In the setting of emergent care, the ability to access equipment rapidly and reliably can be a deciding factor in patient outcome. Poor stocking, inconsistent organization, and dispersal of equipment throughout a large geographic area are realities of practice as well as barriers to rapid and effective patient care. Equipment kits are a great way to ensure rapid access to a select set of tools to deal with emergent scenarios. They result in both decreased time to arrival and decreased time to successful completion of procedure.1,2 Scenarios that can benefit from organized and well provisioned kits include central or peripheral access, airway management, initial stabilization, monitor application, chest tube placement, or cricothyroidotomy. A word of caution: equipment kits are not a substitute for skill and cannot be thought of as a fix-all. They keep a specific set of equipment in an easy-to-locate, all-in-one package for use in a predetermined set of scenarios.
How to Build a Kit
1. Identify a Clinical Scenario that Might Benefit from a Kit
Equipment kits should be purpose-driven by design, and useful only in a specific, finite range of applications. The range of equipment that they contain must be limited to minimize clutter, bulk, and degree of complexity. When creating your kit, outline a well-defined range of scenarios in which your kit can be used. This will prevent indication creep or the ever-growing gear bag. When it comes to these kits, less is more.
Appropriate scenarios will be unique to every clinical setting, department and team of clinical operators. First examine your current practice and identify procedures that are affected by the following:
- Geographic dispersal of equipment over a large area
- Unreliable availability of equipment
- Difficulty with organization, access, or portability of equipment
- Serve as a finite point of access to a set of predetermined equipment
- Are easily checked and restocked
- Organize equipment in a set-up that promotes consistent/standardized organization and mobility
Equipment kits are not ideal for scenarios that require extensive set-ups, include large and/or cumbersome items, or involve set-ups that require perishable items or close monitoring.
2. Choose the Equipment
Once the specific applications of the kit have been identified, make a list of all equipment that may be useful in the selected scenarios. Enlist the aid of operators who are experienced in the proposed scenarios in order to ensure a complete list.3 After the complete list is created, review extensively to include only the essential equipment.
Ideally, kits are streamlined sets of tools to deal with a highly specific and limited set of scenarios to permit rapid response to a dynamic situation. If the equipment required for a given scenario leads to an overcrowded kit, consider narrowing the scope of the kit’s purpose, creating multiple kits, or using a well-modularized kit to allow better accessibility and prevent clutter.
3. Identify a Feasible Platform for the Kit
When selecting a platform for the kit, consider the specific scenarios and operating environments. Things to think about:
- Mobility requirements
- Degree of modularity
- Internal organization structure
- Avoid “dump space,” in which large segments of a kit become disorganized areas packed with miscellaneous tools
- Supported procedure
- Does the application require immediate access to all of its contents? Consider a central pocket that is well divided and organized.
- Does the application require sequential escalation and deployment of sequential sets of equipment? Consider a roll that promotes sequential access to tools.
- Predicted environment of utilization
- For example, is waterproofing necessary?
The platform itself may take the form of a bag, cart, sealed kit, or even a backpack. A limited selection of these options are reviewed below:
Equipment Cart: Already commonly implemented in hospitals in a variety of roles
- Mobility: Allows for easy transport within a hospital setting, but is less ideal for operations in the field or austere environment
- Size: Very large, but can hold a proportional amount of bulky, even heavy equipment
- Storage: Will need designated footprint for storage
- Organization: Usually based upon a drawer system. Different sizes of drawers and different layouts with internal drawer divider can be used to further organize. Labeling the exterior of drawers critical to rapid access. Cabinet doors are also a possibility, but may lead to large areas of unorganized “dump space.”
- Accessibility: Only 1-2 drawers can be opened at once, limiting simultaneous access to equipment. However, it is relatively easy to rapidly cycle drawers to get access to what is needed.
Sealed Kit or Box: Commonly implemented in the hospital setting, often as the airway set-up
- Mobility: High degree of mobility, again limited in the austere environment or for prolonged transport
- Size: Small footprint, size can be adjusted to need
- Storage: Usually stackable. Again, small footprint allows for easy storage
- Organization: Internal dividers are available, however commonly acts as a small “dump-space” for equipment
- Accessibility: Can immediately access all contained equipment
- Mobility: Most mobile of platforms
- Size: Scalable to size and mobility
- Storage: Self-contained, easy to store
- Organization: May be accomplished with multiple compartments, pockets or internal dividers. With platforms that have large pockets or central compartments, dividers or internal organizers are critical. External pockets can be fantastic for organization, but an excessive number of small or poorly labelled pockets or dividers can contribute to difficulties with organization and locating equipment.
- Accessibility: Varies highly by platform. Ideally, platform should provide 1 to 3 main divided areas that are immediately accessible to allow for equipment deployment.
Equipment kits will benefit from judicious labeling to allow for rapid navigation. Labels should be large enough to be easily legible and contain minimal text.
4. Trial the Kit in the Medical Environment
Run your kit through multiple dry-run scenarios or simulations. This process is integral in working out kinks, narrowing the amount of equipment in the kit, and ensuring that the kit is assembled and organized in a manner that ensures ability to efficiently and rapidly access equipment. Enlist expert operators for assistance with this step.
5. Roll out the Kit
All staff who will be expected to use the equipment or restock the equipment set-up should be familiar with the kit’s content and organization. This ensures that the kit can be smoothly deployed no matter who is using it and ensures that all appropriate equipment is present at all times. A durable resource explaining the content and use of the kit should be created and included in the kit and at least annual trainings should be held to keep staff familiar and updated with kit revisions.
6. Ensure a Fully-Stocked Kit
Once the kit has been designed, a system needs to be put in place to ensure that the kit is fully stocked and ready for each use. Any restocking system should involve:
- Designated responsible party for restocking
- Timeframe for regular checks
- A system to indicate when ready for use
- Breakable seals, indication placards, or separate storage areas for complete and used kits
- Periodical inspection of “ready” kits to verify contents have not been expired or been damaged
The more frequently used kits will require constant restocking. The more rarely used kits may rarely be checked for readiness. Either pitfall can be addressed by scheduled inspections to ensure a consistent inventory. At the minimum, this should be done immediately prior to any possible use of the kit.
7. Revise the Kit
The kit should be reviewed periodically to ensure that it can fulfil its designated role. In the dynamic healthcare environment, the niche that is filled by an equipment set may change, requiring a reconceptualization of the kit to ensure that it is able to fulfil its role appropriately. A yearly review should be strongly considered to incorporate feedback from the kits implementation in real-life scenarios and to review the kits ability to fulfil its role.4,5 Dry-run scenarios or simulation can be very helpful in ensuring a kits content and purpose is appropriate during the review process.
Example: The Difficult Airway Bag
At our institution, the emergency department staff is responsible for emergent intubations on the hospital floors and ICU overnight. As such, staff must be able to rapidly respond to a variety of airway emergencies anywhere in the facility with all appropriate airway equipment on very short notice. There are four crucial pieces of equipment:
- An airway roll containing all standard direct laryngoscopy (DL) intubation equipment including endotracheal tube (ETT) from size 6-8, as well as MAC and Miller 3 and 4 laryngoscope blades
- A rapid-sequence intubation (RSI) box containing all RSI meds that may be needed
- A wheeled tower with both Glidescope and C-Mac monitors, blades and stylets
- The difficult airway bag
The difficult airway bag allows for successful intubation on airways that cannot be obtained with simple DL or video-assisted intubation. The kit contains:
- NPAs and OPAs
- Supraglottic tubes
- Smaller ETTs and laryngoscopes (MAC/Miller 2 blades)
- Sub-kit for tracheostomy exchange
- Sub-kit for cricothyroidotomy
- Sub-kit for epistaxis
- Wire cutters
The kit is set up in a durable duffle-type bag that allows immediate access to the epistaxis kit, NPAs/OPAs, spare tracheostomies, LMAs, King laryngeal tubes (LTs), and the cricothyroidotomy kit without accessing the main compartment. The remainder of the kit is organized within the main compartment using dividers. The kit is not designed to deal with any airway contingency. It does not contain the equipment for obtaining IV access, awake intubations, or nasal intubation.
The kit itself is stored in a designated storage cabinet in the main emergency department which has the complete kit inventory list as well as a diagram of the kit. This cabinet is used only for the difficult airway bag. On the outside of the cabinet there is a placard that has a green and red side which reads READY and RESTOCK respectively. Whenever something has been used out of the kit and cannot be immediately replaced, the placard is flipped to the red RESTOCK side so that other providers or the charge nurse are prompted to restock the kit. All emergency providers and the ED charge nurse are responsible for keeping the kit stocked and ready to deploy.
Equipment set-ups are a great way to rapidly and reliably deploy equipment in a variety of clinical settings. They should be designed to fulfil specific roles, and require pristine, predictable organization to permit rapid deployment of equipment in any scenario. The platform and organization that the kit is based upon should be chosen keeping in mind the specific clinical environment(s) that the kit will be used in. Kits can become an important addition to almost any clinical environment and their implementation should be considered in a variety of applications.
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Travers S, Carfantan C, Luft A, et al. Five years of prolonged field care: prehospital challenges during recent French military operations. Transfusion. 2019;59(S2):1459-1466. https://www.ncbi.nlm.nih.gov/pubmed/30980759.