donor/referral process: an overview

Donor/Referral Process:Donor/Referral Process:An OverviewAn Overview

Laura Stacie & Heather Laura Stacie & Heather LindnerLindner

Organ Procurement Organ Procurement CoordinatorsCoordinators

Organ Procurement Organ Procurement CoordinatorCoordinator

8 Coordinators for UW-OPO8 Coordinators for UW-OPO Staffed 24/7Staffed 24/7 Job DescriptionJob Description

– Take new referrals/Check on existing Take new referrals/Check on existing referralsreferrals

– Work-up cases/On-going family Work-up cases/On-going family supportsupport

– Take outside organ offersTake outside organ offers

Referral Phase – Recovery PhaseReferral Phase – Recovery Phase

1.1. Referral PhaseReferral Phase

2.2. Consent PhaseConsent Phase

3.3. Serology PhaseSerology Phase

4.4. Management PhaseManagement Phase

5.5. Allocation PhaseAllocation Phase

6.6. Recovery PhaseRecovery Phase

How do I make a How do I make a referral?referral?

1-866-UWHC-OPO1-866-UWHC-OPO

(1-866-894-2676)(1-866-894-2676)

A A mechanically ventilatedmechanically ventilated patient with patient with

a severe neurologic insult or injurya severe neurologic insult or injury

For whom a physician is evaluating for brain death

OR A patient with a Glasgow Coma Scale (GCS) < 5

OR A plan to discuss withdrawal of life-sustaining

therapies

Clinical TriggersClinical Triggers

What information What information

does the OPOdoes the OPO need on the need on the initial referral?initial referral?

Have patient’s chart available!Have patient’s chart available!

– NameName– AgeAge– Ventilator statusVentilator status– Cause of deathCause of death– Coroner’s Case (County of accident/event)Coroner’s Case (County of accident/event)– Past Medical/Social HistoryPast Medical/Social History– Height/WeightHeight/Weight– Current pressors, vital signs, neuro status, Current pressors, vital signs, neuro status,

labslabs– Family status/ Plan of CareFamily status/ Plan of Care

Initial Screening InformationInitial Screening Information

Kidneys:Kidneys: BUN, Cr, UA, C&S, UOP, Age < 75BUN, Cr, UA, C&S, UOP, Age < 75 Liver:Liver: LFT’s, Age <70LFT’s, Age <70 Pancreas: Amylase, Lipase, Age <55Pancreas: Amylase, Lipase, Age <55 Heart:Heart: EKG, Echo, Cardiac CathEKG, Echo, Cardiac Cath Lungs:Lungs: O2 Challenge, Bronch, CXR, O2 Challenge, Bronch, CXR,

Sputum Gram Stain, Lung Sputum Gram Stain, Lung Measurements Measurements

(Information needed to determine patient (Information needed to determine patient elligibility. May rule a patient out on initial elligibility. May rule a patient out on initial referral.)referral.)

Current Criteria for Organ Current Criteria for Organ DonationDonation

Pt declared brain dead –or—Pt declared brain dead –or— Pts with severe neuro injury and family Pts with severe neuro injury and family

and MD are withdrawing vent supportand MD are withdrawing vent support Up to age 75Up to age 75 No active malignancy (except CNS No active malignancy (except CNS

tumors)tumors)

Remember….donors are evaluated on case by Remember….donors are evaluated on case by case basis.case basis.

Following ReferralsFollowing Referrals

If withdrawal or brain death is not If withdrawal or brain death is not imminent, communication plan made imminent, communication plan made with RNwith RN

Usually 1-2 days between phone calls. Usually 1-2 days between phone calls. On imminent patients, checks made On imminent patients, checks made more frequently more frequently – If RN is busy, OPC will call backIf RN is busy, OPC will call back

If pt improves, referral closedIf pt improves, referral closed

Information the OPC Needs to Information the OPC Needs to KnowKnow

Current status of patient Events happening during the

course of the day Family plans

If brain death is suspected If brain death is suspected or or

the family has decided to WD the family has decided to WD supportsupport

we will move on to the next we will move on to the next phasephase..

Diagnosing and Declaring Brain Diagnosing and Declaring Brain DeathDeath

Known cause of irreversible brain injuryKnown cause of irreversible brain injury Absence of:Absence of:

– CNS depressants, including alcohol or CNS depressants, including alcohol or sedativessedatives

– Neuromuscular blockadeNeuromuscular blockade– Severe metabolic, hemodynamic, or Severe metabolic, hemodynamic, or

endocrine derangementendocrine derangement Core Temperature > 32 degrees C (90 Core Temperature > 32 degrees C (90

degrees F)degrees F) Clinical examClinical exam Confirmatory TestsConfirmatory Tests

Elements of brain death Elements of brain death declarationdeclaration

DateDate TimeTime Complete documentation of clinical exam Complete documentation of clinical exam

and apnea testand apnea test Confirmatory Test results-if performedConfirmatory Test results-if performed Physician SignaturePhysician Signature

Note: We can provide a template if needed.Note: We can provide a template if needed.

Futility NoteFutility Note

Needs to state by MD that they have spoken Needs to state by MD that they have spoken with the family and care is futile. The with the family and care is futile. The decision has been made to withdraw care decision has been made to withdraw care by the family.by the family. – Date, time, and signature are also needed.Date, time, and signature are also needed.

A sample futility note can be provided.A sample futility note can be provided.

Consent PhaseConsent Phase

Team HuddleTeam Huddle Understanding of grave Understanding of grave

prognosis/brain deathprognosis/brain death Dual advocacyDual advocacy

Serology PhaseSerology Phase

Eligible donor + verbal interest Eligible donor + verbal interest from family = start serologies. from family = start serologies.

Serology instruction form Serology instruction form – Please fax back to coordinator once Please fax back to coordinator once

filled out.filled out.

Coordinator sets up Coordinator sets up transportation for serologies.transportation for serologies.

Serology PhaseSerology Phase

RN RN ER ER Courier picks up blood at ER and drives to Courier picks up blood at ER and drives to

Madison.Madison.

OPO Coordinator alerts core lab and tissue typing OPO Coordinator alerts core lab and tissue typing of blood arrival and they prep kits for testing.of blood arrival and they prep kits for testing. – Serologies take about 4 hours to complete.Serologies take about 4 hours to complete.

BLOOD

Serology TestingSerology Testing

HBSAg- Hepatitis B Surface AntigenHBSAg- Hepatitis B Surface Antigen Anti- HBC- Hepatitis B coreAnti- HBC- Hepatitis B core Anti- HCV- Hepatitis C VirusAnti- HCV- Hepatitis C Virus HIV 1 and 2- Human Immunodeficiency VirusHIV 1 and 2- Human Immunodeficiency Virus HTLV 1 and 2- Human T-cell HTLV 1 and 2- Human T-cell

leukemia/lymphoma virusleukemia/lymphoma virus RPR- Rapid Plasma Reagin test- Tests for RPR- Rapid Plasma Reagin test- Tests for

syphilissyphilis CMV- Cytomegalovirus (many are positive)CMV- Cytomegalovirus (many are positive) EBV- Epstein Barr VirusEBV- Epstein Barr Virus

Management PhaseManagement Phase

Medical Social HistoryMedical Social History Family SupportFamily Support Placement of appropriate linesPlacement of appropriate lines Monitoring lab valuesMonitoring lab values Monitor vital signs/UOP/CVP/gtt useMonitor vital signs/UOP/CVP/gtt use Organ EvaluationOrgan Evaluation

Medical/Social History and Medical/Social History and Family SupportFamily Support

Medical/Social History completed Medical/Social History completed prior to allocation/recovery prior to allocation/recovery

Complete with person who knows Complete with person who knows the pt bestthe pt best– May be done with multiple peopleMay be done with multiple people

OPO always available for family OPO always available for family support support

Information Needed to Evaluate Information Needed to Evaluate DonorDonor

– FACE sheet/Demo Sheet (urgent information)FACE sheet/Demo Sheet (urgent information)– Copy of blood type (urgent information)Copy of blood type (urgent information)– H&PH&P– Chest x-rays, CT scans, EKGChest x-rays, CT scans, EKG– Dictated consultsDictated consults– Daily Nursing Flow sheets with vitals and I&O’sDaily Nursing Flow sheets with vitals and I&O’s– ER flow sheetsER flow sheets– Meds from last 24 hoursMeds from last 24 hours– Blood Products administeredBlood Products administered– Consent form (2 if DCD)Consent form (2 if DCD)– Labs since admissionLabs since admission– Brain Death clinical exam/apnea test results or DCD Brain Death clinical exam/apnea test results or DCD

futility notefutility note

Please send ASAP (No need to send all at once)Please send ASAP (No need to send all at once)

Placement of LinesPlacement of Lines

An arterial line and a central line neededAn arterial line and a central line needed– Many times CVP’s will need to be measured Many times CVP’s will need to be measured – Lines placed by the MD’s, residents, etcLines placed by the MD’s, residents, etc– Needed for most casesNeeded for most cases

Lab Values/Blood CulturesLab Values/Blood Cultures

Stat labsStat labs– ABO/RH Typing and Type and Screen ABO/RH Typing and Type and Screen

(IMPORTANT TO OBTAIN ASAP with (IMPORTANT TO OBTAIN ASAP with Demo/FACE Sheet!!!)Demo/FACE Sheet!!!)

– Blood Cultures x 2 (different sites), Blood Cultures x 2 (different sites), Sputum Culture with Gram Stain, Urine Sputum Culture with Gram Stain, Urine Culture and Sensitivity, UACulture and Sensitivity, UA

– CBC with diff., ABG, Chem 10, LFT’s, CBC with diff., ABG, Chem 10, LFT’s, Coags, Amylase, Lipase, Cardiac Enzymes, Coags, Amylase, Lipase, Cardiac Enzymes, HgbA1cHgbA1c

Lab Values (cont.)Lab Values (cont.)

Every 6-8 hours re-checkEvery 6-8 hours re-check– CBC, Chem 10, LFT’s, Coags, Amylase, lipase, CBC, Chem 10, LFT’s, Coags, Amylase, lipase,

cardiac enzymescardiac enzymes

Standing orders are given to replace Standing orders are given to replace electrolytes.electrolytes.

Changes will be made by coordinator if Changes will be made by coordinator if needed.needed.– If brain dead patient--OPO can give ordersIf brain dead patient--OPO can give orders– If DCD patient--OPO can give suggestions.If DCD patient--OPO can give suggestions.

V/S, UOP, CVP, Drips…V/S, UOP, CVP, Drips…

Measured every hour Measured every hour Use orders/recommendations given by the Use orders/recommendations given by the

coordinator.coordinator. Rule of 100’sRule of 100’s

– SBP above 100SBP above 100– PaO2 above 100PaO2 above 100– UOP at 100ml/hrUOP at 100ml/hr

Organ EvaluationOrgan Evaluation

EchocardiogramEchocardiogram BronchoscopyBronchoscopy Multiple chest x-raysMultiple chest x-rays Cardiac CathCardiac Cath Abdominal CTAbdominal CT O2 ChallengesO2 Challenges Multiple ABG’sMultiple ABG’s

Allocation PhaseAllocation Phase

Once all of this information is received, entered into Once all of this information is received, entered into our databases, tests are complete, and serologies our databases, tests are complete, and serologies are done, we can begin allocationare done, we can begin allocation

ALLOCATION: ALLOCATION: The process used to offer out The process used to offer out organs according to the UNOS list of recipients that organs according to the UNOS list of recipients that

need an organ transplant.need an organ transplant.

Organ AllocationOrgan Allocation

Information is entered in database and lists Information is entered in database and lists are runare run

Lists show recipients that are matches to the Lists show recipients that are matches to the donordonor

Based upon:Based upon:– Length of wait timeLength of wait time– AntibodiesAntibodies– Status 1A (Very sick pt)Status 1A (Very sick pt)– 0 mismatches (PERFECT MATCH)0 mismatches (PERFECT MATCH)

Local, regional, and national unless there is a Local, regional, and national unless there is a Status 1 recipient listed.Status 1 recipient listed.

Organ AllocationOrgan Allocation

Each organ allocated separately.Each organ allocated separately. Each transplant center has 1 hour to Each transplant center has 1 hour to

acknowledge offeracknowledge offer Each transplant center has 1 hour from time of Each transplant center has 1 hour from time of

information to make decisioninformation to make decision Can be a very long and tedious processCan be a very long and tedious process There are many, many phone calls during this There are many, many phone calls during this

period period Additional tests may be requested during this Additional tests may be requested during this

time. time. Lots of communication with transplant Lots of communication with transplant

physicians to determine if recipient is a good physicians to determine if recipient is a good fit for this donor fit for this donor

UNet Screen ShotUNet Screen Shot

RecipientsRecipients

Once a recipient is selected for an organ, a Once a recipient is selected for an organ, a transplant coordinator calls the patient into transplant coordinator calls the patient into the hospitalthe hospital– Recipients always are available by cell Recipients always are available by cell

phone or pagerphone or pager They have 1 hour to respond and make They have 1 hour to respond and make

decisiondecision Need to get to hospital and get readyNeed to get to hospital and get ready

– Labs, x-rays, prepped for ORLabs, x-rays, prepped for OR

TIME TO GO!!!TIME TO GO!!!

Once Allocation is complete it is time to get Once Allocation is complete it is time to get our team ready to go!our team ready to go!

Usually a Surgical Recovery Coordinator, a Usually a Surgical Recovery Coordinator, a recovery physican, and an assistant will go recovery physican, and an assistant will go on case on case – An OPC will go on every DCD caseAn OPC will go on every DCD case

The coordinator will arrange transportation The coordinator will arrange transportation (flight) to airport and then transportation (flight) to airport and then transportation from airport to hospitalfrom airport to hospital

Recovery Phase: Surgical Recovery Phase: Surgical Recovery of OrgansRecovery of Organs

All organs except kidneys need to be allocated to All organs except kidneys need to be allocated to specific recipient prior to recoveryspecific recipient prior to recovery

All infectious disease tests must be completed All infectious disease tests must be completed and confirmedand confirmed

Some teams will need time to fly in from their Some teams will need time to fly in from their location (Could be multiple teams)location (Could be multiple teams)

UWHC transplant team must be in the OR before UWHC transplant team must be in the OR before taking the pt to the ORtaking the pt to the OR

Brain Death Recovery Process

Patient is maintained on ventilator throughout Patient is maintained on ventilator throughout organ recoveryorgan recovery

Organs are dissected in situOrgans are dissected in situ 3-4 hour surgery3-4 hour surgery Heart, lungs, liver, kidneys, pancreas and Heart, lungs, liver, kidneys, pancreas and

intestines can be recoveredintestines can be recovered

Donation After Cardiac DeathDonation After Cardiac Death

Withdrawal of life support in OR or ICUWithdrawal of life support in OR or ICU Cardiac death occursCardiac death occurs Surgery begins 5 minutes after cessation of Surgery begins 5 minutes after cessation of

cardiac function and declaration by patient’s cardiac function and declaration by patient’s physicianphysician

Rapid recovery with organs procured en blocRapid recovery with organs procured en bloc 1-2 hour surgery1-2 hour surgery Lungs, liver, kidneys and pancreas can be Lungs, liver, kidneys and pancreas can be

recoveredrecovered

Preservation TimesPreservation Times

Heart: 4-6 hoursHeart: 4-6 hours Lungs: 4-6 hoursLungs: 4-6 hours Liver: 12 hoursLiver: 12 hours Pancreas: 12-18 hoursPancreas: 12-18 hours Kidneys: up to 72 hoursKidneys: up to 72 hours Small Intestines: 4-6 hours+Small Intestines: 4-6 hours+ Tissues: up to 3-4 yearsTissues: up to 3-4 years Corneas: up to 7 daysCorneas: up to 7 days

What happens after a case?

The organs are taken back to the transplant centers The organs are taken back to the transplant centers and either cold stored or transplanted right away.and either cold stored or transplanted right away.

– Liver/Pancreas- Recipient waiting and transplant Liver/Pancreas- Recipient waiting and transplant happens very quickly.happens very quickly.

– Heart/Lungs- Recipient already in OR when organs Heart/Lungs- Recipient already in OR when organs arrive and transplant happens immediately. (Lots arrive and transplant happens immediately. (Lots of communication needed!!) of communication needed!!)

– Kidneys- Can be transplanted soon after arrival or Kidneys- Can be transplanted soon after arrival or placed on kidney pump for up to 24 hours. placed on kidney pump for up to 24 hours.

Pumping helps to preserve and work more Pumping helps to preserve and work more efficiently.efficiently.

What happens after a What happens after a case?? (cont.)case?? (cont.)

If organs are not staying at our transplant If organs are not staying at our transplant center the surgical recovery coordinator center the surgical recovery coordinator packages the organs and ships them to the packages the organs and ships them to the transplant centers accepting the organs.transplant centers accepting the organs.

Other things done after a case…Other things done after a case…– BiopsiesBiopsies– Lymph Node/Spleen typingLymph Node/Spleen typing– More dissection/cleaning up the organsMore dissection/cleaning up the organs

After Action ReviewsAfter Action Reviews

About 1 week after the case happenedAbout 1 week after the case happened– OPO StaffOPO Staff

CoordinatorsCoordinators Hospital Service SpecialistHospital Service Specialist Surgical Recovery StaffSurgical Recovery Staff

– Hospital StaffHospital Staff RN’s working w/ donorRN’s working w/ donor ICU ManagerICU Manager Hosp. LiasonHosp. Liason OR staffOR staff ChaplainsChaplains

Safe environment to discuss what went well Safe environment to discuss what went well and things that need improvement!!and things that need improvement!!

Through donationThrough donation ... ...

......lives are changed lives are changed foreverforever

QUESTIONS????QUESTIONS????