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A review of drug use during air medical transport to optimize an air ambulance formulary
BRIEF REPORT
A Review of Drug Use During Air Medical Transport to Optimize An Air Ambulance Formulaw C. Keith Stone, MD; and Stephen H. Thomas, MD; Division of Air Medical Services, Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina Introduction: The advent of air medical transport has pushed the delivery of critical care medicine into the prehospital arena. As a result, a wide variety of pharmacologic agents must be available in the air medical setting. Purpose: The purpose of this study was to conduct a retrospective review of drugs used during air medical transport to allow a streamlining of the air ambulance formulary. Methods: All flights completed since the inception of the study's helicopter air ambulance program in 1985 through September 1991 were analyzed to determine which medications were used in flight. Drugs were counted if they were administered while in flight for either a scene or interhospital transport. Results: Review of 2,694 flights showed that 45 individual drugs had been routinely carried during the study period. Many of these agents were administered fewer than five times during the six years, and 10 drugs were not used at all. Conclusion: As a result of this investigation, the formulary for our air medical transport service was modified. The authors recommend similar critical audits of drugs carried in flight be performed by other air ambulance services.
This study was presented as a poster at the Air Medical Transport Conference in St. Louis, Mo., October 1993.
Key Words: Drugs, formulary, heficopter, patient transport, pharmacology Introduction As the level of care offered by air ambulance services has improved, the complexity of the air ambulance formulary has increased. The air ambulance team strives to provide a level of care that would optimally emulate the hospital's intensive care unit. The helicopter setting, however, imposes limitations on the number of pharmacologic agents that can be reasonably carried. In addition to the importance of economy of space utilization on the aircraft, the air ambulance formulary is
shaped by financial considerations and the types of patients transported by a particular program. Despite the complexity of these issues, little if any data exist to define the appropriate pharmacologic agents required in the air medical setting. Such data would allow for a streamlining of the air medical formulary, which would save space and money and even potentially improve patient care by reducing the chances of inappropriate drug administration. Since one of the primary variables affecting the air medical for-
mulary is the type of patients transported by a given program, a program-specific analysis of the air medical formulary is necessary to optimize benefits of the drug audit. The authors therefore undertook an analysis of all patients air transported by their p r o g r a m for six years. The goal of the study was to identify rarely u s e d agents that could be justifiably deleted from the medicine packs carried on patient flights. Methods A review of medications administ e r e d by the flight c r e w s of EastCare helicopter emergency air medical service based at Pitt County Memorial Hospital in Greenville, N.C., was performed. The review encompassed all flights from the inception of the p r o g r a m in 1985 through September 1991. The review was performed using a computerized data base into which all flights are e n t e r e d by the flight crew after completion of the transport. Individual drugs that were on the formulary for the helicopter over this period of time were reviewed. D r u g s a d m i n i s t e r e d in flight but which were obtained at referring hospitals were excluded. Medications that were administered
Submitted: Oct. 5, 1993; Revision submitted: Dec. 3, 1993;Accepted: Dec. 7, 1993 Address correspondence to: C. Keith Stone, MD, Department of Emergency Medicine, East Carolina University School of Medicine,
Greenville, NC 27858-4354,
Air Medical Journal • February 1994
63
"able •
Drug Utilization by Class on Air Medical Flights
Number of Flights in Which Each Drug Was Used
40
35
-&
Drug
30
Morphine Diazepam
~7 25
Lidocaine
"6 2o
t- 10 5 0
Cardiac Narcotics
Sedatives Antiemetics Paralytics
by the flight teams either on the ground or during flight for both scene runs and interhospital transports were included. As different m e d i c a t i o n p a c k s are u s e d for neonatal transports, these flights were excluded from the study. Results There were 2,694 completed flights during the study period. Review of the formulary identified 45 individual drugs that were routinely carried during the study. A significant number of medications were used fewer than five times, and 10 drugs were not used at all. Table 1 represents the number of flights in which each drug was used. Drug utilization by class is illustrated graphically in Figure 1. Discussion There are many potential disadvantages to carrying unneeded drugs in an air medical formulary. The costs of stocking and record-keeping are obvious, and there are more subjective advantages to saving space and reducing clutter in the air medical drug packs carried on patient transports. There is obvious importance of carrying the appropriate drugs on patient flights, and there is also clear disadvantage in carrying unneces-
64
Anticonvulsants
Others
Promethazine Nitroglycerine Vecuronium Dopamine Epinephrine Atropine Albumin Bicarbonate Pentobarbital Midazolam Heparin Phenobarbital Dobutamine Meperidine Phenytoin Nitroprusside Prochlorperazine Aminophylline Bretylium Fentanyl Isoproterenol Naloxone Streptokinase Procainamide Mannitol Ca Gluconate Dexamethasone Adenosine Diphenhydramine Mg Sulfate Oxytocin Verapamil Diazoxide Digoxin Glucagon Hydralazine Insulin Lorazepam Methylergonovine Propranolol Terbutaline tPA
No. F l i g h t s
182 118 105 83 66 56 55 52 45 44 41 38 36 30 21 12 11 11 9 9 7 7 6 6 5 5 4 3 2 2 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0
sary drugs. Given these facts, it is surprising that there is a paucity of relevant information in the medical literature. The issue of appropriate drug inclusion in the setting of commercial air travel has been addressed. 1 The authors of this paper report that their company's commercial airliners stock sufficient drugs and equipment to allow on-board physicians to manage "most medical emergencies" while the plane is being landed urgently. This paper has little relevance to air medical transport in the helicopter environment, where space is at a premium and fiscal considerations are more pressing. A second study has more relevance to contemporary air medical transport, reporting (as an abstract) that optimizing the contents of the air medical formulary could result in significant streamlining of agents carried on both scene and interhospital transports. 2 Specific drugs were not named, but it was found medical transport service was modithat almost half of the drugs carried fied. Thirteen drugs were from the on patient flights were rarely used, medicine packs, resulting in a sigand s e l e c t i v e d e l e t i o n of t h e s e nificant cost savings in the areas of agents could result in significant drug purchasing and storage. For cost savings in the air medical pro- example, tPA and s t r e p t o k i n a s e gram's stocking strategy. were removed from the formulary, As a result of this investigation, resulting in a substantial cost reducthe formulary for the study's air tion. In addition, record-keeping for Air Medical Journal • February 1994
the air ambulance formulary was simplified. Finally, elimination of non-utilized drugs helped alleviate space p r o b l e m s in the medicine pack carried on the helicopter, reducing clutter and decreasing the c h a n c e s of m e d i c a t i o n errors. Agents not used during the study period included methylergonovine, tPA, terbutaline, propranolol, lorazepam, insulin, hydralazine, glucagon, digoxin and diazoxide. Most of these drugs were eliminated from the drug packs routinely carried on patient transport. Methylergonovine, however, was retained on the formulary, as it is carried on the medicine pack used for obstetric flights and is potentially useful on certain transports. Some drugs were rarely used because of preferences for other similar agents (e.g., diazepam rather than lorazepam was used for seiz-
Air Medical Journal * February 1994
ure treatment) or rare indications for use in the air transport setting (e.g., diazoxide). Some drugs eliminated from the f o r m u l a r y (e.g., thrombolytic agents) may be administered in flight as a continuation of a regimen begun on the ground at the referring hospital. Since these agents would never be instituted while in flight and they are now widely available at referring institutions, there is little benefit to including these agents in the air medical formulary. Since this study reflects a report of the experience of one air ambulance service, it would be a mistake to recommend uniform adoption of the air medical formulary dictated by EastCare's patterns of drug use. Drugs that were eliminated from this formulary as a result of this study were agents that were either rarely used (and not potentially life-saving)
or duplicated by similar drugs in the same pharmacologic class. Conclusion A critical audit of drugs in an air medical formulary resulted in significant c h a n g e s to the formulary. Streamlining of the formulary may result in monetary, space-saving and record-keeping benefits. This study s u g g e s t s that air medical transport programs may benefit significantly from a review and subsequent modification of their air medical transport formulary. •
References 1. Glazer I, Cohen S. An improved comprehensive medical kit for passenger aircraft. Aviat Sp Env Med 1987; 58:1122-1126. 2. Cunnard V, Lewis W, Ridenour J, et al. Use of a drug inventory audit to optimize the contents of on-board drug supplies. Abstract.JAMT 1991; 10:97.
65
A Review of Drug Use During Air Medical Transport to Optimize An Air Ambulance Formulaw C. Keith Stone, MD; and Stephen H. Thomas, MD; Division of Air Medical Services, Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina Introduction: The advent of air medical transport has pushed the delivery of critical care medicine into the prehospital arena. As a result, a wide variety of pharmacologic agents must be available in the air medical setting. Purpose: The purpose of this study was to conduct a retrospective review of drugs used during air medical transport to allow a streamlining of the air ambulance formulary. Methods: All flights completed since the inception of the study's helicopter air ambulance program in 1985 through September 1991 were analyzed to determine which medications were used in flight. Drugs were counted if they were administered while in flight for either a scene or interhospital transport. Results: Review of 2,694 flights showed that 45 individual drugs had been routinely carried during the study period. Many of these agents were administered fewer than five times during the six years, and 10 drugs were not used at all. Conclusion: As a result of this investigation, the formulary for our air medical transport service was modified. The authors recommend similar critical audits of drugs carried in flight be performed by other air ambulance services.
This study was presented as a poster at the Air Medical Transport Conference in St. Louis, Mo., October 1993.
Key Words: Drugs, formulary, heficopter, patient transport, pharmacology Introduction As the level of care offered by air ambulance services has improved, the complexity of the air ambulance formulary has increased. The air ambulance team strives to provide a level of care that would optimally emulate the hospital's intensive care unit. The helicopter setting, however, imposes limitations on the number of pharmacologic agents that can be reasonably carried. In addition to the importance of economy of space utilization on the aircraft, the air ambulance formulary is
shaped by financial considerations and the types of patients transported by a particular program. Despite the complexity of these issues, little if any data exist to define the appropriate pharmacologic agents required in the air medical setting. Such data would allow for a streamlining of the air medical formulary, which would save space and money and even potentially improve patient care by reducing the chances of inappropriate drug administration. Since one of the primary variables affecting the air medical for-
mulary is the type of patients transported by a given program, a program-specific analysis of the air medical formulary is necessary to optimize benefits of the drug audit. The authors therefore undertook an analysis of all patients air transported by their p r o g r a m for six years. The goal of the study was to identify rarely u s e d agents that could be justifiably deleted from the medicine packs carried on patient flights. Methods A review of medications administ e r e d by the flight c r e w s of EastCare helicopter emergency air medical service based at Pitt County Memorial Hospital in Greenville, N.C., was performed. The review encompassed all flights from the inception of the p r o g r a m in 1985 through September 1991. The review was performed using a computerized data base into which all flights are e n t e r e d by the flight crew after completion of the transport. Individual drugs that were on the formulary for the helicopter over this period of time were reviewed. D r u g s a d m i n i s t e r e d in flight but which were obtained at referring hospitals were excluded. Medications that were administered
Submitted: Oct. 5, 1993; Revision submitted: Dec. 3, 1993;Accepted: Dec. 7, 1993 Address correspondence to: C. Keith Stone, MD, Department of Emergency Medicine, East Carolina University School of Medicine,
Greenville, NC 27858-4354,
Air Medical Journal • February 1994
63
"able •
Drug Utilization by Class on Air Medical Flights
Number of Flights in Which Each Drug Was Used
40
35
-&
Drug
30
Morphine Diazepam
~7 25
Lidocaine
"6 2o
t- 10 5 0
Cardiac Narcotics
Sedatives Antiemetics Paralytics
by the flight teams either on the ground or during flight for both scene runs and interhospital transports were included. As different m e d i c a t i o n p a c k s are u s e d for neonatal transports, these flights were excluded from the study. Results There were 2,694 completed flights during the study period. Review of the formulary identified 45 individual drugs that were routinely carried during the study. A significant number of medications were used fewer than five times, and 10 drugs were not used at all. Table 1 represents the number of flights in which each drug was used. Drug utilization by class is illustrated graphically in Figure 1. Discussion There are many potential disadvantages to carrying unneeded drugs in an air medical formulary. The costs of stocking and record-keeping are obvious, and there are more subjective advantages to saving space and reducing clutter in the air medical drug packs carried on patient transports. There is obvious importance of carrying the appropriate drugs on patient flights, and there is also clear disadvantage in carrying unneces-
64
Anticonvulsants
Others
Promethazine Nitroglycerine Vecuronium Dopamine Epinephrine Atropine Albumin Bicarbonate Pentobarbital Midazolam Heparin Phenobarbital Dobutamine Meperidine Phenytoin Nitroprusside Prochlorperazine Aminophylline Bretylium Fentanyl Isoproterenol Naloxone Streptokinase Procainamide Mannitol Ca Gluconate Dexamethasone Adenosine Diphenhydramine Mg Sulfate Oxytocin Verapamil Diazoxide Digoxin Glucagon Hydralazine Insulin Lorazepam Methylergonovine Propranolol Terbutaline tPA
No. F l i g h t s
182 118 105 83 66 56 55 52 45 44 41 38 36 30 21 12 11 11 9 9 7 7 6 6 5 5 4 3 2 2 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0
sary drugs. Given these facts, it is surprising that there is a paucity of relevant information in the medical literature. The issue of appropriate drug inclusion in the setting of commercial air travel has been addressed. 1 The authors of this paper report that their company's commercial airliners stock sufficient drugs and equipment to allow on-board physicians to manage "most medical emergencies" while the plane is being landed urgently. This paper has little relevance to air medical transport in the helicopter environment, where space is at a premium and fiscal considerations are more pressing. A second study has more relevance to contemporary air medical transport, reporting (as an abstract) that optimizing the contents of the air medical formulary could result in significant streamlining of agents carried on both scene and interhospital transports. 2 Specific drugs were not named, but it was found medical transport service was modithat almost half of the drugs carried fied. Thirteen drugs were from the on patient flights were rarely used, medicine packs, resulting in a sigand s e l e c t i v e d e l e t i o n of t h e s e nificant cost savings in the areas of agents could result in significant drug purchasing and storage. For cost savings in the air medical pro- example, tPA and s t r e p t o k i n a s e gram's stocking strategy. were removed from the formulary, As a result of this investigation, resulting in a substantial cost reducthe formulary for the study's air tion. In addition, record-keeping for Air Medical Journal • February 1994
the air ambulance formulary was simplified. Finally, elimination of non-utilized drugs helped alleviate space p r o b l e m s in the medicine pack carried on the helicopter, reducing clutter and decreasing the c h a n c e s of m e d i c a t i o n errors. Agents not used during the study period included methylergonovine, tPA, terbutaline, propranolol, lorazepam, insulin, hydralazine, glucagon, digoxin and diazoxide. Most of these drugs were eliminated from the drug packs routinely carried on patient transport. Methylergonovine, however, was retained on the formulary, as it is carried on the medicine pack used for obstetric flights and is potentially useful on certain transports. Some drugs were rarely used because of preferences for other similar agents (e.g., diazepam rather than lorazepam was used for seiz-
Air Medical Journal * February 1994
ure treatment) or rare indications for use in the air transport setting (e.g., diazoxide). Some drugs eliminated from the f o r m u l a r y (e.g., thrombolytic agents) may be administered in flight as a continuation of a regimen begun on the ground at the referring hospital. Since these agents would never be instituted while in flight and they are now widely available at referring institutions, there is little benefit to including these agents in the air medical formulary. Since this study reflects a report of the experience of one air ambulance service, it would be a mistake to recommend uniform adoption of the air medical formulary dictated by EastCare's patterns of drug use. Drugs that were eliminated from this formulary as a result of this study were agents that were either rarely used (and not potentially life-saving)
or duplicated by similar drugs in the same pharmacologic class. Conclusion A critical audit of drugs in an air medical formulary resulted in significant c h a n g e s to the formulary. Streamlining of the formulary may result in monetary, space-saving and record-keeping benefits. This study s u g g e s t s that air medical transport programs may benefit significantly from a review and subsequent modification of their air medical transport formulary. •
References 1. Glazer I, Cohen S. An improved comprehensive medical kit for passenger aircraft. Aviat Sp Env Med 1987; 58:1122-1126. 2. Cunnard V, Lewis W, Ridenour J, et al. Use of a drug inventory audit to optimize the contents of on-board drug supplies. Abstract.JAMT 1991; 10:97.
65