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Repair or Replacement of Essential Equipment in Case of Breakdown (Adult & Pediatric) (8.39AP)

Repair or Replacement of Essential Equipment in Case of Breakdown (Adult & Pediatric) (8.39AP) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Misc

8.39AP


NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
February 28, 2017


Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 8.39AP

Original
Revision

Page
1
of 2

Title: Repair or Replacement of Essential
Equipment in Case of Breakdown (Adult &
Pediatric)

I. PURPOSE

To delineate a procedure for repair or replacement of essential equipment in case of
breakdown and to assure compliance with the Food and Drug Administration (FDA)
Safe Medical Devices Act and UW Health Policy 12.40, Reporting of Device-Related
Adverse Events and Other Product Problems

II. POLICY

A Patient Safety Net (PSN) event report should be filed with each repair or
replacement except mechanical circulatory device (MCD). For MCD, a PSN report
should be filed for an unexpected event and manufacturing concern.

III. PROCEDURE

A. Cardiac Monitoring: In the event that cardiac monitor equipment becomes
nonfunctional:
1. During normal business hours 7-4:30pm M-F: Call Clinical Engineering
for immediate replacement or repair at 263-5208 at the University
Hospital (UH) and 234-6656 at The American Center (TAC).
2. Outside of normal business hours: Call the UH Facilities and
Engineering Services Control Room at263-5205 to request immediate
replacement or repair of the broken equipment. The Control Room will
contact the on-call Clinical Engineering Technician. Call 440-6666 for
assistance at TAC,
3. Clinical Engineering will contact the unit to attempt to correct the
situation over the telephone. If this is not possible, the technician will
attempt to replace the bedside monitor with an unused system from
another unit or another available spare.
4. During the interim that it takes Clinical Engineering to respond, patients
should be placed on a portable monitor.
5. Enter a PSN event report describing the incident.

B. Intracranial Pressure Monitoring: In the event that an intracranial pressure
monitor malfunctions, obtain a replacement monitor from the supply maintained
in TLC (telephone: 263-8134), or Neuro ICU (telephone: 265-1978). Enter a PSN
event report describing the incident.


Page 2 of 3

C. Intravenous (IV) Pump: In the event that an IV pump fails, the clinical
staff/caregiver will:
1. Request immediate delivery of a replacement pump from Central
Supply.
2. Remove the pump.
3. Enter in a clinical engineering service request online.
4. Secure the request to the pump.
5. Return the pump to the soiled utility room.
6. If the pump is involved in a patient event, follow steps A-D, sequester
the device, and notify Clinical Engineering (263-5208 at CSC and
234-6656 at TAC).
7. Enter a PSN event report describing the incident.
D. Ventilator: In the event of ventilator malfunction:
1. Provide oxygen and ventilation with the resuscitation bag.
2. Call Respiratory Therapy STAT.
3. Enter a PSN event report describing the incident.
E. Intra-Aortic Balloon Pump (IABP): In the event of IABP malfunction:
1. If there is a problem with IABP, system failure alarm, or IABP
malfunction, obtain a backup IAB console from following places in this
order: 1) cath lab, 2) B45, 3) OR. Switch patient onto replacement
console. Notify clinical engineering at 608-263-5208 and enter a PSN.
2. Manually inflate balloon per manufacturer's recommendation if
necessary if delay in obtaining replacement console and as stated in
Nursing Patient Care Policy 1.34, Intra-Aortic Balloon Pump (IABP)
Set-Up, Insertion, Operation and Maintenance (Adult).
3. Enter a PSN event report describing the incident.
F. Mechanical Circulatory Device (MCD): In the event of a MCD malfunction:
1. Follow emergency response as outlined in MCD guideline emergency
section of each device. Impella® Percutaneous Ventricular Assist
Device (PVAD): Obtain another console from the Heart and Vascular
Procedure Center (“Cath Lab”) storage area or call the toll free number
on the console for vendor support. Notify the provider and enter a PSN
event report describing the incident.
2. TandemHeart PVAD: Obtain another console from the Heart and
Vascular Procedure Center (“Cath Lab”) storage area or call the toll free
number on the console for vendor support. Notify the provider and enter
a PSN event report describing the incident.
G. Extracorporeal Membrane Oxygenation (ECMO): In the event of ECMO
malfunction:
1. ECMO specialist and perfusion will follow emergency procedures in
their ECMO Specialists Guidebook.

IV. UWHC CROSS REFERENCES

A. UW Health Administrative Policy 12.40, Reporting of Device-Related Adverse
Events & Other Product Problems
B. Nursing Patient Care Policy 1.34A, Intra-Aortic Balloon Pump (IABP) Set-Up,
Insertion, Operation and Maintenance (Adult)
C. Clinical Practice Guideline, Mechanical Circulatory Device (MCD) – Adult-

Page 3 of 3

Inpatient/Ambulatory Clinical Practice Guideline
D. ECMO Handbook
E. Nursing Patient Care Policy 1.24AP Alaris® System (Adult & Pediatric)
F. Nursing Patient Care Policy 1.40A Ventricular Assist Device (VAD) (Inpatient
Adult)
G. Nursing Patient Care Policy 7.11A Care of the Intubated Patient (Adult)
H. Nursing Patient Care Policy 7.11P Care of the Intubated Patient (Pediatric &
Neonatal)

V. REVIEWED BY

Director of Nursing Quality and Safety
Director of Facilities Management
Director of Clinical Engineering
Clinical Nurse Specialist, Neurosurgery
Clinical Nurse Specialist, Cardiac Surgery, Cardiopulmonary Transplant and
MCD Programs
Nurse Manager, Neuro ICU
Clinical Nurse Specialist, Cardiology
Director, Professional Services UW Health at The American Center
Nursing Administrative Policy & Procedure Committee, February 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive