Emergency Cart Check Compliance: Crash Cart, MH Cart, and ANB Box Requirements

Emergency Medication Readiness in ASCs

Ambulatory surgery centers must maintain emergency medications and equipment in a state of constant readiness. This includes the crash cart (code cart), malignant hyperthermia (MH) cart, and airway/nausea/bleeding (ANB) supply boxes. Accreditation bodies, CMS, and state regulations all require documented evidence that these resources are checked, maintained, and immediately available.

Emergency cart compliance is one of the areas where surveyors spend significant time. Deficiencies here can signal broader medication management problems.

Crash Cart Requirements

Contents

The crash cart should contain medications and equipment for managing cardiac arrest and other life-threatening emergencies. The specific contents are determined by the facility's medical director and should reflect the types of procedures performed. Common crash cart medications include:

• Epinephrine (1:10,000 for IV and 1:1,000 for IM/SubQ)
• Atropine sulfate
• Amiodarone
• Lidocaine
• Sodium bicarbonate
• Calcium chloride or calcium gluconate
• Vasopressin
• Naloxone (Narcan)
• Flumazenil (Romazicon)
• Dextrose 50%
• Diphenhydramine
• Nitroglycerin

Check Frequency and Documentation

• Daily checks (or each day the facility is operational): Verify the cart seal is intact. If sealed with a tamper-evident tag, record the seal number, date, and initials.
• Full inventory check: Required whenever a seal is broken and at defined intervals (typically monthly or quarterly). This includes checking every medication for expiration, verifying quantities, and testing equipment.
• After every use: Complete inventory and restock. Replace the tamper-evident seal and document.

Seal System

Using a numbered, tamper-evident seal allows daily checks to be completed quickly. The process:

1. Verify the seal is intact and the number matches the log
2. Record the date, time, seal number, and your initials
3. If the seal is broken or missing, perform a full inventory
4. Apply a new seal and record the new number

Malignant Hyperthermia Cart

When Required

An MH cart is required whenever the facility uses triggering agents, including:

• Succinylcholine
• Volatile anesthetic agents (sevoflurane, desflurane, isoflurane)

If your facility does not use any triggering agents and has a written policy documenting this, an MH cart may not be required. However, this should be confirmed with your accreditation body.

Contents

The Malignant Hyperthermia Association of the United States (MHAUS) provides a recommended contents list:

• Dantrolene: At least 36 vials of Dantrium (20 mg each) OR equivalent Ryanodex (250 mg vial). Ryanodex requires fewer vials and significantly less preparation time.
• Sterile water for injection: For reconstitution of dantrolene. At least 1,000 mL if using Dantrium.
• Cooling supplies: Cold saline (refrigerated), ice, cooling blankets
• Supportive medications: Sodium bicarbonate, dextrose, insulin, calcium chloride, lidocaine
• Monitoring supplies: Additional thermometers, foley catheter kits, blood gas syringes

Check Requirements

• Same seal-based daily check system as the crash cart
• Monthly or quarterly full inventory with expiration date verification
• Dantrolene expiration is particularly important to track as it is an expensive medication and facilities may be tempted to retain expired stock
• Temperature-sensitive items should be checked for proper storage

ANB (Airway/Nausea/Bleeding) Box

Some facilities maintain a separate ANB box or difficult airway cart. Requirements vary by facility, but typically include:

• Airway supplies: Laryngeal mask airways (various sizes), oral/nasal airways, bougie, video laryngoscope, emergency cricothyrotomy kit
• Anti-nausea medications: Ondansetron, promethazine, dexamethasone
• Bleeding supplies: Topical hemostatic agents, additional sutures, pressure dressings

Check procedures mirror those for the crash cart: daily seal verification with periodic full inventory.

Common Deficiencies

Survey findings frequently include:

• Expired medications in crash carts or MH carts (the most common finding)
• Missing or incomplete daily check documentation
• Seal numbers not matching logs
• Crash cart contents not matching the facility's approved contents list
• Insufficient dantrolene quantity
• No written policy for crash cart management
• Staff unable to locate or operate emergency equipment during surveyor questions

Best Practices

1. Assign responsibility: Designate specific staff for daily checks and full inventories
2. Create a master contents list: Approved by the medical director, posted on or near each cart
3. Track expiration dates proactively: Maintain a running list of upcoming expirations to allow timely replacement
4. Conduct drills: Regular emergency response drills ensure staff know where carts are located and how to access contents quickly
5. Document everything: If it is not documented, it did not happen. Maintain organized logs that are easy for surveyors to review
6. Use digital tracking: Digital compliance tools can automate expiration tracking, send reminders for daily checks, and maintain audit-ready logs