Early Defibrillation Program

Policies and Procedures

The following document describes the policies and procedures to be used in governing an
early defibrillation program. It is the goal of this program to provide a rapid response to
sudden cardiac arrest for employees and guests. It is the intent of this document to give the
early defibrillation response team members general guidance in response to an incident of
sudden cardiac arrest (SCA). The document is not intended to cover all circumstances
involved in such emergencies. All early defibrillation response team members must operate
within the parameters of this early defibrillation program
1. Scope
This document describes the policies and procedures relating to an early
defibrillation program utilizing employees who serve as trained responders in
CPR and defibrillation therapy in the event of a medical emergency.

2. Purpose
The purpose of this document is to establish a consistent guideline for
application, location, maintenance, and various other components described
herein involving the early defibrillation program. It is the goal to provide the
appropriate defibrillator coverage with a response time of three (3) minutes
from time of incident to first shock to increase the likelihood of survival in
the event of SCA. This workbook is intended to serve as a guide and checklist
for the basic elements of implementing an early defibrillation program.

3. Definitions
Early Defibrillation Response Team Member. An individual who is
trained in AED use to respond to SCA medical emergencies and may also
be a member of the Emergency Response Team.

Automated external defibrillator (AED or defibrillator). An automated

computerized medical device programmed to analyze heart rhythm,
recognize rhythms that require defibrillation, and provide visual and
voice instructions for the device operator, including, if indicated, to push
the button to deliver an electric shock.

Bystander first aid/CPR. Initial first aid/CPR provided by a trained

individual who is not part of an organized medical response system such
as ERT or EMS.

Cardiopulmonary resuscitation (CPR). Rescue breathing and external

cardiac compression applied to a victim in respiratory and/or sudden
cardiac arrest.

Emergency Medical System (EMS). Professional community responder

agency for emergency events, who provide medical assistance and/or
ambulance transport.
 Emergency Response Team (ERT), or Medical Emergency Response
Team (MERT). A group of medical responders who train on a regular
basis to respond to medical emergencies.

Rescue breathing. Artificial ventilation of a victim in respiratory and/or

sudden cardiac arrest.

Sudden cardiac arrest (SCA). A significant life-threatening event when a

person's heart stops or fails to produce a pulse.

4. Early Defibrillation Program Overview

A medical emergency response that includes basic and advanced first aid, CPR, and
emergency defibrillation. The goal of the early defibrillation program is to
participate actively in the chain of survival, illustrated below, by providing early
defibrillation to any victim of sudden cardiac arrest (SCA).

Figure 1. Chain of Survival

5. Early Defibrillation Response Team Roles and Responsibilities

See appendix A for the roster of early defibrillation response team members.
5.1 Environmental Health and Safety Manager or Field Manager. It is the
responsibility of the Environment Health and Safety (EHS) Manager or Field
Manager to:
(1) Communicate to site management the costs and benefits of
expanding the existing medical emergency response by including
defibrillator use.
(2) Ensure adequate resources are allocated to achieve Early
Defibrillation Program goals.
 (3) Designate an Early Defibrillation Program Coordinator who
understands early defibrillation and the use of defibrillators, and
demonstrates the ability to manage employee teams.
(4) Review the program annually to evaluate effectiveness.

5.2 Early Defibrillation Program Coordinator and Site Coordinators. It is the

responsibility of the Early Defibrillation Program Coordinator and Site
Coordinators for each site to:
(1) Participate in case reviews, responder training and retraining, data
collection and other quality assurance activities.
(3) Assure maintenance of the defibrillators and related response
equipment.
(4) Develop and maintain the emergency response plan and company
policies and procedures.
(5) Maintain a list of trained early defibrillation responders.
(6) Ensure compliance with the company policies and procedures of the
Early Defibrillation Program.

5.3 Early Defibrillation Response Team Members. It is the responsibility of the

Early Defibrillation Response Team members to:
(1) Successfully complete all required training and skills evaluations, as
defined by and/or the requirements of this document.
(2) Respond to emergency calls according to the site's early defibrillation
response protocol.
(3) Follow the guidelines of the early defibrillation program and remain
current on all certifications.

6. Defibrillator Equipment
See Appendix B for the Defibrillator Location and Equipment Sheet.
6.1 Description. The equipment provided in support of the early defibrillation
program is to be used in the event of an SCA. This equipment shall not be
used outside the parameters of the AED program except as approved by the
Early Defibrillation Program Coordinator and Site Coordinators. Each device
will be maintained according to manufacturer’s guidelines.
6.2 Accessories. All accessory equipment must remain with the defibrillator and
must be inspected on a regular basis for readiness for use and integrity of the
device.
7. Defibrillator Maintenance
See Appendix C for the Periodic Maintenance Checklist.
7.1 Reports of Damage. Follow the manufacturer’s recommendations for all
scheduled defibrillator maintenance checks. Report any performance
discrepancies, device defects, or missing, expired, and/or damaged
accessories to the Early Defibrillation Program Coordinator immediately.
7.2 Calibration. The defibrillator requires no calibration or verification of energy
delivery. The defibrillator has no user-serviceable parts. The defibrillator
performs regular self-tests to assure that it is ready for use. While the
maintenance required for the defibrillator is minimal, it is important that a
regular check of the defibrillator be performed to assure readiness, as
described in the defibrillator Instructions for Use.
7.3 Suggested Maintenance Schedule. Refer to the suggested maintenance
schedule in the defibrillator Instructions for Use, which also provides detailed
instructions for responding to each maintenance task.
7.4 Cleaning. When necessary, clean the defibrillator using recommended
cleaning agents, per the defibrillator Instructions for Use.

8. Early Defibrillation Response Plan Overview

8.1 Initiation of Emergency Response. Any Employee who recognizes a medical
emergency initiates the Emergency Response Plan immediately, by
_______________________ [method of emergency response initiation for
User Facility] and provides the following information:
• Reporting employee’s name
• Type of emergency
• Location of emergency
• Brief description of the patient
8.2 911 Notification. The communication center contacts 911 and, using
established procedures, dispatches the ERT or Early Defibrillation Response
Team to the location of the emergency with the appropriate equipment.
8.3 Early Defibrillation Team Response. At the scene, the ERT or AED team
verifies scene safety before assessing the patient, then renders appropriate
care based upon the patient’s condition and AED response protocols.
8.4 EMS Contact and Lead-In. When possible, the ERT or Early Defibrillation
Response Team contacts EMS and provides lead-in instructions (directions
 for reaching the patient on site) to the responding EMS unit, while continuing
to provide appropriate patient care until a higher medical authority arrives or
the patient refuses care.
8.5 Transfer of Patient Care. Once EMS arrives, the ERT or Early Defibrillation
Response Team transfers patient care to the EMS agency for appropriate
advanced medical treatment and provides a report including:
• The initial time of the event
• Any care given prior to the team’s arrival
• Patient’s condition upon the team arrival
• All treatment rendered to the patient by the team
• Any available medical information about the patient
• Post-use equipment check
• Replacement of necessary supplies used
• Return of the AED to its designated location
8.6 Post Event Procedures. After transferring patient care to the EMS
responders, the ERT or Early Defibrillation Response Team conducts the
following post-event procedures in accordance with the protocol as provided
in Appendix D, Early Defibrillation Response Protocol and Flow Chart.
8.7 Debriefing Procedures. As soon as possible, a debriefing is conducted to
evaluate the ERT or Early Defibrillation Response Team’s response and the
potential need for emotional support of the responders involved. This
debriefing can be conducted on an informal basis with the team or with the
assistance of professional counselors. The Early Defibrillation Program
Coordinator conducts an evaluation of all aspects of the emergency response
and the strengths and deficiencies of the response plan as revealed by the
incident. Modifications made to the plan must be approved by the Medical
Director and discussed with the ERT or Early Defibrillation Response Team
prior to any changes to the response plan.

9. Protocol Guidelines
See Appendix D for the Early Defibrillation Response Protocol and Flow Chart.
9.1 Defibrillator Application Guidelines. Once the defibrillator is turned on and
the pads applied to the patient, the ERT or Early Defibrillation Response
Team member shall not remove the pads or turn off the device unless
prompted by the device itself or directed by a higher medical authority. In all
 cases, the Team member shall continue to assess the patient’s airway,
breathing, and circulation and provide CPR as indicated.
9.2 AED Application Criteria. The defibrillator shall be applied only to patients
who are unresponsive and not breathing.
9.3 Defibrillation Procedure. Defibrillation shocks are to be delivered only in
accordance with the early defibrillation response protocol. If the device
advises no shocks, the ERT or Early Defibrillation Response Team responder
follows the approved protocols for patient care and CPR.
9.4 Wet Environments and Metal Surfaces. The defibrillator can be used in
fresh and saltwater environments and on metal surfaces that are wet or dry.
Always follow all defibrillator recommended safety precautions.
9.5 Excessive Chest Hair. If required for proper defibrillation pad adhesion, any
excess hair on the patient’s chest is shaved with a prep razor supplied in the
accessory kit. A smooth shave is not required.
9.6 Medication Patches. Using a gloved hand, remove any medication patches,
if present, from the patient’s chest prior to pad placement and wipe the skin
clean with a cloth.
9.7 Implantable Pacemakers and Defibrillators. If the patient has an
implantable pacemaker or internal defibrillator, do not place the
defibrillation pads directly over the implanted device. If the presence of an
implanted device affects pad placement, place the defibrillation pad as close
to the recommended pad placement as possible.
9.8 AED Abuse or Vandalism. No abuse or vandalism of the defibrillator is to be
tolerated. If abuse or vandalism is suspected, it is to be reported to the Early
Defibrillation Program Coordinator immediately so that the defibrillator can
be evaluated for proper operation.

10. Early Defibrillation Response Protocol

(This should match Appendix D, as created by [User Facility].)
10.1 Initial Assessment. The first ERT or Early Defibrillation Response Team
member responding conducts an initial assessment to determine the level of
response required from the team and outside responding agencies. This
initial assessment includes:
• Assessment of the scene for safety of self and other responders.
• Use of gloves and other universal precautions prior to patient contact.
• Assessment of the patient for absence of responsiveness, respiration, and
signs of circulation.
 • Assessment for additional information about the patient or scene.

Information gathered at the scene should be relayed to ___________

[communication center for User Facility] for dissemination to responding
parties.
10.2 Early Defibrillation Response Plan and 911. The initial ERT or Early
Defibrillation Response Team responder verifies that the AED response plan
has been activated and that 911 has been notified. If the defibrillator is not
present at the scene, the responder verifies that it is being brought
immediately.
10.3 CPR Procedures. In the absence of the defibrillator, the ERT or Early
Defibrillation Response Team member initiates the ABCs of CPR –
establishing an airway, ventilating the patient, and beginning chest
compressions – until the defibrillator arrives.
10.4 Defibrillator Application. Turn on the defibrillator as soon as it arrives at the
scene and follow its prompts. If more than one ERT or Early Defibrillation
Response Team member is present, one can apply the defibrillation pads and
operate the defibrillator while the other continues CPR until told to stop.
Perform any special procedures required (removal of medication patches,
shaving of excessive chest hair, etc.) as outlined in the early defibrillation
response protocol guidelines (section 10) prior to placing the pads on the
patient’s bare chest.
10.5 Defibrillator Heart Rhythm Analysis. When the pads are properly attached to
the patient and connected to the defibrillator, the device will automatically
analyze the patient for a shockable rhythm – such as ventricular fibrillation
(VF). Ensure that no one touches the patient during rhythm analysis. On
completion of rhythm analysis, the defibrillator will prompt the rescuers as to
the appropriate course of action. Follow the device prompts in treating the
patient.
10.6 Defibrillation Safety Precautions. If the defibrillator gives a “Shock Advised”
prompt, first ensure that no one is touching by examining the patient area
and loudly stating “I’m clear, you’re clear, everyone clear!” Then press the
shock button to deliver a shock to the patient as prompted. Shock delivery
will be followed by re-analysis of the patient’s heart rhythm by the
defibrillator. If additional shocks are advised by the defibrillator, follow the
above sequence until the defibrillator prompts otherwise or EMS arrives.
10.7 Defibrillation Shock Sequence. Based upon early defibrillation response
protocols and in accordance with defibrillator prompts, administer a shock to
 the patient, followed by two (2) minutes of CPR if signs of circulation are
absent.
10.8 No Shock Advised Procedure. If the defibrillator gives a “No Shock Advised”
prompt and the patient is not breathing and has no signs of circulation,
administer CPR until the patient regains signs of circulation, the defibrillator
advises to stop CPR for analysis, or EMS arrives and assumes care of the
patient. If the patient is not breathing but does have signs of circulation,
perform rescue breathing until the patient regains adequate respiration, the
defibrillator advises to not touch the patient for analysis, or EMS arrives and
assumes patient care. Conduct continuous monitoring of the patient’s
condition and evaluation of rescue in accordance with ERT or Early
Defibrillation Response Team training.
10.9 Patient Monitoring. Once the defibrillator has been applied to the patient,
do not turn off the defibrillator or remove the defibrillation pads unless
prompted by the device (e.g., “Replace battery” or “Replace pads”). The
defibrillator will continue background monitoring of the patient’s heart
rhythm and alert the rescuers if additional shocks are required. Continue to
assess the patient’s airway, breathing, and circulation and provide CPR as
indicated.

11. Transfer of Patient Care to EMS

11.1 EMS Arrival. Upon arrival of EMS, transfer patient care to the EMS team. If
requested by EMS, assist in patient care; otherwise, initiate post-incident
procedures (see section 13).

11.2 Oral Report. Give the EMS agency a complete oral report of the event and
any significant findings. Unless requested to remain at the scene to assist,
complete the Early Defibrillation Incident Report.

11.3 Early Defibrillation Incident Report. The Early Defibrillation Incident Report
may be copied and given to the EMS agency as part of the patient care
document, either while EMS is on-scene or after the ambulance has left with
the patient. If the report is to be given later, it is the responsibility of the
Early Defibrillation Program Coordinator to oversee this data transfer and
delegate responsibility if necessary.

11.4 Defibrillator Data Retrieval. An ERT or Early Defibrillation Response Team

member who responded to the incident is responsible for retrieval of the
defibrillator data.
12. Post-Incident Procedures
See Appendices E and F for the Early Defibrillation Incident Report and the Post-
Incident Critique Form.
12.1 Early Defibrillation Incident Report. The team member who provided care to
the patient must document all accounts of the medical event and any patient
care given on the Early Defibrillation Incident Report form. The team
member will then provide the completed Early Defibrillation Incident Report
to the Early Defibrillation Program Coordinator for data collection and quality
review.
12.2 Early Defibrillation Report Confidentiality. The Early Defibrillation Incident
Report is a part of the patient care record and is confidential to both the
patient and the facility. This report is not to be copied or altered once it is
completed. Discussion of all aspects of the event is to be limited to team
members, in debriefing or training sessions. To prevent violation of patient
confidentiality, ERT or Early Defibrillation Response Team members are to
refrain from open discussion about any aspects of the medical event. Patient
confidentiality must be maintained in accordance with all state and federal
regulations.
12.3 Response Protocol Irregularities. Any protocol or equipment irregularities
that occurred during the SCA event are to be reported to the Early
Defibrillation Program Coordinator immediately for appropriate action. The
Program Coordinator is to ensure that the device manufacturer is notified of
any equipment irregularities.
12.4 Defibrillation Debriefing Procedures. A debriefing, headed by the Early
Defibrillation Program Coordinator, is to be conducted with all team
members who responded to the event, as well as any bystanders and co-
workers who witnessed the event, the Medical Director if necessary, and
professional counselors if deemed appropriate by the Early Defibrillation
Program Coordinator or the Medical Director.
12.5 Post-Event Defibrillator Check Procedures. Before returning the defibrillator
to service, perform the following post-event procedures:
• Check the defibrillator visually for damage or missing parts.
• Replace all supplies used during the event.
• Download the data from internal memory to a PC.
• Run a battery insertion test and replace the battery if indicated.
• Return the defibrillator to its designated area for future use.
 12.6 Incident Critique. A Post-Incident Critique form shall be completed at the
conclusion of each drill and each real SCA event to evaluate the response
model and debrief the ERT or Early Defibrillation Response Team. The
completed form shall be discussed in the debriefing meeting following the
drill or event. Further discussion shall be conducted with the Medical
Director as necessary. In either event, written copies of the form shall be
distributed to all necessary parties within the organization for administrative
review.
13. Data Collection
13.1 Early Defibrillation Incident Report and Incident Data. Data collection begins
with the Early Defibrillation Incident Report and data from the defibrillator.
These two components are to be provided to the Early Defibrillation Program
Coordinator as soon as possible.
13.2 Data Transfer. The incident data is to be provided to the Early Defibrillation
Program Coordinator according to policy. The data will be reviewed by the
Early Defibrillation Program Coordinator in order to assess responder
performance and for quality assurance.
13.3 Data Download Procedure. Data download can be conducted by the Early
Defibrillation Program Coordinator or delegated to other personnel under
the supervision of the Early Defibrillation Program Coordinator. Once the
data is downloaded, it can be transferred via file format or printed in a
hardcopy format.
13.4 Data Storage. Downloaded data and post-incident critique forms are to be
stored in a secure location under the direct supervision of the Early
Defibrillation Program Coordinator.
14. Training and Drill Procedures
See Appendix F for the Post-Incident Critique Form.
14.1 Defibrillation Training Requirements. The ERT or Early Defibrillation
Response Team members shall be responsible for maintaining all required
training. The Early Defibrillation Program Coordinator shall track training
requirements and notify each team member of any deficiencies.
14.2 AED Response Plan Drills. Periodic drills of the early defibrillation response
plan and protocols shall be conducted to evaluate the effectiveness of the
early defibrillation program. These drills may comprise a live re-enactment
of an SCA event or classroom discussion of the overall response plan and
protocols. Additional critique discussions with the ERT or Early Defibrillation
Response Team may also follow any actual defibrillation events.
 APPENDICES

The following appendices are provided in a format suitable for copying and posting
as appropriate:
A. Early Defibrillation Response Team Roster
B. Defibrillator Location and Equipment Sheet
C. Periodic Maintenance Checklist
D. Early Defibrillation Response Protocol and Flow Chart
E. Defibrillation Incident Report
F. Post-Incident Critique Form
 APPENDIX A
Early Defibrillation response Team Roster
(Complete for each site.)

AED COORDINATOR
NAME
PHONE #
LOCATION
Team Members

NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
NAME NAME
PHONE # PHONE #
LOCATION LOCATION
 APPENDIX B
Defibrillator Location and Equipment Sheet

Defibrillator Model # Location Accessories

Defibrillator Serial #
 APPENDIX C
Periodic Maintenance Checklist

DEFIBRILLATOR LOCATION:

DEFIBRILLATOR MODEL NUMBER: DEFIBRILLATOR SERIAL NUMBER:

DATE

SCHEDULED FREQUENCY
DEFIBRILLATOR CONDITION
NO DIRT/DAMAGE/CONTAMINATION
STATUS INDICATOR
SELF-TEST PASSED.

ADULT PADS, SEALED, UNDAMAGED,

UNEXPIRED

INFANT/CHILD PADS, SEALED,

UNDAMAGED, UNEXPIRED

ANCILLARY SUPPLIES (HAND TOWEL,

SCISSORS, RAZOR, POCKET MASK)

DATA CARDS, UNDAMAGED

OTHER:___________________

INSPECTED BY (INITIALS)
REMARKS, PROBLEMS,
CORRECTIVE ACTIONS
 APPENDIX D
Early Defibrillation Response Protocol and Flow Chart
 Early Defibrillation Response Protocol
The following early defibrillation response protocol is provided as a sample. It is required that
your facility’s trained responders follow the steps established by that protocol when responding
to a victim of sudden cardiac arrest. The protocol should be reviewed on an annual basis, and
revisions to the protocol made as necessary.

Conduct an initial assessment:

 Assess for scene safety; use universal precautions.
 Assess patient for unresponsiveness.
 If unresponsive, activate EMS and in-house emergency plan. Call 911 or designated number:
________________. Call for defibrillator.

Assess breathing
 Open airway
 Look, listen and feel for breathing
 If breathing is absent, deliver two rescue breaths

Assess circulation
 If signs of circulation are absent, provide CPR. Continue CPR until defibrillator arrives.

Begin defibrillation treatment

 As soon as the defibrillator is available, turn it on and follow the prompts. If the patient is
an infant or child that is less than 8 years old or 55 pounds, use Infant/Child defibrillator
pads if available.
 Shave chest with razor if indicated. Discard razor in a safe manner. Wipe chest if it is wet.
 Apply defibrillation pads. Look at the icons on the self-adhesive defibrillation pads, peel one
pad at a time and place it as shown in its illustration. Ensure pads are making good contact
with the patient’s chest. Do not place the pads over the nipple, medication patches, or
visible implanted devices.
 Deliver a shock to the patient when advised by the defibrillator, after first clearing the
patient area. Administer additional shocks as prompted by the defibrillator, until it advises
no shock or has delivered a series of three consecutive shocks and prompts the responder
to check the patient.
 When advised by the defibrillator, check the patient’s airway, breathing, and signs of
circulation and initiate CPR if circulation is absent.
 Continue to perform CPR until otherwise prompted by the defibrillator or EMS personnel.
 Continue to follow the defibrillator prompts until EMS arrives.

When EMS arrives

Responders working on the victim should document and communicate important information
to the EMS provider, such as:
 Victim's name
 Known medical problems, allergies or medical history
 Time the victim was found
 Initial and current condition of the victim
 Information about the defibrillator’s operation:
 Number of shocks delivered
 Length of time defibrillator has been on

 Assist as requested by EMS providers

Post-Use Procedure
 Take the defibrillator and the Defibrillation Incident Report to the Early Defibrillation
Program Coordinator within 24 hours post-event for downloading data from internal
memory.
 Check the defibrillator and replace any used supplies as soon as possible following the event
so that the defibrillator may be returned to service. Perform the after-patient-use
maintenance on the defibrillator.
 Early Defibrillation Program Coordinator: conduct employee incident debriefing, as needed.
 Early Defibrillation Program Coordinator: complete the incident follow-up report and
forward to Medical Director.

Defibrillator Maintenance after Each Patient Use

 Inspect the exterior, pads connector port or pads cartridge well for dirt or contamination.
 Check supplies, accessories and spares for expiration dates and damage.
 Check operation of the defibrillator by removing and reinstalling the battery and running a
battery insertion test.
 Download data from defibrillator to a PC then erase the defibrillator memory to ensure
adequate capacity for recording data when next used.
 Early Defibrillation Response Protocol Flow Chart

Immediately upon arrival:

• Assess scene for safety.
• Verify sudden cardiac arrest.

Assess responsiveness
• Activate EMS and in-house Emergency
Response Plan
• Open airway and assess breathing
• Absent? Deliver two (2) rescue breaths
• Assess for signs of circulation
• Absent? Proceed to CPR/defibrillation

After verification of sudden cardiac arrest:

• Perform CPR if there is a delay in

obtaining or using the defibrillator;
otherwise, use defibrillator
immediately upon its arrival
• Turn on the defibrillator
• Apply defibrillation pads
• Follow voice and text prompts

Allow defibrillator to
analyze heart
rhythm (automatic)

Shock Advised No Shock Advised

• “Clear” patient verbally and • Check for signs of circulation.

visually prior to shock delivery. • Absent? Perform CPR.
• Deliver shock. • Present? Support airway and
breathing.

• Defibrillate as advised by • Continue until AED provides additional

defibrillator. prompts or external EMS arrives and
instructs you to stop.

•Check for signs of circulation

••Check for signs
If circulation of circulation.
absent, perform for
• Iftwo
circulation absent,
(2) minutes perform • Leave the AED attached to the patient
CPR for two (2) minutes. until instructed to remove it by EMS
• Continue sequence of a shock and
two (2) minutes of CPR until a “no personnel or higher medical authority.
shock” prompt or external EMS
arrives and instructs you to stop.
 APPENDIX E
Early Defibrillation Incident Report
Incident Details
Incident ID:____________________ Incident Date:__________________
Incident Time:_______________________________________________
Shocks Delivered:_______________ Device ID:_____________________
Device Type:_________________________________________________

Patient Detail
Last Name:_______________________ First Name:___________ MI:___
DOB:____________________________ Age:_______________________
Gender:_________________________ Race:_______________________
Patient ID:___________________________________________________

Additional Information
Defibrillator Operator:_________________________________________
Comments:__________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Report Completed By:________________ Date:_____________________

Patient Name:_______________________ Incident Date:_____________
Employee Number:____________ DOB:________ Age:_______ Sex:____
How was Team alerted?____________________ Time alerted:____:____
 APPENDIX F
Post-Incident Critique Form

How was Team dispatched? ____________________ Dispatch time: ___ : ___

Who initiated 9-1-1 call? _______________________ Time called: ___ : ___
ERT or AED Team arrival time: ___ : ___ AED arrival time: ___ : ___
Collapse/recognition: ___ : ___ Bystander CPR started: ___ : ___
9-1-1 called: ___ : ___ EMS dispatched: ___ : ___

SCA Event Report

ERT Team arrival: ___ : ___ : ___ AED arrival: ___ : ___
Patient unresponsive: Yes No Documented time: ___ : ___
Rescue breathing started: Yes No Documented time: ___ : ___
CPR started: Yes No Documented time: ___ : ___
AED applied: Yes No Documented time: ___ : ___
First shock advised: Yes No Documented time: ___ : ___
Additional shocks: Yes No Total # of shocks delivered: _________
Return of circulation: Yes No Documented time: ___ : ___
Return of respiration: Yes No Documented time: ___ : ___
EMS scene arrival: ___ : ___ : ___ EMS arrival at patient: ___ : ___
Patient condition at EMS hand-off: __________________________________________
Care Given by EMS: ALS BLS Patient transported: ___ : ___
Transported to:__________________________________________________________
Patient condition at hospital: _______________________________________________

Report Completed by: ___________________________ Date: _____________