Full text of DOI:10.1080/10903120290938382

EDUCATION AND PRACTICE
IMPROVEMENTS IN PREHOSPITAL MEDICATION
STORAGE PRACTICES IN RESPONSE TO RESEARCH
Sameer H. Mehta, MD, Jim V. Doran, RN, MICP,
Robert F. Lavery, MICP, John R. Allegra, MD, PhD
ABSTRACT
Most of the MICUs in the state have changed their practices
in controlling and monitoring prehospital medication stor-
age temperature. Key words: EMS; temperature; storage;
monitoring; medications; research.
Previously the authors showed that prehospital medications
were stored outside their recommended temperature range.
In response, the state office of emergency medical services
(EMS) issued regulations regarding temperature control and
monitoring of prehospital medications. Objective: To deter-
mine the impact of previous research (on medication storage
conditions) on current practices among the mobile intensive
care units (MICUs) within the state. Methods: A statewide,
structured telephone survey of MICU directors was con-
ducted between April and December 2000. Questions
focused on changes in storage and monitoring practices
(including modifications to vehicles, medication boxes, and
the use of temperature monitoring devices) since the
authors’ previous research. Results: Thirty-three of 35 (94%)
programs (100 vehicles) participated in the survey. Eighty-
five percent changed their practices since the research five
years ago. Of the five that did not change, three already had
temperature control measures in place, while two have not
made any changes. Twenty-one (63%) of the programs
reported changing specifically because of state regulations.
Eighty-one percent of the programs have taken some meas-
ure to control temperature. Currently, 63% of the 100 vehi-
cles in use have both heating and cooling devices specifical-
ly for the medications, whereas 14% have only a heater and
23% have neither. Thirty-one (94%) MICUs monitor the
temperature in some manner: 42% in the vehicle, 58% in the
medication box. Of these, 68% are using 30-day electronic
temperature data recorders, whereas 32% are using non-
recording digital thermometers. Conclusions: This survey
demonstrates a positive impact from previous research.
PREHOSPITAL EMERGENCY CARE 2002;6:319–321
Previous research has shown that medications stored
in out-of-hospital vehicles are subject to temperatures
outside their safe storage range as recommended by
the manufacturers.1,2 These extreme temperature vari-
ations may cause changes in efficacy and safety of the
medications.3 For example, Church et al.3 showed that
elevated temperatures will cause degradation of epi-
nephrine. At temperatures below 0°C, medications in
aqueous solutions may freeze or increase in viscosity.
Further, many drug manufacturers will warrant and
guarantee their products’ quality, potency, and char-
acteristics only if their drugs are stored at the recom-
mended storage temperatures.4 The New Jersey Office
of Emergency Medical Services (OEMS) has respond-
ed to the previous research by Allegra et al.1 showing
that drugs in New Jersey were being stored outside
their recommended range. In 1998 New Jersey passed
regulations requiring that:
Each vehicle and cabinet or other storage place for med-
ications shall be sufficiently climate controlled so that the
medications and solutions are kept within the tempera-
ture range recommended by the manufacturer. Each
vehicle shall have a temperature recording device which
shall, at least, record the highest and lowest temperature
during a specified time period.5
Received November 16, 2001, from the Residency in Emergency
Medicine, Morristown Memorial Hospital (SHM, JVD, JRA),
Morristown, New Jersey; and the UMDNJ Trauma Center (RFL),
Newark, New Jersey. Revision received February 20, 2002; accepted
for publication February 21, 2002.
Our objective was to determine what the current
medication storage practices are among the mobile
intensive care units (MICUs) in New Jersey and to see
whether any changes have occurred since the previ-
ous research. Specifically, we sought to determine
how the medications are stored, how temperature is
being monitored, and the length of current practices.
Presented as a poster at the American College of Emergency
Physicians annual meeting, Chicago, Illinois, October 2001.
Address correspondence and reprint requests to: Sameer H. Mehta,
MD, Department of Emergency Medicine, 100 Madison Avenue,
Morristown, NJ 07960. e-mail: <smehtamd@hotmail.com>.
319

320
PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
However, 14% have only a heater and 23% have nei-
ther (Fig. 1). No programs reported having only a
cooling device specifically for their medications.
METHODS
Between April and December 2000, we conducted a
structured telephone survey of MICU directors in
New Jersey. The survey consisted of 11 questions and
focused on changes in storage and monitoring prac-
tices since our previous research.1 In regard to med-
ication storage, questions focused on the presence or
absence of heating or cooling devices and whether
these devices were located in the medication box or in
the vehicle. Second, questions focused on whether any
monitoring of medication temperatures occurred.
Furthermore, we inquired about the device used to
monitor the temperature (nonrecording digital ther-
mometer vs. temperature data recorders). Finally, the
last questions focused on the length of time of current
practices and whether there were any recent changes.
Mobile intensive care unit directors were contacted
by one of the four investigators for greater uniformity.
The closed-end, structured survey took less than 5
minutes to complete. Data from each survey were
entered into a Microsoft Excel 97 spreadsheet
(Microsoft Corp., Redmond, WA) for further analysis.
Confidentiality was maintained throughout.
Monitoring
Our second goal was to determine temperature moni-
toring practices. Almost all of the MICU programs
(94%) reported monitoring the temperature in some
manner. Of those that do monitor the temperature,
42% reported they do so in the vehicle compartment,
while 58% check the temperature in the medication
compartment. Two-thirds of this group are using
some form of electronic data recorders, whereas 32%
use nonrecording digital thermometers.
Length of Practices
Finally, the length of current practices was assessed.
Eighty-five percent (28 programs) changed their prac-
tices since our research five years ago, with the major-
ity (67%) of the programs changing their practices in
the last two years (Fig. 2). Of the five that have not
changed in the last five years, three already had some
temperature control measures in place, whereas the
remaining two programs have not made any changes.
Twenty-one (63%) of the programs stated that they
changed specifically because of state regulations,
whereas 9% of the programs (3/33) bought new vehi-
cles. Two of the programs (6%) stated that they
changed their practices due to their own prior experi-
ences.
RESULTS
Storage
Ninety-four percent of programs (33/35, representing
100 vehicles) participated in the survey. Multiple
attempts to obtain information from the remaining
two programs were unsuccessful. Thirty-one (81%) of
the programs have taken some measure to control
temperature. Thirty-seven percent of the vehicles are
parked inside a garage with climate control when the
vehicle is not in use, whereas 53% are parked outside.
Ten percent of the vehicles remain in a garage without
any climate control. Currently, 63% of the 100 vehicles
in use have both heating and cooling devices specifi-
cally for the medications in addition to the normal
heating/air condition system for the vehicle.
DISCUSSION
The issue of whether medications are being stored
within recommended temperature ranges is an impor-
tant consideration. The State of New Jersey has recog-
nized this and has passed regulations requiring
appropriate monitoring and storage of prehospital
medications.5
Our results show that there have been significant
improvements in medication storage and temperature
FIGURE 1. Percentages of vehicles containing current temperature control devices.

Mehta et
al.EMDICATION STORAGE IMPROVEMENTS
321
FIGURE 2. Length of current practices (percentages of programs).
monitoring practices in New Jersey since our research
five years ago. In terms of storage, a majority (63%) of
the programs dedicated heating and cooling devices
for the medications. However, 23% of the vehicles
have neither heating nor cooling mechanisms specifi-
cally for the medications. This represents a significant
number of vehicles (23 of 100) operational in the state
that have not responded either to previous published
research or to state regulations. In regard to monitor-
ing the temperature, only 6% of the programs do not
monitor the temperature in some manner. Impressive-
ly, 85% of the programs stated that they changed their
practices since our original research five years ago.
range would be useful. Furthermore, it would be
interesting to examine the monthly temperature data
log of a random sample of vehicles.
CONCLUSION
Most MICUs in the state have changed their practices
in controlling and monitoring prehospital medication
storage temperature. Our study demonstrates that
there has been a positive impact from previous
research; however, there remains room for further
improvement.
References
1. Allegra JR, Brennan J, Lanier V, et al. Storage temperatures of
out-of-hospital medications. Acad Emerg Med. 1999;6:1098-
103.
2. Palmer RG, Zimmerman J, Clawson JJ. Altered states: the influ-
ence of temperature on prehospital drugs. J Emerg Med Serv.
1985;10(12):29-31.
3. Church WH, Hu SS, Henry AJ. Thermal degradation of
injectable epinephrine. Am J Emerg Med. 1994;12:306-9.
4. Kellow RC, Ferguson CL, Spruill WN. Drug adulteration in pre-
hospital emergency medical services: a report of findings in sci-
ence, practice, law and government. Jackson, MS: Division of
Emergency Medical Services, Mississippi State Department of
Health, Oct 1994.
LIMITATIONS
This study has all the limitations associated with a
telephone survey, including reporting, recall, and
acquiescence bias. Our study demonstrates that most
of the MICU programs in the state have changed their
practices in regard to prehospital storage of medica-
tions. However we are unable to comment on whether
the climate control devices are being used appropri-
ately and whether the temperature measuring devices
are being monitored on a regular basis. Perhaps an
automated temperature recorder with an audible
alarm for temperatures outside the recommended
5. New Jersey Department of Health and Senior Services Suppl.
Section 8:41-3.12, paragraph (f); Aug 17, 1998.