University of Washington Policy Directory

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*Formerly part of the University Handbook
Administrative Policy Statement
10.12


Purchase, Management, and Use of an Automated External Defibrillator at the University of Washington

(Approved by the Executive Director of Health Sciences Administration by authority of Executive Order No. 1 and the Provost and Executive Vice President by authority of Executive Order No. 4)



1.  Policy

As part of the University's commitment to a healthy, safe, working environment, the University makes first aid instruction available to University employees (for more information on First Aid, see APS 10.5). First aid instruction includes training on the use of automated external defibrillators (AEDs) as a life-saving aid. RCW 70.54.310 establishes specific requirements for entities regarding AEDs. In order to comply with RCW 70.54.310, the University's AEDs are placed with, maintained by, and are the responsibility of the University of Washington Police Department (UWPD) and designated public safety departments.

This policy establishes the procedure that an organizational unit must follow to select, acquire, manage, and use an AED that is not serviced by the UWPD or a designated public safety department. Only an AED acquired in accordance with this specified procedure is considered approved and authorized for use by the University.

2.  Scope

This policy applies to University of Washington campuses at Seattle, Bothell, and Tacoma, and off-site locations used for academic teaching, research, and/or administrative purposes where the University maintains authority and responsibility for the property, including but not limited to, Friday Harbor Laboratories, Pack Forest, and South Lake Union.

This policy does not apply to the operations and/or facilities of Harborview Medical Center, the University of Washington Medical Center, Hall Health Primary Care Center, or the Sports Medicine department of Intercollegiate Athletics wherein AEDs are used as part of normal medical equipment.

3.  Compliance Responsibilities

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

Those individuals having management and/or supervisory authority are responsible for directing the units within their respective areas to comply with this policy.
  b. Organizational Units

Organizational units that are approved to purchase AEDs must follow this policy and the procedures herein to purchase, manage, maintain, and use an AED in conformance with all applicable laws, policies, and procedures of the University.
  c. University of Washington Police Department

The UWPD, as part of their first emergency responder responsibilities, equips UWPD patrol cars with the University AEDs. They also place AEDs at other locations under their jurisdiction as they deem necessary. They provide AEDs at the UW Seattle campus and contiguous areas under UWPD jurisdiction. UWPD AEDs are purchased, managed, maintained, and used in conformance with all applicable laws, policies, and procedures. The UWPD AEDs are the standard Medic 1 units with which all other AEDs at UW Seattle must be compatible and consistent.
  d. University of Washington Public Safety Departments at UW Bothell and UW Tacoma

At the UW Bothell and UW Tacoma campuses, the public safety departments purchase, manage, maintain, and use AEDs in conformance with all applicable laws, policies, and procedures. The public safety departments' AEDs are the standard Medic 1 units with which all other AEDs at those University facilities must be compatible and consistent.
  e. University of Washington AED Coordinating Committee

The Executive Director of Health Sciences Administration chairs and appoints the members of the University's AED Coordinating Committee. This committee is responsible for reviewing and approving AED purchase requests in compliance with this policy and procedure, 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. The core membership of this committee consists of the Campus Health Services Director, the UW Police Chief, the Director of Environmental Health and Safety, and the directors of designated public safety departments. Other members may be appointed at the discretion of the committee chair.
  f. Physician Oversight

The Executive Director of the Health Sciences Administration designates a University physician to provide the required medical oversight and direction of AED use at the University. This physician is the primary liaison for the jurisdictional emergency medical responders and trauma centers regarding use and availability of AEDs at the University.
  g. AED Coordinators

An AED coordinator is the designated person in an organizational unit who is responsible for ensuring that the AED purchased by the unit is approved, managed, maintained, and secured in accordance with the provisions of this policy and procedure, the AED manufacturer's requirements, and applicable law.
  h. Campus Health Services

The University's Campus Health Services unit (CHS) provides coordination and oversight of employee health clinical services. In addition, this unit maintains the inventory of the University-authorized AEDs, convenes the AED Coordinating Committee on behalf of the committee chair, provides the physician oversight for the University's AEDs, and coordinates with Medic 1 and trauma centers regarding AED use, as necessary.

  i. Environmental Health and Safety Department

The University's Environmental Health and Safety Department (EH&S) 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. EH&S also conducts annual surveys of authorized units to ensure timely maintenance has occurred and sends reports of findings to the CHS Director. For units not in compliance with University policy and/or maintenance requirements, EH&S is authorized to remove an organization's AEDs, after notifying the responsible organizational authority and the CHS Director.

4.  Compliance Procedures

Organizational units can only purchase AED equipment compatible with AEDs maintained by UWPD and/or the public safety departments. AED type and selection shall be consistent 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.

  #1 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 provide the following information:

  • The conditions that make access to UWPD or public safety departments unlikely, and/or the activities that may make the facility subject to incidents where an AED is needed more quickly than can be provided by city or county emergency medical assistance.

  • The names and availability of appropriately trained first aid responders.

  • The location at which the AED will be housed—documenting access, instructional postings, security, and equipment protection at that location.

  • The name of the responsible AED coordinator who will ensure ongoing maintenance and recordkeeping for the unit.

  • The unit's procedures for ongoing operation and maintenance.
  #2 Submit the application, available at the EH&S website, with the information in Item #1 above, to EH&S for coordination of review/approval by the CHS Director and the University's AED Coordinating Committee.
  #3 If approval to purchase the AED is granted, the organizational unit must complete the following steps:
  • Purchase an AED compatible with UWPD or the local public safety department.

  • Notify CHS when the AED has arrived so it can be listed for inventory management.

  • Request the CHS Director to notify local emergency medical services organizations about the location of the AED.

  • Incorporate the AED operation and maintenance plan, and the AED coordinator information, into the organization's Health and Safety Plan.

  • Make the AED available, only after all notifications have been made and the operation and maintenance plan is completed.

  • Notify EH&S that the unit has been made available for use.
  #4 Safe use of AEDs requires the organizational unit to accept and implement the following ongoing responsibilities:

  • Provide any data or information that emergency medical services or other health care providers request after AED use.

  • Notify the UWPD or local public safety department if an AED is used.

  • Implement appropriate maintenance of the unit.

  • Take immediate action, if the Food and Drug Administration (FDA) or the manufacturer recalls an AED used by the University. The organizational unit must also notify the CHS Director of the disposition of the recalled AED. (Note: AED recall notices received by the University will be posted on the EH&S website.)

  • Document and record all required AED operation and maintenance procedures, history of AED use, and the name of the AED coordinator. This information shall be made available to the UWPD, public safety departments, CHS, and/or EH&S upon request.

  • Remove from service any AED not functioning properly, and notify EH&S and CHS. Also, inform EH&S and CHS if the AED is later reactivated.

5.  Additional Information

Additional information can be found at the EH&S website.

November 18, 2008.