Successful referrals are largely dependent on how well a hospital has been educated or "developed" by the organ procurement organization (OPO) prior to the actual referral. This "development" is a service provided to hospitals by the OPO, with the overall goal of implementing educational programs and strategies that maximize the hospital's ability to identify potential organ and tissue donors.
Specific strategies should include the development of a hospital profile, detailing the flow of decision making within the institution as it affects donor activity. This profile ensures that key hospital personnel involved are aware of their individual role in the process.
Other services provided by the OPO include: assisting hospital personnel in the development and implementation of organ recovery policies and procedures; providing donor education and awareness programs to hospital personnel; conducting donor and referral follow-up conferences and meetings; and assessment of the hospital's compliance with federal and state laws regarding organ and tissue donation.
The Hospital/OPO Relationship
One vital way for OPOs to increase donor referrals is by providing quality service. This is done, in part, by acknowledging that the hospital is the vital link to organ donors. The challenge for the OPO lies in helping hospitals to organize their practices so that: 1) all eligible families are offered donation, and 2) the elements associated with higher rates of consent (privacy, decoupling, and OPO participation) are incorporated into each donation request.1
Generally, hospitals are committed to donation and appreciate assistance in identifying potential areas for improvement. When weaknesses in donor identification are noted, hospitals are eager to improve their performance. By providing hospital-specific feedback on identification and referral rates, along with guidelines on when to call the OPO, this critical first phase of the process can be dramatically improved. During a two-year period following Southwest Transplant Alliance's implementation of development plans targeted to meet specific hospital needs, eight of nine hospitals studied experienced a decrease in the number of "not identified" donors. Essential to these hospital-specific development plans was cultivating and educating key personnel involved in the donor process. Active collaboration between the hospital and OPO is essential to increasing donor referrals. When a hospital feels the working relationship with the OPO is a true partnership, the hospital develops a sense of "ownership" for the success of the donation process and an increased responsibility for identifying and referring potential donors.
A strong working relationship between the OPR and the potential donor's nurse is essential because the nurse serves as an invaluable member in the donation process. Initially, the nurse updates the OPR on the potential donor's medical status and hemodynamic stability. Of equal importance, the nurse may be able to give the OPR insight into the dynamics of the potential donor family. This includes identifying the next of kin, discussing how the family is dealing with the death, and identifying any difficult family dynamics. The nurse can also provide invaluable information on the family's religious, cultural and socioeconomic background. Other staff members, including pastoral care and social work can also be very helpful in this area.
Typically, potential organ donors have suffered a devastating neurological injury, considered nonsurvivable in nature. Calls referring potential organ donors usually originate from critical care areas and emergency departments. The patient being considered as a potential donor requires mechanical ventilation and often requires hemodynamic support.
The OPR gathers essential information during the referral phone call, e.g., the patient's name, age, sex, race and cause of impending death. A brief hemody-namic summary may also be requested.
Depending on the OPO's policy, the OPR usually goes to the hospital to further evaluate the patient as a potential donor. An on site assessment is important for: 1) building the partnership between hospital and OPO, 2) interacting with the family, and 3) making an accurate assessment of the potential donor.
It is also important to get a complete picture of both the medical and family situations through conversations with physicians, nurses, chaplains, or social workers involved. Speaking with the primary physician and/or the neuroscientist helps the OPR in obtaining the potential donor's medical history and hospital course, and also aid in planning the family approach.
The potential donor's physician is encouraged not to bring up organ donation at the same time he/she is explaining that the patient is brain dead. Families need to experience their initial grief before making decisions about what to do next. We recommend that the physician inform the family of the patient's brain dead status and close the conversation by letting them know that there are important options to consider and that someone will be speaking with them about these options shortly.
Once the OPR has become acquainted with the hospital staff, the next phase is developing a pre-donation plan for approaching the family.
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