When it comes to emergency supplies, your best-case scenario is this: All the supplies outdate. It's counter-intuitive to your economical mindset. But since you hope these medications and supplies go to waste, it might also seem like a good idea to have as many as possible, in case a patient does crash. So, every year, you throw out vials of dantrolene and bottles of nitroglycerine. Which do you need? Where can you trim waste? Here's what you need to know.

The standards-makers
The three accreditation bodies - AAAASF, AAAHC and JCAHO - provide guidelines for stocking that incorporate Medicare standards. Each recommends you thoroughly read its standards for specific guidance on medications.

All three require you to have dantrolene in case of malignant hyperthermia, and all three permit automated external defibrillators, though AAAHC is investigating this further. Because AEDs are self-contained, they might save you in stocking pads, pacing electrodes, defibrillating gel and paddles.

' AAAASF. "In our resource guide, we recommend the Banyan Stat Kit (www.statkit.com) for emergency supplies," says AAAASF communications director Jaime Trevino, "and for medicines, a systematic pulmonary/cardiac anaphylaxis resuscitation kit." He says you must make available all medication included in the current ACLS algorithm, a copy of the ACLS algorithm and a copy of the MHAUS MH algorithm. OR personnel must know the location of all emergency drugs.

AAAASF also requires written protocols for MH, CPR, calling appropriate personnel for an unplanned or emergency return of a patient to the OR or transferring patients in an emergency. And you must have "a written transfer agreement with a local accredited or licensed acute care hospital."

' AAAHC. These standards are written so you're able to meet their intent based on the cases you do and the level of anesthesia you administer. When it comes to medications, "the standards do not specify which medications are required," says AAAHC director of accrediation services Stephen Kaufman, RN, MA.

Equipment and supplies are described on a less-than-prescriptive basis. For example, you're expected to have a reliable and adequate source of oxygen, self-inflating resuscitator bag, monitoring equipment and a reliable suction source. "The overriding concept is that the organization is capable of appreciating the significance of the potential risks," says Mr. Kaufman.

' JCAHO. "Emergency medications and supplies should be consistently available, controlled and secure in the organization's patient care areas," says Michael Alcenius, an associate director in the Standards Interpretation Group at JCAHO. "OR leadership should, based on the services provided and the acuity of the patients they're dealing with or the special patient populations they're dealing with, have medication and equipment available in accordance with that."

So if you're treating pediatrics, you should have kid-sized equipment on hand, and you might want to have emergency pediatric dose forms of medications readily available, says Mr. Alcenius. And if you're an ophthalmology center, you might not need as much or as complex an array of emergency supplies as, say, a multi-specialty center performing lap choles and orthopedic procedures.

Working within those rules
When it comes to specific regulations, like that for dantrolene, you're out of luck - you need 36 vials, regardless of whether you'd transfer the patient before using that quantity. But dantrolene's one of those things you can feel good about outdating, because you don't want to have to use it.

For other medications, you might want to sit down with your anesthesia provider and medical director to talk about their comfort levels, sort drugs by priority, and look at the quantities you've been outdating. For example, on the first line, you'll probably have lidocaine and epinephrine; you might have calcium, magnesium and potassium on the second line, for use if the first course of action doesn't work on an arresting patient.

When we first opened, I always had a case of a dozen bottles of nitroglycerine in stock. We were outdating 12 bottles year after year, so I looked into buying in eaches instead of cases. I now keep two bottles on the shelf and reorder only if we need to. In the long run, you save money, because if it's $2 a bottle or $10 for a case of six, you're still further ahead in paying more for the lower quantity, especially if it's going to outdate anyway.

An equipment example: Our accreditor requires portable suction. We have just one battery-operated unit that's tested daily and centrally located in our four-OR, two-procedure room center; that's been enough through three accreditations. A huge facility might need more, but consider your situation before buying one unit for every OR.

One more thing: Consider education. "How close are you to the acute-care facility you have a transfer agreement with and what would EMT response time be?" asks Mr. Alcenius. "Many successful organizations drill staff on medication competency, because if no one knows how to use the drugs, it can cause more harm than good."