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Plan for Hospital-based, Post-Mortem Care, and Mass Fatality Management

I. PURPOSE
The purpose of the Mahaska Health Partnership plan is to provide guidelines for the appropriate care of the body, notification of family/significant other, medical examiner notification as appropriate and disposition of a patientís body and personal belongings. 

II. POLICY:
It shall be the policy of the Mahaska Health Partnership to appropriately prepare, store and arrange for the disposition of a patientís body and belongings after a patient has expired and has been declared deceased by a licensed physician.  In all cases, the body of the deceased will treated in a manner that maintains dignity and respect with every effort made to assist in the arrangement of disposition consistent with the cultural and religious wishes of the deceased and/or family.

III. PROCEDURE:
A.Personal Protection: It shall be the policy of Mahaska Health Partnership to inform any persons handling human remains (e.g. hospital staff, Medical Examiner, funeral home staff) if the patient died of or was recently exposed to an infectious disease. As a general rule, all personnel who handle remains should take protective precautions including:

1.Wear disposable long-sleeved cuffed gown (should be waterproof if exposure to body fluids is anticipated);

2.Wear non-sterile gloves covering the cuffs of the long-sleeve gown;

3.Wear a surgical mask capable of filtering respiratory particulate if handling the body immediately after death;

4.Wear a surgical cap and face shield if exposure to body fluids is anticipated;

5.Wear water-proof shoe covers if exposure to body fluids is anticipated;

6.Maintain proper hand washing. 

B.Personal Belongings:  As a general rule, jewelry, wallets, purses and other valuables should not accompany the body to the hospital morgue. Jewelry or other valuables should be labeled with the patientís full name, address, telephone number and hospital record number.  Jewelry or other patient valuables may be given to a spouse or next of kin as documented in the patient record, unless the death has been determined to be a Medical Examiner case.  The inventoried items should be documented in the patientís record.  If next of kin are not available, the inventoried valuable items should be sent to the Business Office for secured storage.  Any jewelry that remains on the body or is sent to the hospital safe should also be clearly documented in the patient record.

C.Location of Death:  The policy of Mahaska Health Partnership ďCare of the Body after DeathĒ will be utilized for areas within the hospital. In the case that Mass Fatalities are occurring on the inpatient area the body of the deceased will be accompanied to the refrigerated semi trailer and proper documentation kept of their whereabouts.
D.Medical Examiner Case:  Incidents of reportable deaths should be communicated to the County Medical Examinerís Office.  Cases that may result in Medical Examiner jurisdictions are those that may have impact on the ďpublic interestĒ.  Such cases generally include: 

1.Violent deaths, which include homicide, suicide, or accidental death resulting from physical, mechanical, thermal, electrical, or radiation injury.

2.Deaths related to disease thought to be virulent or contagious, which may constitute a public health hazard. 

3.Persons who die suddenly when in apparent good health; 

4.Suspicious circumstances; 

5.Unknown or obscure causes.

6.Unclaimed/unidentified bodies.

The Medical Examiner may take jurisdiction over an apparent natural death if the death was unexpected and no medical cause can be determined; if the deceased was not under the care of a physician for any disease, which could reasonably be expected to cause death; and if death might be due to a public health hazard.  In the event that the Medical Examiner retains custody of the case for further investigation and/or autopsy, the following should be noted:

1.Any material removed from the body (e.g. knives, bullets, personal effects) should be considered as forensic evidence and preserved to maintain a chain of custody.  Such items will be placed in a paper bag sealed, labeled with patientís full name, address, telephone number and hospital record number and placed next to the body but NOT in the shroud. Policy on care of the forensic patient in the Emergency Department will be followed. Note: In the case of gunshot wounds paper bags will be secured on the patients hands.

2.The body should not be cleansed prior to transfer to the hospital morgue;

3.A hospital staff member must be present at all times when family/significant others view the body.

4.All indwelling tubes, needle, catheters, etc. are to be left in place.  Exceptions may be made in neonatal and/or pediatric cases when tubes/lines are judged to be non-essential to the autopsy.  For permission to remove non-disposable items or any other questionable tubes, lines or needles, the County Medical Examiner should be contacted.  

E.Internal Notification:  When a patient expires on an in-patient unit or in an ancillary department, the Nursing Supervisor should be immediately notified.

F.External Notification:  Upon the pronouncement of a patientís death, the patientís attending physician or designee will notify the patientís family.  Notification should be documented in the physician progress notes or nursing notes of the deceased patientís medical record, including who was notified and the time notification occurred.  Concurrently, the death should be reported to the hospitalís host County Medical Examiner to secure a decision on whether the case will be retained for further investigation by the Medical Examiner.

G.Body Preparation for Viewing:  Designated hospital staff should prepare the body for viewing by the family/significant others by bathing if no autopsy is ordered.  Depending on the autopsy status, tubes should be removed or shortened to the entry point level.  Any mutilated or defaced areas should be covered. Foley catheters may be removed even if an autopsy is planned.  Dentures should be returned to the mouth if not precluded by injuries.  Infants should be diapered.

The preferred viewing location at Mahaska Health Partnership shall be in the patients room or in the event of a mass casualty incident an empty procedure room or designated area within the hospital can be utilized.

H.Documentation:  Nursing is responsible for completing documents reflecting actions prior to and post death.  Physicians are responsible for completing other documentation in keeping with the bylaws of the medical staff. If the case is reportable to the Medical Examiner, the nursing staff shall notify the Emergency Department and a Medical Examiner Investigator will be dispatched to review the case. The Medical Examiner Investigator will fill out a Medical Examiner investigation report and assign a state and county number to the case. The attending physician, if not a Medical Examiner case, will be required to complete the Certificate of Death.

I.Preparation of Adults: After viewing by family if at all possible, the body should be shrouded in privacy from the public. 

J.In the event of a Mass Fatality incident patients may be prepared in the following manner 

1.Place tape horizontally across the stretcher at shoulder and ankle level, then lay plastic shroud on top of tape and stretcher; 

2.Complete ID tags (2) with patient name, medical record number, date and name of attending physician;

3.Wrap wrists with ABD pads and fold arms over abdomen; then tie wrists to secure in place with gauze bandage or trach tape;

4.Wrap ankles with ABD pads and secure together with trach tape; attached ID tag to toe;

5.Position rectal pad in place.                                                                                             
6.Transfer body onto shroud, wrap body in shroud, secure with shroud trach tape at shoulder and ankle level and attach ID tag to shroud ties.  Note:  Prevent misalignment of extremities during the shrouding process.  Also, use safe lifting techniques and assure enough staff members are involved with moving the body to avoid risk of injury to staff or the body.

7.Arrange to have the body transferred to the appropriate mortuary with designated paperwork.

8.A prepared ďbody bagĒ may be used

K.Preparation of Infants:  After viewing by family if at all possible, the body should be shrouded in privacy from the public.  

L.
1.Prepare ID tags as noted for adults.  Place one tag on the infantís body;

2.If there is no autopsy, the infant may be swaddled with a blanket in the shroud; 

3.Place the infant diagonally in the shroud and loosely wrap the infant.

4.Mark the head position on the shroud;

5.Pin the second ID tag to the top of the shroud, with the body resting in a supine position;

6.Tape the shroud to keep from unwrapping;

7.Place the shrouded body in an open crib in a supine position and cover with a clean blanket.

Arrange to have the body transferred to the hospital morgue or to a Mortuary with designated paperwork.

M.Storage of Human Remains: Human remains, prior to transfer to the Medical Examiner or selected funeral home/mortuary, should be placed in secure storage. The Emergency Department. has a temporary Morgue facility for storing human remains. This area is not capable of sustaining a temperature of 34-37 degrees F.  As the proper temperature is not attainable, the County Medical Examiner will be promptly informed and an alternative storage venue should be identified whether within the hospital or identified by a county plan. Should capacity be reached and/or the Emergency Department is overloaded with patients bodies will be taken directly to a designated area or a refrigerated semi. Care must be taken to track all movements of the deceased. If a funeral home/mortuary has been selected by the family or Medical Examiner, coordination with the funeral home/mortuary will be beneficial to expedite a resolution to the storage temperature problem.  Other considerations for a functional hospital morgue include:

1.Integrated back-up electrical power and HVAC

2.Close proximity to transportation staging area that offers privacy from public view. The loading dock of Materials Management will be the area for mass storage of human remains in a refrigerated semi trailer

3.Access to communications resources will be by radio and hospital land lines

4.The area for storage of remains will be secured by locks and supervised by hospital staff.

5.Hand washing facilities will be available in the Material Management Department and alcohol based hand solution will be available.

6.Personal Protective Equipment will be kept at the entrance of the loading dock as necessary.

7.Adequate ventilation will be maintained in the semi by auto regulation.

8.Call local Emergency Management Agency when facility capacity is exceeded. 

N.Family Viewing:  The selected location at Mahaska Health Partnership for providing the opportunity for family/significant others to view the deceased is preferred to be the patientís assigned hospital room.  In the case of the Surgery or Emergency Department, every effort should be made to find a suitable unoccupied room with soft light.  If the treatment/procedure room where the patient was resuscitated/treated must be used, efforts should be made to clean-up any spills and dispose of any used supplies.  

O.Security:  The importance of securing the storage of human remains and any accompanying records, forensic evidence and personal belongings should follow the policy of ďThe Forensic PatientĒ of the Emergency Department.  Particular attention should be given to the importance of maintaining a Ďchain-of-custodyí should any of the remains and accompanying items be considered forensic evidence in a criminal investigation. Clothing will be placed in a paper bag.  Arrangements must be made with the incident commander in advance to acquire permission to access the storage area. An access log will be kept in the Emergency Department. A witness will accompany any person to the storage area. The transfer of the human remains to another agency or organization (e.g. Medical Examiner, funeral home/mortuary) will take place by signature on a release of body form.

P.Hazardous Material Decontamination:  In the event that the deceased remains are contaminated either due to the inability to effectively decontaminate or as the result of a decision to preserve forensic evidence, careful attention to safety must be maintained.  If decontamination is to be undertaken, the Mahaska Health Partnership current decontamination procedures outlined in the disaster safety manual should be followed.  In the event that successful decontamination is compromised (e.g. off-gassing of cyanide), further consultation from appropriate resources may be appropriate such as the Oskaloosa Fire Department or Ottumwa Haz-Mat Decon Response Team. The Office of the State Medical Examiner at 515-752-1400 (24 hrs), the Iowa Poison Control Center at 1-800-222-1222 (24 hrs) or with the State Toxicologist at 1-866-834-9671 (24 hrs). 
     
Q.Mass Fatality Event As Mahaska Health Partnership: cannot adequately store and maintain full-body human remains, the possibility must be recognized that circumstances could result in a surge of hospital deaths that would exceed the hospitalís capacity to process, prepare and inventory human remains.  Such circumstances would transition the institutional post mortem care process into a community-based collaborative process.  In the event that the Mahaska Health Partnership is unable to temporarily store a mass casualty event the following steps will be initiated:

1.The Mahaska County Medical Examiner or Deputy Medical Examiner and the Emergency Management Coordinator will be contacted and informed of the situation, circumstances and need to activate the Mahaska County Mass Fatality Plan.

2.Alternative human remains storage facilities will be considered as outlined in the Mahaska County Mass Fatality Plan;

3.Planned expansion of human remains storage will be coordinated with local funeral homes/mortuaries to insure availability of transport resources and adequate access.

4.Planned expansion of human remains storage will be coordinated with local law enforcement representatives to insure adequate security can be maintained;

5.All tracking and documentation of off-site storage of human remains will be under the direction of the County Medical Examiner and pursuant with the Mahaska County Mass Fatality Plan;

6.Final disposition of remains may be delayed if volume exceeds the capacity of funeral homes.  Pursuant with the Mahaska County Mass Fatality Plan, remains may need be retained in inventory until capacity for disposition is able to meet demand.