Which Emergency Medications Should Be Stocked in Automated Dispensing Cabinets?

Automated dispensing cabinets offer quick access to medication and can help reduce harm caused by delays in medication delivery in emergency situations. The Institute for Safe Medication Practices (ISMP) and the American Society of Health-System Pharmacists (ASHP) both recommend stocking these cabinets with reversal agents, rescue agents, and antidotes after an assessment for override status has been performed. A poster presented by Sara F. Wiser, PharmD, of University of North Carolina (UNC) Health Medical Center in Mebane, North Carolina, at the ASHP 2022 Summer Meetings & Exhibition held in Phoenix, Arizona, looked at emergency events to find the medications that should be considered standard stock.

A single-center, retrospective case series included both adult and pediatric patients that were involved in a rapid response” or “code blue” event between June 2020 and May 2021. Investigators collected demographic data as well as unit/type of floor, event type, event start/end times, pharmacy shift during time of event, event outcome event survival, medication(s) administered during event (drug name, dose, route, frequency, order status [STAT, Routine]), and location from which the drug was obtained.

Patients who did not receive medication during the event as well as those admitted to perioperative areas, not currently admitted to the hospital, and those who had the event outside of patient care areas were excluded from the analysis.

During the study period, there were 3634 adult and 374 pediatric events classified as “rapid response” (85.7% for adults; 69.8% for pediatrics) and “code blue” (14.3% for adults; 30.2% for pediatrics). Adults received an average of 3.6 unique medications whereas pediatric patients received 4.1 unique medications. Common medications included sedatives, concentrated electrolyte solutions, antiarrhythmic agents, and vasoactive agents.

When medication could not be taken from a code tray or the floor supply was exhausted, they medication was taken from the automated dispensing cabinets(80.3% for adults; 84.3% for pediatrics) or from the central inpatient pharmacy (19.7% for adults; 11.6% for pediatrics) or pediatric satellite pharmacy (1.9% for pediatrics).

“STAT” priority was designated for medications in 24.7% of adult orders and 33.7% of pediatric orders. Mortality rate for “rapid response” events was 0.3% in adults and 0% in pediatrics. Furthermore, it was 13.8% in adults and 7.1% in pediatrics for “code blue” events. The most commonly ordered medications that came from locations off the patient unit were:

• epinephrine 0.1 mg/mL injection,
• amiodarone 150 mg/3 mL injection,
• calcium chloride 100 mg/mL injection,
• magnesium sulfate 4 mEq/mL injection, and
• norepinephrine 32 mcg/mL infusion.

Investigators concluded that universally stocking medications in automated dispensing cabinets allowed for quick access to medications that reduced potential delays and helped reduce mortality. Medications that helped with survival included:

• vasoactive agents (atropine, dopamine, epinephrine, norepinephrine, phenylephrine, dobutamine, vasopressin),
• sedatives (etomidate, fentanyl, ketamine, midazolam, propofol, succinylcholine),
• concentrated electrolyte solutions (calcium chloride, magnesium sulfate, sodium bicarbonate),
• antidotes (naloxone), and
• antiarrhythmic agents (amiodarone, adenosine, lidocaine, metoprolol)

Reference

Wiser SF. Recommendations for stocking emergency medications in automated dispending cabinets – perspective from a tertiary medical center. Presented at:American Society of Health-System Pharmacists 2022 Summer Meetings & Exhibition; June 11-15, 2022; Phoenix, AZ. Poster 39-T.