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Reporting Culture Results and Other Post-Recovery Results (2.08)

Reporting Culture Results and Other Post-Recovery Results (2.08) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

2.08



POLICY
Established Date: December 2013
Effective Date: January 2018
Title: Reporting Culture Results and Other Post-
Recovery Results
Policy Number: 2.08

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


Page 1 of 5
PURPOSE

The purpose of this policy is to provide clear and standard instructions for a UW Organ and Tissue Donation
(UW OTD) organ procurement coordinator (OPC) to follow for obtaining post-procurement results such as
culture results and reporting those results to all applicable transplant and tissue and eye bank programs for
all organ donors. It is the policy of UW OTD to communicate all changes in results and to document all final
results as required per applicable regulatory requirements.

FORMS

Culture Reporting Worksheet
PSC Reporting Worksheet
Procurement Checklist

POLICY

CULTURE RESULTS
Identifying Cultures Ordered by Donor Hospital Staff (“pre-UW OTD cultures”)
A. After consent for organ donation has been obtained, an OPC will review the hospital medical
record of the patient electronically or via faxed records.
1. This medical record review will include identifying any cultures that have already been
ordered by donor hospital staff during the current hospital admission.
2. This review will be prompted by the Procurement Checklist.
B. As soon as pre-UW OTD cultures are identified, an OPC will complete the following steps.
1. If the pre-UW OTD cultures are final:
i. The culture record will be entered into the Culture/Microbiology section of
DonorNet (this section is located in the Donor Summary tab and then the Labs
tab).
ii. The final results documents will be uploaded to DonorNet in the Attachment tab
within the Donor summary tab.
iii. Any final results documents will be uploaded to the patient record in DonorLink.
iv. Note – do not complete a Culture Reporting Worksheet for these cultures.
2. If the pre-UW OTD cultures are still pending:



POLICY
Established Date: December 2013
Effective Date: January 2018
Title: Reporting Culture Results and Other Post-
Recovery Results
Policy Number: 2.08

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


Page 2 of 5
i. The culture record will be started in the Culture/Microbiology section of
DonorNet (this section is located in the Donor Summary tab and then the Labs
tab).
ii. A Culture Reporting Worksheet will be started for each culture.

Ordering UW OTD Cultures (“UW OTD cultures”)
C. An OPC will order cultures as outlined in UW OTD policy 2.03.
D. The OPC will confirm the cultures were ordered.
E. After the culture is confirmed, the OPC will:
1. Start the culture record in the Culture/Microbiology section of DonorNet (this section is
located in the Donor Summary tab and then the Labs tab)
2. Start the Culture Reporting Worksheet for each culture.

Monitoring Cultures
F. An OPC will review all pending cultures at least once a day.
1. The purpose of these reviews is to monitor any changes (including any new positive
results, changes in organism, and/or changes in sensitivity) in the culture results.
2. These reviews will be recorded on the Culture Reporting Worksheet.
G. During OPC shift handoff, OPCs (both the staff ending a shift and staff beginning a shift) will
review the status of all pending cultures.

Reporting Culture Results Pre-Recovery
H. All initial culture information, changes in culture results, and final results received before organ
recovery will be communicated to any potential transplant center via DonorNet. The patient
safety contact (PSC) and potential transplant centers will not be contacted directly.
I. If there are no changes in culture results, OPCs will record this information on the Culture
Reporting Worksheet.
J. Within 24 hours of identifying any changes in culture results:
1. The changes will be recorded in the Culture/Microbiology section of DonorNet (located
in the Donor Summary tab and then the Labs tab).
2. The changes will be recorded on the Culture Reporting Worksheet.
K. Within 24 hours of identifying any final results:
1. The final results will be recorded in the Culture/Microbiology section of DonorNet
(located in the Donor Summary tab and then the Labs tab).



POLICY
Established Date: December 2013
Effective Date: January 2018
Title: Reporting Culture Results and Other Post-
Recovery Results
Policy Number: 2.08

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


Page 3 of 5
2. The final results documents will be uploaded to DonorNet in the Attachment tab within
the Donor Summary tab.
3. The final results documents will be uploaded to the patient record in DonorLink.
4. The final results will be recorded on the Culture Reporting Worksheet.

Reporting Culture Results Post Recovery
L. If there are no changes in culture results, record this information on the Culture Reporting
Worksheet.
M. Within 24 hours of identifying any changes in culture results (changes that occurred after
recovery because changes before recovery were already reported in DonorNet):
1. Contact the PSC listed on UNET for the applicable transplant center(s) via phone or email
to share the changes in results.
i. Urine Cultures: Contact the PSC for the kidney transplant center(s) only. Do not
contact any other transplant center.
ii. Respiratory Cultures (including Candida species): Contact the PSC for the lung
transplant center(s) only. Do not contact any other transplant center.
iii. All Other Culture Types: Contact the PSC listed on UNET for each transplant
center that received an organ.
2. The PSC reporting activities will be recorded on the PSC Reporting Worksheet. The
completed worksheet and the preliminary results will be uploaded to the patient record
in DonorLink.
3. The changes will be recorded in the Culture/Microbiology section of DonorNet (located
in the Donor Summary tab and then the Labs tab).
4. The changes will be recorded on the Culture Reporting Worksheet.
N. Within 24 hours of identifying any final culture results:
1. Final results for samples that were never positive: Do not report to the PSC.
2. Final results for samples that were positive at any time: Contact the PSC for the
appropriate transplant center(s) via phone or email to share that the results are final.
i. For example, if the preliminary results were positive and are still positive with no
changes when final, the PSC still needs to be contacted to share that the results
are final.
ii. Urine Cultures: Contact the PSC for the kidney transplant center(s) only. Do not
contact any other transplant center.



POLICY
Established Date: December 2013
Effective Date: January 2018
Title: Reporting Culture Results and Other Post-
Recovery Results
Policy Number: 2.08

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


Page 4 of 5
iii. Respiratory Cultures (including Candida species): Contact the PSC for the lung
transplant center(s) only. Do not contact any other transplant center.
iv. All Other Culture Types: Contact the PSC listed on UNET for each transplant
center that received an organ.
3. The final results will be recorded in the Culture/Microbiology section of DonorNet
(located in the Donor Summary tab and then the Labs tab).
4. The final results documents will be uploaded to DonorNet in the Attachment tab within
the Donor Summary tab.
5. The final results documents will be uploaded to the patient record in DonorLink.
6. If a PSC Reporting Worksheet was completed, the completed worksheet will be uploaded
to the patient record in DonorLink.
7. The final result will be recorded on the Culture Reporting Worksheet.

OTHER POST-RECOVERY RESULTS
O. Results received after an organ has been transplanted will be reported to the appropriate
transplant center PSC as required per United Network for Organ Sharing (UNOS) policy 15.4.
P. These results include but are not limited to:
1. Pathogens of special interest
i. UNOS maintains a list of the pathogens of special interest.
ii. If a result from the pathogens of special interest list is received, report this result
to the PSC for all transplant centers via phone or email within 24 hours of
receiving the result.
iii. Report this result to the UNOS patient safety portal within 24 hours of receiving
the result.
2. Malignancy or other findings highly suggestive of malignancy
i. Report these results to the PSC for all transplant centers via phone or email
within 24 hours of receiving the results.
ii. Report the results to the UNOS patient safety portal within 24 hours of receiving
the results.
3. Histopathology results
i. Report the results to the PSC for all transplant centers via phone or email within
24 hours of receiving the result.
4. Any other result or information that may adversely affect a transplant recipient



POLICY
Established Date: December 2013
Effective Date: January 2018
Title: Reporting Culture Results and Other Post-
Recovery Results
Policy Number: 2.08

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


Page 5 of 5
i. Report the results to the PSC for all transplant centers via phone or email within
24 hours of receiving the result.
Q. For All Reported Results:
1. The final results will be recorded in the Culture/Microbiology section of DonorNet
(located in the Donor Summary tab and then the Labs tab).
2. Complete the PSC Reporting Worksheet
3. Upload the completed PSC Reporting Worksheet along with the results documents to the
patient record in DonorLink
4. Upload the results documents to DonorNet in the Attachment tab within the Donor
Summary tab.

REFERENCES

UW OTD Policy 2.03
UNOS Policy 15.4
UNOS List for Pathogens of Special Interest