AED Management Program

According to the American Heart Association, sudden cardiac arrest (SCA) is one of the leading causes of death in the U.S.  SCA can happen to anyone, at anytime or anywhere, so it’s important to implement an AED program that provides the necessary resources to help save a life.  SCA is an immediate, without warning, electrical malfunction in the heart that causes an irregular heartbeat rhythm (arrhythmia).  SCA abruptly stops the heart’s pumping action and prevents blood flow throughout the body.  SCA usually causes death if not treated within minutes.  Automated External Defibrillators (AEDs) are portable electronic devices designed to diagnose a cardiac rhythm and automatically treat through defibrillation. Defibrillation is the application of electric shocks that allows the heart to reestablish a normal rhythm.  AEDs make it possible for lay responders to administer defibrillation prior to the arrival of Emergency Medical Services (EMS). 

The success of the AED Program depends on the effective collaboration of team members from across campus. Specific responsibilities of members are outlined as follows:

AED Program Administrator (Safety and Risk Management Office)

• Act as a liaison between AED owners, manufacturers, and health agencies to assist in unit maintenance and compliance.
• Develop and update the AED program, forms, and resource information for users.
• Review of departmental request for AED purchases.
• Coordinate AED request to ensure that departments are informed on program responsibilities, purchasing requirements, maintenance, and training requirements.

• Coordinate installment of AED equipment locations with AED owners and building Facility Coordinators.
• Maintain documentation of all AED units, locations, and AED Area Coordinators. 
• Conduct annual inspections to verify that AED owners are in compliance with the AED program and are maintaining inspection records.
• Identify and communicate relevant federal and state laws and regulations.
• Conduct incident debriefing and complete follow-up report for each use of an AED.
• Collect and maintain records associated with AED requests, user training documentation, and AED Post - Incident Report forms.

AED Medical Program Advisor (Health Services)

• Provide medical consultation and expertise.
• Review departmental request for AED purchases.
• Oversee and approve protocols for the use of the AED and other medical supplies.
• Act as the medical liaison with local emergency medical services (EMS).

• Review all incidents involving the use of an AED.
• In cooperation with the AED Program Administrator, perform an annual review of all components of the University AED program.

Departmental AED Program Coordinator (AED Owner):

University departments and other administrative units who acquire an AED are responsible for maintaining the device to the standards of its manufacturer, federal and state laws, the programmatic standards of the American Heart Association or the American Red Cross, and WCU AED Program. 
AED Owner responsibilities:

• Agree to all policies and procedures for the AED Program.
• Designate a person who is responsible for management of the AED (i.e., departmental responsible person).  This person will be referred to as the AED Area Coordinator.
• Ensure that requests for AED units are submitted for approval to the Safety and Risk Management Office and Health Services prior to any AED purchases or installations on campus. 
• Complete the Departmental AED Registration Form.
• Ensure inspections and maintenance are conducted in a timely manner and in accordance with the written user and service manuals provided by the manufacturer.  AED Area Coordinators must utilize the Monthly Inspection Form to document activities.
• Provide or arrange for training and refresher training in CPR/AED certification for their faculty and staff, such that:

• Training is conducted in a timely manner and in accordance with the American Heart Association or the American Red Cross.
• Training must be documented, and AED owners must submit training records to the AED Program Administrator.

• Purchase and maintain all AED equipment and supplies according to the manufacturer’s instructions (i.e., batteries, pads, or ancillary supplies).
• Notify the AED Program Administrator of any SCA incidences or the use of an AED.   
• Complete the AED Post-Incident Report form each time an AED unit is used or there is an attempted use of the unit. 
• Maintain a copy of the manufacturer's user and service manuals for each type of AED in service.
• Maintain on-site records, inspections, training, and other supporting documentation.
• Report any abuse or vandalism of the AED to the University Police Department and the AED Program Administrator.
• Notify the AED Program Administrator if the AED Area Coordinator can no longer fulfill their duties as assigned and a replacement is required.   

Installation Administrator (Facilities Management)

• Install building AED cabinets and signage in accordance with manufacturer guidelines, AED Program Administrator and AED Area Coordinator recommendations. Actual AED units will be installed by the AED Area Coordinator.

A department or administrative unit interested in obtaining an AED for their building should submit an AED Request Form to the AED Program Administrator.  The AED Program Administrator will coordinate with the requester to provide an overview of the WCU AED Program guidelines, review potential building locations, review maintenance and inspection requirements, and training requirements of departmental faculty and staff who volunteer to receive training.    AED units are purchased through the North Carolina E-Procurement per state contract by the AED owner.  Requesting departments or administrative units are financially responsible for the AED equipment purchase, alarmed AED storage cabinet, signage, installation, maintenance, training, and all other known or unforeseen costs associated with the AED.  Departments or administrative units who have purchased and installed an AED for service prior to the implementation of the WCU AED Program should follow all guidelines required in this program.

Required Equipment

In addition to the AED, other equipment and ancillary supplies are required for the installation and use of the AED. This includes but is not limited to:

• Alarmed wall-mounted AED cabinet (cabinet and location must be preapproved before ordering)
• AED wall signage (must be preapproved before ordering)
• One set of adult defibrillation electrode pads
• One set of child defibrillation electrode pads
• One prep and response kit at a minimal containing:
• Two pairs of disposable nitrile gloves
• One disposable razor
• One pair of trauma scissors
• One CPR pocket mask
• Antiseptic wipes

 Exception:  In special circumstances, certain departments or campus units may require an AED for portability and are exempt from AED cabinet requirements.

Placement

The department or administrative unit purchasing the AED will coordinate with the AED Program Administrator to identify the most appropriate location in the requested building for proper placement.  The following guidelines should be considered:

• Placement of the unit for optimal response time should be a priority. Placement will not depend on department location within the building.
• Placement location should be visible and provide unobstructed public access. Consider placing the unit in a well supervised area to prevent tampering or theft.
• Locations near large conference rooms, theaters, public use areas, and other high traffic areas are often ideal locations.
• AED units in buildings should be identified with signage placed above the unit in a highly visible location.
• Security along with accessibility should be considered in AED placement with outdoor facilities which may not be supervised at all times.

All AEDs must be stored in a wall mounted storage cabinet per the manufacturer guidelines.  Each cabinet should have a local alarm (not connected to 911 or Emergency Services) which sounds when the cabinet door is opened.  Emergency ancillary supplies for each AED should be included within the cabinet for use.

Anyone may, at their discretion, provide voluntary assistance to victims of medical emergencies to the extent appropriate to their training and experience.  Untrained bystanders are protected from civil liability when using an AED in good faith unless the person was grossly negligent or intentionally engaged in wrongdoing when rendering the treatment (North Carolina General Statute Section 90-21.14).  However, we encourage all persons to have proper prior training.  University employees should be aware that they are not required to use an AED.  Except for trained medical professionals, all university employees are considered volunteers when rendering assistance to any individual suffering a medical emergency.

Accordingly, North Carolina law also expressly provides immunity from civil liability for those who obtain and maintain AEDs, and those who use such devices to attempt to save a life.  North Carolina Statue Section 90-21.15 (d) provides for two classes of persons or entities who are exempt from civil liability related to the procurement and maintenance of AEDs:

• The person or entity that provides the cardiopulmonary resuscitation and AED training to a person using an AED.
• The person responsible for the site where the AED is located when the person has provided for a program of training.

CPR/AED Training

It is the responsibility of AED owners to provide or arrange for training and refresher training in CPR/AED use for their employees.  CPR and AED training is voluntary unless it is part of a written job description.   All training records must be maintained onsite, including a description of the training program. Western Carolina University recommends that all employees identified for AED training successfully complete an American Heart Association or American Red Cross CPR/AED course or a national acceptable equivalent certification which is valid for two (2) years.

The AED Area Coordinator is responsible for the routine inspection and maintenance of each AED according to the manufacturer’s recommendations.  The AED Area Coordinator is responsible for replacing the battery pack and electrode pads prior to their expiration dates.  All AEDs and ancillary supplies shall be maintained in a constant state of readiness.  

In general, AEDs do not require routine maintenance.  AEDs perform an automatic self-test once a week and every time the unit is turned on.  Should the automatic self-test detect a condition that requires attention, the status indicator will change showing a fault and an alarm will sound giving notification. 

The AED Area Coordinator is responsible for conducting AED Monthly Inspection checks of each AED unit under their management.  These inspections should consist of the following:

• Perform a visual check of the AED, the wall mounted cabinet, and AED signage for signs of damage.
• Check the AED status indicator to ensure the green status light or the normal condition symbol is displayed depending on the manufacturer.
• Check the “Use By” date on the electrode packet (visible through the defibrillator lid) and all other electrode packets. If the date has passed, replace all affected electrode packets per manufacturer requirements.     

The AED Area Coordinator should immediately contact the AED Program Administrator if an AED is damaged, missing, or the status indicator light is not green or displays an abnormal condition.  Should the AED unit be removed from service for any amount of time an AED Temporarily Out Of Service notice must be attached over the AED storage cabinet until the AED unit is placed back to normal operating service.

After an AED is used for a medical emergency, all equipment shall be cleaned, decontaminated, serviced, and replenished as required and placed back into service as soon as possible after completing the following tasks:

• Clean and disinfect the AED using the manufacturer’s guidelines.
• Check the electrode pads and replaced used pads per manufacturer’s guidelines.
• Check the battery and replaced per manufacturer’s guidelines.
• Check and replenish used ancillary supplies as appropriate.
• Return the AED to its designated location.

The AED Program Administrator will conduct an annual inspection of each AED on campus for missing or damaged units, examination of all batteries, pads, cables, departmental site documentation, and to confirm no issues have been detected by the AED’s self-diagnostic check. 

Record Retention

The maintenance and inspection records required by this program shall be maintained for a period of three years.  Records that reflect the current status of employee training should be maintained until the next training cycle is completed.  All other records, including those associated with AED use or post event debriefings, should be maintained indefinitely.  The following records must be maintained by the AED Owner:

• Guidelines for use
• Manufacturer's instructions
• Self-inspection records
• Training records, including a description of the training program
• The identity of the department's responsible person
• Blank copies of the AED Incident Reports, Departmental Procedures, AED Monthly Inspection Form, and Temporary out of Service Form

Unit Cleaning Procedures

Cleaning procedures should be followed by the AED manufacture instructions.  The following procedures are to be used as general guidelines:  

• After each use, or any time the unit appears soiled, it should be cleaned and disinfected.
• Clean the carrying case using a soft cloth dampened in nonabrasive soap and water.
• Clean the unit using a soft cloth dampened in nonabrasive soap and water or 70% isopropyl alcohol.
• Do not use any other chemicals to clean the unit unless specified by the manufacturer.
• Do not use abrasives on the display windows or any connection ports.
• Do not immerse the AED in fluids or attempt to sterilize the AED or any AED accessories with the use of an autoclave.
• Ensure that used or damaged AED accessories are disposed of and resupplied.

Trained personnel should follow their training in a cardiac emergency.  Ensure the EMS system is activated by calling 911 or Emergency Services (828-227-8911) to provide additional medical assistance.  Building Emergency Plan (BEP) medical response procedures should be initiated.  It is important to note that the AED may be used by any person, trained or untrained in its use, who in good faith renders emergency care to the victim.   

The following information should be given to the emergency dispatcher:

• Caller’s name
• Type of emergency (e.g. cardiac arrest)
• Exact location, building address, room number, if possible
• If CPR is in process
• If an AED is available
• Further information requested by the dispatcher

Designate a witness or nearby individual familiar with the building or location to meet with the responding EMS unit in order to facilitate the most direct route to the patient.

Incident Notification and Documentation

Departments or administrative units must notify the AED Area Coordinator immediately following an incident. The AED Area Coordinator will conduct an incident debriefing and complete an AED Incident Report. A copy of the AED Incident Report must be sent to the Safety and Risk Management Office within 24 hours.  

A review of each medical event using an AED shall be conducted by the AED Medical Program Advisor. All key participants in the medical event shall participate in a review that includes:
Incident debriefing

• Actions that went well during the medical event
• Opportunities for improvement
• Assigned action items to implement improvement(s)

A summary of the post-incident review shall be sent to the AED Program Administrator for record retention purposes