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Increased Risk for Disease Transmission Identification and Reporting (2.04)

Increased Risk for Disease Transmission Identification and Reporting (2.04) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

2.04



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Increased Risk for Disease Transmission
Identification and Reporting
Policy Number: 2.04

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


Page 1 of 2
PURPOSE

The purpose of this policy is to outline the method of identifying, documenting, and disclosing increased
risk for disease transmission factors, including blood-borne pathogens. University of Wisconsin Organ and
Tissue Donation (UW OTD) will determine if a patient being evaluated for organ donation potential meets
the criteria for increased risk for disease transmission. This criteria will be based on the standards required
per United Network for Organ Sharing (UNOS) policy 2.0 which currently requires the U.S. Public Health
Services (PHS) Guideline for Reducing Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C
Virus Transmission through Organ Transplantation criteria be followed. UW OTD will disclose increased risk
for disease transmission information directly to the UW OTD medical director on-call (MOC) and/or his
designee, all potential receiving transplant centers, and tissue and eye bank agencies according to all
applicable regulatory agency requirements.

FORMS

Increased Risk for Disease Transmission – Reporting Form

POLICY
A. UW OTD organ procurement coordinator (OPC) will conduct a donor risk assessment interview
(DRAI), arrange for infectious disease testing, calculate hemodilution, and will review the donor
hospital medical records for the patient per UW OTD policy 2.03 to determine if the patient
meets criteria for increased risk for disease transmission.
B. After completion of the DRAI, the OPC will complete the Increased Risk for Disease Transmission
– Reporting Form and will record the increased risk status in the UW OTD patient record.
1. If the patient meets the increased risk for disease transmission criteria, the specific risk
factors will be documented on the form.
2. The form will be signed and dated by the OPC.
3. The same OPC that completed the form will enter the increased risk for disease
transmission status in the UW OTD patient record.
4. A second OPC will review all supporting medical records, the completed form, and the
data entry in the UW OTD patient chart to verify the increased risk for disease
transmission status was correctly identified and the documentation is accurate.
5. The second OPC that completed the verification will document completion of the
verification on the form.



POLICY
Established Date: January 2001
Effective Date: January 2018
Title: Increased Risk for Disease Transmission
Identification and Reporting
Policy Number: 2.04

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


Page 2 of 2
6. This verification and documentation will be completed prior to sharing the increased risk
status.
C. The OPC will verbally communicate the increased risk status to the UW OTD MOC.
D. The OPC will verbally communicate the increased risk status to each applicable tissue and eye
bank agency and all known potential receiving transplant centers.
E. All communication activities will be documented on the form.
F. The OPC will document increased risk status information in the patient record in DonorNet and
will ensure the match runs completed per UNOS policy are generated to reflect the correct
increased risk status.
G. All supporting medical records and the completed form will be added to the DonorNet and UW
OTD patient records.

REFERENCES

2013 PHS Guideline for Reducing Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus
Transmission through Organ Transplantation
UNOS Policy 2.0
UW OTD Policy 2.03