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Organ Recovery (3.11)

Organ Recovery (3.11) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

3.11



POLICY
Established Date: August 2011
Effective Date: January 2018
Title: Organ Recovery Policy Number: 3.11

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 outline procedures to be followed by University of Wisconsin Organ and
Tissue Donation (UW OTD) staff involved in organ recovery. It is the policy of UW OTD to recover organs for
the purposes of transplantation, education, or research within the policies and guidelines of the United
Network for Organ Sharing (UNOS), the Centers for Medicare and Medicaid Services (CMS), and the
standards set by the Association of Organ Procurement Organizations (AOPO). UW OTD will comply with all
applicable regulations and standards for organ recovery.

FORMS

Wisconsin Organ and Tissue Recovery and Assessment form
UW OTD Pre-Recovery and Intended Recipient Verification form.

POLICY

Recovery Team Composition
A. The recovery team will be comprised of at least one UW OTD surgical recovery coordinator
(SRC).
B. The recovery team may also be comprised of at least one recovery surgeon and one UW OTD
surgical recovery specialist or Advanced Practice Donation Specialist.
C. An additional UW OTD staff will accompany the team for a donation after circulatory death
(DCD) recovery, per UW OTD policy 2.07.

Pre-Recovery and Intended Recipient Verification
D. Prior to incision, the following donor information will be verified by a SRC and each recovering
surgeon:
1. The UNOS donor ID using a printed match run
2. The organ and laterality, if applicable, for each organ that is intended to be recovered for
transplantation using the printed match runs
3. The donor blood type and subtype if applicable using the information provided on two
source documents for the donor ABO. The ABO source documents will be verified by a



POLICY
Established Date: August 2011
Effective Date: January 2018
Title: Organ Recovery Policy Number: 3.11

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


Page 2 of 3

UW OTD organ procurement coordinator (OPC) per UW OTD policy 2.03 and will include
one result from the donor hospital and one from the University of Wisconsin Hospitals
and Clinics (UWHC) or two results from UWHC for UWHC donors.
E. If the intended recipient information is known prior to organ recovery, the following intended
recipient information will also be verified by a SRC and each recovering surgeon prior to
recovery of the organ:
1. The intended recipient name and unique identifier which will be the last five digits of the
intended recipient social security number using the printed match runs
2. The blood type of the intended recipient and the compatibility or intended
incompatibility of the donor and the intended recipient using the ABO results verified by
an OPC per UW OTD policy 3.03 and the recipient blood type as documented on the
printed match run.
F. The SRC and the recovery surgeons will be qualified healthcare professionals as outlined in UW
OTD policy 1.16.
G. Each recovering surgeon will complete the verification only for the organs and intended
recipients, if applicable, he/she intends to recover the organ for transplant.
H. All verification documentation will be recorded on the UW OTD Pre-Recovery and Intended
Recipient Verification form and maintained in the UW OTD donor record.

Recovery Team OR Procedures
A. The recovery team will provide anesthesia guidelines for intra-operative patient management of
brain dead donors to the anesthesia staff.
B. The recovery team will follow donor hospital policies in regards to OR procedures (such as time-
outs).
C. The recovery team will administer the preservation solutions under the direction of the recovery
surgeon.
D. A recovery surgeon will complete, sign, and date the operative report. A copy of the operative
report will be provided to a member of the recovery team to be maintained in the donor
hospital medical record and in the UW OTD donor record.
E. Organs and tissue typing materials will be packaged per UW OTD policy 3.04.
F. Organ vessels will be packaged per UW OTD policy 3.09.
G. All paperwork related to organ recovery will be maintained in the donor record.



POLICY
Established Date: August 2011
Effective Date: January 2018
Title: Organ Recovery Policy Number: 3.11

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


Page 3 of 3

Organ Check-in Process for Organs Not Recovered at University Hospital
H. Recovered organs that are taken directly to the operating room at University Hospital by
University of Wisconsin (UW) Health Transplant Program staff will be checked-in per UNOS
policy under the direction of the UW Health Transplant Program.
I. Recovered organs that are taken to the UW OTD laboratory at University Hospital by an SRC will
be checked-in per UNOS policy by the SRC on behalf of the UW Health Transplant Program.
J. Prior to opening the organ’s transport container, the SRC will verify the accuracy and completion
of the external UNOS label containing the expected donor ID and organ type and laterality (if
applicable).
K. If information on the external label conflicts with the expected information, the SRC will notify
the OPC within one hour of the determination.
L. The SRC will complete the Organ Check-in Form and will leave the form in the designated area of
the UW OTD laboratory.
M. UW Health Transplant Program staff or designee will collect and maintain the forms. UW OTD
will not maintain the forms in the UW OTD donor record.

REFERENCES

UW OTD Policies 1.16, 2.03, 2.07, 3.04, and 3.09