Please see the main article: Crash Cart Supply & Equipment Checklist. Below are more questions and answers related to that article, which we couldn't fit on the page.

Version control: This document is current with respect to 2015 American Heart Association® Guidelines for CPR and ECC. These guidelines are current until they are replaced on October 2020. If you are reading this page after October 2020, please contact ACLS Training Center at support@acls.net for an updated document.

Where are the NRP cart guidelines?

Please see this page.

I would like to know if you need a crash cart on both floors of our facility. The first floor has an MRI machine and the second floor has pain management, orthopedics and physical therapy.

The need for a crash cart is defined by your state governing authority (usually department of health) or your certifying authority such as JACHO for hospitals. This differs from state to state. It is dependent upon your patient population (risk status) and the procedures (potential for deterioration) that your company does.

Do you have any information on how long we are required to keep the QC checklists for the crash carts and defibrillators?

Most hospitals that I am familiar with keep them for a year, but that is a matter of individual hospital policy not regulation.

I work at a VA hospital in North Carolina. The unit is a 20 bed substance abuse inpatient rehab unit. The patients have already detoxed when they are admitted. These patients are full codes and most have multiple co-morbities. The unit does not have a crash cart. Is there a requirement /law/guideline that requires one to be on the unit?

It would depend upon how the unit is classified with the State. My guess is that it is classified as a rehabilitation facility in which case the answer is no. If that is not the case then it would be governed by the North Carolina DOH.

Yes I agree they are on the cart. But, I think they should be listed in the checklist to make sure they are full. They should be checked just like everything else on the cart. If your O2 is low and you run out during a code you could possibly be in a very unsafe predicament for the patient.

You can add them to your list for your facility. Hospitals almost always utilize the wall oxygen source as a tank running at 15 Liters via Ambu bag will only last several minutes. You can add the oxygen to your checklist to your facility. The checklist is just a suggestion, and not in any means appropriate to every facility and every situation.

My ED was just told that we are not allowed to have suction set up with the tubing out of the package as it is not sterile. Our argument is that the tubing does not need to be sterile, and really needs to be pre-connected to save time when urgently needed. We do keep the suction tips/catheters in sterile packaging until used. * I read the question and response below. What is the reference document for the response?

We just received new crash carts that have a portable suction attached to the top of the machine. An unsterile suction tubing is attached and left on the suction. Our OR director is concerned about this and thinks the suction tubing should be removed and a sterile suction tubing pack should be placed next to the suction instead. She is concerned the exposed tubing will be cited during inspections. Is this a concern? The disposable suction liner comes with the tubing already connected. What is the standard for this?

I don't know what to say except look at the packaging. Unless specifically packed for OR use, it is not packaged sterile.

I had a question regarding crash carts . . . Is there a Texas regulation that requires a crash cart to available in a cardiologist office? V. Mata.

It depends upon what type of office. If you are doing stress tests, then yes, but not for clinical practice. Most guys keep an AED and have a policy to call EMS.

was online and was researching what needed to be in her crash cart and the requirements. does it need to be locked. R. Eakle.

It can’t be locked (no controlled substances”). It needs to be sealed. Most have a plastic breakable seal so that it can be checked daily to see if items need replaced. Multiple people need emergency access to the cart and it needs to be immediate.

I had a question regarding crash carts. Every facility that I have gone to has a red tag that locks the cart and has a serial number. Is there any requirement for the red tag and for documenting the number?

The tag documentation assures that nothing in the cart has been removed or changed. So you know of the number is the same as the last one recorded that is all you have to check. If the tag is missing or not the same then someone was in the cart and you have to check all of the contents to be certain nothing was used.

I am presently researching the efficacy of placing a regular in home use glucometer on the Emergency Cart. My questions are: Are you aware of this being done? Are the guidelines available if used? This is being suggested by some of my comrades at a VA facility where I work. They feel that it would be beneficial during an emergency situation as part of the routine vitals. We are not a critical care facility.

Correction of blood glucose during cardiac arrest is not recommended in fact is considered harmful so unless you have a speciality application for it there is no need for a glucometer on a crash cart.

I wanted to see if you know what equipment we need to have onsite. We are a chiropractic and medical office who performs adjustments, infrared heat therapy, electrical stim therapy through our chiropractors and stem cell, prp inj, trigger point inj, botox and other minor injections by our nurse practitioner or MD.

That is dictated by whoever their licensing agent is.

I went though our Crash Cart information, found PALS, suppliers ect, but nothing for a 10 Crash Cart.

The 10 minute cart is simply Ten Minutes worth of everything in the regular crash cart. It is the same thing.

I am a pharmacy student, practicing at a hospital and I am conducting a crash cart update. I was wondering whether you recommend using the standard crash cart checklist or the neonatal crash cart for pediatric wards?

The Neonatal checklist is only appropriate in a NEONATAL unit which has different needs than a pediatric unit. However, there are different needs in a pediatric unit than in the adult crash cart. There should be a pediatric crash cart standard for the hospital. (Usually utilizes Browslow labelling).

I had a question regarding crash cart, I work in a Neurosurgery/neurology office do we need a crash cart? If so how do I know what needs to be in the crash cart. We do Botox injections, suture/staples removal. And wound changes. Occipital nerve block, and trigger point injections. Nicole B.

Yes, if you do injections with the possibility of vagal reactions and/or allergic reactions you should have at least a ten minute cart. (Those medications and equipment that you need to administer to an acutely I’ll patient for the first ten minutes).

Is there a specific regulation that oxygen tank should always be set-up and readily assembled in the emergency cart?. One of the facility received an IJ (immediate jeopardy) during survey for having emergency supply, particularly, oxygen tank (regulator not attached) and 2 expired suction tubing. Although, there was no actual harm happened, but the surveyor were saying that “there is a POTENTIAL for serious harm”. Please advise. Jenny R.

Absolutely. The idea of an emergency cart is instant access for an emergency. You shouldn’t have to construct it before you can use it.

Hi. I had couple questions about crash cart. I was wondering can any medial professional check the crash cart. By check I mean break it open and check for intact plastic and check for expirations or is this in just the scope of practice of RN. Or can a technologist in radiology or lab tech check a crash cart. Second is it necessary to break open the crash cart daily and check for expirations? Then tag it with a yellow tag. Angie O.

A crash cart is usually checked daily for intact seal and once a month for expiration dates. Intact seal means the lock (which has a number on it) has not been disturbed. The lock is opened and changed once a month to check packaging and dates. There is nothing that defines who does this although it obviously must be someone medical (to know what they are looking at) Since narcotics are not stored in a crash cart, this does not have to be a RN.

I was hoping that someone would be able to provide me with a list of what the current requirements and recommendations are for a crash cart for an Oral Surgery office which administers IV sedation. Thank you in advance. Drs. Delgado and Kuzmik

It is a standard crash cart because of the sedation.

We are a Natural Health Clinic and we will start a new Allergy Treatment. We will need to have a crash cart in case we need it. The Treatment has no records to promote any reaction but we want to be safe. We have your list of supply and equipment checklist for crash cart and we have few questions. What do you mean with "Airway (oral and nasal) all sizes"? What's the difference of "airway all sizes" for "king airway set(3)"? Do we need to have all 5 sizes of the " king airway set"?

The adult airway set has only three sizes for King. The adult oral and nasal airway have only three each.

We are an Integrative Cancer Treatment clinic. Reno (NV) Integrative Medical Center. Is there a federal and/or state statue or code that states a crash cart is not required for a small medical outpatient clinic?

There are no laws that govern the placement or existence of crash carts. That is a matter of regulatory JCAHO, DOH, or hospital/clinic policy and protocol. Susan Z. Operations Administator

I work at a VA outpatient center that does have a crash cart on site. We are looking at performing stress tests, both treadmill and chemical, in the Radiology dept. Since administration does not want to have a crash cart, would it be acceptable to have a non-removable "emergency box" in the stress room that contains the drugs listed on your site (with the exception of narcan), defibrillator, and king airway? Any help is appreciated. Kelly L.

The term crash cart simply means the availability of emergency drugs. It doesn’t have to be a specific type of cart.

We are a specialty clinic in Iowa. We have several clinics with crash carts. I do believe most staff members have a BLS but no ACLS. Would we need to acquire and ACLS certification in order for them to handle a code? If we need to research this who would I get this information from?

No, it is recommended but not required as long as patient treatment is done by someone licensed to do it. ACLS is not a certification, it is a continuing education course.

Is it standard of care for a Crash cart to contain the disposable capnography devices? It is in an ambulatory surgery center. Thanks. Rae G, RN.

Yes, capnography is an integral part of adult resiscitation.

Hi! I work in Rehabilitation facility. I want to ask if there is specific placement of crash cart during the code, like whether it's in the right side or left side of the pts bed? Thank you. Rosemarie C.

There are no such guidelines. That would depend upon the convenience of the providers.

Hello. I am a nurse practitioner student from Ohio. I am currently working at an urgent care in Ohio and in Kentucky that does not have a crash cart. I was wondering if there are any set rules or regulations in regards to having a crash cart at an urgent care facility. Any help would be greatly appreciated! Madison R.

The requirements for patient safety are written by each individual State’s Dept of Health or regulatory agencies so you must check locally.

I have a question regarding neonatal crash carts and equipment. My question is whether you have any guidelines or information on the recommendations for stocking a Glidescope on:
  1. 1) a neonatal/pediatric crash cart, and/or
  2. 2) in the cardiac cath lab.
Diane D. RN.

A glidescope is an option to be utilized by anesthesia in difficult airways. It would be up to your anesthesia department whether to stock it in the cart.

I work in a 2 procedure room endoscopy center. We have suction available in both procedure rooms, and in both admission bays, and recovery bays. Since wall suction is readily available in all patient care areas, is it necessary to have a portable suction machine on our cart? It just takes up room, collects dust, and makes the top of the cart cluttered.

If there is suction available in all areas where an arrest may occur you are good to go.

How often should resuscitator bags and oxygen tubing be replaced if it has a manufacturing date but no expiration date?

It should be inspected regularly (with monthly cart check for expiration dates). It should be checked to make sure the plastic remains soft and pliable and there are no cracks or obvious signs of age or wear.

Here are my questions: 1- what medication should be involved in crash cart as a basic guideline. 2- if there is scheme or chart for using this medication .

[https://aha.channing-bete.com/aha-guidelines.html](https://aha.channing-bete.com/aha-guidelines.html). This handbook does a review of all of the medications used in both adult and pediatric and their uses. Hope this helps.

In our hospital setting there are a number of crash cart locations. We are being told that any location that has a crash cart must be labeled with a sign on the door. To ensure we are in compliance with the proper regulations we have researched this repeatedly but continue to come up empty handed with any such requirement. Is there a requirement that any room/closet/space that contains a crash cart be labeled on the door? If so, are there any verbiage requirements for this signage? Which regulation governs this?

I have never heard of any such requirement. JCAHO has a recommendation that locations with AED’s be “obviously marked and conveniently located” but that is because they are available for public access.

I am work at a free standing surgery center in Massachusetts. I am wondering if you know of any requirements for a thoracentesis tray in a code cart. Thank you

No, unless you have a cardiothoracic surgeon in your surgery center it would be a useless piece of equipment. I can think of no time that a pericardial tap would be performed outside the hospital. I would venture to assure you that even the CT surgeons do not have a thorocentesis tray. I hope this helps.

Are there anesthesia bags on the pediatric carts or self-inflating bags?

There are bag valve masks on pediatric carts.

For the cardiac arrest algorithm pVT/VF, I am wondering if PEA will happen followed by a pulseless VT/VF after AED?

PEA should NOT be treated with defibrillation (AED). The only treatment for PEA is to find the cause (usually hypovolemia or hypoxia) and to fix it. Hope this helps.

Hi! Are there any recommendations if defibrillator pads need to be connected to the defibrillator when not in use? I come from an ICU background where we always left defib pads connected, but my manager at my new location wants to leave the pads in their package. This seems like it creates extra steps in a code to me, but I'm not sure if there are any official recommendations or not. Thank you!

The recommendation from ECC is that they be “attached and ready to use in an expeditious manner.” In reality there is a happy medium. Most of the ICU’s and ED’s I am familiar with simply slide the plug out of the package, plug it in, leave the actual pads on top of the monitor, still in the package, to keep them from drying out. If you work for a facility that does not use them often, dry pads can be an issue. This solution solves both issues. All you have t do is rip open the package. This is similar to how AEDs are loaded with pads.

I recently noticed we have broselow carts for pediatrics. We have the broselow tape but we are using our standard concentration meds in the cart that do not match the dosing card. Obviously this is wrong. I am looking for some guidance as to what to do. What options do we have other than broselow?

You can use whatever system that your hospital approves as long as it provides for the correctly dosed medications. Broselow is just one option that is available to make it easy.

I recently starting doing stress echocardiography in a clinic California. I have done them for 15 years off and on but this one only does stress echocardiography. The crash cart does have a defibrillator but the model is so old that you cannot buy a new battery (and the battery is dead) or paper replacement for printing a strip (we have paper currently). We have an AED also immediately available in the room. What I want to know is, is this acceptable. If I had to shock the patient I would not want to do it with them connected to the treadmill for fear of some type of damage to the treadmill. I would connect them to the defibrillator. I cannot unplug the defibrillator to discharge it as it will not work. Also, I noted someone remarked that the wrong Epinephrine 1:000 was placed on the cart and that is what happened to me. I was told that 1:10,000 is on back order and not available at this time. What can we do. My thought is that the search would continue until we can find it or obtain some from the major hospital that we are affiliated with as they surely can get it. I just want to be sure that we are following the recommendations so as not to have any issues with the law should there be an incident. It is a very safe situation but there is always the one possibility. Please advise. I have never been one to operate below the standard.

I cannot be sure, but it sounds like you are using an old mono phased defibrillator. That is no longer acceptable and hasn’t been recommended since 2010. That is the reason you can no longer purchase parts. Epinephrine 1:1000 is not used in cardiac arrest. That concentration is used IM for anaphylaxis and so although you should have it, you do not have the epinephrine that you would need for cardiac arrest. The only option would be to utilize the monitoring capability of the treadmill and the AED.

I am wondering if you or one of your instructors could please answer a question for me. We are working on making a code protocol for our clinic. Who is allowed to administer ACLS medications during a code? ACLS certified staff only, or BLS certified RNs under the verbal order from a physician/ACLS certified provider?

ACLS is not a CERTIFICATION. It is a recommended continuing education course. For that reason, those who are not licensed to give medications (EMT's for example) may not give them whether they are ACLS certified or not. Those who are covered under their scope of licensure such as RN's, MD's, etc may administer medications as per their licensure or the policy of the facility.

What is your recommendation if a crash cart is brought into an isolation room? I know you recommend using a hot/warm/cold zone for this purpose, but there are occasions where this does not happen and the cart ends up in the room. Do you recommend wiping off supplies that are wipe-able? Or do you recommend discarding everything in the cart?

Actually, the entire cart needs to be decontaminated by central supply. There is nothing that you could wipe off supplies with that would be adequate.

Why can’t we have AEDs, back board, and O2 on the nursing floors? The ACLS code team would bring the meds and supplies needed. First responders really need to focus on compressions and identifying a shockable rhythm while ACLS/PALS team arrive to administer meds and advanced airway if needed. We have crash carts that have things that nothing is ever used during a code and then gathers dust until expiration and waste all equipment and medications.

Many hospital do exactly that and respond with a full cart with the code team. That would work fine as long as you have access to code team coverage 24/7 and they have a reasonable response time.

I had a question regarding crash carts and was also interested in buying your ACLS/BLS/PALS courses. So why have “crash carts?” Why can’t we have AEDs, back board, and O2 on the nursing floors? The ACLS code team would bring the meds and supplies needed. First responders really need to focus on compressions and identifying a shockable rhythm while ACLS/PALS team arrive to administer meds and advanced airway if needed. We have crash carts that nothing is ever used during a code and then gathers dust until expiration and waste all equipment and medications.

Many hospital do exactly that and respond with a full cart with the code team. That would work fine as long as you have access to code team coverage 24/7 and they have a reasonable response time.

Is it necessary to have a crash cart at a cardiac rehab facility? Some cardiac rehabs are hospital-based and some are clinic-based – all with a supervising physician readily available. I’m assuming a crash cart needs to be somewhere on premise, but does it need to be in the actual CR facility/room? For instance, is it okay if it’s in the adjoining doctor’s clinic? Is there a specific distance or time maximum?

The risk of cardiac rehab patients for cardiac arrest is substantially higher than the average population. (By definition they have had cardiac events). The crash cart is for the use of the supervising physician, therefore the physician is of little value in cardiac arrest without the tools needed for the resuscitation (that are in the cart). The recommendation is that defibrillation occur within 3 minutes of cardiac arrest. That would not occur if the only crash cart is located next door.

Does a solo primary care practitioner need a crash cart in office?

Usually not. The answer would depend on relative risk. For example if you were doing procedures with sedation you would require a cart, but for general practice no.

Can we have the guidelines and requirement for the crash cart and medication should be included with justification.

The requirements of a crash cart are different depending upon the patient population of the facility. They are justified by the treatment guidelines in the current 2015 ECC guidelines.

I currently work in an ICU. I am trying to advocate for my unit about getting emergency lock boxes on the unit. We are always traveling with patients for scans, tests, and procedures. We had some instances that happened (such as cardiac arrest, respiratory distress, etc) when transporting patients. I am looking into emergency lock boxes that have similar essentials that a crash cart has to travel with our patients.

Most hospitals have "airway emergency kits" that travel with patients who are on the vent. If you have the patient on a monitor (I assume you do" then you have early defibrillation capabilities and assuming you have an arrest team response, an entire emergency box is probably unnecessary. I travel to a lot of hospitals and have not seen this. Hope this helps.

If we are not storing any medications on the crash cart, is it required for the crash cart to remain locked?

I would think not, however a crash cart is not a crash cart without the emergency medications. It becomes simply an emergency airway intervention cart.

Could I get a copy of the US guidelines concerning either contrast and sedation. I am not certain we have proper records. Hope to hearing from you soon.

They are different from state to state depending upon licensing. There is no one set of healthcare guidelines. This is one of the problems in the States.

I am a radiographer in Ghana and wanted to find out if there are any Standard Operating Procedure for crash trolley in the radiology setting since we are deciding of keeping one around for emergencies.

The guidelines I am familiar with are US guidelines, so you would have to check with you country, but if you are utilizing either contrast or sedation, a crash cart should be available.

ACLS team, Are there any national or regional guidelines for what needs to be in a pediatric CPR cart? I am the Medical Director of the PICU at UNM Children's Hospital and we are in the process of revamping/ updating the CPR carts in the hospital.

Most of those guidelines are JCAHO.

Are there any specific certification requirements for staff to use a crash cart, defibrillator, or airway devices?

It depends on where you are working. Office vs hospital. Most hospitals require ACLS because of JCAHO.

Who is the regulatory organization or guidance issuer for having a crash cart? wish to know if a crash cart has to be present at a clinic? does a crash cart has to be present at a cardiac clinic.

There is no one regulatory agency, although most (probably all) State Departments of Health as well as JCAHO make it clear that "personnel must be trained and equipped to respond to an emergency." It would depend upon what types of procedures, etc you are doing in your clinic. Most "clinical" offices do not have full crash carts, but cardiac clinics that perform stress testing must.

Hi. I am an RT and currently looking into the process we use to check our airway supplies we keep on our crash carts. We keep all airway supplies in a separate box that is locked and tagged and stays on our crash cart. It is respiratory specific and includes things like ET tubes, tube holders, laryngoscope handles and blades, oxygen flow meters, NRB's etc...Our current policy is to open the airway box and recheck supplies every 60 days. Since we do not keep medications in this box is it necessary to open it every 60 days to recheck? If it is July 2017 and I check the equipment and nothing is going to expire until May 2018 it seems like it would be unnecessary to open it every 60 days to recheck what I know is not outdated.

As long as you have documented the expiring dates, you should be fine.

I had a question regarding crash carts. We are an ophthalmology office in Arkansas positioned 0.7mi from a hospital and 0.3mi from a fire station, we do not have an ASC and do not administer sedation. Are we required by any regulations to keep a traditional crash cart

You would have to check with your local regulatory, but I would be very surprised if you were. You are required to have emergency medications to deal with emergencies that "may reasonably result from your practice.

I am the pharmacy clinical manager at a community hospital. We had some location changes to some departments and as a result the code cart moved with the department. The result has left the sub-basement (a non-patient care floor) without a crash cart. Of note, we do have an entrance in the sub-basement that visitors will use. The entrance is not near the emergency room and is not even on the front of the building. The question is, does a non-patient care floor require a crash cart? Any feedback would be of great help.

Most hospitals do not place a cart in these areas. Personnel are required to utilize the cart (nurses etc.) so the cart in such an area would never be utilized. The arrest team or the emergency response team from the ED usually responds with a mobile cart to emergencies (employee/visitor) that occur in these areas.

HEART CELL MATRIX FAST ABSORB VIA ADP CHANAL ONLY GLUCOSE , NS TIME CLEARANCE USUALLY IN 30 MIN BUT YOU NEEDED NOW HELLO THAT IS MY BIGGEST CONCER FOR YOUR REPORT NEED 3 100 CC D5 DW AND X 1 250CC FOR NOREPI 500 CC FOR AMIODARON GTTS THANKS. AMIODARON BOLUS IS GIVEN IN SOLUTION D5W IN 100 CC IN 10 MIN ALSO GTT IN 500 CC D5W MANY OTHER MEDI CATIONS ARE GIVEN IN D5W SOL NOT IN NS ! REASON AFTER PATHOPHYSIOLOGY RESEARCH FOUND THAT CARDIAC CELL MATRIX IN ARRESTED HEART UTILIZED ALL GLUCOSE AND IN HEART BUT MUSCLE LEFT ONLY LACTIC ACID WHICH CAN BE CONVERTED TO GLUCOSE IN RECOVERY FASE BY CREBS CYCLE. HEART CELL MATRIX ABSORB VIA ADP CHANAL FAST ONLY GLUCOSE SO CRASH CART NEEDS 100 CC D5W AND 250 1 BEG FOR NOREPINEPHRINE BUT YPUR SET IS OLD FROM 1995.

American Heart Association® Guidelines use all normal saline. Glucose is contraindicated in cardiac arrest and has been since 2010 guidelines.

I work at an outpatient imaging center in North Carolina. We do not provide sedation but do administer IV contrast media. Where do I find regulatory requirements specific to our state regarding having a crash cart available?

They would be found either at your state department of health or your certifying body. Many states have no requirements other than to "be able to respond to emergencies arising in your patients.

I had a question regarding crash carts. What are the basic items that a crash cart for a clinical research site must have? We are planning on conducting different clinical trials but i need a clarification on what to buy.

Most hospitals do not place a cart in these areas. Personnel are required to utilize the cart (nurses etc.) so the cart in such an area would never be utilized. The arrest team or the emergency response team from the ED usually responds with a mobile cart to emergencies (employee/visitor) that occur in these areas. Hope this helped.

I'm very experienced medical professional with more than 28 years expertise . I always want to ensure I keep learning. I am very keen to give the BLS & ACLS exams, please guide how I can go through with this endeavor. I have visited your website, following are my queries . 01. Are there any age restrictions in giving the exam. 02. I have done my medical degrees in India and have huge experience, I see more than more 50 patients on average per day, so I have vast knowledge in my medical profession from India perspective, therefore my query what is so different between Indian Medical System and the American medical system which can result in potential failure. * I keep getting job offers from USA hospital but at the age of 53 after giving this exam is it worthwhile and is there major scope in the field of PMR in the USA in terms of getting experiences.

The ACLS and BLS standards are international, so people from all countries take these classes successfully.

I work at an outpatient imaging center in North Carolina. We do not provide sedation but do administer IV contrast media. Where do I find regulatory requirements specific to our state regarding having a crash cart available?

They would be found either at your state department of health or your certifying body. Many states have no requirements other than to "be able to respond to emergencies arising in your patients.

So, I'm confused about some things in the course. Here is the confusion: Section 3 Ethics in Resuscitation , Paragraph 5: "Once the patient's wishes become known via family /surrogate they should be acted upon."

Paragraph 8: Healthcare advance Directive - It communicates the thoughts, wishes and preferences for healthcare decisions that might need to be made during periods of incapacity. They can be verbal or written and can be communicated via living wills or conversations. Most courts prefer that an advance directive be in writing but will consider verbal information in the absence of a written document.

Paragraph 10: Do Not Resuscitate or DNR must be dated and signed by an ordering physician.... DNR orders are normally not valid outside of a hospital or health care facility such as a long-term care facility.

So, I would ask, does this mean that a nurse in a nursing home is a valid surrogate, that a paramedic responding to a cardiac arrest at a nursing home can honor the the nurse's words that says, the patient "does not want to be worked". (Actually, this is a question on an exam, I don't exactly know what the patient "does not want to be worked" even really means.) Assuming it means do not resuscitate and this was related verbally by the patient to the nurse , then Paragraphs 5, and 8 allows the paramedic to honor the nurse's words.

The exam question further gives choice of : you are given a signed out-of-hospital DNR Order. If paragraph 10 was to be the controlling rule, then there are problems there: it does not say a physician ordered it, it's outside of a hospital. A "nursing home" is not necessarily a long care facility, (I think, or is it?). So that would not be the choice.

Another choice: "the nurse shows you the hospital DNR order". It would seem to me that if the order was valid in the hospital , it would be valid in the nursing home- it's the same patient=the same DNR order. BUT, this was marked wrong in the past exam that I took and failed. Another choice: "A living will signed by a family member is on the chart". In your section 3 of Ethics.... under paragraph 7 , it does not indicate who can make and sign a Living Will. It does quote a statement in the paragraph's last sentence that says,..."life sustaining treatment is not desired if I am.....". Do family members make living wills for others? So for me the question is confusing and not answerable based on the educational material you provide. Please help.

Similarly, There is a question that a paramedic cannot honor a Do Not Resuscitation request from a family member unless," there is a valid signed out-of hospital form present" Paragraph 10 seems to disqualify this answer. "the patient's physician validates the order via telephone". Paragraph 10 seems to disqualify this; and besides will the paramedic waste precious time trying to call the physician? in the middle of the night? or the physician has to go to his records and look things up? "There is a signed DNR order present from a recent hospitalization". Does paragraph 10 disqualify this answer? This is very confusing and I need help because I do not understand.

They are two completely different environments. A hospital directive, whether it be physician order, DNR, etc is NEVER valid outside of the hospital. The only valid way to communicate the desire to not be resuscitated is to utilize a special out of hospital DNR (each state has a different form) that is especially approved for use outside of the hospital. Any documentation of desire becomes invalid when the patient leaves the hospital. A paramedic cannot honor those requests. He/She can contact their medical command physician (ED physician) to terminate efforts, however. I hope this helps.

What are the requirements for handling of crash cart meds? Can CNAs transport both opened and unopened crash carts to and from codes without a pharmacists?

It would depend on your hospital's policy, but they do it in most hospitals all the time as long as there are not narcotics (which there should not be).

Would you please share a template of a crash cart daily log sheet? I would like to see what the O2 cylinder volume is when in a crash cart.

The checklist for a crashcart is different from facility to facility because it lists the equipment in your cart. An oxygen cylinder in a crash cart should be maintained always greater than half full.

I had a question regarding crash carts. On the crash cart check sheet for pediatric and adult, there is a section for "Outdates Checked" Please tell me what this means.

This means that the drug and equipment expirations have been checked and not expired.

I am trying fo find out if all doctors offices are required to have a crash cart.

Not all doctors offices are required to have a crash cart. It depends on what type of procedures are done there and the risk profile of those procedures.

I am the Medical Director of a company that operates and manages hospitals and clinics. We are in the process of designing a 120 bed hospital combined with a multi specialty outpatient clinic and a modern diagnostic center.
We are compiling a list of necessary equipment. My questions:
Are there any guidelines/standards of care for the how many fully stocked crash carts are needed in a large hospital? How quickly must the cart be accessed? At this time I have considered placing a fully stocked crash cart in the following areas. It is over kill or adequate?
Four operating rooms: one in each room (4)
Recovery room: 1.
TWO endoscopy procedure rooms: 1
One day surgery center: 1
Labor and delivery: 1
Five bed ER with resuscitation room: 1
six inpatient floors med/surg. (approx. 16 patients per floor): one per floor (6)
radiology diagnostic center: 1
Ten bed ICU: 1
five bed NICU: 1
TOTAL: 18 fully stocked crash carts with monitor and defibrillator
My second question:
Is it acceptable to have AED's located on patient floors instead of crash carts? Is it okay to utilize the AED until the crash cart arrives? How soon should a fully stocked crash cart arrive (with monitor and defibrillator)?
My investors are trying to cut down on cost and I need to give them documented standards for the number of crash carts needed in this facility.

The number as well as the placement is reasonable. It is not the crash cart but the defibrillator that has time guided recommendations. The AHA recommends that you be able to reach all your patients with a defibrillator within 3 minutes. More remote departments can utilize AEDs for this purpose. The guidelines will be found (if at all) from your state authority or at the lease your certifying body such as JACHO./p>

Can you provide some direction on who may perform the daily check on the code carts? I recently received some feedback from one of my radiology technologists that she was told by an RN that only RNs are allowed to do the daily checks on the code carts. In my experience, multiple licensed allied health professionals have checked the code cart, not just RNs; however, I am having some difficulty finding anything that specifically designates who should do the daily checks. Any help you can provide would be greatly appreciated.

That is not a licensing issue. It is the policy of the facility. Most hospitals only have a single RN in their radiology deptartment and regularly use techs to check their carts. I cannot think of a valid reason why this mundane task would require a registered nurse.

We are a dermatology practice and we were wondering if we needed to keep a crash cart at the office. I don’t know if you can help us or if you can direct us to someone or a website that can direct us to the answer. We do a surgical procedure on site under local anesthesia no general.

I can find no requirement regarding a crash cart if sedation is not being utilized except to provide "emergency equipment for anything that could 'reasonable arise from treatment modalities offered'. If they are doing injections I would assume, that would be allergic reaction. Without knowing what procedures, that is as close as I can come. The crash cart requirements seems to be related to the use of sedation and general anesthesia. They do neither.

I am currently working on a project regarding crash carts for my preceptor on rotations. I was wondering if you can assist me in identifying any requirements, guidelines, or checklists for cleaning and sterilizing crash carts after their use. I would really appreciate any help that you can offer.

Crash carts are not sterile. While there may be disposable sterile equipment there is nothing sterile on a crash cart. Cleaning and restocking usually occurs after use. Each cart is sealed with a disposable lock. When the seal is broken it is replaced and restocked. They are usually checked by the charge nurse daily utilizing a check list. Drug expirations dates are checked monthly.

How many crash carts are needed per the number of patient beds in a hospital?

That is determined by each state department of health and therefore varies. Some states have a specific number and others simply say “crash cart to meet the needs of the number of patients and their acuity on each unit” You would have to find out what your state recommends.

Is a crash cart required in the Anesthesia Tech Work room?

There are no specific requirements (unless by your state) for the location of crash carts. The recommendation is that every patient should be within three minutes of a defibrillator and all patients receiving sedation should be covered by a crash cart and personnel trained in airway intervention and recognition.

I work at a hospital in Texas and we have "intubation boxes" on each of our crash carts in the hospital. Each of these boxes are replaced each time they are opened and recorded in a book on the crash cart with the new lock number. Each box has a sticker on the outside of the box that has the lock number written, the earliest expiration date of equipment inside box, the date the box was checked and initials of who checked the box. Let's say it is August 2016 and the first expiration date of all equipment inside the box is February 2017, does JCAHO require that the box still be opened every month, checked and documented that there was a monthly check done of this box? This box sits on top of the crash cart and has the supplies necessary for intubation.

As long as the date of the last check is documented and the expiration dates noted, no. As soon as the box is opened, however for any reason, it must be rechecked, including expiration dates.

Is the crash cart supply and equipment list the same for hospitals and ambulatory surgery centers?

No, the recommendations for hospitals come from JACHO and ambulatory care comes from the individual State.

What is the name of the device used to secure an oxygen tank to the side of a crash cart? Currently our oxygen tank is not attached and sits next to the cart.

This device is called an oxygen tank bracket.

We just received new crash carts that have a portable suction attached to the top of the machine. An unsterile suction tubing is attached and left on the suction. Our OR director is concerned about this and thinks the suction tubing should be removed and a sterile suction tubing pack should be placed next to the suction instead. She is concerned the exposed tubing will be cited during inspections. Is this a concern? The disposable suction liner comes with the tubing already connected. What is the standard for this?

Suction is NOT sterile. However, because she is in an OR environment it may be different. Unsterile suction tubing is attached to all of the suction in the Emergency Departments as well as the CATH lab, but neither are sterile environments. If the suction would cross the sterile field it should be sterile. If used only for arrest it does not have to be.

I was wondering where I could obtain a copy of the document stating that unopened vasostrict can be stored for 12 months outside of the refrigerator? The company I work for has stated it has to be kept in the refrigerator.

Vendors have told us we must NOT redistribute from information Material Safety Data Sheet. Please contact your vendor directly for this information. I am sorry that we could not be more helpful here!

Is it a requirement to have Cardiazem in our crash cart? The facility I work for is a cardiac radiology facility where stress perfusion tests are performed. The medications we have in our crash cart are Metoprolol, Amiodarone, Adenosine, Epinephrine, and Atropine among other medications not heart related.

There should be some calcium channel blocker. It can be Cardiazem or Verapamil, but there should be one as that is first line after Adenosine for narrow complex tachycardia.

Are the requirements different in MY STATE?

There are no requirements for crash carts other than the ability to respond to cardiac and respiratory emergencies, so most facilities base the contents on AHA and a little common sense.

Do the supplies have hcpcs that we should be billing, this just looks like supplies to me. Our OR team is asking if we should be billing for the crash cart to insurance carriers.

To our knowledge the "crash cart" is not a billable item any more than the defibrillator is.

Is there any verbiage on how far a crash cart can be located?

The only recommendation is that there be a defibrillator within three minutes so that the patient can be defibrillated within three minutes. That can be converted with an AED. There isn't anything written in stone about carts though.

What is the standard time limit for removing medications from the Crash cart? As far as I am aware, medications are removed before 90 days of the expiration date. If this answer is correct then what is the reason for removing before 90 days? Why can't we remove before 30 days?

Medications are acceptable up until the day of expiration (normally the last day of the month in which they expire). The habit of removing them 90 days ahead came from when facilities would move medications before they expired to units that were more likely to utilize them before expiration. For example, hospitals would move critical care meds from carts on med-surg floors, replace them with new meds and move the medications that were to expire in the next 90 days into their ICU units where they were more likely to be used before their expiration date. If you don’t plan on managing your inventory in that manner, then drugs are good for administration up until the expiration date.

If you have a crash cart in your facility, what is the legal expectation for training of staff as far as use of airways? Where can I find the regulations?

Joint Commission recommends that all staff that administer and/or monitor patients who receive conscious sedation be trained in airway management. They don't specifically name ACLS but most hospitals use it because it has become a standard. The Joint Commission guidelines can be found on their site. Other training guidelines originate from each States DOH and can be different by state.

What is the current standard of practice to have ammonia inhalers (smelling salts) on an emergency cart?

Ammonia capsules have been CONTRAINDICATED for just about everything for about five years. It has no place on a crash cart. Hope this helps

Is it a requirement by AHA, Joint Commission, ACLS, or is there ANY requirement, to have crash carts locked?

Yes, the JCAHO standard MM.2.30(4 & 6) addresses control of supplies on crash carts:

Emergency medications are sealed or stored in containers (for example, crash carts, tackle boxes, emergency drug kits, closed bags that are clearly labeled, and so forth) in such a way that staff can readily determine that the contents are complete and have not expired.
Emergency medications are stored in sealed or in locked containers; in a locked room; or under constant supervision in accordance with law or regulation.

Also laws, usually at the state/province level, regulate access to several of the drugs on the cart, and other laws regulate securing dangerous things in a hospital (sharp and pointy objects). But more directly, each hospital will have its own policies that control the situation you are describing. In many hospitals, one would get written up for stealing from the cart.

We are working in a cardiac center operating room department. Our OR department has 3 rooms that cater to both adult and pediatric patients, and we have 2 beds that serve as our preparation/waiting area for patients who will undergo surgery. As of the moment, we are currently maintaining 2 crash carts and very seldom is it used in the OR. When transferring a patient from the waiting area to OR rooms it does not take more 20 seconds. How many crash carts should we maintain in the OR? And what is the standard patient ratio for each crash cart?

In an operating room, the standard is resuscitation equipment in each OR room. You would only need ONE cart to cover the recovery and preop area.

Is there any regulation that governs the number of code carts a unit or department should have in relation to the number of patient care beds?

One cart for each OR and one for prep/recovery. Source: Joint Commission standards, link: https://www.jointcommission.org/standards_information/tjc_requirements.aspx

Is it necessary to have a laryngoscope with the cart?

It is not necessary to have a laryngoscope if you have King Airways. King Airways provide a decent airway and require little or no training compared to endotracheal intubation. It is the airway standard as a bail-out for EMS as well as in situations where you have no one trained for intubation. King airways are perfect for that application (and cheaper).

Can I remove the other advanced airway equipment?

Maybe. With the recent guideline updates, if you are within 10 minutes distance from an emergency department with ALS equipment then it is possible for you to remove the advanced airway equipment. However, it would be necessary for you to have some airway equipment such as a King airway.

Our current stock of Vasopressin expires at the end of this month. What we found available was a refrigerated product. This product is quite expensive, and for most Critical Access Hospitals in a rural setting, we are all trying to be stewardly with expenses and finances. I did contact the manufacturer and received documentation that does state this product is stable out of refrigeration for 90 days. Still, this leaves the problem of the expense of it becoming unstable and needing to be replaced every 90 days. Currently we do keep the Vasopressin in the crash carts with the other crash cart medications and have done so since this medication was added to ACLS protocols. Is there a reason it needs to be in the crash carts, or can it just be accessible if needed?

The replacement of the first OR second dose of Epinephrine with Vasopressin is OPTIONAL in the AHA Cardiac Arrest Treatment Guidelines. It is not used all that often with the exception of some specialty arrests such as those that involve global ischemia such as ischemic myopathy. There is nothing that says it is recommended in cardiac arrest, just that it is acceptable. Therefore you would be fine to delete it from the crash cart. Unopened Vasostrict vials may be held up to 12 months upon removal from refrigeration to room temperature storage conditions (20°C to 25°C[68°F and 77°F], USP Controlled Room Temperature), anytime within the labeled shelf life. Given the fact that it can now be stored for a longer duration, cost should be less of a factor in your decision to maintain it on the crash cart.

Where are the NRP cart guidelines?

Please see this page.

We are a dermatology office and I was wondering about the need for a crash cart. We do perform procedures and surgeries, such as Mohs surgery, but no conscious sedation is used. We also do not have a physician in the practice that is currently ACLS certified. Our practice mostly hires Medical Assistants and we only have 2 RNs on staff, 1 of which is ACLS certified. We do, however, currently have a crash cart that is kept up to date, with an O2 tank and an AED. If you could help me to understand the criteria for crash carts in medical offices I would greatly appreciate it.

The decision to keep a stocked crash cart is not a bad one. Think like an attorney would think. You mean I had a _______________________ in a doctor’s office and they couldn’t do anything about it? The lay public does not differentiate between a dermatologist and a cardiologist, they just see a doctor and expect them to respond as such. However, having the equipment and not being able to use it may be worse. The answer is to keep the crash cart and train the physician. It’s the cheapest and best solution.

We are struggling with how to maintain the integrity of the cart when it enters a patient care environment during a code, particularly if the patient is in isolation. Typically, for multiple dose vials that are used across patients, we indicate that they should NOT be brought into the patient care environment/patient bedside because then they are "contaminated" and can only be used on that particular patient. The same issue/question is coming up regarding medications in the crash cart that are brought to the bedside. We had a cart go into a C-Diff room and we ended up disposing of the entire cart's contents due to contamination. I have seen some policies that state the cart could be kept just inside the room in a designated area with a "clean" person assigned to handle the cart and hand off medications to the staff inside the room. Wondering if there are recommendations on how to handle this situation?

The only way to maintain a cart in an isolation environment is to create a hot/warm/cold area much like we do for contaminated patients arriving in the Emergency Department. The cart stays just outside the door with a person who NEVER enters the room. A person stays at the bedside which is in the patient's HOT zone. A warm zone person hands medications from the Cold Zone outside of the door to the Hot Zone person. Anyone who touches the patient is contaminated and cannot touch the cart. Multi-dose vials CANNOT be used in this situation. Any multi-dose vial that is used is contaminated. However, there should be no multi-dose vial on any emergency cart. All IV medications should be in safe doses for a 100lb patient. I cannot think of one arrest medication that would be considered multi-dose. All equipment such as airways, suction catheters, etc., are one use only so it can be handed off and opened in the room.

We are a small, 8-bed outpatient surgery center using conscious/moderate sedation (not propofol). You can walk from one end to the other in 20 seconds or less. We have one crash cart that is equipped with everything you could possibly need in an emergency situation. We also have a small e-kit in each procedure room. Are the e-kits necessary? I'm trying to simplify things, and not having to cut the lock on each e-kit every month to inventory, log and document would be nice.

No. If there is enough equipment to handle two simultaneous emergencies for 10 minutes (assuming you do more than one patient at a time) there is no reason to have more than one crash cart. You do however have to be able to monitor pulse oximetry or capnography for all of your sedation patients.

In our ASC we have a crash cart that is not locked. In all our previous surveys the DOH has never cited us for this, or even made mention that it should be locked. However, some of our new employees have brought up that in their previous offices locks were used. Do you know what the requirements or recommendations are for locking the crash cart?

Most hospitals put a breakaway plastic lock, not a lock requiring a key. It is just so it becomes obvious when it has been opened so it can be restocked. Carts with Narcotics (any controlled substance) must be double locked. However, there should be NO controlled substances on a crash cart. There should not be a lock requiring a key on a crash cart because of time and availability. It is an emergency cart and so needs emergency access.

What type of O2 gauge should be attached to the crash cart?

It is a standard 02 regulator attached to an oxygen tank.

Is a dentist office required to have a crash cart?/ Would conscious sedation be if they use Versed (midazolam) IV?

Yes, if you are doing conscious sedation. Yes, this counts.

For safety, can both the defibrillator and an oxygen cylinder be kept on the same side of the crash cart? One of the concerns was that in case of arcing, during defibrillation, the source of oxygen is nearby, thus increase the fire risk.

Yes, it can. The fire risk occurs when there is flowing oxygen between the paddles and there is not good contact. For example, defibrillating a patient who has a BVM with oxygen on and it is set down next to the patient for defibrillation and the oxygen is flowing across the patient's chest. Not a storage issue at all.

Many people ask me from Illinois if they are required to document that the crash cart is checked every shift. My thought is that it should be, because I view it as a pilot views a plane. Each pilot does his own safety check regardless of how many pilots flew the same plane that day before him. It doesn't take that long to see if the crash cart is locked, the defib is plugged in and the pads are accessible. I like your idea about monthly checks for expirations. Do you know if the Illinois Department of Public Health requires daily, weekly or monthly documented checks?

In general, most important is that you have a policy and that you follow that policy... whether for JCI or state audit. Our general recommendation is review monthly, after each use, and after change of stewardship (e.g. cart moved between wards which are managed by different teams). Illinois Department of Public Health has not cited any specific review frequencies in this audit http://illinoisrighttolife.org/wp-content/uploads/2014/11/Michigan-Ave-Inspection-Report-6-23-11.pdf They have used daily audits and DOPH has accepted this without citing compliace to a specific code. In other words, your policy is reasonable and everything should be good to go!


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