780 Automated External Defibrillators

Approved by President
Effective Date: June 5, 2017
Responsible Division: Business and Finance
Responsible Office: Facilities Services
Responsible Officer: Assistant Vice President, Facilities Services

I. Purpose

This policy establishes certain automated external defibrillator devices (AEDs) on the campus of Middle Tennessee State University (MTSU or University), particularly in venues that experience large numbers of attendees from the campus community or general public and/or in areas where the medical director of the AED program determines that the activities involved in those venues create a heightened risk of a cardiac emergency. In addition, this policy sets forth the procedures required of the responsible MTSU departments in management of the AEDs under their control. MTSU departments and units that are responsible for an AED must comply with this policy.

II. Scope

This policy establishes the procedures and responsibilities for the installation, modification, replacement, repair, inspection, maintenance, and non-medical response of AEDs. This policy does not pertain to the procedures required during a medical response to a sudden cardiac arrest (SCA).

III. Definitions

A. Automated external defibrillator (AED). An AED is a device that is used to treat patients who experience SCA. It is only to be applied to patients who are unconscious, not breathing normally, and showing no signs of circulation. The AED analyzes the heart rhythm and advises the operator if a shockable rhythm is detected. If a shockable rhythm is detected, the AED will charge to the appropriate energy.

B. Sudden cardiac arrest (SCA). A significant life-threatening event when a person’s heart stops or fails to produce a pulse.

C. Cardiopulmonary resuscitation (CPR). Artificial ventilation and/or external cardiac compression applied to a patient in respiratory and/or cardiac arrest.

D. Emergency Medical Services (EMS). Professional community responder agency for emergency events, which provide medical assistance and/or ambulance transport.

E. AED Coordinator. The MTSU Fire Marshal shall serve as the AED Coordinator and is responsible for oversight of the MTSU AED Program.

F. AED Director. An employee in the department/unit that is designated as the AED Owner who is responsible for the management of the AED Program for that department/unit.

G. AED Medical Director. A volunteer licensed medical doctor selected by the AED Coordinator. Typically, the AED Medical Director will be a physician employed with MTSU Student Health Services.

H. AED Owner. The MTSU department/unit that places one or more AEDs in service. The owner for each AED on campus is identified in AED locations.

I. AED Responder. A volunteer MTSU employee employed in the department/unit of the AED Owner who has received appropriate training for the use of AEDs.

IV. Responsibilities

A. AED Owner. Only those departments identified as AED Owners in AED Locations are authorized to purchase or maintain an AED. Each AED Owner designated in AED locations is required by this policy to possess an AED and to conform to the requirements of this policy. AED Owners can be removed from AED locations by the AED Coordinator only with the approval of the Vice President of Business and Finance. In addition, a department, with approval of its division head, that desires to obtain an AED may request approval from the AED Coordinator and Vice President of Business and Finance to be added to AED Locations

The AED Owner is responsible for the following:

1. Ensuring that the AED is maintained and operated in a manner that meets regulatory compliance, the standards of the manufacturer, programmatic standards of the American Heart Association (AHA) and/or the American Red Cross (ARC), and this policy;

2. Designating an individual to serve as the AED Director;

3. Purchasing and installing the AED; and

4. Obtaining appropriate training/retraining as set forth in this policy, including payment of costs associated with such training, for its AED Director, Alternate Director, and AED Responders on CPR, the use of AEDs, and Bloodborne Pathogen Exposure Control.

B. AED Director. The AED Director should be a committed volunteer capable of organizing and administering a long-term program. He/she should be familiar with the physical layout of the facility and must have completed CPR/AED and Bloodborne Pathogen Exposure Control training. The AED Director will:

1. Appoint an alternate AED Director;

2. Ensure that he/she has a full AED Response Team at all times and maintain a roster of all team members. The Response Team must have enough members that at least one (1) trained team member will be on site during normal business hours;

3. Ensure that all members of the AED Response Team and any other expected AED users receive training on the use of AEDs, CPR, and Bloodborne Pathogen Exposure Control and that refresher training is provided at least every two (2) years;

4. Ensure that all AED Responders undergo Bloodborne Pathogen Exposure Control training;

5. Prepare the Written Notice of the Establishment of the AED Program for the Rutherford County EMS. The required components of the Notice of the Establishment of AED Program are set forth in Section VI.A. below;

6. Develop an AED Program Written Plan for their respective department/unit prior to purchasing an AED. The required components of the AED Program Written Plan are set forth in Section VI.B. below;

7. For any AEDs already in service at the time of the creation of this policy, the AED Director shall develop an AED Program Written Plan for their respective department/units within thirty (30) days of the issuance of this policy;

8. Develop an AED Response Procedure for their respective department/unit;

9. Notify staff members of their department/unit and building of the location(s) of the nearest AED;

10. Ensure that department-owned AEDs are inspected, tested, and maintained in accordance with the manufacturer’s operational guidelines (daily, monthly, and annually) and maintain written records of all maintenance and testing performed on the AED. The required components of the maintenance record, including daily inspection records, are set forth in Section VI.D. below;

11. Purchase and replace batteries, pads, and other supplies as needed;

12. Tag each AED as MTSU property and clearly mark to identify it as belonging to a specific department/unit;

13. Maintain records as required by Rutherford County EMS;

14. Notify the AED Coordinator, the AED Medical Director, and the Rutherford County EMS within 48 hours of an incident where an AED was used and provide a copy of the Post-Incident Notification;

15. Before allowing the use of any AED, provide to the Rutherford County EMS a copy of the AED Program Written Plan and Written Notice of the Establishment of the AED program, the location of the AED and a description of how the AED is to be coordinated with the Rutherford County EMS system. The AED Director shall also forward copies of these documents to the AED Coordinator;

16. Update and submit updated versions of the AED Program Written Plan and AED Response Procedure to Rutherford County EMS when any substantial change to either is made after initial implementation. The AED Director shall also forward copies of any updated AED Program Written Plans to the AED Coordinator; and

17. Provide all AED documentation, including but not limited to the AED Program Written Plan and the AED Response Procedure to the AED Coordinator at the end of the fiscal year.

Changes that require an updated AED Program Written Plan include, but are not limited to: Removing the AED from service; change in placement location; and/or plan to replace the AED with another unit of substantially different type or with substantially different features.

C. Alternate AED Director: The Alternate AED Director will be responsible for the duties assigned by the AED Director and will assume full AED Director duties if the AED Director is unavailable for any reason.

D. AED Responder: AED Responders will:

1. Respond to a SCA in their building or unit/department;

2. Respond to a SCA in another building/department if requested by Public Safety or EMS;

3. Activate internal emergency response plan;

4. Provide prompt basic life support including AED and first aid according to training and experience;

5. Relinquish primary responsibility for resuscitation once Public Safety or EMS arrives;

6. Comply and understand requirements of this policy; and

7. Follow the procedures and guidelines of the AED Program Written Plan.

E. MTSU Department of Public Safety: MTSU Public Safety Officers are considered the main CPR/AED responders for MTSU. As such, University Police and its individual officers/employees are responsible for:

1. Receiving emergency medical calls from internal locations and external calls from EMS;

2. Contacting the local external EMS as soon as possible for internal medical calls;

3. Dispatching AED-Responder(s) to an emergency location; and

4. Assigning someone to meet responding EMS aid vehicle(s) and direct EMS personnel to site of medical emergency as needed.

F. AED Coordinator: The AED Coordinator will:

1. Oversee the MTSU AED Program;

2. Conduct annual audits of the records of all AEDs to ensure compliance with this policy and state law, and notify the AED Owner and AED Director of the outcome of the audit within sixty (60) days after receipt of documentation from the AED Director;

3. Maintain documents provided or obtained in performing duties required under this policy. The retention periods for these documents are set forth in Section VI.E. below;

4. Review all AED Post-incident Notifications and documentation with the AED Medical Director and modify procedures as necessary to improve the AED response;

5. Solicit volunteers and designate a licensed medical doctor to serve as the AED Medical Director;

6. Maintain the list of AEDs on campus attached as AED Locations, which shall include the name of the AED Owner, a description of the precise location of each AED and the name and contact information for the responsible AED Director, and provide a copy of that list, and any subsequent updated lists, to the Rutherford County EMS;

7. Retain all documentation for the time periods set forth in Section VI.E. below.

8. In consultation with the Office of the University Counsel, maintain the following forms and distribute these forms to the AED Owners and Directors:

AED Response Procedure

AED Written Notice

AED Written Plan

AED Post-Incident Notification

AED Maintenance Record

AED Daily Check Off

AED Approval Form

G. AED Medical Advisor: The AED Medical Advisor will:

1. Supervise and endorse the placement of each AED on campus; and

2. Review all AED Post-incident Notifications and documentation with the AED Coordinator and provide recommendations, if any, for improving the AED response.

V. Training

AED Responders and Directors shall receive training in Bloodborne Pathogen Exposure Control. In addition, AED Responders and Directors shall receive American Heart Association CPR and AED training or an equivalent nationally recognized course in AED use and CPR as set forth in Tenn. Comp. R. & Regs. § 1200-12-01-.19(6). At the time of the implementation of this policy, the following training programs in CPR and AED use are consistent with the scientific guidelines of the American Heart Association and have been approved by the Tennessee Emergency Medical Services Board:

A. Heartsaver AED and Basic Life Support for Healthcare Professional CPR and AED Courses of the American Heart Association;

B. Advanced Cardiac Life Support Course of the American Heart Association (for Healthcare professionals in conjunction with Basic Life Support for Healthcare Providers);

1. Workplace First Aid and Safety; Adult CPR/AED Training Course of the American Red Cross;

2. AED Training Course of the American Red Cross (in conjunction with Adult and Professional Rescuer CPR courses);

3. AED Course of the National Safety Council (in conjunction with AHA, NSC, or ARC Adult CPR Courses);

4. Heartsaver FACTS Course of the National Safety Council or American Heart Association;

5. Medic First Aid family of programs for Basic Life Support for Professionals and AED Training by EMP International, Inc.;

6. American Safety and Health Institute programs for Basic CPR and AED education and training; and

7. Coyne First Aid CPR and AED training program.

VI. Reporting and Recordkeeping

A. Written Notice of the Establishment of the AED Program: The AED Director shall provide a Written Notice of the Establishment of the AED Program to the Rutherford County EMS that includes, at a minimum, the following. Copies of all documents sent to the Rutherford County EMS shall also be forwarded to the AED Coordinator.

1. The name of the AED Owner, the name and contact information, including telephone numbers, of the AED Director and Alternate AED Director, and the mailing address of the location where the AED will be placed;

2. The street location, facility name, and site within the facility where the AED will be placed, the means needed to access the AED, the hours during the day when the AED may be available, and whether the AED may be used off-site;

3. A description of the AED by manufacturer and model;

4. A listing of area emergency medical services and contact information for the Rutherford County EMS;

5. The name and contact information of the AED Medical Advisor;

6. How the use of the AED is coordinated with the local EMS system; and

7. A request that the Rutherford County EMS acknowledge its receipt of the disclosure of the AED placement, plan, and program.

B. AED Program Written Plan: The AED Director shall formulate an AED Program Written Plan that includes, at a minimum, the following:

1. The location of the AED;

2. The names of the individuals who are authorized to operate the AED (i.e., the AED Responders);

3. A designation of the training programs that will be used to prepare AED Responders and/or other expected users of the AED;

4. A description of how the AED will be coordinated with Rutherford County EMS;

5. The maintenance and testing necessary to maintain the AED, including the frequency of such testing, and sample forms necessary to document proper maintenance;

6. A list of all records that will be kept by the AED Owner, including the records set forth in Section VI. E.;

7. A copy of the Written Notice of the Establishment of the AED Program that was sent to the Rutherford County EMS, along with acknowledgment by its representatives of the AED placement, plan, and program;

8. The reports that will be made of AED use; and

9. A plan of action for proper use of the AED.

C. Post-incident notification and documentation: As soon as possible after a SCA that requires deployment of an AED, the AED Responder, with the assistance of the AED Director, shall fill out a Post-incident Report that contains the following information:

1. The time of use or deployment of the AED;

2. The model of AED used;

3. The names of the AED Responders;

4. Patient information, when known, including name, age, race, and gender of the patient;

5. Condition of the patient upon arrival of AED Responders and the resuscitative actions taken;

6. Condition of the patient upon arrival of EMS; and

7. Patient outcome, if known.

The AED Director shall notify the AED Coordinator within 48 hours of an incident and submit a post-incident report in that time frame. The AED Coordinator will provide the AED Medical Advisor with a copy of the AED Post-incident Report, along with any other requested information or data. The AED Coordinator will conduct a debriefing and review the AED Post-incident Report, along with the AED Medical Advisor.

A copy of the completed report shall also be provided to the Rutherford County EMS.

D. AED Maintenance Record and AED Check-off Records: The AED Director shall maintain maintenance and testing records that include, at a minimum, the following:

1. The date of the inspection of the AED;

2. A description of the AED by manufacturer and model;

3. The name of the inspector;

4. Condition of the AED and description of necessary maintenance;

5. Any special checks performed; and

6. The date of the next inspection.

In addition to routine maintenance, the AED should be checked off every day there is someone in the building to ensure that the device is operational. An AED Daily Check Off form is provided to document the operating check.

E. The following records must be maintained on-site by the AED Owner:

1. Written Notice of the Establishment of the AED Program;

2. AED Program Written Plan;

3. AED Response Procedure;

4. Manufacturer’s “Instructions for Use” booklet;

5. Periodic maintenance, repair, and self-inspection records;

6. The identity of the department’s AED Director;

7. Records documenting training of AED Responders on the use of the AED, CPR, Bloodborne Pathogen Exposure Control, and any other relevant training;

8. Other records as defined by equipment manufacturer;

9. AED Post-Incident Report(s); and

10. A current copy of this policy.

Records 5, 7, and 8 shall be maintained for at least three (3) years. In the event of an accident or failure of the AED, where litigation could occur, the record shall be kept for a longer period of time. Records 5, 7, and 8 from this section shall be kept by AED Owner. Record 9 shall be maintained by the Medical Advisor at Student Health Services for at least seven (7) years.

VII. Procurement and Disposal of AED Equipment

All AEDs authorized under this policy shall be purchased through and with the assistance of MTSU Procurement Logistic Services. All AEDs shall comply with the provisions and meet the requirements of T.C.A. § 68-140-401 through 409 and Tenn. Comp. R. & Regs. 1200-12-01-.19(5).

To facilitate the transition of an individual experiencing SCA from an MTSU AED to an AED operated by EMS, MTSU will endeavor to purchase the same model of AED currently in use by the Rutherford County EMS. If necessary, a sole source contract can be issued for this purpose. This paragraph shall only apply to new purchases of AEDs and should not be construed to mandate the replacement of any MTSU AED that is currently in service.

Contact the AED Coordinator for assistance in disposal and removal of the equipment from inventory. For battery disposal, contact the MTSU Recycling Program at 898-2822 for recycling.

VIII. Immunity of AED Owners and Users

Tennessee law provides various protections from liability to the owners and users of AED devices. See T.C.A. § 68-140-406 (Tennessee AED Statute); T.C.A. § 63-6-218 (Tennessee Good Samaritan Act). In addition, the duties performed by AED Directors and AED Responders will be within the scope of their employment and they, therefore, also are protected by T.C.A. § 9-8-307 (Tennessee Claims Commission Statute). For additional information about the liability protections offered by these statutes, please contact the MTSU Office of the University Counsel.

Forms:

References: T.C.A. §§ 9-8-307; 63-6-218; 68-140-406; 68-140-710; Tenn. Comp. R. & Regs. 1200-12-01-.19.