Standard Operational Procedures for Delivery Suite Mortuary Fridge (MAT-SOP002)

Transcription

1 Standard Operational Procedures for Delivery Suite Mortuary Fridge (MAT-SOP002) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Trust HTA Designated Officer Chair, Maternity Clinical Governance Committee 14 th July 2017 Change History Version Date Author, job title Reason 1.0 2/11/2010 J Tuckey Annual Update /09/2012 J Tuckey Annual Update 3.0 July 2013 Gill Valentine, Director of Midwifery 3.1 Oct Dave Asplin, Quality Manager 3.2 Feb 2015 Kate Flack, Bereavement Midwife 3.3 Aug 2015 Kate Flack (Bereavement Midwife), Dave Asplin (Quality Manager) 4.0 June 2017 Amy Wood-Blagrove (Bereavement MW) Amendments following audit New electronic temperature monitoring system Update to procedure for checking babies labels Reviewed + Minor update to labelling on pg 9 to make instructions more clear Reviewed and change to call out procedure This document is valid only on date last printed Page 1 of 11

2 QUALITY PROCEDURE 1. Mortuary Fridge on Delivery Suite 2. Transfer of babies between Maternity and Mortuary Prepared by: Judith Tuckey, Delivery Suite Manager Date of first issue: 30 th October 2009 This version checked by: Signature/date: Gill Valentine, Director of Midwifery This version authorised by: HTA Designated Officer Signature/date: Location of copies: Location of Copies No of copies 1 Quality Manager 1 2 File copy (electronic-policy Hub) 1 3. Delivery Suite 1 Document review: Review date Reason for Review Reviewed by Signature 2/11/2010 Annual Update J Tuckey 28/09/2012 Annual Update J Tuckey 23/07/2013 Following Audit G Valentine 31/10/2013 Implementation of electronic monitoring system G Valentine 17/02/15 Clinical Incident RCA action G Valentine 12/06/17 Reviewed & call out procedure amended A Wood- Blagrove DOCUMENT AMENDMENT Amendments may only be made on the electronic copy to ensure all formally issued location copies are maintained to the updated requirements This document is valid only on date last printed Page 2 of 11

3 Amendments (changes of up to a sentence in length) must be performed by senior members of staff only. Major changes (changes of greater than a sentence in length) must result in immediate review of procedure. No. Date Page No Amendment 23/07/13 5 Details of maintenance company and contact details 23/07/13 6 Number of staff who need to sign the mortuary register when babies are taken for viewings 28/07/13 7 Out of hours process for viewing babies Authorised by: G Valentine G Valentine G Valentine 4 30/10/ New temperature monitoring system D Asplin /02/15 5 Update to procedure for checking babies labels 14/8/15 9 Clarification of instruction on screen print on pg 9 12/6/17 4/6, 11 Text changed highlighted in blue text G Valentine K Flack A Wood-Blagrove 1. SCOPE AND PURPOSE 1.1 Quality Management Procedures (QMPs) are formal authorised documents detailing the procedures to be followed in the accomplishment of various tasks. Note procedures may also be referred to as Standard Operational Procedures (SOPs). 1.2 This QMP describes the monitoring and maintenance of the maternity mortuary fridge and transfers of babies between departments. Document control Document control is an essential part of a quality management system. 1 A robust system for the regular review and updating of all guidelines, protocols, policies and procedures has been agreed by the Maternity Clinical Governance Committee and is monitored through this forum. This document is valid only on date last printed Page 3 of 11

4 2. AUTHORISED STAFF 2.1 Midwives after suitable training. 2.2 Maternity Care assistants after suitable training. 2.3 Administration and Clerical Staff under supervision and following suitable training. 3. SPECIMEN REQUIREMENTS (not applicable) 4. EQUIPEMENT & SPECIAL SUPPLIES (not applicable) 4.1 Dedicated paediatric mortuary fridge 5. REAGENTS, STANDARDSOR CALIBRANTS, IQC MATERIALS AND PROCEDURES (not applicable) 6. PROCEDURE 6.1 Procedure for ensuring fridge is operational The Delivery Suite shift co-ordinator is responsible for ensuring that the mortuary fridge is operational. The electronic monitor / transmitter unit indicates fridge and room temperatures and has a green flashing light when working. The unit is connected across the hospital network to the remote monitoring unit in pathology. It can also be monitored on any computer connected to the hospital network via Log in username is maternity. Password is hta If the fridge temperature falls outside the optimum range (4-8 degrees) or ambient temperature falls outside the optimum range (15-26 degrees) after a predefined time (20 mins), the unit will automatically alarm via the remote monitoring unit in pathology. This triggers phone calls to pathology staff and switchboard and s to enable the appropriate pathology persons to action. They will inform the midwife in charge of the shift who has responsibility for checking the fridge and taking appropriate actions:- Go to the fridge and check for obvious problems such as door not closed properly, aircon unit not working, and no power. Report If not resolvable issue then contact Chiller Technical Solutions ( ) for an engineer to attend as appropriate (see appendix 3). This document is valid only on date last printed Page 4 of 11

5 Log onto a computer and access the fridge monitoring system which can be found by typing into the internet explorer browser. Enter the username maternity and password hta123. Check the status of the fridge on the system and acknowledge the alarm ((see appendix 2 for details).it is the responsibility of the midwife in charge to update the status on the fridge monitoring system. Refer to Appendix 2. Contact the Duty Mortuary Technician to arrange transfer of babies to the mortuary if appropriate. Nominated maternity staff are also ed of alarms to provide an extra resilience Complete an incident form if there is a fridge malfunction or if the delivery suite are not notified of alarm activation by switchboard or pathology The delivery suite mortuary fridge is included in the 6 monthly maintenance programme organised by the Trust. Records of routine maintenance are kept by the mortuary Surfaces to be washed with a mild detergent. Clean with a mild bleach product (e.g. Chloroclean). 6.2 Procedure for security of babies The delivery suite mortuary fridge is kept locked at all times. The key for the fridge is located in the key cupboard which can only be accessed by the midwife in charge of the shift A Mortuary Register is maintained recording all babies stored in the fridge and detailing all transfers to and from this fridge A maximum of 4 babies should be stored in the fridge at any one time. If there is a necessity to store more than 4 then contact the Duty Mortuary Technician so that the most appropriate cases can be transferred to the Main Hospital Mortuary When babies are removed from the fridge for viewings on the wards or Delivery Suite two members of staff are required to sign the register verifying that the details of babies being removed are correct All babies who are returned to the fridge require a new entry in the mortuary register to provide a detailed and continuous audit trail. Details of any valuables, clothing or other personal items left with the baby should be documented in the register When babies are transferred to the main mortuary out of hours two members of staff (one being a porter) are required to sign the register verifying that the details of babies being removed are correct. A Transfer form should be completed. If This document is valid only on date last printed Page 5 of 11

6 available the placenta should also be sent to the mortuary with the baby. Security will also need to be contacted to attend and unlock Log of entries in the register include the following details: name of Mother, gestational age of baby, sex of baby, date of birth, shelf number and signed by staff recording details All babies should be labelled twice. The labels should be placed on the ankles or around the abdomen. The labels should state: 1. Mother s last name, baby Boy/Girl and father s last name if different 2. Date of Birth 3. Time of birth 4. Mother s hospital number 5. In the case of multiple births babies should be labelled consecutively according to birth order Twin I/II or Triplet I/II/III if applicable The baby should be wrapped in an inco sheet and then placed in a body bag. Place a mother s addressograph label or a label with the details of the baby as above, in the pocket on the outside of the body bag. If the baby s father has a different surname please also provide this information all property is to be clearly labelled i.e. teddies etc. placed in with the baby in the body bag. Write clearly on the transfer form, describing clothing or property etc. 6.3 Procedure for collecting and returning babies from the main mortuary for viewing (when the delivery suite mortuary fridge is not in use) In hours (Mon Fri ): A porter will go to the Mortuary. An APT (Mortuary staff) will get baby from dedicated baby fridge. The APT with the porter will fill in all mandatory fields on first section patient transferred to ward.when baby is returned all mandatory fields patient returned to mortuary to be filled in by APT and porter and baby will be checked before placing back into baby fridge Out of Hours (after and week ends): Once notified of viewing the member of maternity staff is to contact porters and security (ext 8845) and arrange for them to meet them at the mortuary entrance. The maternity staff should have with them a box (small remains carrier) available on delivery suite in which to transport the baby back to the ward. No mosses baskets are to be used in this process. The member of maternity staff will get the baby out of the fridge and check the identity and fill in the first section patient transferred to ward (the inter departmental transfer forms are in a clear plastic tray on a large blue notice board by the Mortuary Register (clearly labelled)) they will then contact duty APT via switchboard of this and then take the baby back to ward. This will ensure correct identity and security is This document is valid only on date last printed Page 6 of 11

7 maintained. The paperwork will be left by the mortuary register. When the baby is returned the member of maternity staff and porter are BOTH to attend and the member of maternity staff is to fill in the second part of the paperwork filling in all mandatory fields ensuring correct identity, valuables etc. Maternity staff are to print and sign their respective fields. Completed paperwork is to be left by mortuary book for APT to file accordingly. The member of maternity staff should contact the duty APT via switchboard to advise that the baby has been returned to the mortuary. IF IN DOUBT WITH ANY PART OF THE PROCESS THE MATERNITY STAFF ARE TO CONTACT DUTY APT FOR GUIDANCE. A member of the maternity staff MUST ALWAYS accompany the porter to the mortuary out of hours. 6.4 Risk Assessments Risk assessments on ensuring that the fridge is operational and security has been completed using the Trust general risk assessment form RA1. The risk rating for these procedures are as detailed below: Risk Hazard (s) Description of Potential Harm Likelihood (L) Consequence (C) LxC Failure to monitor temperature control Decomposition of babies U Major 8 Lack of Maintenance Fridge failure and as above R Major 4 Security Baby being removed from fridge by unauthorised person or wrong baby being removed. R Catastrophic 5 This document is valid only on date last printed Page 7 of 11

8 Appendix 1 Training of staff All staff as part of their orientation to Delivery Suite will have an appointment with the Bereavement Specialist Midwife. This is included on the orientation programme. The purpose of this will be to discuss: Care of mothers following fetal loss Use of the care pathway for fetal loss. Procedure and policy for storage of babies in the Delivery Suite mortuary fridge. Organizing transfers of babies to other departments. Bereavement follow-up and what services are available to parents. A register of staff trained in the use of the mortuary fridge with be maintained by the Clinical Skills Trainer. This document is valid only on date last printed Page 8 of 11

9 SOP for Delivery Suite mortuary fridge October 2015 Appendix 2 - Alarm actions Open application ( Type in username and enter/ return, Type in password and enter/ return. You get screen as below (this shows the mouse hovering over a transmitter with an unacknowledged alarm): The RF500A also has a Snoozed function (light green in bar) allowing you to snooze the alarm for a period of time Click on description above highlighted box (pink in this case) Coloured bar shows type of fault Shows time and period of alarm activation When you click on this, you get the following screen. This shows the problem (which must be checked/ reported) and a graph. Also, details of the location (e.g. location 30, maternity). Unit info & location e.g maternity Problem This shows ext1 is below limit (blue). If above, then red. Click on graph This document is valid only on date last printed Page 9 of 11

10 When you click on the graph, you get the following screen. Click on Acknowledge alarm To acknowledge alarm, click on this (see above) the following screen appears: Type in password then type in the actions taken and initial (e.g. called Estates/ Norland). Press acknowledge alarm. Then OK. If the password has not been put in, acknowledgement is not allowed. There is a snooze function which allows you to stop the alarm for a period of time (which you can set). It will re-alarm if action not taken after this time. N.B. If fridge or aircon are out of commission, click on the Sop Logging bar. This will prevent further alarms. When back in commission, click on Start Logging NB. Use back button on screen or back arrow on explorer to return to Home screen. The unacknowledged alarm will have changed to command. Log out. This document is valid only on date last printed Page 10 of 11

11 Appendix 3 DS Annexe fridge alarm instructions This document is valid only on date last printed Page 11 of 11