DPM, RELEASING

SOP-APMO-006Prepared by: A. McDonald

Version 8, Issued 29 March 2016 Page 1 of 7Approved by: F. Delany

1.Purpose

The purpose of this document is to describe the procedures for releasing deceased patients from the Austin Hospital Mortuary.

2.Scope

This procedure applies to all deceased patients released from the Austin Hospital Mortuary.

3.responsibility

3.1.Business hours

During business hours 0800 to 1630the pathology/mortuary staff are responsible for releasing deceased patients.

3.2.After hours – Austin Hospital

After hours the Patient Services Assistants (PSAs) are responsible for releasing deceased patients. This service is coordinated by The PSA Service Desk on extension 3917 or pager 1045.

The mortuary is locked at all times and can only be accessed via approved swipe access. PSA’s are granted swipe access by requesting it from the Principal Scientist, who then notifies security to action.

4.definitions

N/A

5.REFERENCES

SOP-APMO-003 Documentation Requirements

6.FORMS AND TEMPLATES

NA

7.procedure

7.1.General requirements

Authorisation for the release of bodies will be ONLY given once all paperwork is completed.

Deceased patients should be released from the mortuary. Ward releases are only permitted in exceptional circumstances, after discussion with mortuary staff.

Funeral directors must present to the mortuary for all releases.

All patients must be registered in the mortuary register and signed out to the custody of the funeral director.

Deceased patients must not be exposed in a public area. Procedures requiring the deceased to be exposed include verification of identity and valuables in situ. These procedures must occur in a private area.

7.2.Access to the Austin Hospital mortuary

Funeral Directors wishing to transfer a patient must park their vehicle in thefuneral directors carpark which is located in loading dock 3 east off Studley road.

  • On arrival at the roller door, signage tells the funeral directors to call the mortuary to open the roller door, then directs them to the J lift and to travel up to the mortuary foyer.
  • If J Lift is not operational, the funeral director will need to use the kitchen lifts.

7.3.Personal protective equipment

Single use disposable gloves must be worn when releasing deceased patients.

Gloves should be put on before entering the cold room and removed and discarded on exiting the cold room.

Additional personal protective equipment such as safety eye wear and respiratory protection may be warranted in some cases such as when handling patients with a high risk infectious disease.

7.4.Use of scissor lift trolley and mortuary racking system

  • All patients placed on or removed from the mortuary racking must be done so by using the dedicated hydraulic scissor trolley, located out the front of the cold room.
  • Unplug scissor trolley from power charger, remove transport cover if required.
  • Manouvere trolley into cold room and line up the trolley to ensure it is centred to the mortuary tray required. Once in place, lock the front wheels and raise the trolley to the appropriate height in order to remove the required tray from the racking system.
  • The end bar on the trolley should be hard up against the racking and just under the bar of the tray to be removed.
  • Once in the correct position, pull out the tray approximately 40 cm, just enough for it to catch the end retraction wheel, then press the backward button on the controls to bring the trolley out of the racking and onto the scissor trolley.
  • Once the tray is securely on the trolley lock the tray to the trolley with front and side locks.
  • Use up and down controls to raise or lower the trolley to the height of the funeral directors trolley.
  • Allow the funeral director to come up along side the scissor trolley. Once in position, do not alter any controls or move the scissor trolley in any way until the funeral director has moved the patient across to their trolley and existed the cold room.
  • Once the release is complete and the funeral director has left the cold room, it is then ok to place the tray back onto the racking, unlock the trolley wheels and re-dock the trolley outside the cold room and plug it in.
  • The scissor trolley must be docked into a power point after each use, to ensure the battery unit is charged.
  • A second hydraulic trolley is located on 8S ONJ palliative care ward, should one of the trolleys be out of service, a second is available for use.

7.5.Identification of deceased

Funeral directors must always be escorted into the cold room.

On entering the cold room identify the required patient using both the rack number in the mortuary register, but also the identification attached to the body bag or wrapping.

In conjunction with the Mortuary /Pathology staff member the undertakers must open the body bag or wrapping and verify the patient’s identify with the Identification Band on the wrist or ankle and the Deceased Patient Label on the toe or ankle. The identification attached to the patient must match the identification attached to the body bag or wrapping.

When releasing patients with known or suspected CJD or those with a known high infectious risk the body bag IS NOT OPENED.

Identify the patient by the identification attached to the body bag ONLY.

7.6.Valuables in situ

The funeral director is to check the fingers, hands, wrists, toes, ankles, neck, ears and face of the patient for the presence or absence of valuables.

The funeral director should also verify the presence or absence of valuables in situ.

The funeral director may attach additional bands if valuables are present as required by their procedures.

DO NOT check for valuables in situ if releasing patients with known or suspected CJD or those with a known high infectious risk.

7.6.1.Recording valuables at The Austin Hospital

The presence or absence of patient’s valuables must be verified against the “Belongings Left In Situ” section of the “Deceased Patients Belongings Form M230.0” /Toe card.

7.6.2 Valuables missing on release of the patient from the mortuary

The mortuary/ pathology staff member performing the release must enact the following:

Contact a second mortuary/pathology staff member to act as a witness.

Re-check the “Belongings Left In Situ” section of the “Deceased Patients Belongings Form M230.0/ Toe card.”

Re-identify the patient.

Re-examine the deceased for the presence of valuables in situ.

Examine the deceased’s clothing, role the deceased and examine beneath them, examine all parts of the deceased’s body bag or wrapping.

Document findings on valuables form. The deceased is then released to the funeral director.

Inform the Anatomical Pathology Principal Scientist and document the incident in a riskman.

7.7.Transferring the patient

Close the body bag or wrapping.

The funeral director will transfer the patient to their trolley and remove the patient from the cold room.

Close the cold room door.

Remove and discard gloves.

Wash or Debug hands.

7.8.The mortuary register

The funeral director must complete the relevant section of the mortuary register headed ‘Removal from Hospital’ by entering the date and time of the release, their company and their signature.

The staff releasing the patient must counter-sign the release in the second last column of the register.

7.9.Removing the patient from the mortuary

The patient is removed from the mortuary via J lift to the funeral directors carpark on Level 3. Upon leaving the carpark, the roller door will self close after 20 minutes.

7.10.Special procedures for ward releases

Ward releases are only permitted in exceptional circumstances.

The nurse in charge of the ward must be notified that a request for a ward release has been made.

  • All appropriate paperwork must be completed.
  • Funeral directors must present to the mortuary as usual.
  • Once the funeral director has gained access to the mortuary the staff releasing the patient must contact the ward and inform them that the funeral director has arrived.
  • As soon as the ward is ready to transfer the patient the staff releasing the patient may escort the funeral director to the ward.
  • The funeral director should be escorted via the most discreet and direct route.
  • The ward staff should escort the funeral director to the patient’s room as soon as they arrive on the ward.
  • The funeral director should then transfer the patient to their trolley.
  • The staff releasing the deceased should then escort the funeral director back to the mortuary via the most discreet and direct route and follow procedures from 7.6

8.ATTACHMENTS/APPENDICES

N/A

End Of Document