Mortuary Service in Hospital

Dr. Sharad H. GajuryalJunior Resident,

MD(Hospital Administration)BPKIHS

Mortuary is an important integral part of every hospital as it deals with the preservation of the dead body so that the forensic clinicians & pathologists may investigate the cause of death and make scientific investigations.

Bodies may be viewed and identified by relatives and friends (unidentified body), and bodies may be kept until burial can be arranged.

Introduction

The concept of "womb to tomb" in health care of the population in our community health literature clearly indicates that in health care setup, part of doctor's duty is not only caring for the living but also helping in arrange for disposal of those patient who die.

In general ,Mortuary complex consists of Autopsy room/ postmortem room, and preservation room for dead body before disposal arrangement are made( Cold storage room) and ancillary areas. Morgue is pre dominantly used in Northern American English while mortuary is more common in British English.

The term mortuary or morgue is usually not mentioned infront of patient in the hospital, instead ,euphemism "Rose cottage" is used in British hospital to enable discussion infront of patients, relatives and visitors in front of them.

From a practical angle , after the death of a person, a number of procedures are to be carried out under the generic term "Post mortem care ". The body is washed carefully , the orifices are plugged, and the pads are kept in certain areas to prevent bruising.

These procedures not only reflects the scientific requirement for keeping up dead body before disposal but also reflects the respect to the deceased one .

Postmortem care

In Hospital, the effect of death and look at the dead body is great demoralizing factor for the patients and visitors. Similarly, hospitals and physicians prefer to project their success rather than exhibit the dead body.

So, it becomes essential for hospital administration that a suitable provision shall be made in an obscure place where the dead body can be placed, pending final disposal or to rule out the cause of death.

Need of Mortuary

A carefully planned mortuary complex is of great benefit to all those who come in contact with it. i.e police, doctors, medical students, staffs and relatives of deceased.

Provision of mortuary facilities and services in a hospital also has an important bearings in terms of public relation of the hospital.

Lots of sentiments value are attached to the dead body of the person with socio and medico legal importance attached to the mortuary of the hospital. Therefore, establishment and proper management of mortuary is of significance of every hospital.

1. To preserve the dead body till the formalities of the handing over of deacesed is completed.

2. To keep the dead body (unclaimed) till the relative claim and take away for final disposal. Usually unclaimed bodies are kept for 72 hours , and if not cliamed till that period, disposal of dead body is done as per existing policy of hospital and as per law of land.

3. To receive and store dead body requiring postmortem examination.

4. To carry out medico legal postmortem work.

5. To impart teaching programs for undergraduates and post graduates.

Function of Mortuary Service

The types of dead body preserved in the mortuary can be classified as

1. Non medicolegal IdentifiedUnknown

2. Medicolegal Identified Unknown

Location : The location shoud be in obscure place, in a separate building to where the dead bodies can be transported unobstructively. It should be easily accessible from the wards, Emergency, ICU and OT and pathology department

Planning Parameter of a Mortuary

Space Requirement : Depends uopn the size and type of hospital and the workload. Committee on Plan Project (COPP) has recommended an area of 6-8 sq ft/bed as a general guideline.

Parking area & Covered Portico Reception & Waiting area Trolley area Storage Chamber Post mortem Room Office room for record keeping & Processing Doctors room Store room Room for technicians & attendants Changing room Toilets

Functional Areas

Parking with covered portico : Spacious parking area with a covered area of about 18m2 for vehicles should be provided at entrance to the body store as a protection in wet weather and screen from adjoining area with a exit to subsidiary road or parking area.

Reception : A recption of the mortuary is the place where the bodies are viewed and documents checked. It should have easy assecibility and approchable .

Trolley area (3m2): A trolly bay is required to keep the trolley fro transportation of dead body.It should be nearby the reception.

Waiting area: A waiting room of 12-15m2 is recommended for the access to visitors and relatives. It should be pleasantly furnished with provision of WC and drinking water.

In western countries viewing room(20m2) is adjoined to waiting area to enable bodies to be viewed by relatives. It is treated in such way that it can be used by all regions and denominations.

Storage chamber : (3m2) 2 storage chamber- 50-100 bedded hospital 3 storage chamber -200 bedded hospital excluding any provision for special circumstances

like disaster, with some allowance for epidemics and the possibility of major accident (Putsep)

Space needed infront of cold chamber for withdrawal of trays. It should have assess to post-mortem room .

Storage Chamber

Temperature for storage chamber : Negative temperature storage : (-15/-25DC) for

unclaimed body/cause of death not identified . At this temperature, body is completely frozen and decomposition is stopped. linen is adhered firmly on tray.

Positive temperature storage : (+2/+4) , it does not prevent decomposition which continues at slow rate . For bodies which are to be disposed quickly and with no medicologal disputes(preservation).

Post mortem room : The post mortem room is suggested to be treated like an operational theater in all technicality. The major difference between mortuary and OT is that in operation theater, utmost care is needed to prevent outside infection entering inside, and in mortuary care is needed to ensure that inside infection does not spread out.

The room should have 2 or more postmortem table.

Upto 400 bedded hospital – 2 tables Additional 200 bedded- another 1 tableMore than 4 autopsy table is not preferred. A two tabled room need about 40m2 area. About 15m2 area is needed for each extra table

The table are of procelain,fireclay or stainless steel.Stainless steel is favored with

Features of autopsy table : 7 ft long and 3.6 ft wide Have horizontal false top supporting body Have a incline trupe-top for drainage Have either centered or foot drain.

Recent addition is arrangement of air inlets around the sites of it through which air surrounding the body is sucked away thus eliminating all smells.

A cool spot light should be availlabe for use , eg for removing the brain.

A wall mount xray view box is needed. Telephone should be arranged with due

consideration of contamination. Small steralizer should be available Shelf should be provided for formalin, saline

and other solution. Hose point should be available.

Occasionally a so called foul room is provided with tempreture of 10 degree C for autopsy procedure for decomposed body.

The postmosterm room should

• Be Well ventilated, illuminated and cleaned to OT standard.

• Be Flyproof, well lit • Have proper instrument and specimen storing

cupboard• Have heavy duty exhaust fan• Have water impervious floor sloping to drain• Have easily washable floors and walls• Have proper infection control• Have running cold and hot water• Have facilities for collection of specimen• Be hosed down from floor to ceiling with proper

drainage.

Stores : Clean store for clean gown, aprons,gloves, gumboots and towel ; Instrument and equipment store for equipments, jars and solutions; linen store for drapes, shroud, towel etc.

Consultant/Doctors room Changing room Sluice Room : for washing and disinfecting

the instruments Doctor’s office : For report writing Attendants room

Floors : Floor should be RCC, hard and durable & easily washable, nonslippary. Should be of tiles or standard tarazzo to which 3% copper may be added to act as insect inhibitor.

Walls : Washable ; with dadoing and preferably of ceramic tiles.

Other Considerations

Window : If possible natural day light should be used which provides adequate lighteing. Window should be in north side.

Doors : Should be wide enough for passage of portable x-ray, Preferablt itshould be a sliding door.

Corridor : Wide enough to allow passage of trolley and x-ray machine

Adequate supply of heat and cold water

Safe drinking water facility Wash basin with soap seperately for the

staffs and visitors Fire fighiting system Sterilizer should be available Proper heating and ventilation Proper Drainage system

Cold Chamber Autopsy Table Table ,Chair, Stools,File cabinets,Lockers Computer with printers Sterilizer Instrument cabinet Portable xray machine Spectrophotometer Fume chamber

Equipments

Weighing Machine Chromatography machine Essential instruments :• Scissors• Forceps• Scalpels• Brian knives and saw ( preferably electric

saw)• Occasionally a pair of bone forecep Embalming machine if facility available

Chemicals & Articlesi)Bleaching powder for cleaning mortuary table floors, etc.ii) 2% Glutaraldehyde for cleaning instruments.iii)Formative for sending specimens needing his to pathology. iv)Rectified and Methylated spirit as preservativevi)Common saltvii)Sodium fluoride viii) Potassium oxalate ix) EDTA vials and tubes x)Sterilized glass tubes (plain). xi)Sterilized glass tubes with swabs xii) Liquid paraffin xiii)Sealing wax etc.xiv)Big size envelops, plain papers etc. 

(only 2/3rd of the specimen container is Filled with solution) 

For specimen/ viscera examination , specimen are preserved in various viscera jars consisting of saturated solution of salt (stomach and liver/section of Both kidney), fluoride (blood) and formaline for tissues.

Specimen Examination

Embalming Exhumation Mummification

Micelleneous Procedures

The mass disaster plan must have a proper guideline for proper identification, preservation and disposal of the dead body taking into consideration all medicolegal formalities. Ideally every victim who are alive should be labeled by color coding system. These are helpful in identifying and isolating case according to seriousness of injuries to provide first-aid meritwise.

To take care of the dead bodies the disaster plan must include setting up of temporary emergency mortuary. The use of the hospital mortuary is not recommended. There is rarely enough space, access is difficult and it may hinder the accommodation of hospital dead bodies.

Mass Diasater

The medical man has an important role in the disaster management. He may be involved in the following ways:

• Proper scientific numbering and tagging of the dead bodies for future identification purpose by the relatives.

• Identification of body as far as possible by noting down the identification features.

• Issuing of death certificates• Conduction of medicolegal autopsy.

In mass disaster, practically it becomes difficult to conduct postmortems (unnatural death) due to high number of cases. Therefore, the legal authority may waive of the postmortems to minimize the inconvenience to the relatives of the victims.

Medico legal AutopsyAutopsy: Auto = Self

opis = ViewAutopsy literally means to see for oneself.It is non-medico legal.

Post-Mortem Examination:- is a medico legal autopsy (Necropsy)Necropsy Necros = dead

opis = viewor Post mortem examination:- Post:- after

mortem:- deathSo a medico legal autopsy means an

autopsy that is performed by a qualified and registered Medical Officer specifically to meet with certain requirements of law.

Precautions for Medico-legal autopsy or post mortem. 1. Permission or authorization2. Identification3. Visit to scene of crime4. History of the case5. Examination6. Verification of injuries noted by the police7. Notes8. Preservation of viscera and other tissues9. List of articles.

Whenever a body is sent for autopsy it is always accompanied by a

(a) Dead body challan(b) An inquest report

In case of deaths from accidents and cases dying in Hospitals

(c) The accident register(d) Hospital case records are also sent.

Dead body challan :- is a requisition submitted by the investigating police officer to a medical man while handing over the body for performing an autopsy. It contains:-NameAgeSexReligion of the deceasedSuspected cause of deathPurpose for which the body sent for post morterm examination

Cont..

Place from where body has come Name of person accompanying the body

for protection & identification The identification marks Time of dispatch Details of articles and clothing's Medical officer should note down the

time of arrival of the body in the mortuary and time of post mortem.

An inquest reportis a report in which available history of the case and the circumstances under which the body was found or recovered are recorded.

Objectives of a medico-legal autopsy1. To determine / find out the identity of a person,2. To determine the cause of death Whether natural or unnatural, if unnatural whether suicide , homicide or accidentalIf homicide Whether any trace of evidence has been left by the accused on the victim3. To determine the time since death.4. In case of newly born infants to determine the question of live birth and viability of the child.

Instructions Regarding Deaths in the Casualty

Patients who die in Casualty should be given death certificates by the CMO or the Senior Resident of the clinical unit. The CMO should ensure that the body is sent to the mortuary with due care and consideration. The CMO should make every effort to promptly inform the relatives of the patient who dies in the Casualty. When the relatives arrive in the Casualty, the CMO should show due courtesy and sympathy to them and help them in every possible way in the disposal of the dead body.

Instructions regarding patients who are dead on arrival at the Casualty

All cases “brought in dead”, and where the actual cause of death is not known, should be handed over the he police for suitable action.

(i) The name of such cases should be entered in the Casualty attendance register along with all the possible details about the dead person obtained from the accompanying relatives whose name and address should also be noted and recorded in the remarks column of the register.

(ii) In case where death has occurred due to natural causes and there is no suspicion of any foul play, the dead bodies may be recorded with signatures of relatives or attendants.

(iii) All other cases where death has occurred due to accident, assault, burns, suicide, poison, rape or any other causes where it is suspected that death has not been due to natural causes, must be registered as medico-legal cases (MLC) and the police authorities informed accordingly.

(iv) In all the above cases, the out-patient paperwork and the death reports duly completed, must be forwarded to the M.S. for onward transmission tot he Medical Records Section and New Delhi Municipal Committee.

Instructions Regarding Medico-legal CasesA medico-legal situation is defined as one where there is an allegation, confession or suspicion of causes attributing to body injury or danger to life. The CMO is advised not to enter into any arguments with the patient, relatives or attendants regarding the medico-legal aspects of the case. This problem must be left entirely to the Police Constable on duty. The Casualty Medical Officer’s foremost duty is to render medical aid to the patient. All such cases should be promptly entered in the bound medico-legal case register available in the Casualty. The CMO should see that the register pages have been properly numbered

Contd..

Special emphasis should be given to clearly and legibly entering the name, address, time of arrival of the patient and to the cause and nature of injury. Signature should be in full with the name of CMO given in capital letters. At least two marks of identification should be carefully entered. A copy of the report should be handed over to the Police and the register should be kept under lock and key in the Casualty Department. No person, including the Police officer, should have access to the medico-legal record including medico-legal register) without the written consent of Medical Superintendent or any other officer authorised by him.

contd...

All exhibits of legal importance (gastric lavage etc.) should be immediately sealed and kept under lock any key till delivered to the police and their signatures obtained in the book. In all medico-legal matters, where the CMO is in need of expert advice, the faculty staff of the Department of Forensic Medicine should be contacted and proper guidance obtained.

Contd...

The following points may kindly be consideredwhile dealing with MLC cases:

(i) Each entry of identification data of patients in the MLC register should be made by the CMO and not by the Police Officer.

(ii) The MLC reports should be prepared by the CMO’s/Residents and not by the Interns.

(iii) Nature of injuries should be recorded in every MLC case.

(iv) The CMO should write his/her full name in block letters along with the signature for adequate identification.

Contd….

(vi) X-ray Department is requested to provide the X-ray report within 48 hours.

(vii) Remarks of the specialists should be entered in the MLC register and signed by the specialist with his/her name clearly written in block letters.

(viii) The Police Officer posted in the Casualty should expedite the completion of all MLC reports within 7 days.

THANK-YOU