Bone Marrow Biopsy (Adults Only)



Canberra Hospital and Health Services

Clinical Procedure

Bone Marrow Biopsy (Adults Only)

|Contents |

Contents 1

Purpose 2

Alerts 2

Scope 2

Section 1 – Roles and Responsibilities 3

Section 2 – Booking of BMB Procedures 4

Section 3 – Prior to the Procedure 4

Section 4 – Patient Assessment, Preparation and Consent 4

Section 5 – Other Preparations prior to BMB 5

Section 6 – Facilities and Equipment 5

Section 7 – Bone Marrow Biopsy Procedural Roles 7

Section 8 – Discharge and Documentation 11

Implementation 12

Related Policies, Procedures, Guidelines and Legislation 12

References 12

Search Terms 13

Attachments 13

Attachment 1: How to Use Penthrox 14

Attachment 2: Instructions for use of the Bone Marrow Aspiration System/Bone Marrow Biopsy System 15

|Purpose |

To outline the requirements for performing an Adult Bone Marrow Biopsy (BMB) procedure within Canberra Hospital and Health Services (CHHS).

This document describes the processes required to book and perform this procedure including:

• Identification of patients who are appropriate for this procedure

• Identification of patients who are appropriate for the Penthrox inhaler

• Identification of patients who are appropriate for sedation in the rare event that sedation is considered for the patient

• Identification of safety requirements and patients at increased risk during this procedure

• Requirements for staff performing and assisting with this procedure

• A summary of the minimum requirements for this procedure

• For procedures required after hours or on weekends the Haematology Lab need to be informed beforehand.

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This Standard Operating Procedure (SOP) describes for staff the process to

|Scope |

|Alerts |

There must be a minimum of two staff to perform the procedure:

• A Medical Officer who has been deemed competent to perform the procedure or is training to do so under supervision

• A second staff member (either medical or nursing) who is adequately trained to be solely responsible for the administration of medication, monitoring and care of the patient

• A Penthrox inhaler is used for this procedure

• Infection control is a paramount consideration when performing a Bone Marrow Biopsy

• On the rare occasion that sedation is required for this procedure, please refer to the Procedural Sedation guidelines on the Policy Register. All patients requiring sedation will require IV access.

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|Scope |

This document applies to medical and nursing staff in all areas of the Canberra Hospital where an Adult Bone Marrow Biopsy procedure is requested by a Haematology Consultant.

• This procedure should be performed in the BMB procedure room in Building 19.

• Another appropriate area may be used at the discretion of the Medical Officer performing the procedure and the Haematology Clinical Nurse Coordinator (CNC) or other area CNC.

• If the patient is not stable enough this procedure may be performed in an appropriate area of The Canberra Hospital.

For inpatient procedures the Medical Officer performing the procedure is responsible for ensuring the area is appropriate and procedural requirements are met.

Bone marrow biopsies will be performed only after the completion of appropriate actions:

• Adequate patient assessment and preparation

• Notification of appropriate staff and area involved in the performance of the procedure

• Completion of appropriate booking forms

• Patient consented to procedure

• Written consent has been completed

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|Section 1 – Roles and Responsibilities |

|Title / Position |Responsibility |

|Medical Officer |A bone marrow biopsy must be performed by a competent medical officer with the assistance of |

| |an adequately trained staff member. |

| |A training staff member can perform this procedure under the supervision of a competent staff |

| |member |

| |Complete the medication chart for Penthrox inhaler on CHARM |

| |Direct patient when and how to use inhaler. |

|Assisting Staff Member |To provide assistance to the Medical Officer and to educate the patient to self-administer |

| |prescribed Penthrox inhaler |

| |Follow guidelines in clinical procedure bone marrow biopsy |

|Haematology Consultant |Identify consent and request procedure for appropriate adult patients that require a Bone |

| |Marrow Biopsy Procedure |

| |Complete ACT Pathology Request form |

| |Notify Level 4 Haematology Outpatient CNC |

| | |

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|Section 2 – Booking of BMB Procedures |

• BMB procedures are booked through the Haematology Outpatient Clinic Nurse (CNC) on CHARM.

• The staff member making the booking is responsible for ensuring that the patient has been notified of the date and time for the procedure

• Appointment times are not to be changed without the consent of the Haematology Outpatient CNC and/or the booking Registrar or Consultant.

• Emergency procedures, or procedures required outside of normal booking times, are booked at the discretion of the Haematology Outpatient CNC.

• Infectious patients requiring procedures need to be booked as the last procedure of the day or in single room inpatient ward if possible.

• It is the Medical team member’s responsibility when making the booking to notify the area that the patient is infectious.

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|Section 3 – Prior to the Procedure |

• Note that Outpatients do not get admitted and no charts are required.

• Document all patient information and procedure details in CHARM.

• A “Team Time Out” or “Positive Identification” is to occur prior to the procedure. The dedicated staff members involved in the procedure will confirm the following in accordance with ACT Health wide Patient Identification and Procedure Matching Procedure.

• All patients require an Identification band and/or Allergy Band to be applied prior to the procedure.

• Informed consent must be obtained

• The procedure side/site to be marked, if applicable

• Check all relevant documentation and imaging data are available

• Patient may require peripheral blood tests prior to the procedure. These are to be ordered by the requesting Medical Officer.

Patients require baseline observations to be performed and recorded prior to the procedure (BP, Pulse, SpO2, RR, temp). Refer to Vital Signs and Early Warning Scores Procedure

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|Section 4 – Patient Assessment, Preparation and Consent |

Consent

Informed consent for the procedure are to be obtained prior to the procedure. Refer to Consent and Treatment Policy. This applies for both inpatients and outpatients. Consent must be obtained either by:

• By the consultant at the time of the consultation and when initiating the booking of the bone marrow biopsy, or

• By the medical officer performing the bone marrow biopsy preceding the biopsy

Assessment

All patients should be assessed by the Medical Officer before the procedure including

• Prior illnesses and conditions

• Medication history

• Medication allergies recorded on medication chart. Appropriate ID band

• Relevant pathology results for the procedure and patient condition e.g. INR, FBC Renal and Liver Function

• BSL for diabetic patients

• Vital signs

Patients who are considered medically unstable or at high risk, must be discussed with the Haematology Outpatient CNC prior to booking of the procedure. The Haematology CNC will consult with the appropriate medical staff to determine the suitability of performing the procedure in Building 19.

Patient preparation

Patient education:

• Adequate preparation and education of the patient and/or carer should be provided by the Medical Officer wherever possible

• Education and instruction on the use for patient administration of Penthrox inhaler

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|Section 5 – Other Preparations prior to BMB |

Blood products:

• If supportive blood products or treatments are required prior to the BMB these are the responsibility of the Medical Officer requesting the procedure or the Medical Officer performing the procedure.

• The procedure may need to be rescheduled if these have not been organised prior to the booked procedure time.

• Rescheduling will be at the discretion of the Haematology CNC

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|Section 6 – Facilities and Equipment |

Venue

• Building 19 Level 4 BMB procedure room or an uncluttered well-lit treatment area or inpatient room

• A direct alarm system to call the Medical Emergency Team (MET) must be available in the area.

• Facilities for observation should be available and utilised until the patient has recovered and where it is safe for the patient to be discharged from that area

• This procedure should be performed in an area separated from other patients if possible

Tissue Banking

• If tissue banking is required it is the responsibility of the booking Medical Staff member to ensure that the Medical officer performing the procedure are aware of the requirements. (Refer to Bone Marrow Biopsy – Registrar or Medical Officer Information Sheet)

• Consent for the collection of these specimens is required prior to the procedure.

Equipment

• Ensure emergency equipment is available in the area

• Prepare procedure equipment before patient enters the room

Materials

|Procedure component |Equipment required |

|Blood Sampling |Tourniquet |

| |Vacuette |

| |Chlorhexidene gluconate swab- skin antisepsis |

| |Blood Tubes |

| |(Please refer to ACT Pathology bone marrow request Form) |

|Procedural Trolley |Arrow ‘OnControl’ Kit (sterile) |

|‘OnControl Driver’ |‘OnControl Driver’ |

| |Fenestrated drape |

| |1 x Chloraprep 3 ml applicator |

| |3 x 10ml syringe |

| |1 x 25G needle 1 x 23G needle |

| |2% lignocaine ampoules x 2 |

| |Dressing |

| | |

| | |

| |dressing |

|Procedural Trolley |Basic Dressing Pack |

| |Sterile green drapes |

|Manual Bone Marrow |Fenestrated drape |

| |1 x Chloraprep 3 ml applicator |

| |Bone Marrow Biopsy Needle |

| |3 x 10mL syringes |

| |1 x 25G needle 1 x 23G needle |

| |Scalpel Blade No.11 |

| |2% Lignocaine ampoules x 2 |

| |Dressing |

|PPE Trolley |Protective gown and Sterile gloves |

|Slide Production Area |Glass slides (14) |

| |Medium for trephine specimen (Yellow top container) |

| |Pipette (Do Not discard rubber) |

| |Pencil |

| |Cytogenic tubes x 2 |

| |Bone marrow worksheet Slide holder (folder) Glass dish |

| |2x Pink EDTA blood tubes marked Aspirate 1 and 2 |

| |Pathology ‘Hazard bag’ |

|Patient bed |Underpad (bluey) |

| |Slide sheet |

The trained Medical Officer is responsible for the production and labelling of specimens and slides. The production of specimens and slides may be delegated to an appropriately qualified person, including a nurse, with the medical officer’s direction and supervision.

The trained Medical Officer must provide direct supervision until the slides are completed and labelled.

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|Section 7 – Bone Marrow Biopsy Procedural Roles |

1. Medical Officer Bone Marrow Biopsy Procedural Role

Pre Procedure

• Ensure full patient assessment and consent has been performed and documented. Ensure “Time Out “has been performed.

• Medication order Penthrox inhaler

• Position the patient

• Supine for sternal or anterior iliac crest puncture

• Lateral with both knees raised for posterior iliac crest puncture

• Aseptic technique is employed, including sterile gloves

• Wash hands and don gloves and appropriate PPE.

Procedure

Instruct patient to use Penthrox inhaler - see Attachment 3.

The skin and the underlying tissue to the periosteum are infiltrated with a local anaesthetic.

A 10-mL syringe with a 25-gauge needle is used to inject local anaesthetic directly under the skin, raising a wheal. A 22-gauge needle is used to penetrate deeper into the subcutaneous tissue and the underlying periosteum, an area roughly 1 cm in diameter.

Adequacy of the anaesthesia is tested by gently prodding the periosteum with the tip of the needle and questioning the patient for any painful sensation. To ensure sufficient pain control is being managed well, the person performing the procedure should talk to the patient, discuss the steps taken throughout the process, and listen to the manner as well as the content of the patient's response.

A skin incision is made with a small surgical blade, through which the bone marrow aspiration needle, with a stylet locked in place, is inserted.

Once the needle contacts the bone, it is advanced by slowly rotating clockwise and counter clockwise until the cortical bone is penetrated and the marrow cavity is entered. Contact with the marrow cavity is usually noted by a sudden reduction in pressure. The depth of the penetration should not extend beyond an initial 1 cm.

Once within the marrow cavity, the stylet is removed. Using a 10 mL syringe, bone marrow is aspirated. Collect adequate sample amount to fill 2 EDTA tubes (2 mL each) and 2 cytogenetic tubes with lithium heparin (2 mL each).

Transfer aspirate specimen to assistant. Ensure adequate specimen taken. The needle is removed, and pressure is applied to the aspiration site with gauze until any bleeding has stopped.

Bone Marrow Trephine

The bone marrow biopsy is obtained through the same skin incision site used for the marrow aspiration, but the needle is angled differently from the aspirate in order to sample a different area.

Once the needle pierces the periosteum, the stylet is removed.

Using firm pressure, slowly rotate the needle in an alternating clockwise-counter clockwise motion, and advance it into the bone marrow cavity to obtain an adequate bone marrow specimen measuring approximately 1.6-3 cm in length.

Rotate the needle along its axis to help loosen the sample, pull back approximately 2-3 mm, and advance the needle again slightly, at a different angle, to help secure the specimen.

Following this procedure, slowly pull the needle out, while rotating in an alternating clockwise and counter clockwise motion.

Remove the specimen from the needle using a probe through the distal cutting end. If the aspirate was unsuccessful (i.e., a "dry tap"), the trephine may be used to make

trephine rolls. This must be performed before placing the specimen in formalin.

Transfer specimen to Assistant on sterile gauze to place on slide production area. Pressure is applied to the site with gauze until any bleeding has stopped.

Perform slide production

The production of specimens and slides may be delegated to an appropriately qualified person, including a nurse, with the medical officer’s direction and supervision.

Label slides and samples

• Labelling is not to occur until after the specimens are collected

• Slides should be labelled with pencil

• Space should be left for Pathology to scribe on the slide

Specimens must be labelled by the staff member collecting the specimens or producing the slides (as per the ACT Health Patient Identification and Pathology Specimen Labelling Procedure)

Ensure the following are completed

• ACT Pathology Request Form

• Bone Marrow Worksheet

Document procedure details on the Procedural Sedation Form and in the patient’s chart, including specific discharge instructions.

Post procedure

If the Haematology Support Nurse is not available then it is the Assistant’s and/or Medical Officer’s responsibility to ensure all post care is performed.

2. Assistant Staff Member Bone Marrow Biopsy Procedural Role

Pre Procedure

• Ensure Equipment is set up

• Confirm Patient identity and ensure details are correct.

• Attach Patient ID band and/or Allergy Band

• Pre procedure blood tests are performed

• Open and set up all required equipment. Perform “Time Out” with the Medical Officer Don appropriate PPE

• Ensure monitoring equipment is insitu.

Procedure

• Assist Medical Officer to position patient correctly

• In the rare event that sedation is required for the procedure, sedation should occur in accordance with the Procedural Sedation procedure on the Policy Register

• Monitor patient during the procedure

• Receive aspirate and transfer to required specimen tubes

• Place part of aspirate in dish and ensure adequate sample available for slide production. Transfer trephine to slide production area when required

Bone marrow biopsy- Nil

Sternum – Bone marrow aspirate- Nil

Perform slide production (this applies when the slide production has been delegated to the assistant role)

• Label slides and samples. Note labelling is not to occur until after the specimens are collected

• Slides should be labelled with pencil and space should be left for Pathology to scribe on the slide EDTA (pink) specimen tubes must be labelled ‘aspirate’

• Labelling of specimens and slides is not to occur until after the specimens are collected or the slides prepared

• Specimens must be labelled by the staff member collecting the specimens or producing the slides (as per the ACT Health Patient Identification and Pathology Specimen Labelling Procedure)

• Contact Pathology to pick up specimens or place at pick up point for pathology courier.

• Ensure the ACT Pathology Request Form and Bone Marrow Worksheet are completed

• Document procedure details in CHARM encounters

Post Procedure

Position the patient into supine position if possible, to put pressure on the procedure site.

Observations

• Take the patient’s observations immediately prior to discharge from the BMB procedure area

• Check procedure site and education for wound care prior to discharge

• If bleeding occurs contact the performing Medical Officer to review and redress the site as per the Medical Officers instructions

• Clean up equipment and set up for next procedure if required.

• If sedation was used:

o Follow the Procedural sedation guideline on the Policy Register

o Continue with sedation observations every 15 mins until patient’s observations have returned to pre sedation state of consciousness and cardiorespiratory function

o When observations have been returned to pre sedation levels and the procedure site is assessed as stable, a final set of observations are to be recorded

o When a patient is alert and awake provide food and fluids as tolerated

o Diabetic patients may require a BSL to be performed

o IV access to be removed once observations have returned to pre sedation levels

o Check procedure site for further bleeding

For further information see Attachment 2 - BMB Quick Guide (instructions to support staff external to CRCC).

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|Section 8 – Discharge and Documentation |

Patient discharge:

The patient may be discharged home, if required, following discharge instructions being provided to the patient and carer. This is the responsibility of the discharging staff member.

If the patient is an inpatient then Transport Pool or Wards person is to be contacted.

Clinical Documentation:

Summary of forms and documentation to be completed for a BMB:

• The Consultant and Registrar is responsible for ensuring that the following occurs:

o The ACT Pathology Request Form is ready prior to the procedure, is sent to the Clinic Nurse at time of the booking and is sent with the specimen to pathology

o The BMB Consent form is scanned to CHARM.

o The BMB Worksheet is sent with the specimen to pathology.

o The Patient CHARM encounters are documented.

• The Clinic Nurse and Clinical Nurse Consultant is responsible for ensuring that the BMB Booking is scheduled on CHARM at time of booking.

Complications or unexpected outcomes should be recorded onto the Riskman incident reporting system as soon as practically possible.

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|Implementation |

This procedure is implemented as part of an existing training program within the area provided to new medical and nursing staff.

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|Related Policies, Procedures, Guidelines and Legislation |

Policies

• Health Directorate Nursing and Midwifery Continuing Competence Policy

• Consent and Treatment Policy

• Procedural Sedation

• CHHS Patient Identification and Procedure Matching Policy

Procedures

• CHHS Healthcare Associated Infections Clinical Procedure

• CHHS Patient Identification and Procedure Matching Procedure

• Patient Identification – Pathology Specimen Labelling

• Fresh Blood Products Administration (Adults, Paediatrics and Neonates)

• Anticoagulation Management

• Vital Signs and Early Warning Scores Procedure

Guidelines

• ACT Regional Guidelines for the use of Warfarin. ACT adverse Drug Event Project

Legislation

• Health Records (Privacy and Access) Act 1997

• Human Rights Act 2004

• Work Health and Safety Act 2011

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|References |

1. Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. Oct 2001;54(10):737-42.

2. Griep J. In: Rodach BF, Fritsma GA, Doig K, eds. Haematology Clinical Principles and Applications. 3rd ed. St Louis: Saunders & Elsevier 2007:471-81.

3. Heffernan MJ. Bone marrow biopsy and aspiration (perform)

4. In: Lynn-McHale Wiegard DT, Carlson KK, eds. AACN Procedure Manual for Critical Care. 5th ed. St Louis: Elsevier Saunders 2005:1031-6.

5. Heffernan MJ. Bone marrow biopsy and aspiration (Assist)

6. In: Lynn-McHale Wiegard DT, Carlson KK, eds. AACN Procedure Manual for Critical Care. 5th ed. St Louis: Elselvier Saunders 2005:1037-40.

7. Hyun BH, Stevenson AJ, Hanau CA. Fundamentals of bone marrow examination. Hematol Oncol Clin North Am. Aug 1994;8(4):651-63.

8. Reid MM. Bone marrow biopsy: a haematologist's view. Acta Paediatr. Jun-Jul 1993;82(6- 7):599-601

9. Zehnder J. Bone marrow aspiration and biopsy; indicators and technique. In: Schrier S, ed. UpToDate June 3 2008.

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|Search Terms |

Bone Marrow Biopsy, Bone Marrow, Biopsy,

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|Attachments |

Attachment 1: How to use Penthrox

Attachment 2: Instructions for use of the Bone Marrow Aspiration System/Bone Marrow Biopsy System

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

|Date Amended |Section Amended |Divisional Approval |Final Approval |

|15/02/2018 |Complete Review |ED CACHS |CHHS Policy Committee |

| | | | |

This document supersedes the following:

|Document Number |Document Name |

|CHHS13/567 |Bone Marrow Biopsy |

| | |

Attachment 1: How to Use Penthrox

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Attachment 2: Instructions for use of the Bone Marrow Aspiration System/Bone Marrow Biopsy System

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