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Response and Tracking of Referrals of Potential Organ, Tissue and Eye Donors (2.01)

Response and Tracking of Referrals of Potential Organ, Tissue and Eye Donors (2.01) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

2.01



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Response and Tracking of Referrals for
Potential Organ, Tissue, and Eye Donors
Policy Number: 2.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 3

PURPOSE

The purpose of this policy is to establish standard procedures for University of Wisconsin Organ and Tissue
Donation (UW OTD) to respond to referrals of patients who meet clinical triggers from its Designated
Services Area (DSA) hospitals, to share donor information with the appropriate tissue and eye banks, and to
outline the referral tracking system.

POLICY

Responding to Referrals of Patients Who Meet Clinical Triggers
A. DSA hospital staff will call Statline, a referral service vendor, to refer a patient within one hour of
that patient meeting clinical triggers. All hospitals follow the same definition of “Clinical
Triggers:”
1. A mechanically ventilated patient with a confirmed severe neurological insult or injury
and one of the following:
i. A patient with a GCS of five or less;
ii. A physician is evaluating the patient for brain death; or
iii. There is a plan to discuss withdrawal of life-sustaining therapies.
2. A severe neurologic injury is confirmed by:
3. Obvious visual head trauma;
4. Neuro-diagnostic results (i.e. CT, MRI, or EEG); or
5. A medical doctor’s physical assessment of brain stem reflexes.
B. The Organ Procurement Coordinator (OPC) will receive notification of the referral from Statline.
C. The OPC will respond to the referring hospital within 15 minutes from receiving the notification.
D. The OPC will create a referral record as outlined in section “UW OTD Referral Record.”
E. The OPC will determine if the patient made a designation of First Person Authorization (FPA) by
checking the applicable state donor registry or reviewing other legal directives per UW OTD
policy 2.15.
F. The OPC will review the patient’s medical record from the DSA hospital via fax or electronically if
access is available.
G. Initially the OPC will use the Automatic Rule Out Criteria to determine eligibility.
H. If the Automatic Rule Out Criteria doesn’t apply, the OPC will discuss the referral and medical
findings with the UW OTD Medical Director On-Call (MOC) to determine if the patient is eligible



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Response and Tracking of Referrals for
Potential Organ, Tissue, and Eye Donors
Policy Number: 2.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 3
for organ donation. Determination of eligibility will be evaluated on a case by case basis. The
MOC will make a determination about eligibility and communicate it to the OPC. The OPC will
document all eligibility conversations with the MOC in the referral record.
I. The OPC will contact the appropriate coroner/medical examiner and district attorney per UW
OTD policy 2.05.
J. If the patient is deemed ineligible, the DSA hospital staff is notified with the reason. DSA hospital
staff is instructed to call Statline with the patient’s cardiac time of death, at which time the
tissue and eye banks will be contacted to determine eligibility.
K. The OPC will also notify Statline of the patient’s ineligibility for organ donation and the OPC will
close the referral in the UW OTD medical record.
L. If the patient is deemed eligible for organ donation, UW OTD policy 2.03 will be followed.

Referrals to Tissue and Eye Banks
A. After a Donor Risk Assessment Interview (DRAI) is completed on a donor per UW OTD Policy
2.03, the OPC notifies the appropriate tissue and eye bank agencies in a timely manner.
B. The OPC will call Statline to contact the following agencies:
1. American Tissue Services Foundation (ATSF).
2. RTI Donor Services (RTI).
3. Blood Center of Wisconsin (BCW)/Wisconsin Tissue Bank (WTB).
4. Lions Eye Bank of Wisconsin (LEBW).
5. Illinois Eye Bank (IEB).
6. Gift of Life Michigan (GOLM).
7. Michigan Eye Bank (MIEB).
C. The OPC will notify the agency about the shared donor and obtain information to complete the
Pre-Recovery Tissue & Eye Donation Worksheet.
D. The OPC will provide a copy of the following records as they become available to the
appropriate agencies:
1. Preliminary donor chart;
2. Consent;
3. DRAI (Donor Risk Assessment Interview);
4. Infectious disease results;
5. Serology worksheet;
6. Hemodilution worksheet;
7. H&P, chest x-rays, CT scans, consults (unless tissue bank has EMR access); and



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Response and Tracking of Referrals for
Potential Organ, Tissue, and Eye Donors
Policy Number: 2.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 3 of 3
8. Any other pertinent information that’s requested.
E. Relevant changes such as eligibility (DCD vs brain death), ineligibility, the DRAI, consent,
infectious disease results or timing during or after the case will be communicated to the
appropriate agencies in a timely manner by the OPC. This communication shall be documented
in the patient’s record.
F. For DCD patients, the OPC or a designee will communicate the final disposition details (such as
the cardiac time of death or that the patient did not expire within the designated time frame) to
Statline. Statline will notify the appropriate tissue and eye bank agencies of the details and
record the data in the event log.

UW OTD Referral Record
G. Statline will generate a record for each referred patient which includes an event log.
H. The OPC will create a record of all referrals made by DSA hospitals per the current workflow.
I. All imminent and eligible death information as defined by United Network for Organ Sharing
(UNOS) and based on the patient’s neurological assessment will be documented.
J. The OPC will enter an outcome in the “Chart Completion” tab of the referral record.
K. The Senior OPC or designee will review and close all referral records per UW OTD policy 1.09.
L. The UW OTD Data Coordinator will generate referral reports and will review the reports for
completeness and accuracy. The Data Coordinator will contact the necessary staff to make any
corrections.
M. Once the referral report has been finalized, the Data Coordinator will notify UW OTD Hospital
Development Specialist (HD) staff that the referral reports are ready to be reviewed.
N. HSS staff will use the referral reports to identify the number of potential, referred, and actual
organ donors per UW OTD policy 4.01.

REFERENCES

UW OTD Policies 1.09, 2.03, 2.05, 2.15, and 4.01
Automatic Rule Out Criteria