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Bedside Liver Biopsy (2.09)

Bedside Liver Biopsy (2.09) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

2.09



POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 1 of 6

PURPOSE

The purpose of this policy is to outline the process of completing a bedside liver biopsy for a patient being
evaluated for potential organ donation at a University of Wisconsin Organ and Tissue Donation (UW OTD)
Designated Service Area (DSA) hospital. UW OTD will collaborate with donor hospital staff, following their
donor hospital policy.

FORMS

• Instructions for Liver Biopsy of Potential Donor- Biopsy sample obtained and evaluated at Donor
Hospital
• UW OTD Liver Biopsy Consultation Report
• Instructions for Liver Biopsy of Potential Donor- Biopsy sample obtained at Donor Hospital and
transported to UWHC for evaluation
• Instructions for Liver Biopsy of Potential Donor- Biopsy sample obtained and evaluated at UWHC
• UW Health Tissue Examination Request

POLICY

A. The UW OTD Medical On-Call (MOC) and/or potential transplant surgeon will consider but not
be limited to the following factors when determining if a liver biopsy is needed:
1. If a University of Wisconsin Hospital and Clinics (UWHC) transplant candidate is receiving
a primary offer for the liver;
2. If the patient could be a liver-only donor;
3. If the patient is a Donation after Circulatory Death (DCD) donor;
4. The age of the patient;
5. A past social history of alcohol abuse;
6. A Body Mass Index (BMI) >30; and
7. Abnormal liver function.
B. If determined to be needed, the bedside liver biopsy may be requested to be done prior to the
donor going to the operating room for organ recovery.
C. If a biopsy is requested, the MOC or transplant surgeon will communicate the request to a UW
OTD Organ Procurement Coordinator (OPC).



POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 2 of 6
1. If the request is received from a transplant surgeon, the OPC will communicate the
request to the MOC.
2. The MOC will evaluate the request and make the final determination about obtaining a
biopsy.
3. If the request is denied, the OPC will communicate this information to the transplant
surgeon.
D. The OPC will collaborate with donor hospital staff to determine if pathology staff are available to
evaluate the biopsy samples. This is preferred.
1. If pathology staff are available, the samples will be evaluated at the donor hospital.
2. If pathology staff are not available, the samples will be transported to UWHC for
evaluation by the on-call pathologist.
E. If the patient is being evaluated as a potential DCD donor, a procedural consent from the
patient’s family will need to be obtained in order to collect the biopsy samples. A procedural
consent is not required if the patient is brain dead and consent (including first person
authorization) for organ donation has been obtained per UW OTD policy 2.06 or 2.15.
F. If a UNOS chart has not been created, the OPC will generate one. A UNOS identirfication number
will be assigned specifically to the donor. This will be done before the samples are collected.
G. The liver biopsy samples will be collected and evaluated in one of the three following ways
based on the donor hospital’s policy.
1. Collected and evaluated at a donor hospital that is not UWHC
2. Collected at a donor hospital that is not UWHC and evaluated at UWHC
3. Collected and evaluated at UWHC.

Procedure for Samples Collected and Evaluated at a Donor Hospital that is not UWHC

A. The OPC will fax the appropriate biopsy instructions and the UW OTD Liver Biopsy Consultation
Report to donor hospital staff.
B. Hospital staff will follow hospital policy to determine the staff that will collect and/or evaluate
the biopsy samples.
C. Hospital staff will request this procedure be completed in a timely manner.
D. Check to be sure donor’s INR and platelets are within normal parameters. If not, correct them
prior to collecting the biopsy.



POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 3 of 6
E. Hospital staff will collect at least two core samples with an 18 gauge needle, which is the
preferred size considering the potential risk for bleeding. However, hospital staff will have on-
site discretion to determine the most appropriate sample collection method.
F. Hospital staff will place the samples on telfa moistened with sterile saline and in a sterile jar.
G. The samples will be identified with the patient label per donor hospital policy.
H. Hospital staff will deliver the samples to the appropriate pathologist to evaluate the samples per
donor hospital policy.
I. Donor hospital staff will provide the pathologist the UW OTD Liver Biopsy Consultation Report to
be used to document the biopsy findings.
J. The pathologist or a designee will fax the completed UW OTD Liver Biopsy Consultation report
to the UW OTD and the official/dictated report of biopsy to UW OTD and DonorNet.
1. The OPC will share the results with the MOC and/or the transplant surgeon.
2. The OPC will scan the consultation and final reports, as well as record the results in the
UW OTD donor record.
3. The OPC will scan the consultation report and ensure the final report is in DonorNet as
an attachment.

Procedure for Samples Collected at a Donor Hospital that is not UWHC and Evaluated at UWHC

K. The OPC will fax the appropriate biopsy instructions, the UW OTD Liver Biopsy Consultation
Report, and the UW Health Tissue Examination Request form to donor hospital staff.
L. Prior to faxing, the OPC will complete the UW Health Tissue Examination Request form as
follows:
i. Attending Physician Performing Procedure field = OPO
ii. Ordering Physician Needing Report field = Tony D’Alessandro, MD
iii. Check the Surgical Pathology option
iv. Check the Frozen Section option
M. Hospital staff will follow hospital policy to determine the staff that will collect the biopsy
samples.
N. Hospital staff will request this procedure be completed in a timely manner.
O. Check to be sure donor’s INR and platelets are within normal parameters. If not, correct them
prior to collecting the biopsy.



POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 4 of 6
P. Hospital staff will collect at least two core samples with an 18 gauge needle, which is the
preferred size considering the potential risk for bleeding. However, hospital staff will have on-
site discretion to determine the most appropriate sample collection method.
Q. Hospital staff will place the samples in a sample/specimen jar with Formalin.
R. The samples will be identified with the patient label required per donor hospital policy.
S. Donor hospital staff will complete the top half of the UW OTD Liver Biopsy Consultation Report
stating who performed the biopsy the date and time the biopsy was obtained, where it was
performed, and the type of sample that was collected. The partially completed form will be
placed in the bag along with the biopsy sample.
T. Donor hospital staff will complete the Order Date, Collect Date, and Collect Time fields on the
UW Health Tissue Examination Request form and place the partially completed form in the bag
with the biopsy sample and consultation report.
U. Donor hospital staff will deliver the samples and paperwork to the emergency department.
V. The liver biopsy samples may be transported with the blood collected for infectious disease
testing if timing permits.
W. The OPC will make arrangements with a courier to complete the following:
1. Provide the OPC with an estimated time of arrival to the UWHC ED.
2. Notify OPC using UWHC’s paging service when the samples are picked up and delivered.
3. Obtain the samples from the donor hospital emergency department front desk.
4. Deliver the samples to the UWHC emergency department front desk.
X. The OPC will notify the UWHC emergency department and the UWHC surgical pathology
resident on-call of the samples and the estimated time of arrival.
Y. The samples will be delivered to surgical pathology via the pneumatic tube system (destination
501) by UWHC emergency department staff or hand-delivered by an OPC.
Z. The pathologist will notify the OPC of the results and fax the documentation to DonorNet.
1. The OPC will share the results with the MOC and/or the transplant surgeon.
2. The OPC will scan the consultation and UW Health Tissue Examination Report, as well as
record the results in the UW OTD donor record.
3. The OPC will ensure the consultation report and UW Health Tissue Examination Report is
in DonorNet as an attachment.

Procedure for Samples Collected and Evaluated at UWHC
A. The OPC will provide the appropriate biopsy instructions to UWHC staff caring for the patient.
B. UWHC staff will follow UWHC policy to determine the staff that will collect the biopsy samples.



POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 5 of 6
C. Hospital staff will request this procedure be completed in a timely manner.
D. Check to be sure donor’s INR and platelets are within normal parameters. If not, correct them
prior to collecting the biopsy.
E. The OPC will request or enter an order in HealthLink for a “Biopsy Ultrasound Guided (Liver
Biopsy)”.
F. The OPC will call the ultrasound scheduling department from 0700-1630 at 262-5279 or page
the on-call radiology resident from 1630-0700 to request the procedure stat. An interventional
radiologist and a technician will collect the samples.
G. UWHC staff will collect at least two core samples with an 18 gauge needle, which is the
preferred size considering the potential risk for bleeding. However, UWHC staff will have on-site
discretion to determine the most appropriate sample collection method.
H. UWHC staff will place the samples on telfa moistened with sterile saline and in a sterile jar.
I. The samples will be identified with the patient label required per UWHC policy.
J. The OPC will complete the top half of the UW OTD Liver Biopsy Consultation Report stating who
performed the biopsy the date and time the biopsy was obtained, where it was performed, and
the type of sample that was collected.
K. The OPC will complete the UW Health Tissue Examination Request form prior to sending the
form to the UWHC as follows:
1. Complete the Order Date, Collect Date, and Collect Time fields
2. Attending Physician Performing Procedure = OPO
3. Ordering Physician Needing Report field = Tony D’Alessandro, MD
4. Check the Surgical Pathology option
5. Check the Frozen Section option
L. The OPC or designee will either hand-deliver or use the pneumatic tube system to deliver the
biopsy samples, along with the UW Health Tissue Examination Request form and the UW OTD
Liver Biopsy Consultation Report to surgical pathology (destination 501).
M. The pathologist will notify the OPC of the results and fax the documentation to DonorNet.
1. The OPC will share the results with the MOC and/or the transplant surgeon.
2. The OPC will scan the consultation and UW Health Tissue Examination Report, as well as
record the results in the UW OTD donor record.
3. The OPC will ensure the consultation report and UW Health Tissue Examination Report is
in DonorNet as an attachment.
REFERENCES




POLICY
Established Date: 05 February 2016
Effective Date: January 2018
Title: Bedside Liver Biopsy Policy Number: 2.09

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


Page 6 of 6
UW OTD Policy 2.06 and 2.15