Challenges Associated with Anesthesia Tray Fill and Crash Cart Fill

Crash carts and anesthesia trays are vital components of inpatient pharmacy practice in a health system setting. Clinicians rely on them to be functional and fully stocked in life-threatening situations. However, ensuring that carts and trays are filled accurately, promptly, and safely can be challenging. This is especially true given rampant short-staffing during the COVID-19 pandemic.

Safety Issues

Known safety issues linked to carts and trays include:

• Medication errors

• Damaged, contaminated, expired, or missing medications and equipment

• Empty oxygen tanks

• Equipment failure, including drained batteries

• Carts/trays that have been tampered with or have been otherwise unsecured or compromised

• Carts that are difficult to access due to heavy-duty tape or heavy locks

• Wrong equipment sizes

• Policy and procedure failures inspecting carts/trays

• Carts that have been stored in the incorrect location, making them difficult to find

• Staff that is not trained in the items stored in the cart

• Staff that is inadequately trained in procedures when using the cart

• Staff that is not trained in how to restock the items in the cart/tray

Some health systems have successfully addressed these challenges in several ways, including using electronic monitoring and sealed carts/trays, standardizing cart/tray components, and incorporating staff training.

Electronic Monitoring of Crash Carts and Anesthesia Trays

Electronic monitoring, including web-based tracking systems, is available to help track crash carts and anesthesia trays. This can have several benefits, including:

• Replacing paper logs, which may easily be lost or damaged

• Enabling remote tracking and monitoring which teams have checked their carts/trays

• Alerting staff to items nearing their expiration dates

• Notifying management of which carts/trays have been checked and which have not been checked

Some health systems have moved a step further, into automated cart/tray management. For example, RFID tags can be applied to each item and medication. When the cart/tray returns to the pharmacy, it is placed at a scanning station. Each tag is then scanned, and a report is generated to inform the pharmacy of which items need to be replaced. Such systems can benefit the health system in several ways, such as:

• Improving the accuracy of filling medications and supplies

• Reducing the time it takes for staff to check medications and items

• Increasing the efficiency of checking for expired medications and items

• Quickly locating recalled medications and supplies

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Staff Training for Crash Carts and Anesthesia Trays

Staff training is crucial for long-term success in addressing the challenges linked to crash carts and anesthesia trays. Without adequate training, it is difficult to implement and maintain process improvements in managing the filling process. Training should ideally take the form of continued education and may be included on staff competency assessments. Training may include:

• The items stored in the cart

• The location of items in the cart, as well as the location of the cart itself

• Procedures for using the cart

• Who checks the crash cart and how often it is checked

• Who checks emergency equipment

• Emergency drills or simulations

Training and assigning a staff member as team lead for cart/tray filling can be an important factor in success. A pharmacy technician may be assigned to this role, and have responsibilities such as:

• Managing inventory

• Ordering supplies

• Running reports

• Training pharmacy staff

Similarly, on the floor, a nursing staff member may be assigned as team lead for visually inspecting the carts for integrity, keeping them in the proper location, and testing electronic components of the cart.

Standardizing Crash Carts and Anesthesia Trays

Hand-in-hand with training is the importance of equipment standardization and process simplification. This is especially true given the chronic staffing shortages in many hospitals, which leads to staff reassignment to practice areas with which they may not be familiar. By simplifying the filling and checking process, there is a better chance that new or temporary staff will be able to be quickly trained and comply with procedures.

Minimizing the number of items that need to be checked can also help improve the process. Crash carts are generally not standardized. Instead, health systems are given broad latitude in terms of items to include, with the requirement that carts contain the items required to respond to an emergency in each practice setting. Management can consider involving stakeholders from individual crash cart placement areas to give feedback on the items currently in the crash cart, and whether they are necessary.

Stakeholder input can also help optimize the placement of medications and supplies on the cart/tray. For example, the items on an anesthesia tray can be arranged in a linear way based on typical staff needs. Supplies needed at the beginning of the surgery may be placed on the left side of the tray, with a linear progression towards the right side of the tray which may hold supplies needed at the end of a procedure. In addition, the items on a crash cart can be organized by drawer, with medications, respiratory needs, fluids, and procedure supplies all occupying their own clearly-marked drawers.

Sealing Crash Carts and Anesthesia Trays

Sealing crash carts and anesthesia trays after filling can have benefits including:

• Quickly ascertaining whether a cart/tray has been tampered with

• Preventing clinicians from borrowing items from trays, leading to missing items

• Easily see the last time the cart was restocked, by the seal date

• Assigning an expiration date to the whole cart/tray based on the item or medication with the shortest time to expiration

• Giving the cart/tray a unique identifier, which can help it be tracked in the hospital

Optimizing crash cart and anesthesia tray management can be challenging. However, by incorporating staff training, standardization, electronic monitoring, and sealing of trays and carts, it is possible to increase accuracy, reduce errors, and improve staff efficiency.

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References:

The Joint Commission. “Crash-cart preparedness.” Quick Safety, April 2017, Issue 32. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick_safety_issue_32_20171pdf.pdf

Miller, Rachael Fleagle; March, Kristen E. “Automate OR Tray Management.” Pharmacy Purchasing & Products, May 2019. Retrieved from https://www.pppmag.com/article/2391