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Policies,Clinical,UWHC Clinical,Department Specific,UW Organ and Tissue Donation

Equipment Temperature Tracking (3.06)

Equipment Temperature Tracking (3.06) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

3.06



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Equipment Temperature Tracking Policy Number: 3.06

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director



Page 1 of 2
PURPOSE

The purpose of this policy is to ensure a proper temperature is maintained within the University of
Wisconsin Organ and Tissue Donation (UW OTD) walk-in cooler and -80 degree Fahrenheit freezer located
in the UW OTD laboratory in University Hospital room F8/184 for the safety of organs awaiting
transplantation and to ensure temperature sensitive supplies are maintained.

FORMS

Facilities and Engineering Services Temperature Tracking Report

POLICY

A. The temperature within the UW OTD walk-in cooler and -80 degree Fahrenheit freezer will be
continuously monitored by UW Health Facilities and Engineering Services control room via the
temperature alarm system.
B. If the temperature is not within the acceptable parameters for the equipment, the UW Health
Facilities and Engineering Services Department will be contacted by the temperature alarm
system.
C. If the temperature alarm is triggered, UW Health Facilities and Engineering Services staff will:
1. Inspect the equipment to troubleshoot the cause for the temperature alarm.
2. If the temperature issue cannot be resolved in a timely fashion, UW Health Facilities and
Engineering Services staff will use the emergency contact list to notify the appropriate
UW OTD personnel.
D. In the event of an emergency, UW Health Facilities and Engineering Services will contact the
appropriate UW OTD personnel as dictated by the instructions the alarm system will provide.
Upon notification from UW Health Facilities and Engineering Services, UW OTD personnel will
respond by traveling to the UW OTD laboratory in room F8/184 to ensure all temperature
sensitive supplies are moved to an emergency backup location until the equipment temperature
issues are resolved.
E. All temperature sensitive supplies will be placed on ice and moved to the following emergency
backup locations within University Hospital by UW OTD personnel:
1. K4/463B.



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Equipment Temperature Tracking Policy Number: 3.06

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director



Page 2 of 2
2. K4/563B.
F. UW Health Security will be contacted to gain access to the emergency backup locations in the
various areas of the hospital.
G. The supplies placed in the emergency backup locations will be labeled.
H. All supplies will be transferred back to F8/184 by UW OTD personnel as soon as possible after
the equipment has been deemed operational by UW Health Facilities and Engineering Services.
I. A log of temperature alarms will be maintained by UW OTD personnel.