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Policies,Clinical,UWHC Clinical,Department Specific,Surgical Services,Clinical

Skin Tissue Banking - Autologous Bone Flap Storage - Cardiac and Eye Tissue Storage (2.23)

Skin Tissue Banking - Autologous Bone Flap Storage - Cardiac and Eye Tissue Storage (2.23) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Clinical

2.23

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JULY 1990
ORIGINAL
 REVISION
MAY 2015
PAGE 1
OF 4
POLICY #

2.23
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Operating Room
TITLE
AUTOLOGOUS SKIN TISSUE BANKING AND
SKULL BONE FLAP STORAGE and REPLANT

J:\Or\Sec\Policy & Procedure\2015\2-23 final.doc

I. PURPOSE

All skin and skull bone harvested and preserved will be done in such a manner to preserve optimal viability
of the autologous tissue. To provide and establish processes for handling human tissue as required by The
Joint Commission (TJC) and the Food and Drug Administration.

II. POLICY

A. All skin will be stored in a designated moist, sterile, cool environment to maintain viability and
ensure safekeeping..
B. Skin will be typically saved up to a period of fourteen days.
C. Skull bone flaps to be placed in long-term storage at a temperature of -40 θC or below.
D. Tissue storage in the Operating Room will follow the protocol as outlined in steps C and D below.
E. Transfusion Service Tissue Request form (UWH NYATR) will be used when requesting autologous
tissue and skull bone flap.

III. PROCEDURE

A. Skin Banking
1. Place harvested skin with the epidermal layer contacting the non-adherent dressing (e.g.
Cuticerin, Adaptic or similar available product) and the dermal (shiny side) exposed, (not
against the non-adherent dressing). The skin should be smoothed to avoid all wrinkling, if
possible.
Keypoint - This is to avoid ointment and/or residue from occluding the blood flow to the graft.
2. Place saline moistened unmarked woven cotton on top of the dermal layer (shiny side).
3. Cigar roll end to end.
4. Place in a sterile specimen container and cap.
5. Affix a patient label (computer generated or computer downtime label) to the autologous label
(available on the Burn Cart) and then place the entire label on the container.
6. The autologous skin tissue label will include the following information:
a. Hospital Name and address
b. For Autologous Use Only
c. Tissue Description
d. Biohazard Reason - Not Evaluated for Infectious Substances
e. Date and Time Collected
f. Expiration Date (Fourteen Days from Date Collected)
g. Surgeon’s Name
h. Store at 1-10 θC

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JULY 1990
ORIGINAL
 REVISION
MAY 2015
PAGE 2
OF 4
POLICY #

2.23
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Operating Room
TITLE
AUTOLOGOUS SKIN TISSUE BANKING AND
SKULL BONE FLAP STORAGE and REPLANT

J:\Or\Sec\Policy & Procedure\2015\2-23 final.doc

i. Biohazard Sticker or a Biohazard Symbol Imprinted on the above label
7. Hand deliver container(s) as soon as possible to the Blood Bank for refrigeration. Do not allow
the skin to be sent with the patient to PACU or to the specimen box in the OR.
Keypoint - Immediate cooling reduces the microbial growth that occurs.
8. For tracking purposes, the skin should be logged in the specimen book.

B. Autologous Skull bone Flap Storage and Replant
1. Rinse the skull bone in sterile saline irrigation solution.
2. Dry the skull bone thoroughly.
3. Affix the patient label (computer generated or computer downtime label) to the skull bone
autologous label and place the entire label on the outside of container.
4. Place the skull bone in sterile container. The autologous skull bone donor label will contain the
following information:
a. Hospital Name and Address
b. For Autologous Use Only
c. Tissue Description
d. Biohazard Reason - Not Evaluated for Infectious Substances
e. Date and Time Collected
f. Was skull bone rinsed with antibiotic? Yes/No
g. List of Antibiotics Used
h. Surgeon’s Name
i. Store at -40 θC
j. Biohazard Sticker or a Biohazard Symbol Imprinted on the Above Label
5. Document in perioperative notes that the skull bone flap was saved and taken to the Blood
Bank.
6. Hand deliver container for delivery to the Blood Bank.
7. For replanting, skull bone flap preparation to be done at discretion of surgeon.

C. Adverse Reactions
1. If an adverse reaction to tissue occurs, report using the Patient Safety Net and notify the Blood
Bank by calling extension 3-8367.

IV. REFERENCES
A. American Association of Tissue Banks, Current Standards
B. Current TJC Standards for Transplant and Implant Tissue Storage and Issuance
C. UWHC Administrative Policy 7.03 Human Tissue Standards

REVIEWED BY

UNIVERSITY OF WISCONSIN

POLICY & PROCEDURE

EFFECTIVE DATE

JULY 1990
ORIGINAL
 REVISION
MAY 2015
PAGE 3
OF 4
POLICY #

2.23
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER Operating Room
TITLE
AUTOLOGOUS SKIN TISSUE BANKING AND
SKULL BONE FLAP STORAGE and REPLANT

J:\Or\Sec\Policy & Procedure\2015\2-23 final.doc


Surgical Services Policy and Procedure Committee 11/2014
Lee Faucher, MD, General Surgery 11/2014
Suzanne Morris, Clinical Operations Manager 11/2014
Dean Lawler, Director of Lab Services 3/2015
Heather Humphrey, Sr Medical Technologist, Blood Bank 3/2105

SIGNED BY
Jeff Fenne, MHA, RN, CNOR
Director, Surgical Services Department