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UNCP Home About UNC Pembroke Administration Policies and Regulations All Regulations REG 04.25.01 - Automated External Defibrillators (AED) Program
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REG 04.25.01 - Automated External Defibrillators (AED) Program

Authority: Vice Chancellor for Student Affairs

History: First Issued: March 20, 2012. Revised: June 11, 2012. Last Revised: August 8, 2012

Additional References:

Contact Info: Environmental Health and Safety Officer, 910-521-6792.


1.1 Automated External Defibrillators (AEDs) are portable electronic devices designed to assess the heart’s rhythm and, if needed, automatically recommends whether or not an electric shock should be delivered to correct the heart rhythm. These devices allow trained personnel to provide life-saving defibrillation to victims of cardiac arrest (cessation of a heartbeat, usually due to a heart attack). The American College of Occupational and Environmental Medicine (ACOEM) recommends placement, when practical, of Automated External Defibrillators (AEDs) in sufficient workplace locations to allow initiation of resuscitation and use of the AED (the so-called “drop to shock” interval) within 3-5 minutes of recognized cardiac arrest. Access to an AED within 3-5 minutes of cardiac arrest can increase the survival rate by as much as 70% with a 10% decrease in the rate of survival for every minute that treatment is delayed.


2.1 To ensure that the university AED program meets appropriate sections of ACOEM’s Guidelines for the Use of Automatic External Defibrillators (AEDs) in the Workplace Setting and satisfies North Carolina laws pertaining to AED acquisition and use.


3.1 UNC Pembroke AED Medical Program Advisor (Student Health Services).

3.1.1 Develop and/or approve all medical aspects of the program.

3.1.2 Approve for use at the university type(s) of AED unit(s) that satisfy North Carolina state law.

3.1.3 Perform a medical review each time an AED unit is used at the university.

3.1.4 In cooperation with the university AED program coordinator, perform annual review of all components of the university AED program and the efficacy of departmental AED programs with individual coordinators.

3.2 First Responders AED Coordinator (Police & Public Safety).

3.2.1 Communication and coordination of the AED program with Emergency Medical Services (EMS) and coordinating with EMS protocols.

3.3 UNC Pembroke AED Program Administrator (Environmental Health and Safety –EH&S).

3.3.1 Develop and maintain a written AED program for the university.

3.3.2 Assist departmental AED program coordinators in AED requirement compliance.

3.3.3 Approve each departmental AED program.

3.3.4 Assist in conducting annual reviews of the AED program.

3.3.5 Inspect, maintain, and test building AEDs in accordance with manufacturer’s guidelines.

3.3.6 Maintain all AED maintenance and testing records.

3.3.7 Assist in the procurement of AEDs and supplies.

3.4 Athletic Department AED Program Coordinator (designated by the director of athletics).

3.4.1Responsible for the day-to-day management of departments’ AED program in consultation with the university AED medical program advisor.

3.4.2 Responsibilities include:

3.4.2.a. develop and maintain written procedures for department’s AED program;

3.4.2.b. provide a copy of the departmental AED program to the Environmental Health and Safety Office;  

3.4.2.c. inspect, maintain, and test departmental AEDs in accordance with manufacturer’s guidelines;

3.4.2.d. ensure department personnel are trained in accordance with guidelines established by the university AED program medical advisor and manufacturer;

3.4.2.e. ensure that adequate AED-related supplies and recommended ancillary medical equipment are maintained in an adequate supply and discarded when expired;

3.4.2.f. maintain all documented records of personnel AED training;

3.4.2.g. ensure that the university AED program medical advisor and EH&S Office are notified of any use of the department’s AED; and

3.4.2.h. participate and cooperate in annual program reviews.


4.1 The ACOEM recommends, when practical, AEDs be placed in locations throughout a workplace that will allow initiation of resuscitation and use of the AEDs (the “drop-to-shock” interval) within 3-5 minutes of recognized cardiac arrest. Written request for AED units must be submitted for approval to the university AED program medical advisor, who will consider such requests in consultation with the university program administrator, associate vice chancellor for campus safety and emergency operations, and the police chief. The Environmental Health and Safety Office will issue a purchase request to procure the AED once the medical advisor approves. The purchase expense and maintenance of these devices will be covered by the departmental AED program coordinator.

4.2 The University of North Carolina at Pembroke currently owns and maintains AEDs that are strategically placed in several campus buildings and university police vehicles. A complete list is available by contacting the EH&S office.


5.1 All departmental AED program coordinators must develop written procedures for the following purposes:

5.1.a. inspection, maintenance, and replacement of AEDs and ancillary equipment;

5.1.b. the actual use of an AED;

5.1.c. contacting first responders;

5.1.d. post event evaluation;

5.1.e. recordkeeping; and

5.1.f. the establishment of an AED quality assurance program that addresses medical review of AED use, recordkeeping, and methods of program evaluation.

5.2 All written procedures must include at a minimum the following elements:

5.2.a. coordination with the university AED program medical advisor;

5.2.b. identification and location of all AED and ancillary equipment; and

5.2.c. training of authorized personnel.


6.1 All AED-trained employees at UNC Pembroke are volunteers except for university police officers, athletic training staff, and Student Health Services personnel.


7.1. Authorized training must be in accordance with the American Heart Association, American Red Cross, or National Safety Council. Only those who have successfully completed initial certified AED and/or refresher (at least every 2 years) training are permitted to use them in emergency situations. This training should include hands on demonstration with the model of AED intended to be used. University police and Student Health Services will also be required to participate in the UNC Pembroke blood borne pathogen training. Any volunteer responder wishing to attend blood borne pathogen training can contact the Environmental Health and Safety Office.


8.1 The Environmental Health and Safety Office will maintain inspection, maintenance, and testing records. The EH&S Office must also maintain AED training, AED use, and post evaluation records.


9.1 Each AED will have:

9.1.a. one set of adult defibrillation electrodes;

9.1.b. one set of child pads; and

9.1.c.one barrier kit.  

9.2 Each barrier kit should contain:

9.2.a. two pairs of disposable gloves (i.e. latex, nitrile);

9.2.b. one disposable razor;

9.2.c. one pair of scissors;

9.2.d. one CPR one-way filter pocket mask;

9.2.e. gauze pads;

9.2.f. one dry towel; and

9.2.g. antiseptic wipes.


10.1 The AED program administrator shall review annually:

10.1.a. training records;

10.1.b. inspection and maintenance reports; and

10.1.c. program effectiveness.


11.1 The AED program administrator shall inspect all UNC Pembroke AEDs monthly to ensure:

11.1.a. thebarrier kit is adequate;

11.1.b. theAED battery life status is adequate; and

11.1.c. AED operational status.


12.1 An AED Post-Incident Report Form must be completed by a trained responder for each medical event using the AED. The form shall be forwarded to both the UNC Pembroke AED medical program advisor (Student Health Services) and the EH&S Office within 24 hours of the medical event.

12.2 Any and all patient information generated during AED use must be collected and placed in the patient’s confidential medical file in Student Health Services.

12.3 A review of each medical event using an AED shall be conducted by the AED program administrator.

12.4 All key participants in the medical event shall participate in a review that includes:

12.4.a. actions that went well during the medical event;

12.4.b. opportunities for improvement; and

12.4.c. critical incident stress debriefing.

12.5 A summary of the post-incident review shall be maintained by the program administrator.


13.1 Appendix A – AED Monthly Inspection Form

13.2 Appendix B – AED Post-Incident Report Form