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Surgical Skills and Anatomy Procedure

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Section 1 - Purpose

(1) To specify the activities for receipt, tracking, handling, storage and disposal of Bodies / Human Tissue in the Surgical Skills and Anatomy Centre (SSAC) in the Faculty of Medicine, Health and Human Sciences.

Scope

(2) This Procedure applies to all University staff, students and visitors to Macquarie University.

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Section 2 - Policy

(3) Refer to the Surgical Skills and Anatomy Policy.

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Section 3 - Procedures

Responsibilities and Required Actions

(4) This Procedure requires actions by the following:

  1. Authorised User;
  2. Executive Dean, Faculty of Medicine, Health and Human Sciences;
  3. Director, Surgical Skills and Anatomy Centre;
  4. Human Research Ethics Committee (Medical Sciences); and
  5. Staff Member (SSAC).

(5) The Procedure covers the following activities:

  1. oversight of the Anatomy Policy and Body Donations Program;
  2. obtain and maintain Anatomy Licence;
  3. monitor compliance;
  4. induction into SSAC;
  5. obtain consent;
  6. receive delivery of a Body / Human Tissue;
  7. transfer a Body / Human Tissue;
  8. dispose of a Body / Human Tissue;
  9. approve an application for recording an anatomical examination or body / human tissue;
  10. report illegal activity;
  11. access to the SSAC; and
  12. track / store / transport a Body / Human Tissue.

Human Research Ethics Committee (Medical Sciences)

Oversight of the Anatomy Policy and Body Donation Program

(6) When requested by the Executive Dean, Faculty of Medicine, Health and Human Sciences and / or the Director, Surgical Skills and Anatomy Centre, advise on whether or not new areas of teaching or research go beyond the established boundaries of consent given under the University’s Body Donations Program.

(7) When requested by the Executive Dean, Faculty of Medicine, Health and Human Sciences  and / or the Director, Surgical Skills and Anatomy Centre, advise on reviews of the terms of the Body Donations Program consent forms.

Director, Surgical Skills and Anatomy Centre

Obtain and Maintain Anatomy Licence

(8) Obtain a current Anatomy Licence to conduct anatomical examinations from NSW Health.

(9) When the named Anatomy Licence holder is absent for more than three (3) months, apply to NSW Health for reissue of the Anatomy Licence in the name of the holder’s delegate.

(10) Monitor the University's compliance with the Licensing provisions and the Relevant Laws and ensure that the University retains or, where necessary, updates its Anatomy Licence.

Monitor Compliance

(11) Ensure the Body Donations Program and Anatomical Examinations are conducted in accordance with:

  1. the Relevant Laws;
  2. the Anatomy Licence;
  3. the University’s contractual obligations to third parties, in particular the terms and conditions of a Tissue Supplier; and
  4. consents to Anatomical Examinations.

Induction

(12) Ensure that all SSAC Staff, Students and Authorised Users are provided with the relevant induction into the SSAC.

Obtain Consent

(13) View consent to use a Body / Human Tissue as follows:

  1. on receipt of donated Body / Human Tissue;
  2. prior to using a donated Body / Human Tissue for any Anatomical Examination, view relevant consent for the procedures that may be applied. The consent may be:
    1. a Body Donations Program consent form;
    2. an equivalent consent / agreement form obtained from the Anatomy Licence holder; or
    3. documented in the terms and conditions of the Tissue Supplier from which a Body / Human Tissue has been procured or transferred;
  3. in the event that a new area of consent arises, e.g. where it is believed that an activity will go beyond the consent, refer the matter to the University’s Human Research Ethics Committee (Medical Sciences) for advice;
  4. if consent is revoked by a donor, complete the section at the bottom of the revocation form acknowledging that receipt of the revocation has been received and return a copy to the donor.

Receive Delivery of a Body / Human Tissue

(14) Coordinate the receipt of a Body / Human Tissue from the contracted funeral director or Tissue Supplier, as appropriate.

(15) Ensure that a Body / Human Tissue is delivered to SSAC for verification and receipting purposes.

(16) Prior to accepting a Body / Human Tissue into the SSAC, ensure that:

  1. the Body has been delivered by an accredited funeral director in accordance with the Anatomy Act 1977 or in the case of tissue sourced internationally or from interstate, the tissue is delivered by an approved courier;
  2. the Body / Human Tissue is accompanied by all necessary documentation pertaining to the consent / authority to conduct an anatomical examination;
  3. the Body / Human Tissue is consistent with the accompanying paperwork, as far as can be determined by visual inspection;
  4. the transfer of Bodies / Human Tissue into the SSAC is conducted discreetly;
  5. the required screening for Human Immunodeficiency Virus (HIV), Hepatitis B and Hepatitis C and any other prescribed infectious disease has been performed prior to or on receipt of the Body / Human Tissue;
  6. an infected Body / Human Tissue received through the Macquarie University Body Donations Program is quarantined in accordance with any Relevant Laws and not used for teaching / research and NSW Health is notified; and
  7. there is sufficient storage capacity to take the Body / Human Tissue.

(17) On accepting a Body / Human Tissue:

  1. complete a numbered identification tag and attach this to the Body / Human Tissue;
  2. record all prescribed details pertaining to receipt of the Body / Human Tissue, in the Body Register; and
  3. place the Body / Human Tissue in the refrigerator / freezer storage, where the Body / Human Tissue remains until required.

(18) After receiving a Body / Human Tissue that SSAC has reasons to believe is infected with a prescribed infectious disease, clearly label the body bag “prescribed infectious disease – handle with care” before removing the Body / Human Tissue from SSAC in accordance with the Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Transfer

(19) Transfer a Body / Human Tissue to another Anatomy Licence holder within Australia only if this is in accordance with the relevant consent or Tissue Supplier’s terms and conditions.

(20) Transfer a Body / Human Tissue to an Anatomy Licence holder witin Australia only if approval has been received from NSW Health.

(21) Ensure the University retains control over the disposal of Bodies / Human Tissue.

Dispose of a Body / Human Tissue

(22) Arrange for the disposal of the Body / Human Tissue in accordance with the Relevant Laws and, as far as possible, with the relevant consent.

Body Sourced in New South Wales

(23) Co-ordinate collection of a Body with the funeral director. Schedule collection to ensure the Director, Surgical Skills and Anatomy Centre or SSAC Staff delegate is present at the time of collection.

(24) At the time of collection of a Body, ensure the Funeral Director is provided with:

  1. a Medical Certificate of Cause of Death;
  2. an Attending Physician’s Cremation Certificate;
  3. a Transfer Authority Form for ashes collection; and
  4. any additional documentation relevant to the wishes of the deceased.

(25) Immediately following collection of the Body:

  1. update the Body Register, ensuring that details of any disposed Body / Human Tissue are clearly described in accordance with the Relevant Laws; and
  2. where applicable, notify the Anatomy Licence holder from which the Body was procured of the actions that have been taken in disposing of the Body.

(26) For a locally donated Body, when requested in the consent forms, notify the Senior Available Next-of-Kin when cremation has taken place and when the ashes are available for collection.

Body / Human Tissue Sourced from Tissue Supplier

(27) In order to cremate Human Tissue obtained from a Tissue Supplier:

  1. submit a written application to NSW Health requesting permission to dispose of the identified Body / Human Tissue;
  2. place the identified Body / Human Tissue in a coffin;
  3. provide the funeral director collecting the coffin with a copy of the letter of authority from NSW Health; and
  4. update the Body Register, ensuring that details of any disposed Body / Human Tissue are clearly described in accordance with the Relevant Laws.

Approve an Application for Recording an Anatomical Examination of Body / Human Tissue

(28) On receiving a Recording Agreement – Anatomy Laboratory form, check that:

  1. the application is complete and clearly addresses each of the requirements; and
  2. the relevant consent has been provided.

(29) Then either:

  1. return the application for completion / clarification;
  2. reject an application and advise the applicant in writing; or
  3. approve the application.

Report Illegal Activity

(30) Instruct a user who is authorized to be in the SSAC and is acting unlawfully or inappropriately to leave the SSAC, if appropriate.

(31) If there is any activity that directly or indirectly breaches State or Commonwealth law, report illegal activity to the appropriate authorities (e.g. the police). Inform the Campus Security Manager in all cases of potential offences under the Crimes Act 1900 (NSW).

(32) Liaise with external bodies, including law enforcement agencies, as needed.

Oversight of the Anatomy Policy and Body Donations Program

(33) Provide advice to the Executive Dean, Faculty of Medicine, Health and Human Sciences and seek advice from the Human Research Ethics Committee (Medical Sciences) as necessary.

(34) In consultation with the Executive Dean, Faculty of Medicine, Health and Human Sciences and other SSAC Staff, conduct regular and ongoing reviews of the terms of the Body Donations Program to ensure that it:

  1. encompasses all Anatomical Examinations conducted or to be conducted at the University; and
  2. addresses statutory requirements.

Disposal of Records

(35) Records relating to the Anatomy Licence (including applications for the Anatomy Licence) may be disposed of one (1) year after expiry.

(36) The Body Register may be destroyed after five (5) years from the date of transfer or disposal of a Body / Human Tissue.

(37) Records relating to the acquisition, storage, maintenance and management of Bodies / Human Tissue may be disposed of one (1) year after the transfer or disposal of the Body / Human Tissue.

(38) All other records must be retained as required by the State Records Act 1998 and disposed of as authorised by that Act.

Staff Member, SSAC

(39) Grant access to the SSAC only if able to confirm:

  1. the identity of the individual seeking access;
  2. the individual's authority to gain access; and
  3. that appropriate supervision is in place, where required. 

(40) Ensure that all users wear appropriate personal protective equipment.

Students

(41) Prior to granting a Student access to the SSAC:

  1. confirm a Student's formal enrolment in a relevant unit;
  2. verify a Student's identity against their Student identification card;
  3. ensure that a Student completes or has completed induction; and
  4. supervise a Student at all times or ensure supervision is in place.

(42) Do not grant access to the SSAC to a Student who is not formally enrolled in a relevant unit or who fails to produce a valid Student identification card. Accept no other form of identification.

Contractors

(43) Admit contractors only if they:

  1. have booked repairs and general maintenance through the Director, Surgical Skills and Anatomy Centre;
  2. have completed an induction in order to be granted access to the SSAC;
  3. carry formal photographic identification with them during the course of the repairs or maintenance; and
  4. present their formal photographic identification on each entry to the SSAC and / or upon request of the Director, Surgical Skills and Anatomy Centre or a campus security officer.

Auditors / Inspectors

(44) Admit auditors / inspectors as follows:

  1. confirm the identity of the auditor / inspector by sighting their staff identification card;
  2. confirm that each auditor / inspector has completed the necessary induction; and
  3. confirm that supervision is in place to monitor and assist the auditor / inspector while they are in the SSAC. 

Departure of Admitted Parties

(45) Supervise an admitted party until such time as:

  1. supervisor responsibility is handed to another SSAC Staff member; or
  2. the admitted party has departed the facility.

(46) Secure the SSAC following the departure.

Track / Store / Transport a Body / Human Tissue

Track

(47) Allocate an identification number to each Body / Human Tissue received into the SSAC, so that the SSAC Staff and the Inspector can identify all Bodies / Human Tissue and cross reference with the Body Register.

(48) Tag each Body part with the Body's identification number as the Body is dissected. Immediately following the dissection, update the Body Register with details of the dissection. Replace a tag which is removed, lost or damaged.

Store

(49) On completion of an anatomical examination, place a Body / Human Tissue in appropriate storage equipment in accordance with the Relevant Laws.

(50) Remove a Body / Human Tissue from storage:

  1. when required for anatomical examination;
  2. to enable repairs, maintenance or upgrade of facilities;
  3. in preparation for disposal;
  4. to satisfy requirements of an internal audit;
  5. to satisfy requirements of an external inspection conducted by an Inspector; or
  6. as otherwise required by Relevant Laws.

(51) When retrieving a Body / Human Tissue from storage, adhere to any applicable safe work procedure.

(52) On retrieving a Body / Human Tissue from storage, prior to handling any other Body / Human Tissue, ensure that the identification tag is firmly affixed to the Body or bag.

Handling

(53) Handle and arrange transportation of Bodies / Human Tissue in accordance with the Public Health Regulation 2012 and the Australian Guidelines for the Prevention and Control of Infection in Healthcare published by the National Health and Medical Research Council.

Dispose of a Body / Human Tissue

(54) Retain the Body / Human Tissue for the period specified in the relevant consent, Relevant Laws or as permitted by NSW Health. 

Defer Disposal of a Body / Human Tissue

(55) Where the need arises and consent is available, submit via the Dean, or nominee, a request to NSW Health to extend the approved retention period. Submit all requests at least six (6) months in advance of expiry of the approved retention date to ensure the SSAC receives a decision before the approved retention date lapses.

(56) Upon receipt of written approval to extend the retention date from NSW Health, update the Body Register to reflect the amended retention details.

(57) In the event that NSW Health refuses to grant the extension, arrange disposal of the Body / Human Tissue in accordance with the Relevant Laws.

Prepare for Disposal

(58) Re-unite all Human Tissue from a Body in preparation for disposal, except where:

  1. the Human Tissue is sourced from a Tissue Supplier which allows Human Tissue to be disposed of separately;
  2. the University has obtained written consent to permanently retain the Human Tissue;
  3. the Human Tissue being retained is a small sample of Human Tissue, in the form of tissue slides or tissue blocks that enable microscopic examination of the tissue; or
  4. tissue is removed during prosection and not identifiable (refer to NSW Health Policy Directive [PD2011_052]).

Authorised User

Induction

(59) Participate in appropriate induction before entering the SSAC.

Personal Protective Equipment (PPE)

(60) Ensure that PPE is worn while conducting or participating in anatomical examinations.

Report Distress

(61) Inform SSAC Staff as soon as possible when experiencing anxiety, distress or grief when first encountering a Body / Human Tissue, or recognising a Body as a person known prior to that person's death (e.g. a relative, friend or neighbour).

Apply to Record an Image of a Body / Human Tissue

(62) Submit a completed Recording Agreement – Anatomy Laboratory form to the Director, Surgical Skills and Anatomy Centre to request approval to record an image of a Body / Human Tissue.

Executive Dean, Faculty of Medicine, Health and Human Sciences

Oversight of the Anatomy Policy and Body Donations Program

(63) Monitor:

  1. the University’s compliance with the Anatomy Policy and this Procedure and all Relevant Laws, including compliance with the conditions of the Anatomy Licence; and
  2. the University’s Body Donations Program.
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Section 4 - Guidelines

(64) Nil.

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Section 5 - Definitions

(65) Commonly defined terms are located in the University Glossary. Definitions specific to this Procedure are contained in the Surgical Skills and Anatomy Policy.