REFRIGERATOR AND FREEZER TEMPERATURE MONITORING *

Effective Date: 
Mon, 04/01/2002
Reviewed: 
Wed, 06/16/2021
Revised: 
Wed, 06/16/2021
Policy: 

UCSC Student Health Center refrigerator and freezer temperatures are continuously monitored and documented wherever medical products, including vaccines, reagents, supplies, biological samples and pharmaceuticals are stored.

All medical products are stored and managed in accordance with manufacturer instructions and regulatory guidelines.

All equipment is maintained in accordance with manufacturer instructions and regulatory guidelines.

Procedure: 
  • Temperature logs are affixed to each refrigerator and freezer in locations where medical products are stored.  These departments include:  Pharmacy, Medical Clinic - Floor 1 and Floor 2 (with freezer), and the Laboratory (with freezer). See Lab Manual for General Maintenance Program
  • Temperatures are documented on the logs at the beginning and end of each day in each department on days the clinic is open.

NIST THERMOMETERS

  • Staff are trained to read the thermometers, document the temperatures, use the problem log, and to seek assistance from their supervisors whenever there has been a temperature excursion
  • Temperatures are documented by staff twice daily when the clinic is open

  • High and low alarms are set and remain on
  • At the first recording each work day, the minimum and maximum temperature history is reviewed, temperature/s and range/s are noted, and then the thermometer is reset
  • Temperatures are monitored by NIST (National Institute of Science and Technology) certified and calibrated thermometers.  Calibration compliance dates are monitored. 
  • Refrigerators and freezers are maintained at temperatures according to manufacturer requirements.
  • Whenever the temperatures are out of range (either minimum/maximum history or current), the staff member will notify the supervisor and document the event on the Trouble Shooting Record. The staff member should not turn off the alarm.
  • Any malfunctions need to be communicated to the supervisor immediately
  • All medical refrigerators and freezers are on the emergency generator system
  • Logs will be distributed and collected monthly, and stored in Medical Records.

TEMPSTICK THERMOMETERS

  • TempStick thermometers are a back up to the previously mentioned official and certified NIST thermometers
  • TempStick thermometers are wifi-enabled continuous monitoring thermometers, connected to WAPS at the UCSC Student Health Center, that are used in the UCSC Student Health Center refrigerators and freezers. Data is accessed through a password protected website, or an application. Alerts can be created and shared so that protective action can be taken in case of a temperature excursion
  • Temperatures (and humidity) are tracked up to 30 days
  • Battery charge level is monitored; new lithium batteries are installed every 6 months or earlier if needed.  Facilities staff monitor and exchange batteries. (Lithium batteries are used in equipment with cold environments)
  • Connectivity to wifi is monitored at least weekly by facilities staff.  See https://docs.google.com/forms/d/e/1FAIpQLScNLrWg1D1ZA34_iRXACIcfYI2XCW31x8pORX8j_dy3_-wNpA/viewform?gxids=7628
  • Sensors are set for two parameters:
    • Data is sent to the server at specific intervals, i.e. hourly
      • Optional setting for more frequent readings if the temperatures near minimum and maximum allowable settings, i.e. every 15 minutes if temperature reaches 44 degrees F (near maximum for refrigerator)
    • Required temperature ranges for medical refrigerators and freezers
  • Specific staff are alerted by text messages and/or email addresses (loaded onto TempStick website) regarding:
    • data connectivity
    • approaching temperature excursions
    • additional alerts may be set up by specified users

TEMPERATURE EXCURSIONS

All reported temperature excursions will be investigated and assessed. Whenever possible, the time out of compliance and the limits reached when out of compliance will be documented. Manufacturers may need to be contacted, since some products allow for limited temperature excursions.

Any excursion, and any product or specimen losses will be documented in RL Datix.