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ABO & Other Vital Data Verification of Deceased Donor and Intended Recipient Prior to Organ Procurement (3.59)

ABO & Other Vital Data Verification of Deceased Donor and Intended Recipient Prior to Organ Procurement (3.59) - Policies, Administrative, UWHC, Department Specific, Transplant, Transplant - Solid Organ

3.59



POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: June 2015
Title: ABO & Other Vital Data Verification of
Deceased Donor and Intended Recipient Prior to
Organ Procurement
Policy Number: 3.59

Page 1 of 4
I. PURPOSE

The purpose of this policy is to establish the UWHC procedure for verification of the deceased donor
organ(s) and the intended recipient blood type and other vital information for the transplantation of
deceased donor solid organs and vessels (if applicable). Transplantation of deceased donor organs
into specific patients is based upon many factors (e.g., ABO, HLA tissue typing, body size,
appropriate consent to accept such organs, etc.), and thus it is imperative to correctly identify and
match the deceased donor organ to the intended recipient.

II. POLICY

A. It is the policy to adhere to the University of Wisconsin Hospital & Clinics (UWHC) standards of
patient care, as well as the standards determined by regulatory and accrediting agencies, such
as The Joint Commission (TJC), the Organ Procurement and Transplantation Network
(OPTN)/United Network for Organ Sharing (UNOS), and the Centers for Medicare & Medicaid
Services (CMS).
B. Verification of the donor and intended recipient ABO and other vital data/identifying
information will occur at the donor hospital prior to the organ recovery taking place.
C. This policy does not apply to organs that are not procured by the UWHC recovery team which
are imported to UWHC for transplantation.
D. There are several ABO/vital data verification processes that occur:
1. The Donor/Recipient Pre-Transplant Verification Form, which is completed electronically
by the on-call transplant coordinator, and the inpatient nursing staff.
2. The OTD Recovery ABO/Vital Data Verification Form for the donor and intended
recipient, which is completed by the organ recovery team at the donor hospital prior to
commencement of organ recovery. The form is maintained in the donor chart, which is
addressed by this policy.
3. The verification of ABO/vital data of the donor and the ‘actual recipient’ at the transplant
center, prior to the organ being transplanted (see policy #3.60).

III. FORMS
The following forms can be found on the “related tab” for this policy:

Organ Procurement Organization (OPO) Vessel Verification (4006765-DT)
Organ Transplant and Vital Data Verification of Intended Recipient






POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: June 2015
Title: ABO & Other Vital Data Verification of
Deceased Donor and Intended Recipient Prior to
Organ Procurement
Policy Number: 3.59

Page 2 of 4



IV. PROCEDURE

A. Upon notification of available organ donor:
1. Every organ donor shall undergo ABO typing at UWHC prior to transplantation of the
organ. The Organ and Tissue Donation (OTD) Coordinator shall verify the donor ABO
typing from the UWHC Blood Bank and the United Network of Organ Sharing (UNOS) ID
number. The UNOS ID number is a number assigned to a donor by the United Network
for Organ Sharing, which serves as a patient identifier. Vital/identifying data may include,
but is not limited to: patient’s age, date of birth, cause of death, and may be obtained
with the UNOS ID for the deceased donor.
2. The on-call Transplant Coordinator will verify the recipient ABO typing from the
electronic patient medical record and shall notify the OTD coordinator on call of the
intended recipient. The Transplant Coordinator completes the electronic ABO verification
form in the electronic medical record (EMR).
3. The inpatient nurse manager and care team nurse will complete the electronic
Donor/Recipient Pre-Transplant Verification Form in the EMR. The completed electronic
ABO verification form is reviewed by OR staff prior to surgery.
4. The OTD Coordinator shall contact the on-call Transplant Coordinator prior to
commencement of the organ recovery to identify the intended recipients(s), if it has not
yet been communicated. At this time, if the intended recipient(s) is/are known, the OTD
Coordinator will document the last five (5) digits of the intended recipient(s) social
security number and ABO on the UWHC OTD and UWHC Transplant Program Organ
Donor and Intended Transplant Recipient ABO/Other Vital Data Verification Form for
Abdominal and Thoracic Organs (OTD Forms) and place in the Surgical Recovery
Coordinator ("SRC") recovery chart. If the intended recipient(s) is/are unknown prior to
the recovery team departing for the donor hospital, due to donor instability, tissue
typing and/or final cross match, the Transplant Coordinator will contact the recovery
surgeon with the intended recipient(s) when this information becomes available. At this
time, if the donor incision has not yet been made, the Transplant Coordinator will
communicate to the recovery surgeon the intended recipient(s) information. The
recovery surgeon will document on the match run(s) the intended recipient(s), and will
also document on the UWHC OTD and UWHC Transplant Program Organ Donor and
Intended Transplant Recipient ABO/Other Vital Data Verification Form for Abdominal
and Thoracic Organs (OTD Forms), the last five (5) digits of the social security number
and ABO. If the incision has already been made, a notation will be made on the form



POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: June 2015
Title: ABO & Other Vital Data Verification of
Deceased Donor and Intended Recipient Prior to
Organ Procurement
Policy Number: 3.59

Page 3 of 4
that the intended recipient(s) was/were unknown at the time of incision. The match run
list placed in the donor file must show a time that occurs after the organ recovery
incision time if the recipient was unknown.
5. At the donor hospital, the SRC shall complete and sign the OTD section of the ABO
Verification Form for each organ and vessel (if applicable) intended to be recovered.
Additionally, prior to incision, the SRC/surgical first assistant and the recovery surgeon
are responsible for obtaining, reviewing, and comparing the donor ABO and vital data
with the intended recipient ABO and vital data that is available on the UNOS match
runs. This process is documented on the UWHC OTD and UWHC Transplant Program
Organ Donor and Intended Transplant Recipient ABO/Other Vital Data Verification Form
for Abdominal and Cardiopulmonary Organs (OTD Forms).
6. The completed UWHC OTD and UWHC Transplant Program Organ Donor and Intended
Transplant Recipient ABO/Other Vital Data Verification Form for Abdominal and Thoracic
Organs (OTD Forms) are filed in the deceased donor chart.
B. Any deviations to the identification and verification process must be investigated immediately
with resolve in order to proceed with the transplant. When hand-writing the UNOS ID number,
the number zero (“Ø”) has a slash through it and the letter O has no slash and would appear as
“O”. There may be zeros (“Ø”) and O’s in the same UNOS ID. Usually the first two or three
characters are letters with the last three or four being numbers.


V. COORDINATION

University of Wisconsin Transplant Program
University of Wisconsin Organ Tissue Donation


VI. REVIEWED AND APPROVED BY

Kidney Transplant Manager
Liver Transplant Manager
Heart and Lung Transplant Manager
Operations Director
Operating Room Manager
OTD Surgical Recovery Manager






POLICY & PROCEDURE
Effective Date: June 2007
Revised Date: June 2015
Title: ABO & Other Vital Data Verification of
Deceased Donor and Intended Recipient Prior to
Organ Procurement
Policy Number: 3.59

Page 4 of 4



VII. SIGNED BY

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