The Organ Procurement Process

Virtually all OPOs recover multiple organs from donors, whenever possible. Additionally, some OPOs also recover eyes and tissues. It is the responsibility of the OPO to initially evaluate potential donors for medical suitability. This requires the clinical coordinators to have extensive medical knowledge about the physiology and function of multiple organ and tissue systems. The coordinators must be skilled at reviewing, sometimes voluminous, medical records for pertinent information that may provide insight about organ function or that may identify contraindications to donation. Coordinators also must be resourceful in determining past medical history and high-risk behaviors. This information is obtained through previous hospital admissions, as well as discussions with nurses, attending and family physicians, and friends and family members. Obviously, the coordinators must exercise the utmost sensitivity when discussing these issues with family members and friends.

Clinical coordinators and other staff receive specific training in counseling grieving family members about the organ donation process. Some OPOs also train designated requestors, who typically are hospital employees. This is especially important in situations where the hospital is located a significant distance from the OPO. It is imperative that the families of potential donors are approached regarding the option of donation with compassion and sensitivity, recognizing the sudden loss of their loved one. As noted previously in this chapter, OPOs are required either to speak directly to the family about consent for donation or they must be involved by training a designated requestor. Many past studies have shown that personnel from OPOs are more effective than nurses, physicians or hospital h clergy in securing consent. However, recent studies have demonstrated that the 4 consent rate is even higher when the discussion is conducted jointly by a member of the OPO along with a member of the hospital staff. It is important that the OPO coordinator provide complete information to the family about the donation process, including the timeframe for completion. The coordinator also must provide updates to the family if there are unexpected delays. It is imperative that the family not feel pressured or harassed. Their decision about donation should be respected even if their answer is no. Coordinators must be cognizant of the critical balance between the desire to get consent for a given donation and the possible ill will that could result from alienating a potential donor's family.

Once a donor has been identified and the family has consented to donation, it is critical that appropriate medical management is provided to ensure that the organs are functioning optimally at the time of recovery. Before the OPO can begin its involvement in medical management, death must be declared and documented appropriately in the donor's medical record. The first step in the donor management process is to determine the current status of organ function. This is accomplished by physical examination, review of past and current medical records, obtaining necessary laboratory tests and other diagnostic tests or consultations. A detailed discussion of medical management of deceased organ donors is beyond the scope of this chapter, but several key objectives are described as follows. Perfusion and oxygenation are the two main goals of donor management. Maintenance of normal blood pressure, fluid electrolytes and blood oxygen levels are the key ingredients in accomplishing those objectives. In the process of managing the donor to achieve optimal function of one organ, coordinators must be careful not to compromise the function of another organ. For example, it is desirable to maintain a brisk diuresis in the kidneys up to the moment of surgical recovery. However, overhydrating a donor may cause excess fluid in the lungs and may compromise pulmonary function. It is important for the medical management of the donor to be performed in a manner consistent with the optimum function of all transplantable organs.

The coordinators also are responsible for ordering laboratory tests to determine the presence of any transmissible diseases such as HIV, hepatitis or other systemic infections. All OPOs have Medical Directors or physicians designated to oversee and assist as necessary in the screening and medical management of donors. Their level of involvement in a given case depends on the complexity of the case and the experience level of the coordinator. Additionally, physicians from each of the receiving transplant teams may request specific tests or management parameters. It is the role of the coordinator of the host OPO to coordinate the numerous variations that often occur with different recovery teams and be as responsive as possible to the needs of each. Of course, special requests must not interfere with sound donor management and should not be permitted to compromise one organ to the benefit of another.

After the evaluation and management of the donor is in progress, the coordinator must place the organs. The federal government, through the contracted OPTN, regulates organ allocation. Coordinators must register each donor with the OPTN, and allocation is determined through computer matching by the OPTN. Once a transplant center has accepted an organ, it is the responsibility of the coordinator HI from the host OPO to communicate with the coordinator from the receiving center to coordinate and schedule the surgical recovery. The host coordinator often assists in obtaining local transportation for a team flying in from a distant location. The coordinator also should determine and assist with any special needs of that team. In some situations, one team may be removing all organs. More typically, several teams are involved in each surgical procedure. The coordinator of the host OPO is responsible for coordinating the arrival of each team and discussing the order of the surgical procedure with members of the surgical teams.

Typically, each recovery team provides its own preservation fluids and supplies. The coordinators are responsible for preparing preservation solutions and making them available to the surgical recovery team at the appropriate time during the procedure. The length of warm and cold ischemic periods are important to the anticipated function of transplanted organs, and the coordinators are responsible for documenting when these periods begin and end. Other times, such as the incision time and the time of drug administration also are documented during the procedure. Although most organs are preserved by static cold storage, some OPOs preserve kidneys by continuous pulsatile perfusion. This requires special knowledge and technical skills including surgical skills and the operation of perfusion equipment. Each preservation method has its advantages and disadvantages, but both work well provided that the length of preservation is kept within acceptable parameters.

The coordinator for each recovery team is responsible for appropriate packaging and labeling of organs, tissue typing materials, and any specimens that will accompany their organ(s). This must be done in strict compliance with OPTN policies to prevent errors and provide consistency. The receiving transplant center or laboratory may refuse organs or tissue samples that are not appropriately labeled. The OPO must have established relationships with histocompatibility laboratories for tissue typing and crossmatching. Ideally, blood or tissue samples are delivered to the histocompatibility laboratory prior to the start of the surgical recovery. However, in distant locations, it may not be practical or cost effective to arrange for prerecovery tissue typing. Lymph nodes, blood and other tissue samples are collected during the surgical recovery and the coordinator is responsible for arranging for those samples to be delivered to the histocompatibility laboratory.

Organs are transported in several ways. Sometimes they accompany the recovery team back to the transplant hospital; sometimes they are shipped by commercial or charter aircraft unaccompanied. In the case of pulsatile perfusion, the coordinator or perfusion technician attends to the machine whether the kidney is used locally or at a distant center.

Organ donation only occurs through the good will of the general public and the participation of the medical community. Successful OPOs do an effective job of following-up with members of the donor's family, medical professionals and others who were involved in a given case. An organ recovery is an enormous event involving from 20 to 100 individuals. This includes all the immediate family members, nurses and physicians in the emergency room, ICU and operating room, 4 hospital administrators, hospital security, transportation personnel and a host of I others. Prompt feedback to each of these individuals is generally very meaningful to them. Letting them know how much they are appreciated and how much their efforts contributed to saving and improving the lives of others can motivate them to participate in the future. At the very least, it helps them to feel appreciated for participating in a process that can be very stressful and emotional. Typically the feedback is in the form of a letter, but it can also come in other ways. Appropriately timed phone calls to the family are sometimes helpful and provide an opening for the family members to ask any unanswered questions they may have regarding the process. De-briefing meetings with medical professionals have been shown to be an effective way to allow staff members to ask questions or simply vent their feelings. It is also the responsibility of the OPO to follow-up on blood cultures or any other laboratory tests that were not completed prior to the recovery and report the results to receiving transplant centers.

Organ transplantation is an effective, but expensive, treatment for end-stage organ failure. Organ acquisition is a significant component of the overall expense, with the procurement-related costs of some organs exceeding $25,000. The OPO bears the initial cost of organ acquisition and is reimbursed by the transplant center that receives the organ. The transplant center then recovers that cost directly from the patient or third party payer. For kidneys, the third party payer is usually Medicare. Since kidneys represent approximately half of the activity for most OPOs, a substantial portion of OPO funding comes from this source. In fact, OPOs are required to file an annual cost report with CMS. If the cost report indicates that the OPO charged more than its actual cost for kidneys, the OPO must pay that amount back to Medicare. Conversely, if the OPO undercharged for those organs, Medicare reimburses the OPO. Where kidney costs and reimbursements are concerned, the OPO must break even with Medicare for reimbursed expenses. Although the cost report is due annually, OPOs may file for an interim adjustment during the year if they can document a substantial loss.

In the case of kidneys, all OPOs charge transplant hospitals a standard acquisition charge. They create a cost center specifically for kidneys and track all expenses attributable to kidney acquisition over the course of a year. This includes direct expenses such as donor hospital charges and transportation, as well as indirect expenses such as professional education, salaries and rent. Direct expenses are relatively simple to identify, but indirect expenses can only be reimbursed by Medicare to the extent those expenses can be tied to kidney acquisition. A portion of salaries and other indirect expenses also are allocated to the acquisition of ex tra-renal organs. Furthermore, Medicare has strict procedures for determining what expenses can be included in the kidney cost center. Once the OPO has established a financial history, it can accurately project expenses in an annual budget. The standard kidney acquisition fee is then calculated by dividing the projected kidney related expenses by the number of projected kidney transplants. Since this is only done at the beginning of each fiscal year, variations in actual versus projected costs can easily result.

Revenues that occur as a result of reimbursement for extra-renal organs are m similar to reimbursement for kidneys; however, OPOs are not required to break HI even for extra-renal organs. As nonprofit entities, OPOs are allowed to build and I maintain a fund balance, although no revenues in excess of actual cost can be acquired from kidney revenues. For many years, some OPOs operated with little or no cash reserves, which created serious difficulties in times of slow donor activity. As OPOs have become more sophisticated in their financial practices, they have realized that a strong fund balance is essential for the effective operation of their organizations. Many OPOs include financial planning as part of their annual strategic planning process. Although presently there is no industry standard, many OPOs are wisely building fund balances equal to several months of operating expenses. Unquestionably, OPOs are under intense public scrutiny to be cost effective. It is important for OPOs to expend their resources wisely and to avoid unnecessary expenses or anything the public might consider extravagant. However, it would be very fiscally irresponsible for an OPO to allow its cash reserves to diminish to a point that routine operations are compromised.

All OPOs must report their financial data to CMS annually. They also are subject to periodic financial audits by CMS. Additionally, most OPOs undergo independent financial audits. They must file a corporate tax return to the Internal Revenue Service. And, even though not required, most OPOs provide detailed information to affiliated transplant centers regarding the determination of their organ acquisition charges. In addition, OPOs have public board members that review their budgets and financial data.

In addition to financial reporting, OPOs also must comply with the data reporting requirements of the OPTN, various offices of the federal government and, in some cases, state government or health associations. OPOs must document and report organ recovery activity, compliance with federal OPO regulations, compliance with health and safety standards, compliance with OPTN membership standards, and compliance with OPTN allocation policies. Occasionally OPOs must respond to inquiries from the Office of the Inspector General and other governmental agencies. In some cases, state laws regarding donation have been enacted that require OPOs to report information to state or local health authorities. Affiliated hospitals certainly expect a high level of reporting from the OPO regarding organ recovery activity, marketing activity and finances.

Organ recovery productivity varies, sometimes dramatically, from one OPO to the next. It is in the public's interest for all OPOs to perform at a high level. High-producing OPOs often demonstrate many innovative practices that have maximized their performance. Conversely, low-performing OPOs often identify unique and sometimes unavoidable areas that detract from their performance. An open exchange of information that contributes to the industry knowledge is healthy and beneficial to all OPOs. This can best be accomplished through active participation in trade associations such as AOPO or professional associations such as NATCO, verbal or poster presentations at national meetings, and the publishing of professional papers. Although most OPOs have developed a high level of technical expertise, no OPO has claimed to discover the secret to maximizing organ h donation. There is no single magic formula for improved performance. Rather, 4 this is best achieved through a host of activities that combine to affect the behav-I ior of the public and the medical professionals. The extent to which an OPO can discover and implement effective techniques will ultimately determine its performance.

Dealing With Sorrow

Dealing With Sorrow

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