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Maintaining and Securing the Emergency Response Carts, Defibrillators and Automated External Defibrillators (AED) (5.1.15)

Maintaining and Securing the Emergency Response Carts, Defibrillators and Automated External Defibrillators (AED) (5.1.15) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.15


UW HEALTH CLINICAL POLICY 1
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators,
and Automated External Defibrillators (AED)
Policy Number: 5.1.15
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: January 2, 2018

I. PURPOSE

To establish a process to ensure emergency medication, equipment, and supplies are present and
maintained for immediate use during an emergency response at all UW Health locations, excluding Surgical
Services (see Surgical Services departmental policy #1.05, Daily Audit of Emergency Carts).

For information on replenishment and bi-annual auditing procedures for emergency and non-emergency kits,
boxes, and trays supplied by the Department of Pharmacy, please see Pharmacy departmental policy #8.7,
Management and oversight of Emergency and non-emergent kits, boxes and trays.

II. DEFINITIONS

UH: University Hospital

AFCH: American Family Children’s Hospital

TAC: The American Center

DHC: Digestive Health Center

On-Site Clinic: An ambulatory clinic site that is at the same location as a UW Health hospital.

Off-Site Clinic: An ambulatory clinic site that is NOT at the same location as a UW Health hospital.

III. POLICY ELEMENTS

A. UW Health has two levels of unit/clinic-based emergency response carts, Advanced Cardiac Life Support
(ACLS) and Basic Life Support (BLS).
i. ACLS Carts and Defibrillators
a. Zoll R Series defibrillators
1. Located throughout UH, AFCH, TAC, and DHC sites
b. LifePak defibrillators are located:
1. UH
A. Cardiothoracic Surgery ICU, Cardiac Medical ICU, Heart & Vascular
Procedure Center
2. AFCH
A. Hybrid Lab
3. Clinics
A. Urgent Care
B. Cardiology
C. Various other primary care clinic sites
ii. BLS Carts and AEDs
a. Located in various areas at each UW Health site.
B. The integrity of the emergency response cart is assured via a numbered locking system. All emergency
response carts, airway boxes, and medication tray/drawers are to remain locked at all times with a
numbered plastic breakaway seal.

The integrity of the emergency response cart is checked daily and documented on the UW Health
Emergency Response Cart Audit Form (BLS or ACLS) by assigned staff.

Each time the cart is entered and the plastic breakaway seal is broken (emergency event, supply audit, or
found open) the plastic seal needs to be replaced.

i. UH:



UW HEALTH CLINICAL POLICY 2
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15

a. These locks are to be kept in a secured location and dispensed by the hospital nursing
supervisor or designee. A master list of the sequential numbered locks must be
maintained in the nursing resource office.
ii. TAC:
a. These locks are to be kept in a secured location within Pharmacy and dispensed by a
pharmacist or designee. A master list of the sequential numbered locks must be
maintained in the pharmacy.
iii. DHC:
a. These locks are to be kept in a secured location within Pharmacy and dispensed by a
pharmacist or designee. A master list of the sequential numbered locks must be
maintained in the pharmacy
iv. AFCH:
a. These locks are to be kept in a secured location and dispensed by the hospital nursing
supervisor or designee. A master list of the sequential numbered locks must be
maintained in the nursing resource office.
v. On-Site clinics:
a. These locks are to be kept in a secured location and dispensed by the hospital nursing
supervisor or designee. A master list of the sequential numbered locks must be
maintained in the nursing resource office.
vi. Off-Site Clinic:
a. These locks are to be kept in a secured location and dispensed by off-site building
secretaries or designee. A master list of the sequential numbered locks must be
maintained in the building secretary office or other designated place.
C. Oxygen Cylinder Maintenance:
i. All oxygen cylinders on the Emergency Response Carts should only be used for emergency
events. Cylinders are to be full and attached to the Emergency Response Cart
a. UH: Respiratory Care Services is responsible for maintenance of the oxygen cylinder
b. TAC: Respiratory Care Services is responsible for maintenance of the oxygen cylinder
c. DHC: If oxygen is used for emergency event, used cylinders will be taken to the loading
dock at DHC. New cylinder is obtained from “full cylinder” rack and placed on emergency
cart.
d. AFCH: Respiratory Care Services is responsible for maintenance of the oxygen cylinder
e. On-Site Clinics: Respiratory Care Services is responsible for maintenance of oxygen
cylinder.
f. Off-site Clinics: If oxygen is used for emergency event, place used cylinder in “used
cylinder” area within department and replace with full cylinder from clinic supply.
D. Emergency Medications:
i. UH, TAC, DHC, AFCH, On-Site and Off-Site Clinics
a. Emergency medications are secured for integrity (e.g. wrapped, sealed) with an expiration
affixed to the tray/drawer
b. Bi-annually the medication trays/drawers are exchanged by pharmacy
E. Binder and Forms
i. The code binder will contain the following documents pertinent to the Emergency Response Carts:
a. Inventory lists of medication and cart contents
b. UW Health Emergency Response Cart Audit Form (ACLS or BLS)
c. Resuscitation Report for inpatient sites (UWH 1280007) or Ambulatory Emergency
Response Form for ambulatory sites (UWH 301952-DT)
ii. Checks of the Emergency Response Cart are documented on the appropriate UW Health
Emergency Response Cart Audit Form (BLS vs. ACLS) by assigned staff. The form is located in
the code binder.
a. All audit forms should be kept for three (3) years.

IV. PROCEDURE

A. Daily Checks: Record on UW Health Emergency Response Cart Audit Form
i. Record cart lock number and that lock is intact
ii. Record the presence of a FULL oxygen tank secured to the cart.
iii. Record that the following are present on the Emergency Response Cart:



UW HEALTH CLINICAL POLICY 3
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15

a. CPR Board
b. PPE (mask/gloves)
c. Emergency Response Cart Binder
d. Needle box
iv. Record the following regarding the Portable Suction Machine
a. Unit is clean and ready for use with suction tubing and Yankauer next to machine.
b. Check to make sure suction machine is plugged into power strip on the emergency
response cart and the cart is plugged into the wall.
c. Green battery charging light is on

SPECIAL NOTICE: A blinking LED on the control panel of the suction machine indicates
low battery capacity. This means the battery has been subjected to irreparable damage.
Call Facilities and Engineering Services to REPLACE THE BATTERY!
v. AED and Defibrillator Check
a. AED
1. Check the Ready light
A. If the Ready light is off or displays ‘X’ contact Clinical Engineering
2. Battery
A. One (1) installed
B. Philips HeartStart FR2 has spare; other models do not.
3. Verify supplies
A. Correct pads based on location (adult vs. pediatric) based on
department specific need.

AED’s placed in non-patient areas or waiting areas will be checked by UW Health
Security or other assigned trained staff. These checks will be documented on a
separate AED Audit Form.
b. LifePak and Zoll R series defibrillators
1. Machine to be plugged into AC power when not in use
2. Check for indicator light notifying service or battery is needed
A. Contact Clinical Engineering
3. Check presence of paper
4. Perform user test daily or check that automatic self-test was performed.
A. Refer to the Defibrillator Guidelines (see related tab of this policy on U-
Connect)
5. Battery
A. Zoll R series One (1) installed
B. LifePak One (1) installed
6. Verify supplies
A. Correct pads (adult vs. pediatric) based on department specific needs
B. Monthly Checks: Record on Emergency Response Cart Audit Form
i. AED and Defibrillator Check:
a. Record battery expiration date
b. Record Adult pads expiration date
c. Record Pediatric pads expiration date
d. AED/defibrillator exterior clean and free of damage
1. If dirty, clean AED/Defibrillator and cables (refer to UW Health Clinical Policy
4.1.7- Cleaning, Disinfection and Sterilization of Patient Care Instruments and
Equipment, for additional equipment cleaning information).
2. Contact Clinical Engineering if damage is found

AED’s placed in non-patient areas or waiting areas will be checked by UW Health Security
or other assigned trained staff. These checks will be documented on a separate AED
Audit Form.
ii. Portable Suction Machine:
a. Unplug the suction machine from AC power and run the pump for approximately one (1)
minute to make sure the battery is holding a charge.



UW HEALTH CLINICAL POLICY 4
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15

b. Check the unit has GREEN PM sticker (ensuring the annual preventive maintenance is
up-to-date).
1. If PM sticker is not up-to-date, Contact facilities and engineering services and
request a replacement unit from Central Services until serviced
iii. ACLS Carts Only
a. Check the light on the laryngoscope blade to assure the light works. Document on the top
of the monthly audit form.
iv. Oxygen Cylinders
a. Respiratory Care Services performs a monthly check on all oxygen cylinders at UH, TAC,
and On-site clinics.
C. Bi-Annual Checks: Record on Emergency Response Cart Audit Form
i. All internal contents of the emergency response cart are checked by assigned staff twice a year
(February and August).
a. All cart items are compared against the Emergency Response Cart equipment list (BLS
vs. ACLS)
b. Replace items expiring in less than six (6) months.
c. Replace lock per Section III.B.
d. Check condition of suction canister.
1. Replace canister after every patient use
2. Replace canister every five (5) years or as needed.
3. DATE the canister (bottom of canister) with opened date
ii. Emergency Medications
a. UH/TAC/DHC/AFCH/On-Site Clinics/Off-Site Clinics:
1. Pharmacy maintains records and automatically updates all drawers/trays on a bi-
annual basis.
D. Following a Resuscitative or Emergency Event
i. Restocking supplies: If the cart is opened for a medical emergency or found open, all cart contents
need to be verified against the emergency response cart equipment list and accounted for before
putting on a new plastic lock.
a. UH:
1. After a code blue is called and/or the cart has been opened for use, Central
Services (CS) Distribution will deliver a replacement cart to the location of the
resuscitation.
2. If the code blue cart is not paged overhead, CS will need to be called to obtain a
replacement cart.
3. The used cart will be returned to CS by unit staff with the completed Emergency
Response Cart Checklist, including patient identifiers.
b. TAC:
1. After a code blue is called and/or the cart has been opened for use, Materials
Management will deliver a replacement cart to the location of the resuscitation.
2. If the code blue is not paged overhead, Materials Management will need to be
called to obtain a replacement cart.
3. The used cart will be returned to Materials Management by unit staff with the
completed Emergency Response Cart Checklist, including patient identifiers.
c. DHC:
1. Staff are responsible for restocking the cart immediately after the code or
emergency event. Supplies can be obtained from the clean supply room
2. Any bagged but reusable item(s) that were used during the event need to be
cleaned with a Cavi wipe and placed in new ziplock bag and labeled with sticker
“clean but not sterile”.
d. AFCH:
1. After a code blue is called and/or the cart has been opened for use, Central
Services (CS) Distribution will deliver a replacement cart to the location of the
resuscitation.
2. If the code blue cart is not paged overhead, CS will need to be called to obtain a
replacement cart.
3. The used cart will be returned to CS by unit staff with the completed Emergency
Response Cart Checklist, including patient identifiers.



UW HEALTH CLINICAL POLICY 5
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15

e. On-Site Clinic:
1. Staff can choose to restock from own cart from clinic supply or take the used cart
with the completed Emergency Response Cart Checklist, including patient
identifiers, to CS Distribution for replacement.
2. If staff does not send to CS Distribution, all bagged but reusable item(s) that
were used during the event need to be cleaned with a Cavi wipe and placed in
new ziplock bag and labeled with sticker “clean but not sterile”.
3.
f. Off-Site Clinic:
1. Staff should replace all the items from their own supply room
2. Any bagged, but reusable item(s) that were used during the event need to be
cleaned with a Cavi wipe and placed in new ziplock bag and labeled with sticker
“clean but not sterile”.

ii. Medication Tray/Drawer Exchange
a. UH:
1. If only the medication drawer is used, the medication tray can be exchanged
through Pharmacy without exchanging the entire cart with Central Services.
Document expiration date on emergency response cart audit form.
2. Call Central Nursing Office for a replacement lock.
3. Lock the drawer with the new numbered lock.
4. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
b. TAC:
1. If only the medication drawer is used, the medication tray can be exchanged
through Pharmacy without exchanging the entire cart with Materials
Management. Document expiration date on emergency response cart audit form.
2. Call Pharmacy for a replacement lock.
3. Lock the drawer with the new numbered lock.
4. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
c. DHC:
1. Pharmacy will be responsible for double checking the medications and replacing
the tray or drug box. Pharmacy will provide the numbered lock to seal the cart
once restocking is complete.
2. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
d. AFCH:
1. If only the medication drawer is used, the medication tray can be exchanged
through Pharmacy without exchanging the entire cart with Central Services.
Document expiration date on emergency response cart audit form.
2. Call Central Nursing Office for a replacement lock.
3. Lock the drawer with the new numbered lock.
4. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
e. On-Site Clinic:
1. If only the medication drawer is used, the medication tray can be exchanged
through Pharmacy without exchanging the entire cart with Central Services.
Document expiration date on emergency response cart audit form.
2. Call Central Nursing Office for a replacement lock.
3. Lock the drawer with the new numbered lock.
4. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
f. Off-Site Clinic
1. Obtain a replacement medication (sending used tray back to pharmacy)
2. Record the new lock number on the UW Health Emergency Response Cart Audit
Form.
iii. Oxygen cylinders used during emergency event:



UW HEALTH CLINICAL POLICY 6
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15

a. UH: Respiratory Care Services is responsible for maintenance of the oxygen cylinder.
Notify Respiratory Care Services whenever oxygen is used from the Emergency
Response Cart and a full cylinder replacement is needed. If oxygen supplies are missing
or used, Central Services will restock when the cart is brought to them.
b. TAC: Respiratory Care Services is responsible for maintenance of the oxygen cylinder.
Notify Respiratory Care Services whenever oxygen is used from the Emergency
Response Cart and a full cylinder replacement is needed. If oxygen supplies are missing
or used, Materials Management will restock when the cart is brought to them.
c. DHC: Used cylinders will be taken to the loading dock at DHC. New cylinder is obtained
from “full cylinder” rack and placed on emergency cart. If oxygen supplies are missing or
used, replace from clinic stock or order.
d. AFCH: Respiratory Care Services is responsible for maintenance of the oxygen cylinder.
Notify Respiratory Care Services whenever oxygen is used from the Emergency
Response Cart and a full cylinder replacement is needed. If oxygen supplies are missing
or used, Central Services will restock when the cart is brought to them.
e. On-Site Clinics: Respiratory Care Services is responsible for maintenance of the oxygen
cylinder. Notify Respiratory Care Services whenever oxygen is used from the Emergency
Response Cart and a full cylinder replacement is needed. If oxygen supplies are missing
or used, Central Services will restock when the cart is brought to them or replaced from
clinic stock.
f. Off-Site Clinics: Cylinder will be placed in the “used cylinder” area within the department
and new full oxygen cylinder to be placed on the cart. If oxygen supplies are missing or
used, replace from clinic stock or order.
iv. AED/Defibrillators
a. Clean AED/Defibrillator and cables (refer to UW Health Clinical Policy 4.1.7- Cleaning,
Disinfection and Sterilization of Patient Care Instruments and Equipment, for additional
equipment cleaning information).
b. Check exterior is free of damage
1. Contact Clinical Engineering if damage is found
c. Restock pads
d. AED -Check battery and presence of indicator light
e. Defibrillator-plug into electrical outlet for charging and check presence of indicator light

V. FORMS

UW Health Emergency Response Cart Audit Form (BLS & ACLS)
Ambulatory Emergency Response Form (UWH 301952-DT)
Resuscitation Form (UWH 1280007)
Emergency Response Cart Equipment List (BLS & ACLS)
UW Health Additional AED Audit

VI. COORDINATION

Author: Clinical Staff Educator (Ambulatory), Clinical Nurse Specialist, Cardiology
Reviewers: Clinical Nurse Specialist, Cardiothoracic Surgery; Clinical Nurse Specialist, Digestive Health
Center; Clinic Coordinator, Digestive Health Center; Nurse Manager, Emergency Services; Director,
Professional Services; UW Health-The American Center Pharmacy Manager; Manager, Clinical Staff
Education; Nurse Education Specialist-Heart, Vascular and Thoracic
Approval committees: Resuscitation Review Committee, Pediatric Resuscitation Review Committee, UW
Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.




UW HEALTH CLINICAL POLICY 7
Policy Title: Maintaining and Securing the Emergency Response Carts, Defibrillators, and Automated External
Defibrillators (AED)
Policy Number: 5.1.15


VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

A. UW Health Clinical Policy 5.1.16, Emergency Response Teams
B. UW Health Clinical Policy 4.1.7, Cleaning, Disinfection and Sterilization of Patient Care Devices and
Equipment
C. Surgical Services Policy 1.05, Daily Audit of Emergency Carts – Surgical Services
D. Pharmacy Departmental Policy 8.7, Management and oversight of Emergency and non-emergent kits, boxes
and trays

IX. REVIEW DETAILS

Version: Original
Last Full Review Date: January 2, 2018
Next Revision Due: January 2020
Formerly Known as:
- Nursing Patient Care Policy & Procedure #6.33
- 6.35 Maintenance of the Automated External Defibrillators (AED): Heartstream F-2, Philips HeartStart,
LifePak 12, and Zoll R Series
-MF Policy 101.040, Crash Cart Equipment Checks