Health Care Department Operations Manual

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Chapter 5 – Administrative

Article 5 – Business Services

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5.5.8 Automated External Defibrillator

  • Policy

    • California Correctional Health Care Services (CCHCS) shall maintain Automated External Defibrillators (AED) in all headquarters (HQ) facilities and leased office buildings for use in an emergency by authorized users.

  • Purpose

    • To describe how the AED shall be used in conjunction with Cardio-Pulmonary Resuscitation (CPR) in cases of sudden cardiac arrest at CCHCS facilities, in accordance with accepted protocols, including those developed by the American Red Cross and American Heart Association.

  • Applicability

    • This policy applies to all CCHCS HQ staff and all staff who utilize office space in any CCHCS leased location.

  • Procedure

    • Authorized Users

      • Anyone that has successfully completed an approved Cardio-Pulmonary Resuscitation (CPR) and AED training program.

      • Anyone at their discretion may provide voluntary assistance to individuals of medical emergencies.  The emergency medical response of these individuals may include CPR, AED, or basic first aid.

    • Training

      • Certification Training:

        • Anyone may complete training to provide basic first aid and CPR and to use the AED. Training is provided by the Business Continuity Unit (BCU).

        • The AED Program Coordinator is responsible for maintaining updated records of all staff that attend and pass the basic first aid, CPR, and AED procedures courses offered by the BCU.

      • Recertification Training:

        • Basic first aid, CPR and AED certification remain active for two years and shall be renewed through a renewal course that provides training on basic first aid, CPR, and AED procedures.

        • Recertification and renewals for AED shall be monitored by the BCU.

    • AED Use

      • The AED is used to treat individuals who experience sudden cardiac arrest. It is only to be applied to individuals who are unconscious, without a pulse, not breathing normally, and/or showing no signs of circulation such as normal breathing, coughing, or movement.

      • CPR shall be performed in conjunction with the AED.

        • The AED analyzes the heart rhythm and advises the operator if a shockable rhythm is needed. If a shockable rhythm is needed, the AED charges to the appropriate energy level and delivers a shock.

      • Before using the AED on an individual:

        • Assess the scene for safety.

        • Determine the individual’s unresponsiveness.

        • Dial 9-911 and advise dispatch of the individual’s status.

        • If unresponsive, position the individual on his/her back face up.

        • Open the individual’s airway.

        • Check for a pulse and/or signs of circulation such as normal breathing, coughing, or movement.

        • If there is no pulse and/or signs of circulation, obtain an AED device immediately.

        • Press the ON/OFF button to turn on the AED.

        • Follow the AED verbal instructions.

      • Use of the AED and CPR shall continue as appropriate during the course of emergency care until the individual resumes pulse and respiration and/or local Emergency Medical Services arrive on the scene.

    • Medical Response Documentation

      • Post-Incident Internal Documentation:

        • When an AED is used by staff, the AED Incident Report shall be completed within 24 hours by that staff member. The AED Incident Report can be requested through the BCU by email via: BusinessContinuityOffice@cdcr.ca.gov.

        • The AED Incident Report shall be submitted to the AED Program Coordinator, BCU, and the Return-to-Work Coordinator.

        • The AED Program Coordinator shall report AED use to the local county Health and Human Services office.

      • Post-Incident External Documentation:

        • The AED Program Coordinator shall contact the AED vendor to download event data from the AED. The data must be retained in the AED Program Coordinator’s records for seven years.

    • Post-Event Review

      • A review of each medical event where an AED was used shall be conducted by the AED Program Coordinator.

      • All key participants in the medical event, including the AED Program Medical Director, shall participate in a review that includes:

        • Actions that went well during the medical event.

        • Opportunities for improvement.

        • Critical incident stress debriefing.

      • A summary of the post-event review shall be completed by the AED Program Coordinator within 30 business days and retained for four years.

    • Responsibilities

      • The AED Program Medical Director shall:

        • Write a prescription for purchase and use of the AED device.

        • Review and approve guidelines and updates for emergency procedures related to the use of AEDs and CPR.

        • Evaluate post-event review forms and electronic files downloaded from the AED.

      • The CCHCS BCU shall assume responsibility for program coordination and the role of the AED Program Coordinator as follows:

        • Organize AED training for Emergency Response Team members.

        • Maintain records of AED training in accordance with accepted protocols, including those developed by the American Red Cross and American Heart Association.

        • Coordinate monthly equipment and accessory maintenance per manufacture’s recommendations and for record keeping.

        • Review and revise the AED procedures annually as needed.

        • Work as a liaison between CCHCS and the AED manufacturer.

        • Organize meetings and work with the Medical Director to maintain records, AED guidelines, and protocols as necessary.

        • Communicate with the Medical Director on issues related to AED procedures, including post-event reviews.

    • System Verification and Review

      • Annual AED Program Review:

        • Once each year, the AED Program Coordinator shall conduct and document a system readiness review, including the following elements:

        • Training records.

        • Equipment operation.

        • Maintenance records.

      • Periodic Systems Check:

        • Once each calendar month, the AED Program Coordinator shall conduct and document a system check including, but not limited to the following elements:

        • Emergency kit supplies.

        • AED battery life.

        • AED operation and status.

      • Annual Equipment Check:

        • Once each year, the local Fire Department shall conduct an equipment check including the following elements:

        • Check expiration dates of battery pack and electrodes.

        • Check AED operational status.

        • Perform AED self-diagnostic check.

    • AED Equipment and Maintenance

      • The AED is approved for the CCHCS AED program and conforms to all State and local standards. The location of each AED is listed on the building directory floor maps throughout the CCHCS locations and on the Business Continuity Lifeline page.

      • All AED equipment and accessories shall be maintained by the CCHCS BCU in a state of readiness and pursuant to manufacturer guidelines.

      • The CCHCS BCU shall ensure maintenance checks are performed and recorded monthly on the AED Monthly Maintenance Check form.  Written documentation is recorded on a card stored with each AED, and electronic records are kept with the BCU.

      • Following the use of emergency response equipment, all equipment shall be cleaned and/or decontaminated by the BCU. The AED is to be cleaned with a soft cloth dampened with 90 percent isopropyl alcohol, soap and water, or chlorine bleach.

      • The BCU shall contact the AED manufacturer representative regarding equipment which requires troubleshooting or repairs.

  • References

    • California Code of Regulations, Title 22, Division 9, Chapter 1.8

    • California Emergency Medical Services Authority, Health and Safety Code Sections (1797.190 – 1797.196)

  • Revision History

    • Effective: 09/2017