally, the department of pharmacy was always contacted, which may limit knowledge surrounding other departments’ impact on EDC stocking and monitoring procedures which were assessed in this study.

Our results identify an opportunity to further explore this topic and provide a rationale for greater EDC standardization and the need for universal policies to be developed. While full standardization among all hospitals will streamline staff use, especially if more practitioners float between hospitals, this may not be feasible. With medication shortages already a challenge for many hospitals, requiring all facilities to use the same medications and concentrations may further burden the drug manufacturing system and lead to additional or longer shortages. Furthermore, it may not be practical for critical access hospitals to stock the same medications as a Level 1 Trauma Center as the patient population seen will vary significantly, and the likelihood of EDC use is dramatically different.

While the use of medications during medical emergencies is recommended, the lack of literature surrounding how best to stock and deliver these medications is significant.10,16,17 We know that code situations are time sensitive, but how can medication stocking affect this? We suggest future studies investigate human factors surrounding EDC stocking and use. The next steps may include examining the time for getting EDCs to the patient’s bedside and the time from medication requests to administration during a mock code situation. It would also be desirable to develop best practices around medication drawer layouts, locations for EDC placements, patient-toEDC ratios, and the utility of EDC standardization among hospital systems. Our results demonstrate the high variability of EDC contents and stocking practices across hospitals within North Carolina.

Authors: Meghan E. Peterson, PharmD, PGY-1 Pharmacy Resident Vanderbilt University Medical Center; Nashville, Tennessee. Meghan.Peterson@vumc.org. Greene Shepherd, PharmD, Professor, Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy; Ashville, North Carolina.

References

1. Andersen LW, Holmberg MJ, Berg KM, et al. In-Hospital Cardiac Arrest: A Review. JAMA. 2019;321(12):1200-10.

2. Pearson AM, Caird JK, Mayer A. Crash cart drug drawer layout and design. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2012;56(1):792-6.

3. Sandroni C, Nolan J, Cavallaro F, et al. In-hospital cardiac arrest: incidence, prognosis, and possible means to improve survival. Intensive Care Med. 2017;33(2):237-45.

4. Spitzer CR, Evans K, Beuhler J, et al. Code blue pit crew model: A novel approach to in-hospital cardiac arrest resuscitation. Resuscitation. 2019;143:158-64.

5. Jacquet GA, Hamade B, Diab KA, et al. The Emergency Department Crash Cart: A systematic review and suggested contents. World J Emerg Med. 2018;9(2):93-8.

6. Rousek JB, Hallenbeck MS. Improving medication management through the redesign of the hospital code cart medication drawer. Hum Facotrs. 2011;53(6):626-36.

7. Kienle PC. Meeting the standards for emergency medications and labeling. Hosp Pharm. 2006;41(9):888-94.

8. Hall MH. A resuscitation trolley for the emergency and accident department. Injury. 1972;3(3):203-4.

9. Begg JE. A pediatric care and resuscitation cart: one community hospital’s ED experience. J Emerg Nurs. 1995;21(6):555-9.

10. Berg KM, Soar J, Andersen LW, et al. Adult advanced life support: international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. 2020

11. Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult basic and advanced life support: 2020 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142(16):S366-468.

12. Topjjan AA, Raymond TT, Atkins D, et al. Part 4: Pediatric basic and advanced life support: 2020 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142(16):S4469-523

13. Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal resuscitation: 2020 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020; 142(16):S52450.

14. Box, F. Hospitals by County: Hospitals Licensed by the State of North Carolina. Department of Health and Human Services – Division of Health Service Regulation. 2022. https://info.ncdhhs. gov/dhsr/data/hllistco.pdf

15. North Carolina Rural and Urban Counties. North Carolina Department of Health and Human Services – Office of Rural Health. 2019. https://files. nc.gov/ncdhhs/RuralUrban_2019.pdf

16. Simons FE, Ebisawa M, Sanchez-Borges M, et al. 2015 update of the evidence based: World Allergy Organization anaphylaxis guidelines. World Allergy Organiz J. 2015;8(1):32.

17. Brophy GM, Bell R, Claasen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23.

18. Salvatori R. Adrenal insufficiency. JAMA 2005;294(19):2481-8.

19. Preventing Medication Errors During Codes. Instiute for Safe Medication Practices. 2011. https://www.ismp. org/resources/preventing-medication-errors-during-codes

20. Fast Facts on U.S. Hospitals, 2021. American Hospital Association. 2021. https://www.aha.org/system/files/ media/file/2021/01/Fast-Facts-2021table-FY19-data-14jan21.pdf

Survey Questions

1. Does your hospital use a standardized emergency drug cart throughout the entire hospital?

a. If no, what types of carts do you use?

b. How many different types of layouts do you use?

2. What medications are stocked within your emergency drug cart?

3. Is the department of pharmacy responsible for emergency drug cart management at your hospital?

a. Yes b. No a. If pharmacy technicians are performing the restocking, is this a dedicated job, or is this built into their normal workflow? b. Estimate how many pharmacy FTE is dedicated to maintaining emergency drug carts. c. Are emergency drug carts restocked on site? a. Before each shift b. Daily c. Weekly d. Monthly e. Other: _______ a. Pharmacy Technician b. Pharmacist c. Nurse d. Medical/Nursing Assistant e. Other: __________ a. Pharmacy Technician b. Pharmacist c. Nurse d. Medical/Nursing Assistant e. Other: _________ a. 3 months b. 6 months c. 1 year d. Other: _________ a. Who does this? a. Yes b. No a. Yes b. No a. Yes b. No c. Unsure

4. How many total emergency drug carts does your hospital have on the floors/units or in total?

5. How many emergency drug carts do you keep in reserve?

6. How many emergency drug carts are found within each floor/unit?

7. On average, what is the ratio between beds and emergency drug carts on each floor/unit?

8. Estimate, what is the farthest distance from a bed to an emergency drug cart.

9. When an emergency drug cart is used, how quickly is a new cart brought to the floor/unit?

10. Who performs, and what is your hospital’s process for restocking emergency drug carts?

11. Describe your hospital’s system for maintaining emergency drug cart content security.

12. How often are emergency drug carts checked when they are on the floor/unit?

13. Who does this?

14. When medications expire within emergency drug carts, who ensures the medications are updated appropriately?

15. Does your hospital have a minimum expiration date for medications when restocking?

16. How often are the types of medications that are stocked within the emergency drug cart reviewed and updated?

17. Does your hospital perform mock codes utilizing the emergency drug cart unique to your hospital?

18. Are carts used in training stocked the same as actual carts that are used in the hospital?

19. Do pharmacists routinely participate in codes at your hospital?

20. If the hospital operates with a code response team, what pharmacist involvement is there?

Demographic Questions: a. How many total beds does your hospital have? b. Is this hospital a primary teaching hospital for a medical school? a. Yes b. No c. Is this hospital a primary teaching hospital for a pharmacy school? a. Yes b. No d. What is the trauma level rating of the Emergency Department and hospital? a.

Table 1: Demographics

Table 2: EDC Stocking Practices by Facility (N=97)

only calculated if hospital restocks EDC on site utilized a combination of listed strategies for maintaining EDC security

Medication

Percent of Hospitals Surveyed that Stock Medication

Supplemental Appendices

Table S1: Search terms

(Crash cart[tw] OR crash carts[tw] OR drug cart[tw] OR drug carts[tw]) AND (stock*[tw] OR organiz*[tw] OR layout[tw] OR design*[tw] OR redesign*[tw])

Pubmed

(advanced trauma life support care[tw] OR cardiopulmonary resuscitation[tw]) AND (cart[tiab] OR carts[tiab] OR drugs[tw] OR medications[tw])

(Emergency Department[tw] OR emergency room[tw] OR emergency ward[tw] OR Emergency Departments[tw] OR emergency rooms[tw] OR emergency wards[tw] OR ER[tiab] OR ED[tiab] OR "Accident and emergency"[tw])

Embase

('emergency department':ti,ab,de,tn OR 'emergency room':ti,ab,de,tn OR 'emergency ward':ti,ab,de,tn OR 'emergency departments':ti,ab,de,tn OR 'emergency rooms':ti,ab,de,tn OR 'emergency wards':ti,ab,de,tn OR er:ti,ab OR ed:ti,ab OR 'accident and emergency':ti,ab,de,tn)

('crash cart':ti,ab,de,tn OR 'crash carts':ti,ab,de,tn OR 'drug cart':ti,ab,de,tn OR 'drug carts':ti,ab,de,tn) OR (('advanced trauma life support care':ti,ab,de,tn OR 'cardiopulmonary resuscitation':ti,ab,de,tn) AND (cart:ti,ab OR carts:ti,ab OR drugs:ti,ab,de,tn OR medications;ti,ab,de,tn))

Table S2: Adult, pediatric, and neonatal EDC medication concentrations stocked among surveyed hospitals

Medication Stocked

Phenylephrine

Nitroglycerin

Glucagon

Furosemide

Hydrocortisone

Procanamide

Norepinephrine

Heparin

Dobutamine

Diphenhydramine

Flumazenil

Vecuronium

Terbualine

Calcium Gluconate

Phenytoin

Mannitol

Magnesium Sulfate

Dopamine

Naloxone

Amiodarone

Sodium Bicarbonate

Dextrose

Calcium Chloride

Atropine

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