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Policies,Administrative,UWHC,Department Specific,Transplant,Transplant - Solid Organ

Adding Patients to the UNOS National Waitlist (3.09)

Adding Patients to the UNOS National Waitlist (3.09) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.09



POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: September 2017
Title: Adding Patients to the UNOS National
Waitlist
Policy Number: 3.09

Page 1 of 3
I. PURPOSE

The purpose of this policy is to establish guidelines for a uniform and systematic method for placing
transplant patients on the United Network of Organ Sharing (UNOS) national waitlist for
transplantation and to ensure that all regulatory requirements are met in the process.

II. POLICY

It is the policy of the UW Transplant program to adhere to the University of Wisconsin Hospital and
Clinics (UWHC) standards of patient care, as well as the standards determined by regulatory and
accrediting agencies, such as The Joint Commission, the Organ Procurement and Transplantation
Network (“OPTN”) and the United Network of Organ Sharing (“UNOS”) and the Centers for
Medicare and Medicaid Services (“CMS”), and any State and Federal laws.

III. DEFINITIONS

Qualified health care professional: a senior department assistant, data coordinator, or transplant
nurse who has been trained in the UNOS wait listing process.

IV. PROCEDURE

Upon determination by the multidisciplinary team that the patient meets the selection criteria for
transplantation, the following will occur:

A. Transplant Coordinator reviews the patient medical record and completes the assigned
portion of the organ specific internal wait list form (if applicable, see attached), completes all
sections of the Episodes of Care Report in the electronic medical record, then forwards the
information to the assigned staff to list the patient with UNOS, adhering to UNOS Wait List
Policy 3.3.
a. The qualified health care professional responsible for adding a patient to the UNOS
wait list is also responsible for removing that same patient from the wait list.
i. In the event a qualified health care professional is unavailable to take a
patient off the UNOS waitlist that they added, another qualified health care
professional must be available to remove the patient.

B. Prior to being listed with UNOS, each patient will have at least two blood type samples,
tested from two separate blood draws, taken at two different times. If the two blood



POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: September 2017
Title: Adding Patients to the UNOS National
Waitlist
Policy Number: 3.09

Page 2 of 3
samples have conflicting results, testing will be repeated on both samples, followed by an
investigation per UW Transfusion Services policy.

C. When listing a patient with UNOS, verification of candidate’s ABO on UNet must be
performed independently by two separate qualified health care professionals, as defined in
Section III.

a. Reporting must be done using all blood type determination source documents
b. Qualified health care profession must document that the reporting was completed

D. Patients are listed according with the specific donor organ criteria that have been
established for each organ type (see attached).

E. Wait time adjustments: As outlined in UNOS Policy 3.6, if patient wait time needs to be
reinstated, the assigned staff must complete and submit a Waiting Time Modification Form
or Renal Waiting Time Reinstatement form (kidney only) with all required information. As
outlined in policy 3.6, if a patient is transferring primary center from another transplant
center, a Center Transfer Form must be submitted.

F. Patient notification of waitlisting: Per UNOS Bylaws Appendix B Section II, written
correspondence is provided to patients regarding their addition to the waitlist within 10 days
of listing, with copy to referring physician, and dialysis unit (if applicable), containing
documentation as outlined in the UNOS Bylaws and selection criteria, if requested.

G. All patients on the waitlist will be managed according to UWHC Transplant policy 3.12,
Management of Patients Waiting for Transplant, and associated guidelines.

V. COORDINATION

University of Wisconsin Transplant Program


VI. REVIEWED AND APPROVED BY

Kidney Transplant Manager
Liver Transplant Manager
Heart and Lung Transplant Manager
Operations Director




POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: September 2017
Title: Adding Patients to the UNOS National
Waitlist
Policy Number: 3.09

Page 3 of 3
VII. SIGNED BY

________________________________ _________________________________
Jill Ellefson, MBA Dixon Kaufman, M.D., PhD
Director, Organ Donation and Transplant Service Line Chair, UW Transplant Program