LOCAL ORGAN DONOR CHECKLIST

DATE: ______

COORDINATOR: ______

DONOR NAME: ______

UNOS ID#______CORE ID#______

TT Material (Minimum 8-sets)OPC Initial ______RC Initial ______

Blood Cultures – 2 sets (4-10cc tubes)OPC Initial ______RC Initial ______

Urine CultureOPC Initial ______RC Initial ______

Medical Examiner/Coroner SpecimensOPC Initial ______RC Initial ______

I-Stat ReturnedOPC Initial ______RC Initial ______

Serology and Tissue Typing Minimum Specimen Requirements

Required # of ACD Yellow Top Tubes Needed just for HLA Typing / Required # of Yellow Top Tubes Needed just for Crossmatches / Required # of Lymph Nodes Needed for Crossmatches
Tissue Typing Lab / 4 Tubes / 4 Tubes / 3-5
Absolute Minimum # of ACD Yellow Top Tubes Needed just for HLA Typing / Absolute Minimum # of Yellow Top Tubes Acceptable just for Crossmatches / Absolute Minimum # of Lymph Nodes Acceptable for Crossmatches
Tissue Typing Lab / 4 Tubes / 4 Tubes / 3

Serology testing on infants/pediatric donors – please drawn a minimum of six (6) plain red bullet tubes

Pediatric donors …get what you can for HLA’s in pediatric tubes…….what you have been doing. Cross matches can be done on lymph nodes after the organ recovery.

Note: The tissue typing labs always run their cross matches at the same time that they are running the HLA typing. Please draw enough blood to do both tests. i.e. 4+4 = 8 tubes

In the event that your donor is unstable and you absolutely cannot get blood for both tests, send enough blood for the HLA typing and inform tissue typing to run only HLA’s.

SECTION I - INITIAL CONTACTS (On-Site Coordinator)

* Did you:

______Notify Administrator on call?

______Introduce yourself to unit staff: Head Nurse Primary Nurse Unit Clerk

______Alert attending physician that CORE was notified?

______Send blood (marked "pre" or "post") for serologies?

(2 red tops and 1 purple (EDTA) top) - document transportation on donor chart)

______Qualify blood samples using Hemodilution Worksheet

______Ensure that blood for two ABO’s are obtained and performed from two separately collected blood draws

______Tape blood tubes securely?

______Send blood for tissue typing if donor is stable? (DO NOT PUT ON ICE)

______Send Tissue Typing to appropriate Tissue-Typing Lab (If the donor is in West Virginia contact the AOCto see if HLA’s should be performed in Charleston)

______Get early consideration, evaluation for cardiac consult, if applicable?

______Use *'s to indicate all tests requested by CORE?

______Perform complete physical assessment of patient?

______Stop pre-pronouncement medications?

SECTION II - PRE-CONSENT (On-Site OPC)

______Inquire regarding patient hemodynamics? family dynamics?

______Inquire regarding results of first/second clinical exam (apnea test)?

______Review patient's medical record?

______Establish whether confirmatory test will be performed at this time?

______Obtain hard copy (+ABO) and declaration of death?

______If ordering blood, request CMV (-) or CMV Safe blood?

If a tissue/eye donor,

_____ Instill sterile ophthalmic antibiotic solution or sterile saline or balanced salt solution (2 drops per both eyes).

Apply lubricating ointment to ventilator maintained donors.

Lightly tape eyelids closed with paper tape.

Lightly apply wet ice packs over eyes, securing them gently into place.

Elevate head 35 degrees

Determine suitability for transplant, research or education

SECTION III – CONSENT (On-Site OPC)

______Obtain consent from legal next-of-kin?

______Provide family with CORE "Billing" letter? (CORE Form B-1)

______Obtain Coroner/Medical Examiner consent form immediately after consent (if applicable) ?

______Obtain autopsy consent, if applicable?

______Offer use of donor symbol to family?

SECTION IV - ADDITIONAL CONTACTS

______Consult CCM Intensivist on brain death and DCD donors.

______Obtain tissue Identification number?

______Notify proper Eye Bank with preliminary call (Eye donor only)?

______Contact OR to schedule OR time/inform of potential recovery?

______Contact funeral home?

Offer option of PittsburghInstitute of Mortuary Science Involvement, if within 50 mile radius

______Provide consulting physicians billing letter.

SECTION V - PRE-RECOVERY (ON-SITE COORDINATOR)

______Complete Coroner's booklet (if applicable)?

______Order two (2) slush machines for the operating room

______Complete labels for organ disposition and Tissue Typing?

______Document CORE's involvement in patient medical record?

______Assure documentation of disposition of all organs consented for?

______Assure that chest Xray was taken and recorded on donor form?

______Complete Hospital Certificate of Request?

______If split liver, order four (4) units of PRBC's from blood bank with two being in the OR at scheduled time?

______Provide Anesthesia with:

"Anesthesia Checklist"? (CORE Form R-4)

Anesthesia billing letter (CORE Form B-4)

Conduct a pre-recovery conference?

_____ Verify and confirm the donor’s ABO with each organ’s lead surgeon.

______Verify that there are two ABO’s drawn from two different blood collection times

Introduce team?

Provide copy of consent and pronouncement?

Provide instruments to be flashed?

Provide surgeons' license numbers and glove sizes? (CORE Form D-6)

Provide Performance Survey and envelope?

Provide surgeons with:

Medical record?

Chart?

Lab and serology findings?

Chest x-ray?

______Obtain defibrillator paddles and have charged in OR prior to incision.

Secure six (6) red tops and label?

______Secure and label blood cultures from 2 sites (2- 10 cc SPS yellow tops each site) and 1 urine culture

If donor is unstable the second site blood culture can be secured in the OR.

Local Organ Donor Checklist

(ORGAN PROCUREMENT COORDINATOR)

______Meet recovery coordinator and team in the OR?

______If Coroner/Medical Examiner Case:

Obtain 40 - 50cc blood? Obtain 15cc bile (organ donor only) Obtain 50cc urine

Establish whether procedure must be videotaped? Complete Coroner's booklet,

Label all specimens/photos? Tape specimens to body?

______If a drowning, use a dry syringe and extract 2-5 cc of blood from right and left atrium?

______Obtain renal anatomy of kidneys?

______Have renal surgeon sign donor chart regarding anatomy?

______Place Operative Note in patient chart?

______Obtain copy of ABO?

______Obtain hard copy of pronouncement?

______Contact specific Eye Bank regarding enucleation arrangements?

SECTION VI - POST RECOVERY

(ORGAN PROCUREMENT COORDINATOR)

______If autopsy will be performed, assure that the body will not be released until a.m.?

______Leave Pathologist form with body (only in designated cases)?

______Leave coroner specimens attached to the body (unless Charleston ME case)?

______Complete Post Recovery OR Form /leave with body? (CORE Form R-1)

______Notify funeral home or coroner's office to pick up body?

Name of Funeral Director or coroner/ME: ______

______Assist OR staff with transport of body to morgue?

______Complete donor chart?

______Fax or export all chart information, including kidney anatomy to DRC and/or give recovery staff disk with chart before leaving hospital?

______Provide Data Coordinator with Coroner's booklet, photos, and video, if applicable?

______Complete QA Local Donor Survey?

Verify funeral home, pathologist., coroner/Medical Examiner notified?