LOCAL ORGAN DONOR CHECKLIST
DATE: __________________________
COORDINATOR: __________________________________________
DONOR NAME: ___________________________________________
UNOS ID#___________________
CORE ID#___________________
TT Material (Minimum 8-sets)
Blood Cultures – 2 sets (4-10cc tubes)
Urine Culture
Medical Examiner/Coroner Specimens
I-Stat Returned
OPC Initial ________
OPC Initial ________
OPC Initial ________
OPC Initial ________
OPC Initial ________
RC Initial __________
RC Initial __________
RC Initial __________
RC Initial __________
RC Initial __________
Serology and Tissue Typing Minimum Specimen Requirements
Required # of ACD Yellow Top
Tubes Needed just for HLA
Typing
Tissue Typing Lab
4 Tubes
Absolute Minimum # of ACD
Yellow Top Tubes Needed just
for HLA Typing
Tissue Typing Lab
4 Tubes
Required # of Yellow Top
Tubes Needed just for
Crossmatches
Required # of Lymph
Nodes Needed for
Crossmatches
4 Tubes
3-5
Absolute Minimum # of
Yellow Top Tubes
Acceptable just for
Crossmatches
4 Tubes
Absolute Minimum #
of Lymph Nodes
Acceptable for
Crossmatches
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
AOC to 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 Pittsburgh Institute 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?