AUTOMATED EXTERNAL DEFIBRILLATOR (AED)  PROCEDURES

Policy Number: 1002

Adopted: September, 2011

Procedure: Automated External Defibrillator (AED) Program Procedures

Reference: MCA 50-6-502; ARM 37.104.601-616

1. Scope

These procedures applies to the University of Montana – Missoula, Missoula College, and off-site locations used for academic teaching, research, and/or administrative purposes where the University maintains authority and responsibility for the property.  The property includes but, not limited to the Yellow Bay Biological Station and Lubrecht Forest.

This policy does not apply to the operations and/or facilities of Curry Health Center (CHC) or the Reinhardt Athletic Training Center of Intercollegiate Athletics or New Directions. Trained licensed staff use AEDs as part of their normal medical equipment.

2. Compliance Responsibilities

a. Chancellors, Vice Presidents, Deans, Directors, Chairs, Department Heads, and Supervisors

Those individuals having management and/or supervisory authority must ensure areas within their responsibility comply with this policy.

b. Organizational Units

Organizational units approved to purchase AEDs must follow these procedures to purchase, manage, maintain and use an AED in conformance with all applicable laws, policies, and procedures of the University.

c. University of Montana Office of Public Safety

The UM Police Dept. as part of their first emergency responder responsibilities equips their main patrol car with an AED.  UM Police Dept.’s AEDs must be purchased, managed, maintained, and used in conformance with all applicable laws, policies, and procedures. 

d. AED Oversight Committee

The AED Oversight Committee consists of an AED Medical Supervisor, a UM Police Dept. representative and Office of Risk Management representative.  Other members may be appointed by the Vice President of Operation and Finance or the Committee Chair. This committee's responsibilities include reviewing and approving AED purchase requests, with specific emphasis on assuring medical oversight, reviewing organizational unit responsibilities, and selecting the type of AED equipment.  In addition, the committee periodically reviews the history of AED use at University facilities, any unusual outcomes of AED use, results of any inspections concerning AED use or maintenance, and may recommend policy changes. 

e. Medical Supervisor

The Vice President for Operations and Finance has designated the Director of Curry Health Services (or their designee) as the Medical Supervisor to provide the required medical oversight and direction of AED use at the University.  The Medical Supervisor will also serve as the Chair of the Oversight Committee.

f. AED Coordinators

An AED Coordinator is the designated person in an organizational unit who must ensure that the AED within the unit is managed, maintained, and secured in accordance with the provisions of this procedure, AED manufacturer’s requirements, and applicable law.  The AED Coordinator is also responsible for the coordination of CPR/AED training for trained responders with the Office of Risk Management.

g. Office of Risk Management

The University’s Office of Risk Management (ORM) maintains AED information on its website and serves as the point of contact for organizations wishing to submit materials to the AED Coordinating Committee for review and possible approval.  It also convenes the AED Coordinating Committee on behalf of the committee chair.  ORM maintains the complete inventory list of the University authorized AEDs; copies of organizational units written plans, conducts annual surveys of authorized units to ensure timely maintenance has occurred and sends reports of findings to the Medical Supervisor.  For units not in compliance with University policy and/or maintenance requirements, ORM may remove an organization’s AED, after notifying the responsible organizational authority and the Medical Supervisor.  ORM is the  liaison for the jurisdictional emergency medical responders and trauma centers regarding use and availability of AEDs at the University.  ORM is responsible for registering all approved AED’s on Montana’s DPHHS website.

h. Authorized AED Users:

Employees or individuals who have successfully completed training in CPR/AED within the last two years or a licensed health care professional, including an emergency medical technician, whose scope of practice includes the use of an AED.  In the event an AED is used it is the responsibility of the Authorized User to:

• Ensure prompt notification of the campus police/local EMS through the 911 system. 
• Assign someone to meet and direct EMS personnel to the scene of the medical emergency. 
• Complete the AED Use Form for Cardiac Arrests within 24 hours to be submitted to medical supervisor or designee. 
• Participate in the post-incident debriefing session.

3. Compliance Procedures

AED type and selection should be as consistent as possible for each University location to simplify training, maintenance, operational requirements and practices, as well as improve compatibility and use with community emergency medical responders.  Consistent compliance is attained by the review and approval process described below.

•  Prior to obtaining an AED, an organizational unit must receive approval for its purchase from the AED Coordinating Committee.  To do so, the unit must submit an AED Application Form  to ORM for coordination of review/approval by the Medical Supervisor and the University’s AED Coordinating Committee.  Once approval to purchase the AED is granted by the Committee, the organizational unit must submit a copy of their written AED operation and maintenance plan, and the list of unit members that have completed AED training.

• Safe use of AEDs requires the organizational unit to accept and implement the following ongoing responsibilities:
  • Complete required reports of AED use to be made in person with the medical supervisor (or his/her designee), within 24 hours of the occurrence of the event.  Required components of the written reports that must be sent to the DPHHS will be mailed within 48 hours of the occurrence of the event.
  • Implement and document appropriate maintenance, testing and operation of the AED according to the manufacturer’s guidelines and maintain written records (keep a log) of all maintenance and testing performed on the AED and by whom.
  • Immediately remove from service any AED not functioning properly, and notify ORM, UM Police Dept. and CHC of its removal.  Also, inform ORM, UM Police Dept. and CHC if the AED later becomes reactivated.