PROCEDURES FOR THE EXCHANGE & STORAGE
OF IV BOXES BY ADVANCED MOBILE EMERGENCY CARE SYSTEMS

1.      Each cooperating advanced mobile emergency care vehicle shall be in compliance with
MDCIS Regulation R325.24011, Rule 1011, "Ambulances equipped with intravenous fluids
and other lifesaving items; regulations".
 

2.       Mercy-Memorial Hospital pharmacy shall be responsible for permanent inventory reconciliation
of a specific number of IV boxes.  Appropriate record keeping and security measures will be maintained.
 

3.       All of the IV boxes within the advanced mobile emergency care system shall be numbered
consecutively, therefore making it possible for the pharmacy to recall specific boxes for
inventory reconciliation at any time.
 

4.       Each cooperating hospital pharmacy will stock the IV box in accordance with the IV list
approved by Monroe County Medical Control Authority  - Advisory Board and shall contain,
at a minimum, the IV solutions required by the Michigan Department of Consumer and Industry
Services, Division of Emergency Medical Services.  A copy of the IV box inventory list will be
securely attached to the inside lid of each IV box.
 

5.       The intravenous administration sets placed in the boxes shall be consistent throughout the
advanced mobile emergency care system as to the dosage, concentration and administration
requirements prescribed by the Monroe County Medical Control Authority in the advanced
mobile emergency care system's protocols and procedures.
 

6.       Labels will be securely attached to the outside of all IV boxes, which shall include:

          a.         The name of the hospital pharmacy which last restocked the box

       b.         The date the box was last restocked.

          c.         The legible initials of the pharmacist /or designee who inventoried and restocked the drug box.

          d.         The earliest date at which any solution in the box would expire (30 day lead time recommended).
 

7.       IV boxes will be opened and inspected by a pharmacist from Mercy-Memorial Hospital at least
 once each quarter.

8.       IV boxes are to be inventoried, restocked and appropriately labeled after each user per paramedic.

9.       IV box supplies will then be placed in a locked storage compartment in, or convenient to,
the emergency department.  Only appropriate on-duty pharmacy or emergency department staff
shall have access to this compartment.  Appropriate emergency department staff shall be defined as an emergency department physician, registered nurse (R.N.) or licensed practical nurse (L.P.N.).

          Appropriate pharmacy staff shall be defined as a registered pharmacist or a pharmacy
intern/pharmacy technician under the direct supervision of a registered pharmacist.

10.     A permanent record shall be maintained indicating the following:

          a.         The number of the IV box being returned and the used seal number.

          b.         The new seal number issued.

          c.         The EMS agency name.

          d.         The name of the EMT-P to whom the IV box is being issued (signature).

          e.         The name of the person restocking the IV box (signature).

          f.          The date of issue/return.

11.     The EMS run report form shall serve as the permanent medical record of physician orders for drugs or intravenous solution administration.  It shall not be valid without a physician signature.
 

12.     Whenever intravenous solutions or supplies for the IV box are used (or whenever the pharmacy seal
on the IV box is broken), a "Documentation of IV Use and Replacement" form must be completed
and signed by the EMT-P and signed by a physician/or designee.
 

13.     The white pharmacy copy of the documentation form will be placed inside the IV box.
 

14.     The yellow (billing) copy of the documentation form will be completed by emergency room personnel,
totaling the patient's charges, and sent to data processing.
 

15.     The IV box will then be resupplied with appropriate solutions at the designated area in, or near,
the emergency department under the supervision of appropriate emergency department or
pharmacy staff.

Mercy Memorial Hospital Pharmacy
Hours of Operation:  7 a.m. to 11 p.m. - Monday through Friday
7 a.m. to  8 p.m. - Saturday, Sunday & Holidays
Phone Number: (734) 240-5289 or 26#

16.     Once sealed by designated personnel, the IV boxes will not be inventoried by the EMT-P
personnel prior to the documented necessity for utilization.
 

17.     Any discrepancies in the IV box inventory that are discovered by the

          EMT-P at the time of utilization will be documented on the "Documentation of IV Use
and Replacement" form and will include:

          a.         Name of hospital pharmacy last restocking the IV box.

          b.         Date of last restocking

          c.          Pharmacist/physician/or designee initials who last restocked the IV box.

          The form shall be co-signed by another EMT-P, nurse or physician.
 

18.     IV box procedure following transportation of patient outside of Monroe County:

          Transport to cooperating hospitals:

          a.         The EMT-P will request IV replacement from the receiving hospital in accordance with
local procedure unless specific billing procedures have been established with Mercy
Memorial Hospital (i.e., Saline Community Hospital).

          b.       The replacement IV items will be placed in the box and locked with a yellow locking device.

          c.          "Documentation of IV Use and Replacement" Form:

                      1.   White Copy (Pharmacy):  To be sent to Mercy-Memorial Hospital pharmacy.

                      2.   Yellow Copy (Billing):  To be given to receiving hospital's emergency room
personnel to incorporate into patient's emergency admission charge.

19.     Locked and secure compartments, or other locking devices, approved by the Medical Control Board
and the Michigan Department of Public Health, shall be provided on the advanced mobile emergency
care vehicle and utilized to prevent access to stored IVs by unauthorized persons.

PROCEDURES FOR THE EXCHANGE & STORAGE OF DRUGS BY
ADVANCED MOBILE EMERGENCY CARE SYSTEMS

1 .      Mercy-Memorial Hospital pharmacy shall be responsible for permanent inventory reconciliation
of a specific number of drug boxes.  Appropriate record keeping and security measures will be
maintained in accordance with the Federal Controlled Substances Act (Title 20), to minimize
the potential for diversion.
 

2.       All of the drug boxes within the advanced mobile emergency care system shall be numbered
consecutively; therefore, making it possible for the pharmacy to recall specific boxes for inventory
reconciliation at any time.
 

3.       Each cooperating hospital pharmacy will stock the drug box in accordance with the drug list
approved by Monroe County Medical Control  Authority - Advisory Board and shall contain, at a
minimum, the drugs required by the Michigan Department of Consumer and Industry Services,
Division of Emergency Medical Services.  A copy of the drug box inventory list will be securely
attached to the inside lid of each drug box.
 

4.       The drugs, syringes, needles and intravenous administration sets placed in the boxes shall
be consistent throughout the advanced mobile emergency care system as to the dosage,
concentration and administration requirements prescribed by the Medical Control Authority in
the advanced mobile emergency care system's protocols and procedures.
 

5.       Labels will be securely attached to the outside of all drug boxes, which shall include:

          a.         The name of the hospital pharmacy which last restocked the box.

          b.         The date the box was last restocked.

          c.         The legible initials of the pharmacist who inventoried and restocked the drug box.

          d.         The earliest date at which any drug or solution in the box would expire (30 day lead time recommended).
 

6.       Drug boxes will be opened and inspected by a pharmacist from Mercy-Memorial Hospital at
least once each quarter.
 

7.       After the drug boxes have been inventoried, restocked and appropriately labeled, the pharmacist
will attach a consecutively numbered GREEN plastic seal onto the drug box.  (The hospital pharmacy
shall be solely responsible for dispensing and accounting for these seals).  A numbered RED seal
will be placed in the box by the restocking pharmacy for use by the EMT-P. 
 

8.       The sealed drug boxes will then be placed in a locked storage compartment in, or convenient to,
the emergency department.  Only appropriate on-duty pharmacy or emergency department staff
shall have access to this compartment.  Appropriate emergency department staff shall be defined
as an emergency department physician, registered nurse (R.N.) or licensed practical nurse (L.P.N.).   Appropriate pharmacy staff shall be defined as a registered pharmacist or a pharmacy intern/pharmacy technician under the direct supervision of a registered pharmacist.

9.       A permanent record shall be maintained indicating the following:

          a.         The number of the drug box being returned and the seal number.

          b.         The number of the drug box being issued and the seal number.

          c.         The E.M.S. agency name.

          d.         The name of the EMT-P  to whom the drug box is being issued (signature).

          e.         The name of the person issuing the drug box (signature).

          f.          The date of issue/return.

10.     The EMS run report form shall serve as the permanent medical record of physician orders for drugs or intravenous solution administration.  It shall NOT be valid without a physician signature.
 

11.     Whenever drug, intravenous solutions or supplies from the drug box are used (or whenever the
pharmacy seal on the drug box is broken), a "Documentation of Medical Use and Medical Replacement"
form must be completed and signed by the EMT-P and signed by a physician.
 

12.     The broken (green) pharmacy seal and the white pharmacy copy of the documentation form will
be placed inside the drug box.  The EMT-P will then reseal the box, utilizing the RED numbered
seal provided for that purpose.
 

13.     The yellow (billing) copy of the documentation form will be completed by emergency room
personnel, totaling the patient's charges, and sent to data processing.
 

14.      The drug box must remain sealed at all times except when in actual use.  In the interim
period between the actual use of the drug  box and the time until the "Documentation of Medication
use and Replacement" form can be completed, including a valid physician signature, and the box
can be resealed with the red numbered seal, the EMT-P shall use an appropriate padlock or other
locking device to seal the drug box.  Only the EMT-P on duty shall have access to the key to
this locking device.
 

15.     The used drug box will then be exchanged for a pharmacy-sealed drug box at the designated area in,
or near, the emergency department under the supervision of appropriate emergency department or
pharmacy staff.    The used box will then be placed in the locked designated storage compartment
in, or near, the emergency department.  Appropriate record keeping of the exchange must be kept. 
Pharmacy staff will make daily rounds to pick up used drug boxes for inspection and restocking. 
During the hours in which pharmacy is open, the EMT-P will notify pharmacy whenever an
exchange of drug boxes has taken place.
 

16.     Once sealed by the pharmacist, the exchange drug boxes WILL NOT be inventoried by the
EMT-P personnel prior to the documented necessity for utilization.
 

17.     Any discrepancies in the drug box inventory that are discovered by the EMT-P at the time
of utilization will be documented on the "Documentation of Medication Use and Replacement"
form and will include:

          a.         Name of hospital pharmacy last restocking the drug box.

          b.         Date of last restocking.

          c.          Pharmacist's initials who last restocked the drug box.

          The form shall be co-signed by another EMT-P, EMT, nurse or physician.
 

18.     Controlled substances which are administered, contaminated, lost through spillage or partially used,
must be documented and accounted for on the EMT-P's "Documentation of Medication Use and
Replacement" form and co-signed by a physician, registered nurse, pharmacist, another EMT-P or
an EMT.  All used or partially used controlled substance containers  must be returned to the
emergency room physician or registered nurse before the documentation form is signed
by the physician.

19.     Emergency restocking of drug boxes:

          a.         In the event that all Mercy-Memorial Hospital drug exchange boxes have been utilized
after normal pharmacy hours of operation, the pharmacist on call may be called in
to restock the drug boxes.  The nursing supervisor on duty must be contacted to
call the pharmacist in.
 

          b.           Emergency restocking of a drug box may be performed by a licensed emergency department physician ONLY if a pharmacist is not readily available and prevailing conditions necessitate
the immediate restocking of the drug box.  All procedures and record keeping outlined above
must be followed.  In addition, a record must be made, in writing, by the emergency room
physician restocking the drug box documenting the events that necessitated the emergency
 restocking of the drug box.  Pharmacy must be notified as soon as possible that an
emergency restocking has taken place.
 

20.     Drug box procedure following transportation of patient outside of Monroe County:

          Transport to cooperating hospitals:

          a.         The drug box will be locked with an interim locking device.

          b.         The EMT-P will request drug replacement from the receiving hospital in accordance with
local procedure unless specific billing procedures have been established with
Mercy-Memorial Hospital (i.e., Saline Community Hospital).

          c.       The replacement drug items will be placed in the box and locked with an interim locking device (numbered seal).  The box is then returned to Mercy-Memorial Hospital to be exchanged
following all closed box exchange procedures.

          d.          "Documentation of Medical Use and Replacement" Form:

                      1.   White Copy (Pharmacy):  To be sent to Mercy-Memorial Hospital pharmacy.

                      2.   Yellow Copy (Billing):  To be given to receiving hospital's emergency room
personnel to incorporate into patient's emergency admission charge.

21.     TWO drug boxes shall be issued for each authorized transporting advanced life support vehicle
operating within the advanced mobile emergency care system.

          a. A single drug box shall be issued for each authorized non-transporting prehospital life support vehicle.
 

22.     Locked and secure compartments or other locking devices, approved by the Medical Control Authority - Advisory Board and the Michigan Department of Consumer and Industry Services, shall be provided
on the advanced mobile emergency care vehicle and utilized to prevent access to stored drugs
by unauthorized persons.

23.     Any incident resulting in diversion of a controlled substance shall be promptly reported to the following agencies:

          a.          Michigan State Board of Pharmacy

          b.           Michigan Department of Consumer and Industry Services, Emergency Medical
Services Division

          c.         Local law enforcement agency

          d.         U.S. Department of Justice/Drug Enforcement Administration

                      (Must be submitted on DEA Form 106, "Report of Theft or Loss of Controlled Substances)
 

In addition to the above agencies, the pharmacist member of the Medical Control Board and the Monroe County E.M.S. Coordinator shall be notified immediately and they will assume responsibility for the above notifications.

MONROE COUNTY ADVANCED EMERGENCY MEDICAL SERVICES
MEDICATION BOX CONTENTS LIST

MEDICATIONS                                 UNIT/SIZE                             NUMBER

Adenosine 3mg/ml                                  Vial 2mL                                 6
Albuterol Solution 2.5mg/3ml                    Vial 3mL                                2      
Amiodarone 150mg  (Cordarone)               Ampule 3mL                          4
Aspirin 8 1mg chewable                           Tablet                                    2
Atropine 1mg/10ml                                  Syringe 10mL                         3
Dextrose 5% in Water                             Bag 250mL                             1
Dextrose 50% - 25gm/50ml                     Syringe 50mL                          2
Diazepam 10mg/2ml (Valium)                  Syringe 2mL                           2
Diphenhydramine 50mg/ml (Benadryl)      Syringe 1mL                           2
Dopamine HCL 400mg in Dextrose 5%    Bag 500mL                              1
Epinephrine 1:10,000                             Syringe 10mL                         10
Epinephrine 1:1,000 (1mg/mL)(Adrenalin)  Tubex/Amp 1mL                     2
Furosemide 40mg/4mL (Lasix)                 Syringe                                  2
Ketorolac 30 mg/ml                                 Syringe 1mL                          2
Ketorolac 60 mg/2 ml                              Syringe 2mL                          1
Lidocaine 100mg/5mL (Bolus)                  Syringe 5mL                          4
Lidocaine HCL 2gm in Dextrose 5%          Bag 500mL                           1
Nalbuphine 20mg/ml (Nubain)                   Syringe lmL                          2
Naloxone 1.0mg/mL (Narcan)                   Amp. 2mL                             3
Nitroglycerin SL 1/150gr (0.4mg)               Bottle 25 tab                         1
Procainamide 1gm/2mLl                           Vial 2mL                               1
Sodium Bicarbonate 8.4% (50mEq/50mL)  Syringe 50mL                        2
Sodium Chloride 0.9% (IV)                        Bag 500mL                           1
Sodium Chloride 0.9% (Vial)                     Vial 10mL                              3
Vasopressin 20 units/lmL                         Vial 1mL                                3

SUPPLIES

Nebulizer                             1          Syringe 3ml with Needle          2

Intraosseous Needle             2          Syringe 10ml with Needle          2

Adhesive Tape           1          Syringe 20ml (No Needle)          1

Carpuject Holder                   1           Tourniquet          2

Gauze Pads (4 x 4)              2          Tubex Holder            2

Y extension #20019E            1          IVPB tubing 3

Needle 18 gauge                  4          Disposable Needle Box     1

Huber Needle 20 gauge 1          Medication Additive Sticker          6

Huber Needle 22 gauge 1          Red Tamper Lock   1

CRIC Needle 10 gauge          1          DOCUMENTATION OF

Syringe 1ml TB + Needle            1          MEDICATION USE   1
 

MONROE COUNTYADVANCED EMERGENCY MEDICAL SERVICES
MINIMUM REQUIRED INTRAVENOUS SOLUTIONS AND EQUIPMENT

QUANTITY                                       ITEM

             1                   500ml Bag Dextrose 5% in Water

             3                  1000ml Bag Dextrose 5% in Water

             5                  1000ml Bag Lactated Ringers

             5                  1000ml Bag Normal Saline 0.9%

             3                  Angiocath 14 gauge (Jelco)

             3                  Angiocath 16 gauge (Jelco)

             6                  Angiocath 18 gauge (Jelco)

             3                  Angiocath 20 gauge (Jelco)

             3                  Angiocath 22 gauge (Jelco)

             3                  Scalp Vein Needle 19 gauge (Minicath; Butterfly)

             3                  Scalp Vein Needle 21 gauge (Minicath; Butterfly)

             3                  Scalp Vein Needle 25 gauge (Minicath; Butterfly)

             4                  Primary Venoset - Abbott #1818

             4                  Primary Microdrip Venoset - Abbott #7393

             2                  30 inch Extension Set (Abbott or Travenol)

             2                  Tourniquets

            12                  Alcohol Swabs

             2                  Armboard 18" x 3"

            12                   Band-aids

             2     rolls       2 inch or larger Kling

             2                 #9166 Blood tubing and pump