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UPPS 07.09.05 - Automated External Defibrillator Program

Automated External Defibrillator Program

UPPS No. 07.09.05
Issue No. 1
Effective Date: 2/21/2020
Next Review Date: 4/01/2024 (E4Y)
Sr. Reviewer: Director, Student Health Center

  1. POLICY STATEMENTS

    1. Texas State University is responsible for establishing policies and procedures that support the health and safety of faculty, staff, students, and visitors on campus. Sudden cardiac arrest (SCA) is a leading cause of death in the United States. The risk for SCA increases with age or level of physical exertion. Automated external defibrillators (AEDs) are portable medical devices that can analyze heart rhythm to detect cardiac arrest and deliver an electric shock to the heart that may be lifesaving. The purpose of this document is to establish a policy for obtaining an AED for use in university buildings and by university departments and programs.

    2. The Food and Drug Administration (FDA) regulates the use of AEDs and requires that any AED program must have medical oversight by a physician familiar with sudden cardiac arrest and the operation of AEDs.

    3. The use of AEDs in Texas is governed by Chapter 779 of the Health and Safety Code, which includes the following requirements:

      1. a physician must provide medical oversight including the development of a training program;

      2. a person or entity that acquires an AED must ensure that the user receives training in cardiopulmonary resuscitation and the use of the AED;

      3. AEDs must be maintained and tested according to the manufacturer’s guidelines; and

      4. a person that provides emergency care to a person in cardiac arrest using the AED must promptly notify emergency medical services (EMS).

    4. Failure to comply with the requirements listed in Chapter 779 of the Health and Safety Code may result in liability for civil damages caused by such negligence.

    5. Section 74.151 of the Civil Practice and Remedies Code stipulates that a person who in good faith provides emergency care using an AED is not liable for civil damages unless the care was willfully negligent.

  2. CRITERIA FOR ASSESSING AED PLACEMENT

    1. To ensure that AEDs are placed in locations and settings where they are most likely to be needed due to a higher risk for sudden cardiac arrest, the following criteria will be used to assess the appropriateness of the AED placement:

      1. locations with very high volumes of employee or visitor traffic such as sports venues, performing arts centers, and conference facilities;

      2. locations conducting research, testing, or other activities requiring significant exertion or with higher risks for sudden cardiac arrest;

      3. athletic or recreational programs;

      4. remote locations with poor emergency response access; and

      5. university police vehicles.

    2. A list and map of campus locations with AEDs will be maintained at university AED program offices.

  3. AED REQUEST PROCEDURES

    1. Department and program administrators may submit a request for an AED to the AED program coordinator in the Environmental Health, Safety, and Risk Management office. The Automated External Defibrillator Request form should be completed and submitted to the AED program coordinator.

    2. AED requests will be reviewed by the AED program coordinator and medical director to determine if criteria are met for placement of an AED.

    3. After receiving written approval from the AED program coordinator, the requesting department or program may purchase an approved AED. The AED program has established the Philips Heartstart FRx or Physio-Control LIFEPAK CR PLUS AEDs as the university standard. Only these two AED models may be purchased, unless written approval is obtained from the medical director of the AED program to purchase a different model. If a wall-mounted AED cabinet is needed, the type and location must be approved by the AED program coordinator.

    4. After purchasing the AED, it must be submitted to the AED program coordinator for inspection to ensure that it is operating properly and has two sets of electrode pads and an emergency kit. The AED serial number and placement location will be documented and maintained as part of the university record.

  4. RESPONSIBILITIES OF DEPARTMENTS AND PROGRAM ADMINISTRATORS

    1. Department and program administrators that request approval for placement of an AED are responsible for the following:

      1. purchasing the AED, two sets of electrode pads, battery, and emergency kit;

      2. purchasing a wall-mounted AED cabinet with alarm if placing the AED in a public access location;

      3. designating AED managers to be responsible for monitoring and maintaining the AED according to manufacturer instructions;

      4. documenting the monitoring and maintenance of the AED and providing the records for review by the AED program coordinator;

      5. ensuring that at least two faculty or staff are trained in cardiopulmonary resuscitation (CPR) and the use of the AED (the AED program coordinator will ensure that such training is provided when an AED is deployed);

      6. renewing their training to maintain competency and certification; and

      7. purchasing replacement AEDs if needed.

  5. PROCEDURES FOR AED PROGRAM MONITORING AND COMPLIANCE

    1. The AED program coordinator in the Environmental Health, Safety, and Risk Management office will be responsible for developing and maintaining a process for inspection of the AEDs. On a quarterly basis, AEDs will be inspected and site monitoring and training records reviewed to ensure compliance with manufacturer maintenance and CPR and AED training requirements.

    2. The AED program coordinator will meet with the medical director of the AED program at least annually to review compliance with program requirements for AED maintenance and CPR and AED training.

    3. The AED program coordinator will maintain an inventory of AED units in operation and their location. An AED campus map showing locations of AED units will be maintained and updated when new units are added. The AED campus map will be published on the departmental websites for both Environmental Health, Safety, and Risk Management and the Student Health Center.

    4. The AED program coordinator will notify the medical director within two business days when an AED has been utilized in an emergency. An incident report with details of the emergency use will be reviewed with the medical director. Any recommended changes or improvements will be documented and shared with the department or program that maintains the AED.

  6. AED PROGRAM MEDICAL OVERSIGHT

    1. The Student Health Center director, or designee, is the medical director for the AED program. The medical director will meet at least annually with the AED program coordinator to assess compliance with AED program requirements.

    2. The medical director will review requests for placement of an AED with the AED program coordinator. If approval for the AED is granted, the AED program coordinator will notify the department or program. No AED should be purchased for university use without such approval.

    3. The medical director will review incidents involving emergency use of an AED with the program coordinator. Recommendations for changes or improvements will be discussed with the AED program coordinator.

    4. The medical director will provide the local EMS office with updated information on the location of AEDs on the San Marcos and Round Rock campuses annually.

  7. FUNDING FOR AED PROGRAMS

    1. New buildings constructed on campus property that meet the eligibility criteria set forth in this policy should include AEDs. The cost of the AED will be the responsibility of the building occupants. An AED request should be submitted to the AED program coordinator, as directed in Section 03.01. Maintenance costs for approved AEDs will be covered by the university.

    2. Departments or programs approved to have an AED are responsible for all costs associated with purchase and replacement of the unit. Departments and programs are also responsible for any costs associated with the monitoring and CPR and AED training required. Failure to comply with the monitoring and training requirements of the AED program may result in removal of the AED to avoid exposing the university to liability due to negligence. Maintenance costs for approved AEDs will be covered by the university.

  8. REVIEWERS OF THIS UPPS

    1. Reviewers of this UPPS include the following:

      Position Date
      Director, Student Health Center April 1 E4Y
      Director, Environmental Health, Safety, and Risk Management April 1 E4Y
  9. CERTIFICATION STATEMENT

    This UPPS has been approved by the following individuals in their official capacities and represents Texas State policy and procedure from the date of this document until superseded.

    Director of Student Health Center; senior reviewer of this UPPS

    Vice President for Student Affairs

    President