As of October 1, 2017, this administrative policy applies to the operations and staff of legacy UWHC. Effective July
1, 2015, the legacy operations and staff of UWHC and UWMF were integrated into the University of Wisconsin
Hospitals and Clinics Authority (UWHCA). All administrative policies are being transitioned to apply UWHCA-wide,
but until future revision to this policy #9.35, it applies only to the operations and staff of legacy UWHC.
9.35 Certification Cardiopulmonary Resuscitation & Other Life Saving Interventions
Category: UWHC Administrative Policy
Policy Number: 9.35
Effective Date: October 23, 2017
Section: Personnel (Hospital Administrative)
To establish guidelines on staff requirements for certification in cardiopulmonary resuscitation and other life-saving
A. All incoming Graduate Medical Education (GME) Trainees (residents and fellows) are required to show
certification in an American Heart Association approved Health Care Provider Basic life Support (BLS/CPR)
prior to hire date at UW Health. All GME Trainees must maintain CPR certification throughout the entire
training period unless excused by the GME Office. Some training programs have additional lifesaving
certification requirements that must be maintained throughout the entire training period (unless otherwise
noted). They are:
1. Pediatric Advanced Life Support (PALS): Emergency Medicine, Pediatric Anesthesia, Pediatrics,
Pediatric Critical Care, and Neonatal/Perinatal Medicine
2. Neonatal Resuscitation Program (NRP): Pediatrics, Pediatrics Neonatal/Perinatal Medicine, and
Obstetrics & Gynecology (renewal after PG-3 not required for OB/Gyn)
3. Advanced Cardiac Life Support (ACLS): Anesthesiology, Anesthesia Critical Care, Cardiothoracic
Surgery, Emergency Medicine, Gastroenterology, Transplant Hepatology, Medicine,
Cardiovascular Disease, Clinical Cardiac Electrophysiology, Interventional Cardiology, Advanced
Heart Failure, Pulmonary/Critical Care, Neurology, Neurosurgery, Nuclear Medicine,
Otolaryngology, Pain Medicine, Plastic Surgery, Radiology, Neuroradiology,
Vascular/Interventional Radiology, Surgery, Surgery Critical Care, Vascular Surgery (residents
4. Advanced Trauma Life Support (ATLS): Emergency Medicine, Neurosurgery, Otolaryngology
(renewal after PG-3 not required), Plastic Surgery (renewal after PG-2 year not required),
Surgery, Surgical Critical Care, Vascular Surgery (renewal after PG-3 not required)
B. Registered Nurses, Nursing Residents, Licensed Practical Nurses, Nursing Assistants, Medical Assistants,
Respiratory Therapists, Pharmacists, Radiation Therapists and Technicians having direct patient contact
must demonstrate, on a biennial basis, certification in Health Care Provider CPR. Re-certification must
occur prior to expiration (per American Heart Association Guidelines). Beyond the aforementioned
disciplines, each department is responsible to determine whether its employees need to be CPR certified.
Medical staff members who are not involved in performing CPR are exempted from this requirement.
Registered Nurses who are permanently assigned to Med Flight, the Emergency Department, D65 PCU,
Radiology or the Adult Intensive Care Units will maintain current certification in ACLS. Registered nurses
who are permanently assigned to CHETA, Med Flight, the Emergency Department and PICU, the Pediatric
Sedation Clinic, and the Burn Unit will maintain certification in PALS. Registered nurses who are
permanently assigned to Med Flight, CHETA and the NICU will maintain certification in Neonatal
Resuscitation Program (NRP). Other certifications may be required as detailed by position requirements.
All employees must maintain required certifications throughout employment with UW Health. Persons with a
medical leave or other extenuating circumstances will be granted a grace period on a case by case basis.
A. GME Trainees:
1. The GME Office is responsible for informing GME trainees of the lifesaving certification
2. GME trainees will provide proof of CPR certification prior to hire date and will maintain all required
certifications throughout training. GME trainees will provide proof of certification for any
subsequent certifications to their Program Coordinators to allow timely documentation of
compliance in MedHub.
3. For all certifications other than CPR, GME trainees must show current certification or be certified
within the first 3 months of employment. Certification must be kept current throughout training
at UW Health (unless otherwise noted or excused by the GME Office).
4. Program Coordinators will upload copies of certifications into MedHub for GME Office verification.
B. All Other Employees:
1. For new employees, a Human Resource Department's Recruitment Representative will confirm
previous employment, certification, and other relevant information, such as educational history
when appropriate. If the employee’s certification is due to expire prior to his/ her start of
employment, he/ she will be expected to complete the renewal process and bring the new
certification card to the Department Manager. Those who have never been certified in basic life
support will be scheduled to attend a basic CPR course provided by the Emergency Education
Center within 3 months of employment.
2. Department Managers are responsible for informing new employees of this policy at departmental
3. It is the responsibility of Department Managers to document initial training and ongoing
4. Each department will establish procedures to ensure enforcement of the requirement for current
certification. These procedures may include temporary removal from patient care responsibilities
A. The employee demonstrates ability to perform CPR by successfully attaining Health Care
Provider CPR certification.
B. The performance review must occur biennially. A renewal course must be completed
prior to the expiration date on the card.
A. RNs newly employed in Med Flight, the Emergency Department and the ICUs are
scheduled for respective advanced life support training during their first six months of
employment, unless already holding current ACLS/PALS certification.
B. RNs newly employed in the IP PACU are required to be ACLS certified and PALS certified
within their first year of hire. An agency staff clinician who is not PALS certified shall not
be assigned to care for a pediatric patient.
C. RNs newly employed in the AFCH PACU are required to be PALS certified within their first
year of hire.
D. Department Managers will require employees to provide proof of certification in
ACLS/PALS/ATLS. Certification is attained after the employee demonstrates the ability to
perform ACLS/PALS/ATLS by meeting criteria to be an advanced rescuer, as established
by the American Heart Association/American College of Surgeons.
E. Re-certification training will be scheduled every two years for ACLS and PALS, as
established by the American Heart Association, and every four years for ATLS, as
established by the American College of Surgeons.
F. RNs and RTs newly employed in Med Flight, CHETA, and the NICU are required to attain
NRP certification during their first six months of employment, unless already holding
current NRP certification. Continued certification is required every two years as
established by the American Academy of Pediatrics and American Heart Association.
G. NRP Courses.
A. The NICU will provide limited NRP courses for certification maintenance through
the Learning and Development System, with prioritization for NICU RNs and
B. If unable to enroll in a NICU NRP course, staff must seek alternative courses to
meet certification requirements.
IV. REFERENCE POLICIES
UW Health Clinical Policy # 5.1.2, Cardiopulmonary Resuscitation Response Team
Hospital Administrative Policy & Procedure # 9.41, Licensure/Certification/Registration
Hospital Administrative Policy & Procedure #9.18-Employment/Pre-Employment Reference and Background Checks
Sr. Management Sponsor: Sr. VP, Patient Care Services and CNO
Author: Director, Nursing Practice Innovations; Director, Emergency Services; Director, Graduate Medical
Review/Approval Committee: Resuscitation Review Committee; UW Health Clinical Policy Committee
Peter Newcomer, MD
Chief Clinical Officer
J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee