Date and Time of Check
Now M-D-Y H:M
Resident's Name
Role R1
R2
R3
Is resus ultrasound clean and plugged in by room 21? Yes
No
Nasal Cannula Sufficient
Insufficient
Par 20
How many nasal cannula are needed? 5 10 15 20
Nonrebreather masks Sufficient
Insufficient
Par 20
How many NRBs are needed? 5 10 15 20
EtCO2 Nasal Cannula Sufficient
Insufficient
Par 10
How many etco2 nasal cannula are needed 5 10
Adult BVM Sufficient
Insufficient
Par 5
How many adult BVM are needed? 0 1 2 3 4 5
Chest Tubes (28, 32) Sufficient
Insufficient
Par 2 each size
What is needed? 28 French
32 French
Pleur-evac (labeled as "chest tray") Sufficient
Insufficient
Par 2 and 2 in storage room
How many pleur-evacs are needed? 1 2 3 4
Thora-para kits Sufficient
Insufficient
Par: 3
How many thora-para kits are needed? 1
2
3
Sterile Bundles (labeled as "crit care drapes") Sufficient
Insufficient
Par 3
How many sterile bundles are needed? 1 2 3 4 5
Par 3 and 2 in storage room
Triple Lumen Catheters / Shiley / Cordis Sufficient
Insufficient
Par 3/2/2, Choose insufficient if any need stocking
What is needed? TLC
Shiley
Cordis
Arterial Line kit Sufficient
Insufficient
Par 3
How many arterial line kits are needed? 1 2 3 4 5
Pigtail trays (labeled as "Wayne pneumothorax trays") Sufficient
Insufficient
Par 2 and 2 in storage room
How many pigtail trays are needed? 1 2 3 4
Pericardiocentesis kits Sufficient
Insufficient
Par 2
Lumbar Puncture Kit Sufficient
Insufficient
Par 2 and 2 in storage room
How many LP trays are needed? 1 2 3 4
OB Bundle Sufficient
Insufficient
Par 2
How many OB bundles are needed? 1 2
Trans-venous pacer kit ("pacing electrode tray") Sufficient
Insufficient
Par 3
How many TVP kits are needed? 1 2 3
Par 3
Pacemaker/magnet in place Yes
No
Par 1
Blakemore Sufficient
Insufficient
Par 2
Airway box Sufficient
Insufficient
Par: 4
How many airway boxes are needed? 1 2 3 4 5
Glidescope present Yes
No
Par 1
Glidescope MAC Blades S3 / S4; Hyperangulated Blades S3 / S4 Sufficient
Insufficient
Par 2/2/2/2, Choose insufficient if any need stocking
What is needed? Glidescope S3
Glidescope S4
Glidescope Hyperangulated S3
Glidescope Hyperangulated S4
CMAC present including video attachment Yes
No
Par 1
CMAC Blades MAC 3/4 and Hyperangulated blades Sufficient
Insufficient
Par 1/1/1, choose insufficient if any need stocking
What is needed? CMAC S3 Blades
CMAC S4 Blades
CMAC Hyperangulated Blades
Hyperangulated stylets Sufficient
Insufficient
Par 3
How many hyperangulated stylets are needed? 1 2 3 4 5
LMA 3.5 / 4.5 Sufficient
Insufficient
Par 3/3
What is needed? LMA 3.5
LMA 4.5
EtCO2 water trap, sample line, adapter (If needed, notify RT) Sufficient
Insufficient
Par 5/5/5, choose insufficient if any need stocking
What is needed? Water trap
Sample line
Adapter
11-blade scalpel Sufficient
Insufficient
Par 5
How many 11-blade scalpels are needed? 1 2 3 4 5
Awake intubation meds/equipment (2&4% lido, glyco, atomizer) Sufficient
Insufficient
Par 1
What is needed? 2% lidocaine
4% lidocaine
glyco
atomizer
Bougies Sufficient
Insufficient
Par 5
How many bougies are needed? 1 2 3 4 5
Trachs (Shileys), 4.0 / 6.0 Sufficient
Insufficient
Par 2/2, choose insufficient if any need stocking
What size is needed? 4.0
6.0
Long angiocatheters (18ga, 20ga) Sufficient
Insufficient
Par 10 each size
What is needed? 18 gauge
20 gauge
Is the EZ IO Drill present? Yes
No
Par 1
Is the EZ IO Drill functional? Yes
No
Press it on to see if it works
EZ IO Needles (pink, blue, yellow) Sufficient
Insufficient
Par 3/3/3, Choose insufficient if any need stocking
What is needed? Pink
Blue
Yellow
Radial Arterial Lines Sufficient
Insufficient
Par 5
How many radial arterial lines are needed? 1 2 3 4 5
Chest Tube Tray Sufficient
Insufficient
Par 2
Chest tubes (28, 32) Sufficient
Insufficient
Par 1/1
Thoracotomy Tray Sufficient
Insufficient
Par 1
Betadine Yes
No
BIPAP Masks (S / M / L) - If needed notify RT Sufficient
Insufficient
Par 3/3/3, Choose insufficient if any need stocking
What size masks need restocked? Small
Medium
Large
CMAC Blades MAC 3/4 and Hyperangulated blades
Glidescope MAC 3/4 and Hyperangulated blades Sufficient
Insufficient
Par 3/3/3, 3/3/3, Choose insufficient if any need stocking
What needs stocking? CMAC MAC 3
CMAC MAC 4
CMAC Hyperangulated
Glidescope MAC 3
Glidescope MAC 4
Glidescope Hyperangulated
Lucas device Present
Not Present
Par 1
Is the LUCAS device plugged in? Yes
No
Phenylephrine sticks Sufficient
Insufficient
Par 5
How many phenyl sticks are needed? 1 2 3 4 5
Epinephrine Sufficient
Insufficient
Par 5; Note: 1 mL epi from cardiac amp + 9 mL saline = 10 mcg/mL push-dose epi
How many epi sticks are needed? 1 2 3 4 5
Did you notify the Resus lead RN of the missing supply items? Yes
No
Why not?
Did you notify the RT? Yes
No
Why not?