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

Donor Vessel Recovery, Transplant and Storage Policy (3.52)

Donor Vessel Recovery, Transplant and Storage Policy (3.52) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.52

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POLICY & PROCEDURE
Effective Date: December 2008
Revised Date: February 2017
Title: Donor Vessel Recovery, Transplant & Storage
Policy
Policy Number: 3.52

I. PURPOSE
The purpose of this policy is to provide clinical standards for the preservation and disposition of
donor vessels to ensure patient safety.

II. POLICY
It is the policy of the UW Transplant program to adhere to the standards of the Organ Procurement
and Transplantation Network (OPTN) Policy 16.6: Vessel Recovery, Transplant, and Storage.

III. ASSOCIATED POLICIES
• UW OTD: 3.09 Packaging and Labeling of Organ Donor Vessels
• TRANSFUSION SERVICES: 1566.5.20 Receipt, Storage, Dispensing and tracking of Vessels

IV. PROCEDURE

RECOVERY

Organ and Tissue Donation (OTD)

A. Vessels are recovered from organ donors in accordance with UW OTD Policy 3.09 Packaging and
Labeling of Organ Donor Vessels.
B. After recovery, UW OTD will deliver the recovered donor vessels to Transfusion Services with
UW Transplant Vessel Verification form(s) for check in.
1. If vessels are recovered per expedited recovery they are quarantined at Transfusion
Services until serology and blood type results are available.

TRANSPLANT
Transfusion Services
A. Transfusion Services will receive and inspect vessels delivered from the OTD where they will be
inspected, checked-in, and reissued according to Transfusion Services’ Policy 1566.5.20 Receipt,
Storage, Dispensing and tracking of Vessels.



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Operating Room
A. Upon the patient being admitted for transplant, the Resident, Fellow, or Attending Transplant
Surgeon will complete and submit a Tissue Request Form to the Operating Room (OR) Charge
RN or Transfusion Services.
B. The OR Charge RN or a designee will retrieve the vessels and UW Transplant Vessel Verification
form(s) from Transfusion Services.
1. If a designee retrieves the vessels, they will deliver them to the OR Charge RN, RN
designee, or circulating RN as appropriate.
C. Process if vessels are used or discarded:
1. If a cutdown room is being utilized, the OR Charge RN or an RN designee will oversee the
process of verifying the vessels with the Fellow or Attending Transplant Surgeon and will
facilitate the UW Transplant Vessel Verification forms being completed.
A. The OR Charge RN or RN designee and the Fellow or Attending Transplant
Surgeon will ensure the UW Transplant Vessel Verification form(s) are completed
and taken to the OR suite where the transplant is occurring. If the transplant is
not occurring consecutively to cutdown, any remaining unused and unopened
vessels and UW Transplant Vessel Verification form(s) that are unaltered as
issued will be taken back to Transfusion Services by the OR Change RN or a
designee.
B. Any vessels that have been opened to the operative field will be discarded in the
OR and the OR Charge RN, RN designee, or Circulating RN will document this
appropriately on the UW Transplant Vessel Verification form(s) that will be
returned to Transfusion Services.
2. If a cutdown room is not utilized, but vessels are still used in the OR suite where the
transplant is occurring, the Circulating RN and Fellow or Attending Transplant Surgeon
will complete the UW Transplant Vessel Verification form(s).
A. The Circulating RN will ensure completed UW Transplant Vessel Verification
form(s) are returned to Transfusion Services
B. Any vessels that have been opened onto the operative field will be discarded in
the OR and the Circulating RN will document this appropriately on the UW
Transplant Vessel Verification form(s) that will be returned to Transfusion
Services
D. Process if vessels are not used and not discarded:
1. The Circulating RN or designee will return the unused vessels to Transfusion Services
with all UW Transplant Vessel Verification form(s) unaltered as issued.
E. All UW Transplant Vessel Verification form(s) are to be returned directly to Transfusion Services
by the Charge RN, Circulating RN, or designee.
F. If the organ is not transplanted and the vessels have been opened onto the recipient’s operative
field, or if there has been a cross contamination between recipient and the back table, the
vessels will be discarded in the OR and the Circulating RN will document this appropriately on
the UW Transplant Vessel Verification form(s) that are returned to Transfusion Services.




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STORAGE
Transfusion Services (when returned from OR)

A. In the event vessels are not used, the OR will return the unused vessels to Transfusion Services
with the UW Transplant Vessel Verification form(s) unaltered as issued. A medical technician will
receive and inspect the vessels for packaging and labeling requirements. Vessels will be
maintained according to Transfusion Services’ policy 1566.5.20.

Transplant
A. The Data Coordinator reviews the daily vessel storage report that is updated by Transfusion
Services in the BBIS.
1. The Data Coordinator updates UNET with final disposition within seven days.

B. Paper forms are received by the Data Administrator (DA) from Transfusion Services.
1. These paper forms must be kept for a minimum of six months after recovery.
A. If vessels were used during the patient’s transplant the Transplant DA scans the
vessel forms into the patient’s chart.
VESSEL SHARING
A. In the event UW Health receives a shared vessel from another transplant center, UW Health will
submit a detailed explanation to the OPTN Contractor justifying why sharing occurred.
1. If UW Health disposes of any shared vessel it will notify the OPTN contractor.


II. FORMS

The following forms can be found on the “related tab” for this policy:
A. UW Transplant Vessel Verification Form #4006765-DT
B. Vessel Acceptance Form 1566.5.20 F1
C. UWHC Tissue Request Form 170301
III. REFERENCES

1. 3.09 Packaging and Labeling of Organ Donor Vessels
2. UWHC Clinical Laboratories Transfusion Service Policy Document ID 1566.5.20 Receipt,
Storage, Dispensing and Tracking of Vessels
3. OPTN Policy 16.6, Vessel Recovery, Storage and Transplant






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IV. COORDINATION

University of Wisconsin Transplant Program
University of Wisconsin Organ and Tissue Donation
Transfusion Services

V. REVIEWED AND APPROVED BY

Organ Tissue Donation
Transfusion Services
Operating Room
Kidney Transplant Manager
Liver Transplant Manager
Operations Director
Service Line Director
Chair of Transplant

VI. SIGNED BY

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