Introduction
Purpose
Medical emergencies may occur among patients, visitors, faculty, staff, residents, learners, and other individuals within the Adams School of Dentistry (ASOD). This policy defines the responsibilities of ASOD personnel involved in an emergency response. Medical emergencies and related injuries must also be reported in accordance with the ASOD Incident Report, Documentation, & Corrections policy.
Scope
This policy applies to all individuals participating in or affected by ASOD operations, including patients, visitors, faculty, staff, residents, learners, affiliates, volunteers, and contractors. It applies to medical emergencies occurring in ASOD clinical and non-clinical locations and other areas where ASOD personnel are responsible for the response.
Definitions
| ASOD Complex |
Brauer Hall, Tarrson Hall, First Dental Building, and Koury Oral Health Sciences Building. |
| ASOD Medical Emergency Team |
Designated clinical response team, consisting primarily of Oral and Maxillofacial Surgery faculty, residents, nurses, and other assigned personnel, that responds to medical emergencies during applicable operating hours. |
| Health Care Provider |
An ASOD faculty member, resident, learner, or other authorized individual responsible for providing or supervising patient care. |
| Incident Report |
Official report used to document an injury, medical emergency, accident, near miss, or other reportable event in accordance with the applicable ASOD incident reporting policy. |
| Incident Reporting App |
ASOD electronic system used to submit incident reports, provide incident-specific instructions, route reports to an assigned reviewer, and upload supporting documentation. |
| Medical Emergency |
An acute illness, injury, or change in physical or mental condition that requires immediate evaluation, intervention, emergency-team activation, or assistance from emergency medical services. |
| Medical Emergency Response Record |
Form completed when the ASOD Medical Emergency Team responds to an emergency. Record documents the individual’s condition, assessment, treatment, disposition, and other relevant information. |
| Regular Hours |
Monday through Friday, 8:00 a.m. through 5:00 p.m., excluding University holidays or other periods when normal ASOD operations are closed. |
| Responsible Adult |
An adult who is able and willing to assume responsibility for assisting the affected individual after release from ASOD. |
| Supervising Faculty or Provider |
Faculty member or licensed health care provider responsible for overseeing the clinical activity, learner, resident, or treatment area involved in the emergency. |
Emergency Prevention and Preparedness
Patient Assessment and Vital Signs
Health care providers must review and update each patient’s medical history before providing treatment. Relevant medical conditions, medications, allergies, prior adverse events, and other identified risk factors must be considered when planning and providing care.
Blood pressure and pulse must be obtained and documented at each treatment visit for patients age 18 and older. For patients ages 10 through 17, blood pressure and pulse must be obtained at the initial visit and at least every six months thereafter. Patients receiving sedation must be monitored in accordance with applicable laws, regulations, professional standards, and ASOD requirements. Additional monitoring must be completed when indicated by the patient’s condition, planned treatment, or clinical judgment.
Emergency Readiness
Clinical and operational areas must maintain access to appropriate emergency equipment, supplies, communication methods, and trained personnel. Personnel must be familiar with emergency activation procedures, the location and use of emergency equipment, their assigned responsibilities, emergency access and transportation procedures, and applicable documentation and reporting requirements.
Medical Emergency Response
General Response Requirements
Personnel who become aware of a medical emergency must respond within the limits of their training and authority. Immediate actions may include stopping treatment or other activity, assessing the affected individual, activating the appropriate emergency response, providing basic emergency care, obtaining oxygen or other emergency equipment, initiating cardiopulmonary resuscitation or use of an automated external defibrillator when indicated, and directing responders to the emergency location.
Immediate care must not be delayed to complete administrative documentation. A chronological account of the event should begin as soon as sufficient personnel are available.
Clinical and Non-Clinical Areas
In a clinical area, the responsible health care provider must initiate the evaluation and management of the emergency, direct available personnel, activate the appropriate response, and continue care until responsibility is transferred to the ASOD Medical Emergency Team or emergency medical services.
In a non-clinical area, the first available ASOD employee or learner must activate the appropriate emergency response. A qualified health care provider who arrives at the scene must assume responsibility for the initial clinical response until care is transferred.
Emergency Activation
Emergency medical services must be activated when required by the individual’s condition, the emergency location, established response procedures, or the direction of the ASOD Medical Emergency Team. During regular operating hours, Monday through Friday, from 8 AM to 5 PM, personnel must contact the ASOD Medical Emergency Team by dialing 7-3911 from an ASOD landline. Caller must provide the location and known nature of the emergency, remain available to relay information, follow instructions, and ensure that responders are directed to the affected individual.
Outside regular operating hours, when the ASOD Medical Emergency Team is unavailable, or when direct emergency medical services response is required, personnel must call 911. An ASOD employee, learner, or other designated individual must meet responders at the appropriate entrance and direct them to the emergency location when reasonably possible. For emergencies occurring immediately outside an ASOD building, personnel must activate emergency medical services when assistance is needed and may provide reasonable support within the limits of their training while awaiting responders.
Transfer of Responsibility
Responsibility for emergency management transfers to the ASOD Medical Emergency Team or emergency medical services upon their arrival and acceptance of care. Individual transferring responsibility must communicate relevant information, including the nature and sequence of the event, known medical history, vital signs, changes in condition, treatment or medication provided, and the individual’s response to care.
ASOD Medical Emergency Team
Composition and Responsibilities
The ASOD Medical Emergency Team consists of designated personnel qualified to respond to medical emergencies. Team composition may include Oral and Maxillofacial Surgery faculty, residents, nurses, and other assigned personnel. A designated faculty member serves as team leader. When the designated faculty member is unavailable, leadership transfers according to the established emergency response structure.
The team is responsible for assessing the affected individual, directing emergency treatment, determining whether emergency medical services are required, coordinating transfer of care, determining the immediate disposition within its authority, completing required documentation, and communicating follow-up requirements to the responsible provider or unit.
Disposition and Transportation
Designated leader of the ASOD Medical Emergency team determines whether the individual may remain at ASOD, resume treatment or other activity, leave independently, be released to a responsible adult, receive additional medical evaluation, or require emergency medical services. Decisions must be based on the individual’s condition, available clinical information, and professional judgment.
The ASOD Medical Emergency Team does not provide transportation to hospitals or other health care facilities. Emergency medical services must be used when emergency transportation is required. For non-emergency conditions requiring additional evaluation, the individual may be released to a responsible adult or directed to seek appropriate medical care.
When emergency medical services responds, ASOD personnel must provide a concise clinical report and relevant documentation when appropriate and permitted. Emergency medical services assumes responsibility for transportation and further disposition after accepting care.
Documentation and Reporting
General Requirements
Medical emergencies must be documented accurately, within at least 24 hours of incident, and through the appropriate clinical and administrative records. Documentation must be factual, objective, and limited to information relevant to the event and response. Documentation should include, as applicable, the date, time, and location of the event; the affected individual; relevant medical history; observed signs and symptoms; vital signs; treatment or medication provided; individuals involved in the response; transfer of care; disposition; follow-up instructions; and supporting records.
Medical Emergency Response Record
A Medical Emergency Response Record must be completed whenever the ASOD Medical Emergency Team responds. The designated team member must complete the record, and the responsible team leader or faculty member must review and sign it. For an ASOD patient, the record must be included in the patient’s health record. For a non-patient, the record must be maintained in the designated administrative record. A copy must also be attached to the corresponding incident report when required.
Patient Record Documentation
When a medical emergency involves an ASOD patient, the responsible health care provider must document the event in the patient’s health record. The patient record must include the clinically relevant facts, treatment provided, patient response, disposition, and follow-up instructions. An ASOD Incident Report does not replace documentation in the patient record.
Incident Report
A medical emergency, related injury, use of emergency response services, or other reportable event must be submitted through the ASOD Incident Reporting App no later than 24 hours of the incident.
Report should be completed by the ASOD member that was directly involved, the responsible provider, supervising faculty member, or other person with appropriate access and sufficient knowledge of the event. When no reporter is available, ASOD Clinical Compliance may complete or facilitate the report.
Corrections, supplemental information, and supporting documentation must be added through the ASOD Incident Reporting App whenever available. Additional submission, review, correction, access, retention, and closure requirements are governed by the ASOD: Incident Report, Documentation, & Corrections policy.
Training Requirements
Personnel must complete and maintain training appropriate to their assigned duties, level of patient contact, and emergency response responsibilities. Personnel providing direct patient care must maintain current Basic Life Support certification. Personnel providing patient or human subject care must complete medical emergency training annually. Failure to maintain to maintain the appropriate training may result in restriction or suspension of clinical access until compliance is restored.
Designated ASOD Medical Emergency Team members must maintain Advanced Cardiac Life Support, Pediatric Advanced Life Support, automated external defibrillator training, or other advanced certification when required by law, regulation, professional standards, assigned responsibilities, or ASOD policy. Failure to maintain required training may result in restriction or suspension of clinical or emergency response duties until compliance is restored.
Emergency Equipment and Supplies
ASOD units must maintain emergency equipment, medications, and supplies appropriate to the services provided and the risks associated with each location. Equipment must be accessible, properly stored, inspected at the required frequency, serviced when needed, and replaced when used, expired, damaged, missing, or otherwise unsuitable for use.
AED's must be inspected monthly and after each use by designated ASOD personnel. AED units must be serviced by an outside vendor every two years, or sooner when indicated by manufacturer requirements, equipment condition, or identified concerns.
Emergency oxygen tanks and related equipment must be inspected monthly and after use, as applicable, by designated ASOD personnel. Use, inspection findings, equipment concerns, maintenance, and replacement needs must be documented through https://go.unc.edu/asod-o2. Inspection and maintenance records must identify the date, responsible individual, findings, and corrective action when applicable. Equipment used during an emergency must be evaluated and returned to service promptly. Any condition that may affect safe operation must be reported and addressed without delay.
Emergency drugs, supplies, AED, and other equipment maintained by the ASOD Medical Emergency Team must be inspected weekly and restocked immediately after use. Departmentally maintained emergency drugs, supplies, and equipment must also be inspected weekly by personnel designated by the responsible department leader.
ASOD clinics must maintain emergency equipment, medications, and supplies appropriate to the services provided and risks associated with the location. Equipment and supplies must be accessible, properly stored, inspected at least monthly, serviced as required, and replaced when used, expired, damaged, missing, or otherwise unsuitable for use.
ASOD clinics must document inspection, maintenance, servicing, and replacement activities through a method accessible to the applicable oversight committee. Equipment used during an emergency must be evaluated and returned to service promptly, and any condition that may affect safe operation must be reported and addressed without delay.
Records and Confidentiality
Medical emergency and incident records must be maintained in accordance with applicable law, University policy, records retention requirements, and ASOD procedures. Access must be limited to individuals with an authorized clinical, administrative, legal, safety, or operational need. Personnel must not disclose patient, learner, employee, or incident information outside approved systems or authorized processes. Incident documentation must not be used to replace required patient-record entries, employee health documentation, workers’ compensation records, or reports required by another institutional office.
Related Requirements
External Regulations and Consequences
Unit Policies, Standards, and Procedures
IX. Contact Information
General Questions
Office: Director of Clinical Compliance
Email: ASOD_ClinicalCompliance@unc.edu
Medical Emergency (clinic hours)
Office: ASOD Medical Emergency Team (OMFS)
Telephone: 7-3911
Medical Emergency (after hours, weekends, or holidays)
Office: Orange County EMS
Telephone: 911