Most of the time, a crash cart is like a soldier at attention, standing unobtrusively in a corner or hallway of your facility. But when a patient codes, the crash cart becomes the most important piece of equipment in your facility. To ensure that there are no surprises if you need to swing your crash carts into action, we asked for expert advice on how to select, stock, organize and maintain them.

Choosing a cart
Many companies offer medical-grade carts with features such as impact-resistant construction, tamper-proof locking systems and drawers that can be configured in a multitude of ways. But some facilities choose a more bare-bones option.

Take Landmark Surgery Center, a small facility in St. Paul, Minn., which purchased Sears Craftsman lockable carts from a local hardware store and modified them with label racks, says co-director Lesley Nace. "Medical carts cost about three times as much; we feel these work just as well," she says. They keep the carts in the pre- and post-op areas and use them for storing various nursing and anesthesia medications, in addition to emergency equipment and meds. They're in constant use, so they're locked only at night.

Other facilities, such as the Asheville Eye Surgery Center in Asheville, N.C., appreciate the advantages of today's streamlined, all-inclusive medical-grade carts (see "What's New in Crash Carts," above). "There's a place to put everything - from oxygen to suction to all the medications and supplies - and everything fits right and is secure," says administrator Susie Winterling, RN, who recently purchased a specialized crash cart. "It's so nice to have everything in a concise setup."

Whichever type of cart you choose, don't purchase more than you need. In small, single-specialty facilities, one cart may be sufficient; larger facilities should have one cart in each patient-care area, experts say. However, "too many carts require extra staff time to maintain," notes Ann Geier, RN, MS, CNOR, a surgery center administrator and consultant with Progressive Surgical Solutions.

Keep carts in centrally located, highly visible areas. "The key is, can you get to the cart quickly, and can you get it to the patient quickly?" says Cheryl Stanley, RN, director of the Elkhart Clinic Endoscopy and Surgery Center in Elkhart, Ind. In her facility, which is fairly small and located on one level, the crash cart is stored between the procedure rooms and the PACU.

Stocking the cart
A crash cart's contents are dictated by

• your facility's advanced cardiac life support (ACLS) policies and procedures;
• the types of procedures you perform and the level of anesthesia you use;
• your patient population (such factors as age and ASA class) and
• your proximity to emergency medical services.

Experts stress the importance of customizing the cart to your needs. "Many times, facilities just adopt a standard cart without thinking about what they really need and whether their staff is competent to use all the items and medications," says Michael Alcenius, associate director of the Joint Commission's Standard Interpretations Group. "It's not good enough to have items just in case," he says. "Ask yourself if you and your staff would know how to use each drug or supply if it's needed. Make sure there is logical reasoning behind every item."

Some facilities stock their carts from scratch by examining the ACLS guidelines and other facilities' inventory lists and getting input from anesthesiologists and pharmacists. Others, like the Reading Hospital's Surgicenter at Spring Ridge in Wyomissing, Pa., start with existing carts and pare them down. Education Coordinator Karen Fischer started with the Reading Hospital's crash cart inventory list and, with the help of the anesthesia team, removed specific items that wouldn't be needed, such as invasive monitoring equipment.

Keeping the cart's contents current is an ongoing task. The American Heart Association updates the recommended ACLS drugs and drug dosages about once every two years (for more information, visit www.acls.net), says Gerald Pousho, MD, an anesthesiologist and senior AAAHC surveyor. Michelle Alonzo-Whittaker, a perioperative educator at East Texas Medical Center in Tyler, Texas, notes that many facilities are also converting the equipment and supplies on their carts to latex-free versions; this includes gloves, blood pressure cuffs, Ambu bags, tubing, medication stoppers and syringes.

Because crash carts aren't used often, some facilities inadvertently use them as makeshift bookshelves and storage areas, says Dr. Pousho. This makes them top heavy and difficult to move. He advises ensuring that your carts only hold items that are meant to be there.

Organizing your cart
Take the time to meticulously organize your cart, says Ms. Geier. "I've seen too many poorly organized carts, where items are loose on the shelves and jumbled together," she says. She recommends using dividers and individually labeled bins to ensure that everything has its place. Medical-grade carts will often feature drawer liners, custom-cut foam inserts to hold drugs and equipment, removable drawers and swing-away or swing-out modules to hold supplies, notes Scotty Farris, a medical-technology planner for EQ International.

Some organization tips:

• The same anesthesia and pharmacy experts who helped stock the cart initially should also help organize the items.
• Label each drawer and drawer compartment carefully and specifically.
• Take a photograph of each fully-stocked drawer, making sure that each compartment and medication label is clearly visible, so someone can tell at a glance where everything is. Laminate the pictures and keep them with the inventory list, maintenance logs and other documents on the cart.
• If you have a medical-grade cart, reevaluate whether you are using the features to their best advantage. For example, the Asheville Eye Surgery Center's cart features a clear top compartment, which had been used to store reference checklists and other documents, according to Ms. Winterling. During a recent accreditation survey, the surveyor suggested moving the first-line drugs to the clear top compartment instead, so staff could easily see them.

Maintaining the cart
Crash carts require regular maintenance. You should check and document the following on a daily basis:

• the defibrillator (Dr. Pousho recommends checking the function of the defibrillator while it's plugged into a non-interruptible power source and also testing it on battery-backup power)
• the portable suction device;
• the oxygen tank levels;
• all peripheral items and accessories; and
• the drawer locks.

Experts recommend checking the contents of the cart at least once a month to ensure the supplies are intact and the medications are current (many facilities affix a sticker to the top of the cart with the date of the earliest medication expiration date). Although it may be easiest to assign one nurse to do the daily checks, rotating the monthly maintenance is one way to ensure that everyone becomes familiar with the cart's contents, says Ms. Geier.

Consider contracting with a hospital pharmacist (perhaps the same one who helped you stock the cart initially) for regular maintenance visits, advises Dr. Pousho. "A pharmacist can double-check the logs and outdates, keep you up to date on the latest ACLS recommendations and ensure that you're following all state and federal regulations," he says.

Educating your staff
Ensuring that your staff know how to use the crash carts starts with making sure they have current ACLS and PALS certifications (they must be renewed biannually), says Dr. Pousho. "If you don't have trained personnel, it doesn't matter how sophisticated your carts are," he says.

Beyond certification, there are a number of ways you can ensure crash cart competency. At the Spring Ridge Surgery Center, Ms. Fischer runs yearly defibrillator training with each staff member. The facility also has monthly open house days, when one cart is left unlocked so staff can come by at their leisure and review the contents.

Most experts recommend running a mock code or drill at least twice a year. To get the most out of a mock code, make sure it's a surprise, hands-on drill, and try to change the situation every time. "We've done mock codes in an elevator and even in a parking lot, where there are no electrical outlets," says Ms. Geier. After the code, take time to critique it and immediately fix any problems you've detected.

Passing muster with surveyors
Accreditation surveyors will doubtless want to examine your crash cart contents and documentation and may ask your staff to demonstrate their competency with certain tasks, such as assembling a laryngoscope. They can also provide valuable suggestions and insight.

Dr. Pousho always requires a nurse to rapidly move the cart at least 10 feet to 15 feet. "In many instances, the cart hasn't been moved for a while, and in at least two occasions, the cart tipped over - in the first case, the cart was too top heavy, in the other, a wheel had broken but had gone unnoticed."

At the Landmark Surgery Center, Ms. Nace took the advice of a surveyor to modify her daily defibrillator check. "Originally we only checked the units while they were connected to a power source," she says, "but the surveyor asked to see the units checked on battery backup, so we added that criteria to our daily routine."

Whether they're bare bones or high-tech, all crash carts have one thing in common - nobody ever wants to be called upon to use them. But with careful planning and regular maintenance, you can help ensure that if a crisis occurs, your crash cart will be ready.