CHHS14/040

Canberra Hospital and Health ServicesClinical ProcedureStorage of Skull Flaps

Contents

Contents....................................................................................................................................1

Purpose..................................................................................................................................... 2

Scope........................................................................................................................................ 2

Section 1 – Intra-operative preparation of skull flap.................................................................2

Section 2 – Register for Skull Flaps............................................................................................3

Section 3 – Re-implantation of skull flaps.................................................................................4

Section 4 – Discarding expired skull flaps..................................................................................4

Implementation........................................................................................................................ 5

Evaluation................................................................................................................................. 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

References................................................................................................................................ 6

Definition of Terms................................................................................................................... 7

Search Terms............................................................................................................................ 7

Consultation..............................................................................................................................7

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CHHS14/040

Purpose

To provide clear guidance for Canberra Hospital and Health Services staff to follow when storing skull flaps at Canberra Hospital.

To ensure safe storage of skull flaps To maintain a standard of Occupational Health and Safety To ensure records maintained are accurate To ensure a sterile skull flap is reimplanted in patient To ensure that a skull flap is stored for the correct period of time

Scope

This document sets out the processes relating to skull flaps and should be used by all staff.

Staff covered by this document are: Registered Nurses Neurosurgical Staff Specialists and Visiting Medical Officers (VMOs) Neurosurgical Registrars

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Section 1 – Intra-operative preparation of skull flap

The bone is to be collected under aseptic conditions.Equipment required:- Leksell ronguer from setup (Craniotomy tray) Bone Kit from location M5F in sterile stock room

Surgeon to use Leksell ronguer to remove two small pieces of bone from flap Place two small pieces of bone in two sterile specimen jars (one in each jar). Label both jars with patient details (at least 3 identifiers: name, date of birth, URN,

address) and skull bone chip and date. Send one of these jars with a small piece of bone to pathology for culture. The other jar

with a small piece of bone is to be stored in the freezer with flap for culture at a later date (Registrars responsibility)

Ensure two pathology forms for culture are completed: one to go with first bone chip specimen, the other to remain in register for culture at a later date.

Place skull flap inside sterile zip-lock bag from kit, remove air from bag, then seal the bag with zip-lock.

Place bag with skull flap into biggest jar from kit, screw the lid on tightly and seal with long Tegaderms x 2.

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NOTE: If skull flap is too large to fit into the jar provided, follow this procedure: Place skull flap in sterile zip-lock bag from kit. Place this inside two sterile bowel bags (one inside the other) and tie both bags tightly

with the string. Hand this off to Scout Nurse who will then add a patient sticker and place into white

pathology container and seal with sleek tape. Scout will also add patient details to pathology container using permanent marker on the outside of the pathology container.

Scout to place patient label with date on this jar. Place sealed bone flap and one specimen jar into unsterile plastic bag and place the

patient label on the outside. Place flap and bone specimen in skull flap freezer (bone freezer room, next to frozen

section room) Take one patient sticker for the register with you Ensure gloves are used when handling inside of freezer. (Insulated gloves located in

drawer) Fill out register form in the blue ‘Skull Flap Register’ folder. Place pathology form and

register form in plastic sleeve in the register located in the Bone Bank room. Blank register forms are in the folder.

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Section 2 – Register for Skull Flaps

A register of skull flaps will be kept. The register is kept adjacent to the freezer. Details required in register:-1. Patient label (with at least 3 identifiers)2. Date collected3. Neurosurgeon’s name4. Name of person recording storage5. Confirmation of bone sent for culture6. Result of 1st culture*7. Date 2nd specimen sent for culture*8. Result of 2nd culture*9. Registrar's or Neurosurgeon’s signature confirming bone flap suitable for re-insertion*10. Date of reinsertion or disposal and reason for removal from freezer, e.g. Re-

implantation, disposal

NOTE: Points marked with * are the responsibility of the Neurosurgical Registrar

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Section 3 – Re-implantation of skull flaps

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Replacement of skull flap is an elective procedure and will be booked through surgical bookings. When case booked, Surgical Bookings to send copy of form to L2 Neurosurgery RN in

Operating Rooms and Neurosurgical Registrar, at least 12 days in advance of procedure. The 2nd jar with small piece of bone with the form from the registrar will be removed

from freezer and sent to pathology by the registrar. Neurosurgical Registrar to check pathology results and confirm suitability for reinsertion

by signing register. On day of surgery remove skull flap from freezer and thaw at room temperature for

one hour pre-operatively. (Can also be thawed on sterile setup in warm Ringers Solution if required)

Ensure insulated gloves are worn when removing jar from freezer Record date and name of person removing flap in register + reason for removal.

Procedure for removing Skull Flap from Jar:- Scout nurse will remove Tegaderm from outside of jar, then carefully open jar for scrub

RN to remove the sterile bag with skull flap inside. If opening skull flap from sterile bowel bags,

- Remove from white container- Scout Nurse opens first bowel bag and takes out the inner bag,- This bag is peeled back and opened to the Scrub Nurse in a sterile fashion,- The 2nd inner bag (zip-lock bag) is regarded as sterile

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Section 4 – Discarding expired skull flaps

Skull Flaps are to be stored for no longer than six (6) months (as per Head of Neurosurgery).

Stored Skull Flaps will be checked quarterly by nursing staff for expiration date, this can be achieved by checking skull flap register (blue folder in freezer room). Registrar consultation is required prior to skull flap being disposed of.

Skull Flaps of deceased patients may be discarded automatically as per NHMRC guidelines.

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Implementation

This procedure is an update. The new procedure will be made available to all staff and new staff will be informed of this procedure during the introduction to the operating theatres. In-service will be conducted by the Registered Nurse L2 of nursing and medical staff in relation to storage of Skull flaps. Step-by-step instructions on correct skull-flap storage procedure displayed in emergency theatre (OR8) and Neuro Trolley.

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Evaluation

Outcome Measure Accurate maintenance of Skull Flap Register Appropriate freezing and care of Skull Flaps during surgical timeframes

Method The Registered Nurse L2 for Neurosurgery will maintain audits on information recorded

in Skull Flap register Infection Control Audits on re-implantation adverse outcomes-skull flap patients Riskman reporting at ward level of adverse outcomes Reporting of outcomes of audits at regular Infection Control Meetings Reporting of adverse outcomes to the Neurosurgical Unit by Infection Control

Coordinator Infection Control audits and outcomes on surgical re-implantation of Skull flaps

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Related Policies, Procedures, Guidelines and Legislation

LegislationACORN Standards for Peri-operative Nursing 2010-2011 Nursing Roles Guidelines Position StatementsHealth Practitioner Regulation National Law (ACT) Act 2010Health Records (Privacy and Access) Act 1997Health Regulation (Maternal Health Information) Act 1998 Human Rights Act 2004Privacy Act 1988Children and Young Peoples Act 2008 Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Doc Number Version Issued Review Date Area Responsible PageCHHS14/040 1.0 Oct 2014 Oct 2018 Surgery and Oral

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Mental Health Act 2015Powers of Attorney Act 2006

Standards National Safety and Quality Health Service StandardsStandard 1- Governance for Safety and Quality in Health Service OrganisationsStandard 3-Healthcare Acquired InfectionsStandard 5-Patient Identification and Procedure MatchingStandard 6-Clinical HandoverStandard 7-Blood and Blood ProductsACORN Standards for Peri-operative NursingNHMRC National Guidelines for Waste Management in the Health Industry, 1999

PoliciesPatient Identification-Correct Patient, Correct Site, Correct Procedure Policy and SOPPatient identification-Patient Identification Band SOPPatient Identification-Pathology Specimen Labelling SOPPatient Identification-Surgical Safety Checklist SOPInfection Control Policy: ACT Health - June 2009 (currently under review Dec 2011)Nursing and Midwifery Continuing Competence PolicyEssential Education Policy Skin Preparation SOPClinical Record Documentation PolicyClinical Records PolicyConsent to Treatment PolicyConsent to Treatment SOPOpen Disclosure PolicyACT Elective Surgery Access PolicyCode of Dress-Restricted Area Attire SOPSignificant Incident Reporting PolicyWaste Management Policy

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References

ACORN Standards for Peri-operative Nursing. (2011). “S4 Disposal of surgically removed human tissue and explanted items”. The Australian Collage of Operating Room Nurses, Adelaide, South Australia.

Barwon. (2004). “Clinical and related wastes” Retrieved on 21/10/2008. From http://www.brwmg.vic.gov.au/waste_wise/documents/Quick_guide_grampians.pdf

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National Health and Medical Research Council. (1999). “National Guidelines for Waste Management in the Health Care Industry”. Retrieved on 20/10/2008. From http://www.nhmrc.gov.au/publications/synopses/withdrawn/eh11.pdf

The Canberra Hospital – Nursing Practice standards. (1998). “Skin Grafts”. The Canberra

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Definition of Terms

ACORN Australian Collage of Operating Room Nurses

Search Terms

Skull flapCraniotomyBoneHuman TissueNeurosurgeryNeurosurgical ProcedureStorage

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Consultation

NAME/POSITION/LOCATION (of person/s; groups consulted)

DATE FEEDBACK RECEIVED

FEEDBACK ACTION COMMENTS

Neurosurgery 30/9/2014 Y Nil, Happy with Document

ADON, Operating Theatres

7/10/2014 Y Document amended

Donatelife ACT 22/9/2014 Y Not used by Donatelift

Doc Number Version Issued Review Date Area Responsible PageCHHS14/040 1.0 Oct 2014 Oct 2018 Surgery and Oral

Health7 of 7

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register