The following plan has been developed to establish appropriate procedures for the placement and use of Automated External Defibrillators (AED). An Automated External Defibrillator is a medical device that is used to recognize the presence or absence of ventricular fibrillation (when electrical activity becomes disordered) and rapid ventricular tachycardia (extremely rapid heart beat), and is able to determine, without intervention by an operator, whether defibrillation (an electrical shock to the heart) should be performed.
The AED must only be used on victims who are unconscious and not breathing normally. The AED shall be used in combination with Cardio Pulmonary Resuscitation (CPR) in instances of sudden cardiac arrest. AED devices shall not be used on victims weighing less than 55 pounds or less than 8 years of age.
Physical fitness facilities operated by the University, supervised by one or more persons and serve 100 or more individuals, are required under the Physical Fitness Facility Medical Emergency Preparedness Code from the Illinois Department of Public Health Title 77, Chapter I, Subchapter f, Part 527 to install AEDs. All other building managers or departments on campus have the option to install AEDs.
Once an AED is installed, the building occupants should follow the AED policy. Guidelines include the following:
AEDs should be located in public spaces and near a campus phone in a wall-mounted secured cabinet to prevent tampering;
AEDs should be easily accessible and allow for facilitation of periodic inspections;
AEDs should be equipped with support equipment including two pairs of disposable gloves, two disposable facemasks, extra electrode pads, safety razor, absorbent towels or trauma pads, a pair of scissors, a biohazard bag for infectious waste disposal, and an AED incident report form and pen. (In locations where children are likely to be present (e.g. Ratner), there should also be pediatric-sized electrode pads available);
Only trained AED users should access the AED.
See the Campus AED Locations.
Optional AED locations might include the following:
- Facilities with a high number of visitors (e.g. sports venues, concert halls);
- Facilities in which high stress activities take place (e.g., gymnasiums, fitness centers, track facilities, swimming pools); or
- Designated health care facilities.
Authority and Responsibility
Departments shall be responsible for the following:
- Designating a department AED Coordinator;
- Purchasing, installing and maintaining AED’s;
- Coordinating training for employees;
- Coordinating with local resource hospital;
- Maintaining records of maintenance and testing
- Developing a site specific medical emergency plan; and
- Retaining copies of all AED training records as well as equipment maintenance and testing logs which shall be available for review by Environmental Health and Safety during annual building inspections.
Department AED Coordinator shall be responsible for the following:
- Overseeing the placement and maintenance of AED equipment;
- Identifying trained or authorized users, selecting employees and selection of volunteer employees as well as coordination of initial and refresher training in CPR, AED usage and Bloodborne Pathogens training;
- Supplying all AED information to the local resource hospital;
- Verifying maintenance records and testing are being conducted and documented regularly;
- Developing a site specific medical emergency plan;
- Replacing expiring, missing or used support equipment;
- Managing day-to-day operations;
- Overseeing training of personnel associated with the program;
- Placing AED back in service after use; and
- Training personnel on the location of AEDs and site-specific Medical Response Plan.
Special Event Sponsors shall be responsible for arranging for a trained AED user to be onsite during the special event.
Environmental Health and Safety (EHS)
shall be responsible for:
- Initially reviewing department or building manager’s Medical Emergency Plans;
- Verifying Medical Emergency Plans have been updated annually during building inspections;
- Verifying departments or building managers are maintaining records of maintenance and testing during building inspections;
- Reviewing the AED plan annually; and
- Directing departments to remove AED’s for non-compliance to this policy.
University of Chicago Medical Center Student Health Services shall be responsible for:
- Providing medical oversight of the AED program;
- Writing a prescription for the use of the AED device;
- Supplying equipment recommendations and placement locations;
- Initially reviewing and approving guidelines for Emergency Medical Plans;
- Evaluating post-incident review forms, downloaded incident related information from the AED in addition to providing follow-up counseling for faculty, staff, and students; and,
- Reviewing the AED policy on an annual basis.
Purchase and Installation of AEDs
For optional locations requesting authorization for an AED, a request must be submitted to EHS at firstname.lastname@example.org Once a request is received, EHS will meet with the requestor and perform an on-site evaluation for the need of an AED. A written decision will be provided to the requestor within 30 calendar days.
The department or building manager is responsible for purchasing AEDs, cabinet, signage, and software to download data after AED use. In order to purchase an AED, a prescription is needed from the physician providing oversight. Contact the University of Chicago Hospital Student Health Services for the Illinois State contract and the name of the physician providing oversight. The Emergency Resuscitation Center can also provide assistance finding a manufacturer or supplier of AEDs. A projecting sign shall be installed marking the location of the AED. Once the AED is purchased, contact Facilities Services at 773.834.1414 for installation and signage for the AED.
Maintenance and Testing
Maintenance and testing of all AED units shall be conducted in accordance with the manufacturer’s guidelines. AED Weekly Operation and Status Check records shall be maintained for each AED unit and shall be reviewed by EHS during the annual building inspections. A copy of the requirements shall be kept with the AED and in a central location of the facility.
After using an AED, follow the manufacturer’s instructions for disinfection of the unit and how to download incident-related information from the device’s data card before placing the AED back into service.
Note: EHS reserves the right to remove any AED unit not being properly inspected or maintained.
Resource Hospital - Registration and Reporting
The resource hospital for the University is the University of Chicago Medicine (UCMC) Student Health Services. When an AED is purchased, it shall be registered with them.
The registration process requires providing the UCMC Student Health Services with a list of the following:
- Registered users and copies of their training certificates;
- Manufacturer’s guidelines for training and maintenance; and
- Documentation confirming the manufacturer’s guidelines were met.
When an AED is used, the user shall complete the AED Post Incident Report Form and forward a copy immediately or within 24 hours. All incident-related information stored in the AED will be reviewed by the Medical Director and EHS.
Medical Emergency Plan
Any department or building manager who purchases an AED shall create a site-specific medical emergency plan. The plan shall include, at a minimum:
- Facility contacts, including trained AED users;
- Response plan for a medical emergency;
- Use of an AED;
- AED training requirements;
- Name of training class, training provider and location of training class;
- Copy of manufacturer’s guidelines on training and maintenance;
- Name of the resource hospital and contact information for the program coordinator; and
- A statement indicating the AED has been registered with the resource hospital (including the provision of the training certificates for each user and manufacturer’s guidelines for training and maintenance).
The plan shall be updated when:
- The facility is closed for more than 45 days;
- The AED is inoperable for more than 45 days; or
- There is a shortage of trained AED users for more than 45 days.
All physical fitness facilities shall submit the plan and any updates to the Illinois Department of Public Health. All buildings and/or departments with an AED shall submit the site-specific Medical Emergency Plan to EHS initially for review and are responsible for annual updates to the plan thereafter. EHS will verify updates are made annually during the building inspection. If it is determined by EHS that the plan, train users, or equipment is not maintained in accordance with the plan, the AED Coordinator will be directed by EHS to remove the unit from service.
Note: The Medical Emergency Plan template should be used for the creation of site-specific information for your facility.
Training shall be provided to each AED user and meet the requirements of Illinois Department of Public Health codes under Title 77, Chapter I, Subchapter f, Part 525 & 527. Every staff member at a physical fitness facility, including those not trained in AED use, shall be trained on the location of the AED at the specific site and site-specific medical emergency response. The training shall be provided to employees at least every two years. At all buildings or in all departments with an AED, a minimum of one trained user shall be on site at all times during normal operating hours.
During special events in all buildings where an AED is required, a minimum of one trained user shall be onsite for the duration of the event. It is the responsibility of the special event sponsor to arrange for the trained AED user to be onsite. The special event sponsor can have his or her own personnel trained or can arrange with the building manager to have a trained AED user from the building attend the event.
Bloodborne Pathogens Training is online at ehsa.uchicago.edu/training.
University of Chicago Medicine, Department of Medicine
University of Chicago Medicine Simulation Center
Mitchell Hospital, 6SW
American Heart Association
208 South LaSalle Street, Suite 900,
Chicago, Illinois 60604-1197
American Red Cross
American Red Cross First Aid/CPR/AED for the Workplace (2006)
311 W. John Gwynn Avenue
Peoria, Illinois 61605-2566
Maintenance and Testing
Maintenance and Testing
Maintenance and testing of all AED units shall be conducted in accordance with the manufacturer’s specifications. Records of maintenance and testing shall be maintained for each AED unit and shall be reviewed annually by EHS during the building inspection. Each trained user shall be given a copy of the manufacturer’s maintenance and testing requirements. A copy of the requirements shall also be kept with the AED and in a central location of the facility.
After using an AED, follow the manufacturer’s instructions before placing the AED back into service.
Reviewed: May 2021