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AUTOPSY the Hospital Autopsy Plays an Important Role in the Education of Medical Students, Physicians-In- Training, and Other Practicing Physicians

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AUTOPSY the Hospital Autopsy Plays an Important Role in the Education of Medical Students, Physicians-In- Training, and Other Practicing Physicians AUTOPSY The hospital autopsy plays an important role in the education of medical students, physicians-in- training, and other practicing physicians. A clearer understanding of the physiologic processes leading up to and at the time of death may significantly aid physicians at all levels to increase their diagnostic skills in order to help patients in the future. Report of Inpatient or Emergency Room Death A report of all deaths should be made to the Autopsy Service by telephone within 15 minutes of the patient's death, call (802) 847-3570. In effect, this means immediately. Instructions are available in PRISM under Reference Links/Vermont State Links/Death Certificate. Admissions and Discharges of Bodies from within UVM Medical Center the Morgue Identification of the Deceased: It is paramount that all bodies admitted to or discharged from the Morgue be properly identified. Proper identification and tagging of bodies must be accomplished prior to transport of the deceased to the Morgue. Appropriate forms are in PRISM under Reference Links/Vermont State Links/Death Certificate and tags are an in house supply available on the floor or may also be ordered through Medi Click, stock #81143, “Tag, Toe”. Proper identification consists of: full name, date of birth and Medical Record Number (if available). Labels or tags affixed to shrouds, sheets, or clothing, or labels stuck directly to the body are NOT sufficient. Tags or bracelets must be affixed by or in the presence of someone who can positively identify the body. Tags should be affixed to the toe (or wrist in case of double amputees). Valuables and Personal Effects: Dentures should accompany the body to the Morgue and should be placed in a denture cup labeled with patient’s full name/MRN. All personal effects, including removable jewelry, should be removed at bedside and placed in the custody of security or given to a family member. Any valuables which cannot be physically removed from the body must be noted on the Morgue Control Form. Transport: Medical Examiner/Autopsy Service is located at the Medical Center Campus, Baird 1. To facilitate transfer of the body to the Medical Examiner/Autopsy Service storage facility, two attendants should accompany the body whenever possible. Admission and Discharge Sheet: Persons admitting or discharging a deceased patient should go to the Discharge Navigator in PRISM under “Discharge to Morgue”. Complete the Post Mortem Flowsheet, Nursing Required Notifications (for Nursing staff) and the Post Mortem Inpatient MD sections (for attendings and residents). If there will not be an autopsy the Attending must certify death as soon as possible, see Death Certification below or go to Reference Links/Vermont State Links/Death Certificate in PRISM. Nursing must complete the Morgue Trip Slip section and this two page form should accompany body to morgue and forms placed in Morgue Control form notebook located in the Autopsy receiving area. Any non-removable personal effects and infectious disease precaution, especially know or suspected tuberculosis and Jakob - Creutzfeldt disease should be Page 1 of 8 Laboratory Customer Service 847-5121 or 1-800-991-2799 Autopsy specifically itemized on the Morgue Control Sheet/Morgue Trip Slip. Death Certificate: If there is not to be an autopsy the death certification must be done by the attending (or the attending who is covering for that attending in their absence) within 24 hours per State of Vermont Department of Health. This is done electronically under the Electronic Death Reporting System (EDRS) on the Vermont Department of Health (VDH) website: http://healthvermont.gov/hc/EDRS/index.aspx Links to EDRS are in PRISM under Reference Links/Vermont State Links/Death Certificate. Bodies cannot be released from University of Vermont Medical Center until the death certification is done. Attendings are urged to do the certification as soon as possible to meet family need. Positioning of Body: The body should be oriented face up, head first into the storage facility completely covered by a sheet to prevent drying. Admission of a Body from Outside UVM Medical Center 1. Proper identification must be provided by a red tag or other device. 2. If not identified, or if a red tag not available, admit the body as “John Doe or Jane Doe” and refer case to Medical Examiner on call. 3. Include infectious disease precautions if known. Fill out Morgue Control Form and position body as above. Page 2 of 8 Laboratory Customer Service 847-5121 or 1-800-991-2799 Autopsy Medical Examiner Cases Information required when reporting a case to the UVM Medical Center Regional Medical Examiner: Full Name of Patient Address of Patient Sex, Age, and Date of Birth Marital Status and Occupation A Clinical History Including: Date and Time of Injury and Date and Time of Death Relevant Therapy and Procedures Name of Family Physician Name of Ambulance Squad and/or Police Investigation Unit Consultation with the Medical Examiner: If it is unclear whether the patient is a medical examiner's case, call the Chief Medical Examiner's Office (24 hours a day). A telephone consultation with an Assistant Medical Examiner (888-552-2952) takes only a few minutes and can assure that the case is handled smoothly. Hospital Deaths to be reported to a Medical Examiner: Vermont State law requires that the following deaths be reported to the Medical Examiner: deaths “.... from violence, suddenly when in apparent good health, when unattended by a physician, by casualty, by suicide, as a result of injury, when in jail, or prison, or mental institution, in an unusual, unnatural or suspicious manner, and in circumstances involving a hazard to public health, welfare, or safety..." In short, if the death of the patient is in any way related, even remotely to an accident or injury, burn, homicide or suicide, or if the cause of death is undetermined, call the Assistant Medical Examiner, (888)552-2952. Any deaths in UVM Medical Center, which are thought to be non-natural, should be reported. There is no 24-hour rule in Vermont. Deaths in the Emergency Room and in the Operating Room are not required to be reported, unless known or suspected to be non-natural. If you have trouble determining whether or not a death is non-natural, then call the Chief Medical Examiner Office, (888)552-2952. Any trauma patient whose family wishes to donate kidneys or other organs should be reported to the Medical Examiner before death and donation. To obtain legal clearance from the Chief Medical Examiner and from the State's Attorney, telephone (888)552-2952 and ask for the Assistant Medical Examiner. Page 3 of 8 Laboratory Customer Service 847-5121 or 1-800-991-2799 Autopsy Important: What to Tell the Family About Medical Examiner Cases: Reporting a case to the Chief Medical Examiner does not mean that an autopsy will automatically be performed. Therefore, in cases reported to the Medical Examiner, inform the patient's family that there will probably be a Medical Examiner's investigation, which may include an autopsy, but if an autopsy is not performed by the Medical Examiner, the hospital would like permission to perform an autopsy. (Autopsy permission is not required for a Medical-Legal autopsy). Hospital Autopsy Permits It is the policy of the UVM Medical Center Medical Staff that autopsy permission be sought on ALL patients whenever appropriate. That is, in all patients whose deaths are natural and all patients with non-natural deaths released by the Medical Examiner, unless the family or patient wishes to donate the body for scientific purposes. (See the Anatomical Gifts section). Do not obtain autopsy permission in those cases. Autopsy and donation of the body for scientific purposes are mutually exclusive. If an autopsy is to be performed, permission is required on all adults, live born infants, and all stillborn infants. Instructions are attached to the Autopsy Permission Form. This form is available in PRISM under Reference Links/Vermont State Links/Death Certificate. Copies of the UVM Medical Center permission form can be obtained from any of the clinical floors or the Emergency Room. Copies are also available during the day from the Autopsy Service, (802)847-3570 or from the autopsy secretary, (802)847-3566. Complete Autopsy Versus Restricted Complete Autopsy: An unrestricted or complete autopsy includes: cranial, abdominal, thoracic, and pelvic contents. It may include spinal cord, lower extremities, or the posterior portion of the globe of the eyes. It does not include the face or distal upper extremities. Non-routine examinations should be specified explicitly on the permit (e.g. "Eyes may be removed for examination" or "Includes examination of facial tumor"). Consult with the pathologist on call if you have questions about the wording of permits. Restricted Autopsy: An unrestricted autopsy is always preferable. A partial autopsy often yields partial information. If the family wishes to restrict the extent of examination, determine exactly what parts of the body the family does not wish to have examined and state these restrictions as specifically as possible. For example, "No brain examination" is much less restrictive than "Chest and abdomen only". By wording the restriction in this way one can reduce or eliminate a family's distress concerning the autopsy without unnecessarily limiting the information to be gained from the procedure. If you have questions, call the pathologist on call, (802)847-5121 or (800)991- 2799. Page 4 of 8 Laboratory Customer Service 847-5121 or 1-800-991-2799 Autopsy Special Examinations and Procedures If you think special procedures (such as electron microscopy, immunofluorescence microscopy, or viral cultures) are needed, do not put these on the permit. Rather, write them into a note attached to the permit or at the end of the medical record and call the pathologist.
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