U.S. patent application number 09/897689 was filed with the patent office on 2002-01-31 for anesthesia cart.
Invention is credited to Chang, Steven W., Kurtz, Michael, Phoon, Florence H., Radziminski, Thomas E., Richter-Dycaico, Paula A., Ross, Christopher G..
Application Number | 20020013640 09/897689 |
Document ID | / |
Family ID | 22635268 |
Filed Date | 2002-01-31 |
United States Patent
Application |
20020013640 |
Kind Code |
A1 |
Phoon, Florence H. ; et
al. |
January 31, 2002 |
Anesthesia cart
Abstract
A computerized medication dispensing station that addresses
anesthesia medication management and tracking problems is
disclosed. Medications, including narcotic and non-narcotic, and
supplies for use in anesthesia, are stored in secured,
semi-secured, and unsecured containers of a mobile station. A
computer housed in the station is used to track the anesthesiology
items that have been removed from the station. For each item
removed, the time of removal, who removed it, and to whom it was
administered is tracked. Items that are not administered to a
patient are returned to the pharmacy or wasted (i.e., disposed in
accordance with regulations). Each type of event (administration to
a patient, return, or waste) is documented so that a health care
institution can track usage of items, including narcotic
medications, for use in anesthesia.
Inventors: |
Phoon, Florence H.; (San
Diego, CA) ; Ross, Christopher G.; (San Diego,
CA) ; Chang, Steven W.; (Chandler, AZ) ;
Radziminski, Thomas E.; (San Diego, CA) ;
Richter-Dycaico, Paula A.; (San Diego, CA) ; Kurtz,
Michael; (San Diego, CA) |
Correspondence
Address: |
Michael D. Steffensmeier
Cardinal Health, Inc.
7000 Cardinal Place
Dublin
OH
43017
US
|
Family ID: |
22635268 |
Appl. No.: |
09/897689 |
Filed: |
July 2, 2001 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
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09897689 |
Jul 2, 2001 |
|
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09174205 |
Oct 16, 1998 |
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Current U.S.
Class: |
700/237 |
Current CPC
Class: |
A61G 12/001 20130101;
A61J 7/0084 20130101 |
Class at
Publication: |
700/237 |
International
Class: |
G06F 017/00 |
Claims
What is claimed is:
1. An apparatus for storing, tracking, and documenting usage of
anesthesiology items, comprising: a mobile cart having a plurality
of containers at least one of said containers adapted to be secured
for authorized access; a plurality of anesthesiology items adapted
for use during anesthetic procedures, resident in at least one of
said containers; a data entry device on said cart, said data entry
device adapted to enable an individual administering anesthetic
procedures to enter an identifier for said individual and
information relevant to a selected anesthesiology item and adapted
to associate said identifier with said selected anesthesiology
item; a lock in association with said at least one secured
container and in electronic communication with said data entry
device, said lock adapted to enable said container to be opened
upon receiving said relevant information from said data entry
device.
2. The apparatus of claim 1, wherein said containers include one or
more of the group consisting of secured, semi-secured, and
unsecured.
3. The apparatus of claim 1, wherein said containers are drawers
and latched receptacles.
4. The apparatus of claim 3, wherein said latched receptacles are
housed within said drawers.
5. The apparatus of claim 1, wherein said data entry device
includes a rotating extension monitor stand.
6. The apparatus of claim 5, wherein said rotating extension
monitor stand is equipped with a plurality of pivot points.
7. The apparatus of claim 1, wherein said anesthesiology items
include one or more of the group consisting of narcotic
medications, non-narcotic medications, and supplies.
8. A method for storing, tracking, and documenting anesthesiology
items comprising the steps of: (a) storing a plurality of
anesthesiology items in containers in an anesthesia cart; (b)
prompting a user for an identifier; (c) providing a list of said
anesthesiology items stored in said containers in said anesthesia
cart; (d) selecting for removal one of said plurality of
anesthesiology items on said list; (e) removing said selected
anesthesiology item; (f) associating said anesthesiology item with
said identifier; (g) defining a case; and (h) documenting usage of
said anesthesiology item.
9. The method of claim 8, wherein the step of defining a case
includes entering one or more of the group consisting of a patient
identifier, a case type, and a case number.
10. The method of claim 8, wherein the step of documenting usage of
said anesthesiology item occurs after the administration of said
anesthesiology item to an anesthesia patient.
11. The method of claim 8, wherein the step of documenting usage
comprises the steps of assigning a removed anesthesiology item to
said case, returning at least a portion of said removed
anesthesiology item to said anesthesia cart, or wasting said
anesthesiology item.
12. The method of claim 11, wherein the step of assigning said
removed anesthesiology item comprises the steps of selecting said
case, entering a dosage amount, and entering a time of
administration.
13. The method of claim 8, further comprising the step of assigning
said anesthesiology item to said case upon removal of said
anesthesiology item from said anesthesia cart.
14. The method of claim 11, further comprising the step of
transferring said removed anesthesiology item to another anesthesia
cart.
15. The method of claim 8, wherein said anesthesiology items
include one or more of the group consisting of narcotic
medications, non-narcotic medications, and supplies.
16. The method of claim 15, wherein said narcotic medications are
stored in secured containers in said anesthesia cart.
17. The method of claim 15, wherein said non-narcotic medications
are stored in semi-secured or unsecured containers in said
anesthesia cart.
18. The method of claim 8, further comprising the step of
monitoring the inventory stored in said anesthesia cart.
19. A system for storing, tracking, and documenting anesthesiology
items comprising: a cabinet for storing anesthesiology items in
containers; a container control unit in communication with said
containers for controlling access to said anesthesiology items in
said containers; an access control unit in communication with said
container control unit for determining which of said anesthesiology
items have been removed from said containers and documenting usage
of said anesthesiology items removed from said containers after
administration of said anesthesiology items to at least one
anesthesia patient.
20. The system of claim 19, wherein said cabinet further comprises
secured, semi-secured, and unsecured containers.
21. The system of claim 19, wherein said anesthesiology items are
stored in kits.
22. The system of claim 21, wherein said kits are designed to be
case-specific or user-specific.
23. The system of claim 19, wherein said access control unit
documents usage of said anesthesiology items by storing case
information and information regarding administration, return, and
wasting of said anesthesiology items.
24. A method of administering anesthesia, comprising: providing a
mobile cart with containers, said mobile cart adapted to be freely
moved apart from connections to a computer network; stocking said
containers in said cart with anesthesiology items; providing a data
processor with a data entry device on said cart; providing
electronic communication between said data processor and said
containers to enable said containers to be opened upon entry of
predetermined data; entering data in said data entry device
relevant to a procedure involving the use of anesthetic; accessing
one of said containers; removing an anesthesiology item from said
one of said containers; administering said anesthesiology item to a
patient; and entering data regarding said anesthesiology item
administered to said patient through said data entry device.
25. The method of claim 24, further comprising: moving said cart to
an area where anesthetic is administered to a patient.
26. The method of claim 24, further comprising: downloading said
data regarding said anesthesiology item administered, to a pharmacy
computer system.
27. The method of claim 24, further comprising: providing an
electronic viewing terminal on said cart, said viewing terminal
electronically connected to said data processor.
28. The method of claim 27, further comprising: providing a
computer program operable on said data processor to query a health
care provider through a user interface visible on said viewing
terminal for data regarding said anesthesiology items, said
anesthetic procedure, said patient, or said health care
provider.
29. The method of claim 24, further comprising: providing storage
compartments on said cart.
30. The method of claim 24, wherein said cart is on wheels, rollers
or casters.
31. The method of claim 24, wherein said containers are secured
until required data is entered into said data processor.
32. The method of claim 24, wherein said containers automatically
open upon entry of required data in said data processor.
33. The method of claim 24, wherein one of said containers
automatically opens upon entry of required data in said data
processor.
34. The method of claim 24, wherein said containers are drawers or
latched receptacles.
35. The method of claim 34, wherein said containers comprise
drawers containing latched receptacles.
36. The method of claim 24, wherein said containers contain unit
dose packages of drugs.
37. The method of claim 24, wherein said containers contain only
one type of anesthesiology item per container.
38. A system comprising: a health care facility computer network;
and a mobile cart including a data processor on said cart, said
cart adapted to be supplied with anesthesiology items in containers
on said cart, at said health care facility, said data processor
adapted to be connected to said computer network and adapted to be
disconnected from said computer network when said cart is moved to
an area where anesthesiology items are administered, said data
processor adapted for entry of data regarding anesthesiology items
removed from said containers even while said data processor is not
connected to said computer network, said data transferred to said
computer network when said data processor is connected to said
computer network.
39. The system of claim 38, further comprising: a touchscreen data
entry video terminal on said cart and connected to said data
processor. items in ordered fashion and the contents of each
container is input into a computer memory prior to said
anesthesiology items being administered.
40. The system of claim 38, further comprising: a security device
in association with at least some of said containers on said cart
to prohibit access to said at least some of said containers prior
to entry of required data in said data processor.
41. The system of claim 38, wherein each of said containers are
loaded with anesthesiology items in an ordered fashion and the
contents of each container is input into a computer memory prior to
said anesthesiology items being administered.
42. The system of claim 41, wherein said computer memory is in said
computer network.
43. The system of claim 41, wherein said computer memory is in said
data processor.
44. The system of claim 40, wherein said security device is an
electronically operable lock in communication with said data
processor.
45. The system of claim 38, wherein said data processor is adapted
to perform inventory control functions.
Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] The present invention relates generally to computerized
medication management and dispensing stations. More particularly,
the present invention relates to a system, method, and apparatus
for controlling the dispensing and inventory of anesthesiology
items in a health care institution.
[0003] 2. Description of Related Art
[0004] Medication management in anesthesia presents a challenge for
both the pharmacy and the anesthesia departments in health care
institutions. Anesthesia requires open, unrestricted access to many
medications, including narcotics as well as supplies. Pharmacies,
on the other hand, must control access to medications and impose
security measures. Organizations such as the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), the Drug
Enforcement Agency, and the State Boards of Pharmacy require strict
documentation and record keeping of narcotic usage. The JCAHO
provides accreditation to member hospitals. In order to earn and
keep the JCAHO accreditation, hospitals must adhere to strict
access and control policies for medications or risk potential fines
and possible shut down of the facility. Fines related to improper
management of narcotics in one operating room can be $15,000.00 or
more per offense. A study found that 11% of all hospitals reviewed
by the JCAHO received a recommendation for improvement based on
improper handling of narcotics.
[0005] The pharmacy is responsible for medications, particularly
from a regulatory perspective, but is able to manage the
medications only remotely. As a consequence, a serious
responsibility gap exists in medication control from the time the
medications are issued to anesthesiologists until the end of the
day when remaining medications are returned. Complying with federal
regulations is often a tedious task. Anesthesia records are often
incomplete with respect to accurate medication usage documentation
during and after a procedure. Current methods of anesthesia
narcotic medication management are labor intensive for pharmacists
and anesthesiologists, often leading to costly errors. Currently,
narcotics are generally tracked in one of two fashions.
[0006] A first method of tracking narcotics, the satellite
pharmacy, is used at some of the larger hospitals. Affluent
hospitals often provide a satellite pharmacy that services the
special needs of the operating room. The anesthesiologist signs out
narcotics from the satellite pharmacy by going to the pharmacy and
interacting with a pharmacist. If a pharmacist is not available,
one must be paged. The anesthesiologist returns to the satellite
pharmacy when a free moment is found to reconcile the unused
medications with a pharmacist. Reconciling unused medications
requires documenting on the patient record or returning to the
pharmacy all medications that were signed out by the
anesthesiologist. The pharmacy disposes of contaminated medications
(referred to as "waste") or returns unused medications to stock.
This process is time-consuming and cumbersome to both the pharmacy
and the anesthesiologist. The task requires a pharmacist to be
available at all times that the operating room is in operation.
Anesthesiologists must take time away from patient care to
reconcile medication usage with the pharmacy. To mitigate these
constraints, anesthesia and nursing staff have unsupervised access
to the satellite pharmacy during off hours. The burden of narcotic
tracking, however, still falls on the pharmacy during these off
hour periods and the healthcare facility is exposed to potentially
severe regulatory agency repercussions.
[0007] Satellite pharmacies are becoming rare due to the expense
and overhead of running a specialized pharmacy. As an alternative,
many hospitals are using a second method of tracking narcotics
called the tackle-box method. The tackle box is a small, locked
container that is prepared by the main pharmacy for each
anesthesiologist. The anesthesiologist picks up his or her tackle
box in the morning from the main pharmacy or from a locked room in
the operating room. The location usually depends upon the
pharmacy's delivery capabilities. The tackle box usually contains a
usage sheet where the anesthesiologist records the medications that
were used, the patients on which the medications were used, and the
quantities dispensed. The completed sheet and unused medications
are returned at the end of the day to the main pharmacy or to the
locked room. The pharmacy must inspect each medication record to
insure accuracy and compliance. Any inconsistencies must be
addressed with the anesthesiologist. However, the inconsistencies
may not be addressed for several days at which point the
anesthesiologist may not remember the exact circumstances
surrounding the medication discrepancy. The hospital is in direct
violation of the regulations until the discrepancy is resolved.
[0008] Attempts to automate the medication management process in
anesthesia have been made. One product that is currently available
is a semi-automated tackle-box system of narcotic medication
control made by Secure-1, Inc. of Hamilton, Ohio. A small (about
the size of a loaf of bread) metal box with a LCD screen and keypad
on its face is used to perform narcotic medication control. The
anesthesiologist signs out a box from a storage location. After the
box has been removed from the storage location, only the
anesthesiologist who signed out the box may open it. Once open, all
the medications, including narcotics, are readily accessible.
Documentation is provided via the small LCD screen and keypad.
Dosages are recorded in the system by time and patient. Although
the system provides some electronic information capture, there is
still much legwork to be done. First, the anesthesiologist must go
someplace to sign out the box. Because of the small size, only
narcotics may be stored in the box. The anesthesiologist must
gather the required non-narcotics via the old methods described
above--either through a satellite pharmacy or a medication cabinet
located somewhere outside the operating room. When a case is over,
the anesthesiologist must return the box to its storage location
where the pharmacy retrieves it to verify and refill contents
usage. This product still requires a great deal of manual labor to
complete the tracking process. The anesthesiologist is required to
carry the box throughout the day. In addition, the anesthesiologist
must personally remove the box from a storage location (e.g.,
outside the operating room) and return it to the same storage area
at the end of the day.
[0009] The above two scenarios form the basis for medication
management in the operating room today. Each requires both time and
people to complete the tracking process. Even in a perfect
environment, mistakes are made, medications are not documented,
documentation is not accurate, or items are diverted without a
record. Often, the mistakes are due to uncontrollable events that
occur during a procedure. In some cases, an anesthesiologist may
require additional medications not anticipated prior to a case. A
circulating nurse must then leave the procedure room to retrieve
the needed item. This requirement adds unnecessary and costly
delays to the procedure. Whatever the case, the result is
inaccurate medication usage documentation.
[0010] In addition to control of narcotic medications, management
of non-narcotic medications and supplies is often inefficient and
leads to costly errors. To manage non-narcotic medications and
supplies, anesthesiologists typically use a system separate from
narcotic management. Anesthesiologists employ a non-secured,
non-automated mobile drawer cart, often a Blue Bell Cart or a Sears
Craftsman tool chest, to store these non-secured items. Narcotics
are not stored in these carts because the cart is not locked.
Therefore, a separate system for narcotic management is still
required. Typically, every operating room has its own cart so that
non-narcotics and supplies are readily available for use by any
anesthesiologist using the room.
[0011] This non-automated, non-secured practice often results in
errors in patient billing and stock-outs (i.e., depletion of the
entire inventory of a particular item). Stock-out risks cause
anesthesiologists to overstock all medications and supplies in the
carts, thus incurring a much greater storage cost than necessary.
If an operating room has anesthesia technicians on staff, then the
responsibility of refilling the carts falls to them. However, due
to cost cutting measures, few facilities have the luxury of
anesthesia technicians. The responsibility of restocking the carts
then falls to operating room technicians for supplies and the
pharmacy or nursing for non-narcotics, further adding to their
non-patient care oriented responsibilities.
[0012] Another factor that makes tracking difficult is the manner
in which an anesthesiologist works. An anesthesiologist's workflow
is very different from that of a nurse working on a general care
floor of the hospital. Typically, an anesthesiologist collects all
needed medications before a case begins. The medications are
prepared by a pharmacy or satellite pharmacy and provided in a
tackle box. Alternatively, the doctor may retrieve narcotics from a
locked cabinet. In either case, the anesthesiologist must take a
significant amount of time to prepare for a case. In many cases,
the anesthesiologist requires additional medications or additional
quantities of a medication that were not anticipated before the
case began. To address these problems, the anesthesiologist sends
the circulating nurse out of the procedure room to gather the
required medication. This time-consuming process delays the
procedure.
[0013] Another factor that makes the tracking problem complex is
that some medications may not be used during a procedure. Unlike in
a general care unit, when medications are signed out by an
anesthesiologist, they are not necessarily going to be
administered. An anesthesiologist works within a given set of
medications and uses those that he or she deems necessary for the
given conditions of the patient. The medications that are not used
during the procedure must be returned to pharmacy or disposed of
(i.e., "wasting").
[0014] Another complicating factor in the tracking process is that
the practice of anesthesia uses a small number of medications. Most
of them are non-controlled. The types of medications remain
relatively constant for each type of case. Pharmacies typically
provide anesthesia drug packs or kits for certain cases such as
cardiac, neuro, critical care, pediatric, and general to address
these medication and supply problems. Anesthesiologists are
accustomed to working with such kits and expect such kits to be
readily available.
SUMMARY OF THE INVENTION
[0015] The present invention--the Anesthesia Cart--is a
computerized medication and supply dispensing station that
addresses anesthesia medication management and tracking problems.
The Anesthesia Cart is a mobile cart that securely stores all
narcotic medications, non-narcotic medications, and supplies
(collectively, anesthesiology items or items) for anesthesiologists
in one complete system. Items may be stored in secured drawers that
remain locked at all times and require the input of specific
information each time they are accessed (e.g., for storing
narcotics), semi-secured drawers that remain locked until a user
logs in to the system (e.g., for certain types of non-narcotics and
supplies), and unsecured drawers that are always unlocked (e.g.,
for non-narcotics and supplies). The unit may be placed in each
operating room of a healthcare facility and replaces current
anesthesia storage cabinets. It also adds several valuable features
such as tracking features. The system automates patient usage
records, documents waste, manages inventory levels, and tracks the
anesthesiology items that have been removed from the station, the
time of removal, who removed them, and to whom they were
administered. The tracking features include information regarding
practitioner, patient, procedure, and medication or supply item. An
automated account of medication usage may be created that reports
on effectiveness during a case as well as comparisons between
practices of the different doctors on staff. The reports may be
based on procedure type, practitioner, patient, or any other piece
of data captured by the system.
[0016] Many of the problems with current tracking methods are
addressed. Operation of the present invention is extremely
intuitive and is conducive to the anesthesiologist's workflow.
Medication or supply usage is recorded at the time the
anesthesiologist confirms an administration of an item rather than
at the time of removal from the station. The invention stores kits
containing multiple items, individual line items, or a mixture of
both so that the anesthesiologist may administer the medications or
use the supplies that are appropriate for the given conditions of
the patient. Additional functions for set up, loading, refilling,
unloading, and performing inventory operations are also
supported.
[0017] The present invention is a cabinet supported by wheels,
casters, or rollers for mobility. The cabinet is equipped with a
control unit comprising a computer, a monitor (preferably, an
illuminated touchscreen), and a keyboard to provide access to the
medications and supplies that are stored in the drawers of the
cabinet. An anesthesiologist interacts with the control unit via
the touchscreen monitor and/or keyboard to enter and review patient
and case information, to access the medications and supplies stored
in the cabinet drawers, and to reconcile item usage (e.g., record
the assignment, return, waste, or transfer of medications or
supplies).
[0018] To use the present invention, an anesthesiologist logs into
the station's computer, removes one or more anesthesiology items,
and after administration of the anesthesiology items, documents
item usage. Documenting item usage includes assigning items to a
case, returning items, wasting items, and transferring items.
Alternatively, the anesthesiologist may log into the stations'
computer and select a case so that anesthesiology items are
assigned to the selected case as they are removed. The control unit
of the station is adapted to capture case information as well as
information regarding the anesthesiologist(s) associated with the
case. Case information includes information about the
anesthesiology items used for a specific procedure associated with
a patient including the medications that will be or have been
administered to the patient. Case information may be entered either
before or after removal of items from the cart. It is important to
note, therefore, that the anesthesiologist is not required to
select a case prior to removing anesthesiology items from the cart.
This flexibility in determining when anesthesiology items may be
documented (i.e., after items have been removed or as items are
being removed) is unique to the present invention.
[0019] When the anesthesiologist is ready to administer the
medications or supplies to the patient, he or she selects an item
to be removed from a list of medications or supplies appearing on
the screen. If the item is in a secured drawer (e.g., a narcotic),
it is made available for removal. Each removal of an item from the
cabinet, whether from a secured or unsecured drawer, is associated
with the anesthesiologist who has logged in to the station's
computer. If the anesthesiologist has selected a case, the items
are also assigned to the selected case as they are removed. For
items removed from secured drawers, the system prompts for
information based on the medications removed, acting as a reminder
to the anesthesiologist to insure proper documentation. This
documentation process may be done for any previously removed item
at any time during the procedure or at a later time. Following
completion of the documentation process, the captured data provides
the pharmacy with an electronic record of each medication's usage
during a case. If an anesthesiologist fails to document usage, the
pharmacy may then check with the anesthesiologist to determine why
the anesthesiology item use has not been reconciled.
[0020] The present invention provides significant advantages over
the prior art. First, the station is mobile and may hold all
medications required for a procedure in the room. An
anesthesiologist may locate medications and supplies quickly and
easily as they are needed. Using the present invention, the
anesthesiologist no longer needs to stand in line at a satellite
pharmacy or carry around keys to a narcotic room or use
simultaneous processes to obtain needed supplies. Second, the
documentation process is facilitated with the real-time,
interactive system of the station. The necessary information is
collected and processed as anesthesiologists assign items to cases.
Third, the reporting capabilities provide the pharmacy and
administration with accurate drug practice information. Health care
institutions that use the present invention feel secure that
required items will be immediately available and that medication
and supply usage documentation will be completed properly. The
present invention saves hours of unproductive legwork and manual
documentation that are required by prior art systems.
BRIEF DESCRIPTION OF THE DRAWING(S)
[0021] FIG. 1 is an example of an anesthesia cart in accordance
with the present invention;
[0022] FIG. 2 is an example of a molded handle for an anesthesia
cart in accordance with the present invention;
[0023] FIG. 3 is an example of a cabinet cover and computer
components for an anesthesia cart in accordance with the present
invention;
[0024] FIGS. 4A and 4B are examples of a monitor and keyboard for a
computer housed in an anesthesia cart in accordance with the
present invention;
[0025] FIG. 5 is a flowchart of the process for interacting with
the anesthesia cart of the present invention;
[0026] FIG. 6 is an example of a login screen for a preferred
embodiment of the present invention;
[0027] FIG. 7 is an example of a main menu screen for a preferred
embodiment of the present invention;
[0028] FIG. 8 is an example of a item list screen for a preferred
embodiment of the present invention;
[0029] FIG. 9 is an example of a take screen for a preferred
embodiment of the present invention;
[0030] FIG. 10 is an example of a cases screen for a preferred
embodiment of the present invention;
[0031] FIG. 11 is an example of a case summary screen for a
preferred embodiment of the present invention;
[0032] FIG. 12 is an example of a removed item list screen for a
preferred embodiment of the present invention;
[0033] FIG. 13 is an example of a reconcile screen for a preferred
embodiment of the present invention;
[0034] FIG. 14 is an example of a detailed functional organization
chart for a preferred embodiment of the present invention; and
[0035] FIG. 15 is a flowchart for the overall operation of the
anesthesia cart for a preferred embodiment of the present
invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT(S)
[0036] Referring to FIG. 1, the anesthesia cart 100 of the present
invention, preferably, is a compact cabinet 102 supported by wheels
104 so that it may be moved easily throughout an operating room.
Alternatively, casters or rollers may be used to increase
maneuverability of the cart. A handle 106 molded with the top
surface facilitates movement of the cart in all directions. A
bumper 108 around the bottom periphery of the unitop surface
protects the cart from being damaged in the event of a collision.
Finally, a flat work surface area 110 and pull-out shelf 112
provides ample space for performing a variety of tasks in addition
to dispensing and controlling anesthesiology items.
[0037] As used herein, "anesthesiology items" refers to all
narcotic medications, non-narcotic medications, and supplies such
as Fentanyl, Pentothal Sodium, Demerol, Prostigmin, Robinul,
syringes, needles, catheters, masks, etc. Anesthesiology items to
be dispensed are stored in drawers or receptacles 114, 116 of a
variety of shapes and sizes. Drawers may be secured 114,
semi-secured 116, or unsecured depending on their contents. Each
drawer may have associated with it a control mechanism comprised of
hardware (e.g., solenoids and additional circuitry for accepting
authorization signals from software components) and/or software
components (e.g., user and password requirements for communicating
authorization signals to drawer hardware). Secured drawers remain
locked until a user requests an item (usually a narcotic
medication) and follows a procedure for accessing the contents of a
drawer. Preferably, only the drawer containing the requested item
is temporarily unlocked for access. Upon closing, the drawer is
re-secured (i.e., locked) so that the user is required to input
information to open the drawer and access its contents a second
time. For example, in one embodiment of the present invention,
secured drawers may be partitioned into consecutively spaced
compartments and controlled by a solenoid and other hardware to
allow graduated access to the compartments. Previous activity of
the drawer is tracked so that when later accessed, the drawer may
pop open or may be allowed to be pulled open to a length that
exposes the contents of a compartment either not emptied or
uncovered in previous openings. Drawers in accordance with the
present invention may be fashioned as described in U.S. Pat. No.
5,716,114, entitled Jerk-Resistant Drawer Operating System, issued
to the applicant of the present invention on Feb. 10, 1998 which is
hereby incorporated by reference herein.
[0038] Another type of drawer that may be employed in the
anesthesia cart is the semi-secured drawer. A semi-secured drawer
may be coupled with a control mechanism that allows the entire
drawer to be opened upon input of required information (e.g.,
logging on to a station computer). The drawer remains unlocked and
may be opened and closed repeatedly until an event causing the
drawer to be secured occurs (e.g., logging off of a station
computer).
[0039] In an alternative embodiment of the present invention, the
anesthesia cart may be equipped with latched receptacles in which
each receptacle has a computer controlled latch and associated
hardware that provides information about the contents of the
receptacle to a computer. The latch may be opened and the contents
of the receptacle accessed upon entry of required information at
which time an authorization signal is received at the latch.
Latched receptacles may be configured to required entry of required
information upon each access or to be unlatched upon the occurrence
of a first event (e.g., login to a station computer) and latched
upon the occurrence of a second event (e.g., logout of a station
computer). In this respect, the latched receptacles may be
configured to operate in a fashion similar to that of the secured
and semi-secured drawers. Latched receptacles in accordance with
the present invention may be fashioned as described in U.S. patent
application Ser. No. 09/987,388, entitled System and Apparatus for
the Dispensing of Drugs, assigned to the applicant of the present
invention and filed on May 29, 1998, which is hereby incorporated
by reference herein.
[0040] In a preferred embodiment of the present invention, narcotic
medications are stored in secured drawers 116 such that the
anesthesiologist is required to follow specific procedures to reach
their contents. Preferably, the anesthesiologist is required to
request a specific amount of a secured medication before the drawer
containing it is opened. The anesthesiologist accesses the specific
amount of the secured medication that was requested. Non-narcotic
medications and supplies may be stored in semi-secured drawers 116
so that the anesthesiologist may access them after login.
Preferably, the semi-secured drawers unlatch and latch
simultaneously upon user login and log-out, respectively, so their
contents are freely available during a procedure. Finally,
non-narcotic medications and supplies may be stored in unsecured
drawers so they are accessible to anyone at any time. It is
understood that the anesthesia cart may be configured with any
combination and size of secured, semi-secured, and unsecured
drawers and/or latched receptacles depending on the needs of the
users. In other words, the anesthesia cart of the present invention
may be configured with a plurality containers (e.g., drawers and/or
latched receptacles) any of which may be secured, semi-secured, or
unsecured. In addition, it is understood that anesthesiology items
may be stored in any type of container (e.g., drawer and/or
receptacle) depending on the needs of the users.
[0041] An access control unit comprising a computer, monitor 118,
and keyboard 120 (or equivalent type of data entry device and/or
data processor) equipped with appropriate user interface,
communications, etc. software provides access to the anesthesiology
items that are stored in the containers of the cart. A container
control unit comprising additional hardware (e.g., switches,
sensors, solenoids, pulleys, stops, cables, motors, drums, etc.),
circuitry, and logic provides communication between the software of
the access control unit and container hardware including any latch
that may be used for securing the container. Each container may
have its own control unit. Software and hardware for the control of
containers (e.g., drawers and/or latched receptacles) in accordance
with the present invention may be fashioned as described in U.S.
Pat. No. 5,445,294, entitled Method for Automatic Dispensing of
Articles Stored in a Cabinet, assigned to the applicant of the
present invention and issued on Aug. 29, 1995. Consequently, the
containers of the present invention may be controlled by a computer
or its equivalent (e.g., data entry device and/or data
processor).
[0042] Each drawer may be further subdivided into two or more
compartments each of which may hold the various medications or
supplies to be administered to patients. The computer and other
components that an anesthesiologist need not access while using the
cart may be housed inside the cart. Preferably, housed components
are accessible through a cover 122 on the side of the cart. A
rotating extension monitor stand 124 makes it easy to view the
monitor 118 from a variety of angles. Preferably, the monitor 118
is a color touchscreen for easy data entry. Lists of patients,
anesthesiology items, etc. may be presented and selected by
touching the desired list item. The attached keyboard 120 may also
be used for data entry. Other types of data entry devices and/or
data processors may be used as well.
[0043] Preferably, the cart is equipped with a floppy disk drive
126 for loading information onto the station computer and
performing maintenance functions, etc. Preferably, the floppy disk
drive is accessible only to authorized personnel such as
maintenance technicians. The cart may also be equipped with a
CD-ROM 128 that may be used to access reference manuals and other
information that may assist the anesthesiologist in performing his
or her duties. Preferably, the cart is equipped with a network card
and other devices that support networked communications such as
those that may be required to interact with the pharmacy computer
systems and other departmental computers. Although equipped with a
network card, the cart computer need not be connected to a computer
network to operate. The network card allows the cart computer to be
connected to another computer system to facilitate the exchange of
information between the cart computer and another computer system
(e.g., for inventory control, for maintenance, for transferring
status information). Finally, the cart may be equipped with
accessory holders 128, 130 that allow the anesthesiologist to
transport items that may be required such as gloves, tape
dispensers, container for waste, clock with timer, file folders,
vial holders and an IV pole.
[0044] Referring to FIG. 2, a unitop 200 for a preferred embodiment
of the anesthesia cart is shown. As explained above, the handles
106 and 110 are a one piece unit. A bumper 108 around the periphery
provides protection of the station and its contents.
[0045] Referring to FIG. 3, a cabinet cover 122 and computer
components for an anesthesia cart in accordance with the present
invention is shown. The cover 122 protects the computer housed in
the station as well as provides easy access to the various
components that comprise the computer. First, a mother board 302
may be mounted inside the station. In addition, the station may be
equipped with an electronic display sled 310 and a wire harness
routing hold 308. Other computer components include a floppy disk
drive 126 and a CD-ROM drive 128.
[0046] Referring to FIG. 4A, a monitor 118 and keyboard 120 (or
equivalent data entry video terminal) for a computer housed in an
anesthesia cart in accordance with the present invention is shown.
As explained above, the monitor 118 and keyboard 120 are preferably
mounted on a rotating stand 124 for easy access. The rotating stand
124 preferably, is equipped with several pivot points 408 and 410
for easy storage of the monitor and keyboard and transportation of
the unit. The monitor 118 and keyboard 120 may also be connected by
a pivot point 406. The incorporation of pivot points 406, 408, 410
allow the monitor 118 and keyboard 120 to be closed in a
configuration similar to a laptop computer and folded on to the
work surface as shown in FIG. 4B. In the closed configuration, the
monitor and keyboard may be protected during transportation of the
station. Other types of data entry video terminals may be used as
well.
[0047] A set up function in the software provided with the cart
computer allows a user with appropriate privileges to perform
general administrative tasks as well as to set station and
container configurations and create kits. Load, refill, unload, and
inventory functions that are supported in the software provide
assistance in stocking the cart with appropriate anesthesiology
items. Medications to be administered from the containers of the
cart may be stored as individual items, logical kits, or physical
kits. A logical kit (or personal kit) is a logical grouping of
medications and/or supplies and may be personalized for each
anesthesiologist. The logical kit may contain logical groupings of
anesthesiology items for a specific procedure (e.g., neuro,
cardiac, etc.) The logical or personal kit provides a shorthand
method for selecting multiple items in specific quantities. Each
item in a logical or personal kit is an individual inventory item
stored in its own location (e.g., its own compartment in the cart).
A physical kit, on the other hand, contains multiple anesthesiology
items of the same type. For physical kits, individual components
may be pre-packaged in the pharmacy and stored in a single
compartment in the cart. In this case, the items are removed from a
single compartment. When either type of kit is removed from the
cart, the kit is expanded into its component items which are then
associated with the anesthesiologist and may be managed
individually. Transaction documentation may be completed for each
individual item contained in the kit.
[0048] Preferably, the cart system of the present invention
supports two units of measure--vending units and administration
units. Vending units relate to the manner in which medications are
packaged (e.g., one vial containing 10 ml of a medication).
Functions related to cart inventory (e.g., loading, unloading, and
refilling) use vending units. Administration units relate to the
manner in which items are used on a patient regardless of how they
may have been packaged (e.g., 10 ml of Amidate may be administered,
not one vial). Conversion between vending and administration units
is accomplished through the integer ratio of administration units
to vend units for each item.
[0049] Referring to FIG. 5, the process for use of the anesthesia
cart by an anesthesiologist is shown. First, in step 500, the
anesthesiologist logs into the station. An example of a login
screen for a preferred embodiment of the present invention is shown
in FIG. 6. The login procedure may be based on a standard
identifier and password scheme. Alternatively or in conjunction
with the primary login procedure, the login procedure may be based
on biometrics such as eyeprint, fingerprint, etc. Upon login, the
anesthesiologist is presented with a main menu presenting options
for proceeding. An example of a main menu for a preferred
embodiment of the present invention is shown in FIG. 7. As shown in
FIG. 7, the three options of greatest interest to the
anesthesiologist are the "Take," "My Items," and "Cases." The
"Setup," "Load," "Refill," "Inventory," and "Unload" functions may
be used by personnel responsible for stocking the cart and
performing other administrative functions necessary for maintenance
of the cart. As shown in step 502 of the flowchart of FIG. 5, the
primary functional options of the main menu are presented to the
anesthesiologist (i.e., "Cases," "My Items," and "Take"). By
selecting "Cases," the anesthesiologist may perform actions related
to definition of patient cases (step 504). A case is a specific
procedure (e.g., cardiac, neuro, orthopedic, etc.) that is
associated with a specific patient. By selecting "My Items," the
anesthesiologist may perform actions related to documentation of
items removed from the cart (step 518). By selecting "Take," the
anesthesiologist may perform actions related to removal of items
from the cart (step 516). Once the doctor signs in (step 500), a
permanent anchor is set until he or she logs out. Preferably, the
system does not automatically log out the anesthesiologist.
Instead, the anesthesiologist may choose when to logoff the system.
This procedure prevents untimely time-outs that may serve only to
frustrate the anesthesiologist. Preferably, at this point,
semi-secured containers may be unlatched so that their contents may
be accessed. The anesthesiologist may lock the cart to prevent
unauthorized access if he or she needs to leave the cart's locale
for any reason. Locking a cart prevents access to the cart by
anyone except the authorized anesthesiologist(s) or a system
administrator. If an administrator logs on, any outstanding items
are recorded as not accounted for by the doctor who removed
them.
[0050] In step 516, the anesthesiologist may begin the process of
removing items from the cart (Take). To take an item, the
anesthesiologist indicates that he or she has removed an item from
the cart. The removed item is automatically associated with the
identifier provided by the anesthesiologist during the login
procedure. The removed item is not, however, assigned to a case
unless the anesthesiologist has already selected a case. In this
case, the item is "take case specific" and is automatically
assigned to the selected case. An example of a take list for a
preferred embodiment of the present invention is shown in FIG. 8.
As shown in FIG. 8, the anesthesiologist is presented with the
options of selecting secured items, unsecured items, or supplies.
Preferably, items are removed in vend units which may or may not
correspond to administration units. For example, one 10 ml of vial
of Amidate may be removed resulting in 10 ml of medication that may
be administered individually. Therefore, the removal of one vial
may be shown as 10 ml. A window showing selected items and
quantities of items may be presented to the anesthesiologist (e.g.,
by selecting a "Picks" button). Preferably, the quantity of an item
may be changed by repeated touches or by using a numeric input
field and increment/decrement buttons. If a kit is selected, the
component line items that comprise the kit may be viewed by
selecting, for example, a "Contents" button.
[0051] As explained above, the contents of semi-secured containers
may be accessed following the login procedure. The anesthesiologist
may then open the semi-secured containers and remove items as
needed. Preferably, the anesthesiologist is not required to request
items from semi-secured containers using the software interface. If
a kit is selected, preferably, the anesthesiologist may view the
component items by selecting a Contents button. When convenient,
the anesthesiologist may inform the system of which items have been
removed from semi-secured containers by selecting them from a list
of semi-secured items that may include non-narcotic medications or
supplies. For secured medications (i.e., narcotics), the
anesthesiologist, preferably, is required to request a specific
amount of medication before the container containing it opens. An
example of a screen for requesting a secured medication for a
preferred embodiment of the present invention is shown in FIG. 9.
Upon selection of a Take button, access to the secured container
may be permitted. Referring again to FIG. 5, as secured items are
removed from the cart, they are added to a table of removed items
to be reconciled or documented as shown in step 518. The removed
items are associated with the identifier provided by the
anesthesiologist at login. The removal of semi-secured and
unsecured items is recorded (i.e., associated with the identifier)
without further interaction from the anesthesiologist. Additional
item removal may be done at any time during a procedure.
[0052] Following completion of the item removal, the
anesthesiologist is presented with one of two screens. If the take
operation was initiated from the main menu or the My Items option,
the anesthesiologist is presented with the list of medications that
have been removed (step 518). If the take operation was initiated
from a case summary, the anesthesiologist returns to the case
summary page (step 512). The anesthesiologist therefore, may begin
the process of removing items using one of two methods and may
choose the one he or she finds most convenient.
[0053] Step 504 is the entry point for case management functions.
At step 504, a list of all cases that have been entered into the
system is presented to the anesthesiologist. An example of a case
list for a preferred embodiment of the present invention is shown
in FIG. 10. Referring again to FIG. 5, at step 504, the
anesthesiologist has the option of performing tasks related to an
existing case by selecting a case from the case list (step 512) or
entering a new case (step 506). To enter a new case (step 506), the
anesthesiologist preferably selects a patient name from a list of
admitted patients. To further facilitate the procedure of selecting
a patient name, an interface to an operating room scheduling system
may be provided so that the anesthesiologist may see which patients
are scheduled for surgery. Alternatively, the anesthesiologist may
enter a patient name or other patient identifier to locate a
patient. If a patient cannot be found in the system, the
anesthesiologist may enter new patient data. Once a patient has
been selected, the anesthesiologist may enter additional patient
data including a case type, a case number, a CPT code, general
notes and other data relevant to the patient's condition, etc.
(Step 508). In the next step related to a new case (step 510), the
anesthesiologist enters case data for the selected patient. The
case data is then saved and may be available in a case summary.
[0054] In the next step (step 512), the anesthesiologist may review
a summary of the case before assigning items to the case. An
example of a case summary screen for a preferred embodiment of the
present invention is shown in FIG. 11. Referring again to FIG. 5,
if case information had been entered previously, the
anesthesiologist may select a case (step 504) and then, review a
summary for the selected case (step 512). Otherwise, the
anesthesiologist may proceed to the case summary function (step
512) after entering the case data (step 510). The case summary
displays a list of all items that have been assigned to a specific
case. Items preferably, are displayed in quantities of
administration units (e.g., 10 ml rather than 1 vial).
[0055] In step 514, the anesthesiologist assigns items (i.e.,
medications or supplies or kits) to the selected case. In the
assigning items, individual items that have been taken from the
cart are associated with the selected case. Individual items and
dosages may be selected from predefined lists or they may be
entered through a dialog box or other screen appearing on the
monitor. The anesthesiologist may change the quantity of a
medication administered to a patient. For example, if the case
indicated that 10 ml of a medication would be administered, but
only 5 ml was actually administered, the anesthesiologist may
indicate that a smaller quantity was actually given. The balance
not recorded as administered may be wasted, returned, or may remain
in the possession of the anesthesiologist for administration to a
different patient. Alternatively, the anesthesiologist may assign a
kit to the case. As items and/or kits are assigned, a medication
list is compiled to indicate which items or kits are in the cart.
Preferably, in all operations in which lists of medications or
supplies are displayed, the anesthesiologist has the option of
reviewing items in brand name descriptions or generic name
descriptions. Preferably, brand/generic name display modes may be
controlled by a toggle button at the bottom of a list.
[0056] In step 518, the reconciliation or documentation procedure
is performed. As shown in FIG. 5, the anesthesiologist may reach
this function by selecting "My Items" or "Take" from the main menu
502 or from a Case Summary 512. To reconcile usage, the
anesthesiologist begins by reviewing a list of items that are in
his or her possession (i.e., that have been associated with his or
her identifier) that have been removed from the cart, but have not
been assigned to a case, returned to the pharmacy, wasted, or
transferred to another anesthesiologist. An example of a "My Items"
list for a preferred embodiment of the present invention is shown
in FIG. 12. Quantities of each item are also shown. From the
earlier example, a 10 ml vial of Amidate may be represented on the
screen as 10 ml rather than one vial of Amidate. From this list,
the anesthesiologist informs the system as to where each dose of
every medication goes. Once an item from the list is chosen, the
anesthesiologist is prompted for the dosage amount, the
administration time (default to current time), the amount wasted,
the amount returned, and/or the amount transferred. Any remaining
amount is assumed to still be in the anesthesiologist's possession.
After each medication is accounted for, the list of removed items
is redisplayed until all items have been accounted for. If there
are no items outstanding (i.e., no items are in the doctor's
possession and still associated with his or her identifier), the
anesthesiologist may logoff the system.
[0057] In step 520, items are assigned thus indicating that
medications were actually administered to a patient. The amount of
medication actually administered to the patient is recorded. An
example of a "Reconcile" screen for a preferred embodiment of the
present invention is shown in FIG. 13. Referring again to FIG. 5,
first, the system determines whether a case is open (step 522). If
a case is open, in step 512, the anesthesiologist may review the
case summary and proceed to step 514 to assign items and/or kits.
The case information may be displayed at the bottom of the screen.
If a case is not open, in step 504, the anesthesiologist may review
a list of cases as explained above.
[0058] In addition to assigning items to a case (i.e., indicating
that medications were actually administered to a patient), items
may be returned to the pharmacy, wasted, or transferred to another
anesthesiologist (step 524). For the transfer function, the
accepting anesthesiologist, preferably, is required to enter an ID
and password to confirm the transfer. Items may be returned,
wasted, or transferred at any time although preferably, they are
returned, wasted, or transferred after the patient procedure is
finished.
[0059] Once items have been documented (which includes assigning,
returning, wasting, or transferring), they no longer appear in the
list of medications removed by the anesthesiologist and are no
longer considered to be in the possession of the anesthesiologist.
Documentation, which includes assigning, returning, or wasting
items, may be performed at any time on an open case. Preferably,
multiple cases may be open at a time. The documentation procedure
is automatically activated when the items are assigned to a
case.
[0060] The process of wasting medications or supplies is a matter
of hospital and JCAHO policy. Federal regulations require a witness
to be present when a narcotic medication is wasted. The system
requires a witness identifier (e.g., name or code of a witness to
the wasting transaction) before recording a narcotic waste
transaction. If all wastes are saved until the case is completed, a
single witness identifier may be entered for all wastes that the
anesthesiologist performs. Returned medications may be made
available to the pharmacy for inspection. The pharmacy may then
determine whether the returned medication may be used. These wasted
transactions may be saved at the pharmacy system and reconciled
manually with the physically returned and wasted medications.
[0061] Referring to FIG. 14, a complete list of the functions of
the present invention is shown. In addition to operating as an
administration tool, the present invention may be used for
inventory control. In a preferred embodiment, the present invention
supports three "refill" modes. Item counts are tracked as items are
removed from the cart. The system preferably informs the
anesthesiologist when certain items are at or below a reorder
point, at or below a critical low level, and below the full level.
The system may further be designed to accept a refill amount to be
delivered which may or may not correspond to the prior "fall"
level. When used for inventory control, the system may include a
feature in which the pharmacy or materials management is alerted
regarding items in the cabinet that need to be refilled.
[0062] Referring to FIG. 15, a flowchart of the overall operation
of the anesthesia cart for a preferred embodiment of the present
invention is shown. As explained previously, the anesthesia cart
may operate in conjunction with a pharmacy computer system so that
inventory control functions may be performed. To begin the process
(step 600), the cart is stocked with anesthesiology items. As
indicated above, the anesthesiology items may include narcotic and
non-narcotic medications as well as supplies. In addition,
individual items may be packaged and loaded into the cart as kits.
All items that are required by the anesthesiologist to perform his
or her job may be packaged (e.g., into kits) and loaded into the
cart. In this respect, the cart contents may be tailored or
personalized for a particular anesthesiologist. Items may be loaded
into secured, semi-secured, and unsecured containers as required
and depending upon how the cart has been configured. Stocking may
be performed by the pharmacy or any department responsible for
anesthesiology items.
[0063] In the next step (step 604), the cart may be moved to an
area in which a procedure may be performed on a patient. The
anesthesiologist then logins into the cart computer (step 606).
Preferably, the semi-secured containers are then unlocked. In the
next step, the anesthesiologist then decides which item should be
removed for the procedure and selects the required item (step 608).
If the selected item is in a secured container (step 610), the
anesthesiologist may be prompted for additional information to
access the contents of the secured container. In step 612, the
anesthesiologist enters the required information and the secured
container is unlocked. If the selected item is not in a secured
container, the anesthesiologist may simply remove the item from the
semi-secured or unsecure container. In step 614, the item is
removed from the container. In step 616, the anesthesiologist
administers the medication to the patient or otherwise uses the
item as appropriate for the procedure. In step 618, the
anesthesiologist decides whether additional items are necessary to
complete the procedure. If the anesthesiologist is ready to start
performing another procedure while completing the current
procedure, he or she may start the process of removing items for
the next procedure. The anesthesiologist is not restricted to
removing items for only the current procedure. As explained
previously, the anesthesiologist may elect to have all items
removed assigned to an open case, but is not required to do so. If
the anesthesiologist would like to remove additional items, he or
she returns to step 608.
[0064] If the anesthesiologist has completed the procedure or has
otherwise determined that no additional items are required at the
present time, the process of documenting usage or reconciling items
may begin (step 620). Items that have been removed from the cart,
in this step, are assigned, returned, wasted, or transferred
depending on whether the item was used and how it was used. When
the documentation or reconciliation process is completed, the cart
may be connected to the pharmacy computer system (step 622) so
information regarding status of the items in the cart may be
communicated to the pharmacy computer system (step 624). At this
point, the pharmacy may determine whether all items have been
accounted for and whether narcotic medications may still be in the
possession of the anesthesiologist. In addition to supporting this
important regulatory function, the pharmacy may also determine what
items need to be restocked so the cart may be used again for
additional procedures (step 626).
[0065] The present invention may be used as either an electronic
medication administration record for anesthesia or a medication and
supply accountability and inventory system. The system may be
designed to accept administration information for each dosage of a
medication given or a summation of all medications used. The former
provides an accurate administration record while the latter
provides an inventory record. In a preferred embodiment of the
present invention, both methods are available as a configuration
parameter. The hospital may then decide which method to use
depending on the its needs and policies.
[0066] The present invention balances the need for anesthesiology
item management with convenience and accessibility. The pharmacy's
concerns regarding control are addressed as are the
anesthesiologist's need for accessibility. The Anesthesia Cart is a
fully integrated system that addresses the functional needs of
anesthesiologists and closely complements their workflow. The
Anesthesia Cart supports healthcare facilities in their efforts to
comply with medication management regulations and reduces the
potential for facilities to experience noncompliances. In addition,
the data that may be obtained and analyzed from the system may be
used to develop best practices for the facility.
[0067] Numerous modifications and variations in the invention are
expected to occur to those skilled in the art upon considerations
of the foregoing descriptions. Although described in relation for
use by an anesthesiologist, it is understood that the present
invention may be useful to surgeons and other physicians and
technicians who administer certain types or categories of
medications to patients. The invention should not be construed as
limited to the preferred embodiments and modes of preparation
described herein, since these are to be regarded as illustrative
rather than restrictive.
* * * * *