When a colleague of mine called for a crash cart during a mid-procedure crisis, the responding nurse was in such a rush that all of the cart's drawers flew open, spilling the contents onto the floor. Needless to say, the patient didn't receive the prompt, seamless attention he needed. In order to avoid a similar disaster, don't ignore the importance of outfitting your center with secure, easy-to-maneuver crash carts with enough storage space to keep vital drugs and equipment within arm's length of your surgical team.

Which cart is right for you?
The number of carts you need stocked and ready to go depends on the design of your facility, the number of ORs you have running simultaneously and the amount of cases you host. Perhaps a few carts in a centralized location will serve your needs, or maybe you'll need to place a cart in each room if your facility's layout is more spread out. Take a look around your clinical area with a critical eye. Judge the distance between rooms, the width of the hallways and obstacles — doors, stairs, tight corners — that staff need to maneuver around to get from place to place. Bottom line: Your surgical team and anesthesia providers must be able to access emergency equipment and medications quickly and easily. Make sure you have enough carts on hand for them to do that.

Avoid carts that are top-heavy and make sure the drawers close securely. Test carts by pushing them with the drawers empty to see how easily they roll and if drawers stay shut while the cart is maneuvered and turned. How do the wheels rotate? Many carts have only 2 freely rotating wheels, making it more difficult to push the cart in close to patients. Keep in mind that larger wheels are better for maneuverability.

Automatic locking drawers can be a pain to deal with; many rely upon a mechanism that detects when a drawer is opened, which can be fouled up if you fill the drawers too full or if a medication vial falls behind a drawer. I prefer carts with combination locks as opposed to key locks, as it's easy to misplace keys.

Equipment essentials
CMS surveyors will inspect your crash carts and emergency-response policies during their next visit. According to the CMS State Operations Manual — Guidance for Surveyors: Ambulatory Surgical Centers, surveyors will ask to see your medical staff's policy on the use and storage of emergency equipment. If you run an ASC with multiple ORs, surveyors will want to know if the policy clearly identifies the quantity of equipment required and its location in relation to where it's needed. They'll try to determine whether all required safety equipment is readily available. If your medical staff adds equipment to the facility's must-have list, verify that it is easily accessed and make sure your clinical staff knows where the new devices are located. Surveyors will conduct random employee interviews during their tour to ensure they do. Document that mechanical or electrical equipment is regularly inspected, tested and maintained. Also document that emergency supplies and medications aren't expired.

According to CMS, emergency equipment available in the operating rooms must include at least the following: emergency call system; oxygen; mechanical ventilatory assistance equipment, including airways, manual breathing bag and ventilator; cardiac defibrillator; cardiac monitoring equipment; tracheostomy or cricoidotomy set; laryngoscope and endotracheal tubes; suction equipment; and emergency medical equipment and supplies specified by your medical staff.

Your medical staff can add needed supplies to those basics, but can't delete items from the list, according to the guideline. You need enough devices in-house to handle multiple simultaneous emergencies, says CMS. If you work in a multiple-OR facility, have written policies in place that detail which supplies must be present in each OR and which can be kept in storage areas that can be quickly accessed as needed. Regularly inspect and test mechanical and electrical safety equipment to ensure devices are well maintained, says CMS, and monitor and replace emergency supplies as they expire. The guideline suggests you also keep emergency equipment close to patient recovery areas.

Under review
Audit the contents of your crash carts monthly. Make sure whoever does the checking is acutely aware of the importance of ensuring medications and supplies are present and up to date. If medications need replacing, the staff member in charge of stocking the cart must understand the intended use of the various drugs and grasp the subtle differences between them (see "Medication Musts for Your Crash Cart"). Add reviews of the carts' contents to your quarterly quality improvement initiatives so someone is always checking the initial checker.

Conduct regular mock drills to review the contents of the crash carts' drawers, noting the specific location and intended purpose of each device and medication. Your staff and anesthesia providers might quibble over which drugs and supplies to include on crash carts. Just make sure you have an emergency drug storage policy that is approved by your medical staff. A single individual should not decide which medications to stock without clear reference to the responsibility and authority of the people who are qualified to make the decisions.