LOCAL ORGAN DONOR CHECKLIST
DATE: __________________________
COORDINATOR: __________________________________________
DONOR NAME: ___________________________________________
UNOS ID#___________________
CORE ID#___________________
OR Blood (1 red, 2 yellow per organ)
OPC Initial ________
RC Initial __________
Blood Cultures – 2 sets (4-10cc tubes)
OPC Initial ________
RC Initial __________
Urine Culture
OPC Initial ________
RC Initial __________
Medical Examiner/Coroner Specimens
OPC Initial ________
RC Initial __________
I-Stat Transferred
OPC Initial ________
RC Initial __________
Lidco Monitor Transferred
OPC Initial ________
RC Initial __________
( DATE, TIME, INITAL EACH LINE, AND CIRCLE YES OR NO TO BEING COMPLETED IN THE
DESIGNATED HOUR)
*Don't Forget* Date/Time _______________
Check the Idio list
Y / N
Order CMV negative blood if your pt is CMV negative
Y / N
Document involvement in patient medical record
Y / N
If split liver order 4 units of PRBC, take 2 to OR, place 2 on hold Y / N
Verify remains tracker has been started before you leave the unit at all UPMC facilities
Y / N
Verify Hospital Referral Certificate of Request has been completed
Y / N
* First Hour* Date/Time _______________
Call DRC to notify them of your arrival & document arrival date/time in LL
Introduce yourself to bedside RN & notify Attending physician of our involvement
Complete initial evaluation for O/T/E donation and determine plan of care Y / N
Give report to AOC and document initial evaluation in LL notes Y / N
*Second Hour*
Date/Time _______________
CORE Form D-2 1/3/97, 6/5, 7/25, 8/5, 8/27, 7/10/98, 3/23/00, 3/7/01, 10/2/01, 3/03,
7/04, 7/05, 2/08, 11/08, 4/09, 11/5/09, 5/19/10, 12/13/10, 12/20/10, 6/29/11
Y / N
Y / N
LOCAL ORGAN DONOR CHECKLIST
Draw blood for serologies & TT and qualify sample (2 reds, 1 purple, 12 yellows)
Y / N
Complete Hemodilution and Shipping information in LL
Y / N
Notify DRC blood is ready to be picked up and request ISTAT and Lidco
Y / N
Request DL be faxed from DRC & verify Y / N
Print ABO and fax to DRC (Order stat ABO if one hasn't been completed, make sure ABOs have two
different draw times)
Y / N
*Third & Fourth Hours* Date/Time _______________
Huddle with bedside RN, Attending physician, Social Work, and Pastoral Care Y / N
Verify Pronouncement Completed & Documented Accurately, Request death certificate & hospital
paperwork be completed by pronouncing physician before they leave
Y / N
Approach family & complete Consent & med/soc (Provide family with billing sheet, book, plaque, &
offer use of donor symbol)
Y / N
*Fifth Hour* Date/Time _______________
Fax Consent, DL and Pronouncement to DRC
Y / N
Notify ACR and PSL of your presence at the hospital
Y / N
Consult Intensivist & start ODST/CCM form & billing sheet
Y / N
Stop Pre-pronouncement meds & order antibiotics if needed
Y / N
Order Eye Care (Lacrilube and/or saline pads)
Y / N
Review most current labs and add/change/continue maintenance fluid
Y / N
Order T4 and give cardiology a heads up if you think you might need an echo or cath
Y / N
Order initial labs (ABG, BMP, LFTs, GGT, LDH, Coags, CBC, Amylase, Lipase, Urinalysis)
Y / N
*Sixth & Seventh Hours* Date/Time _______________
Enter patient into Monitor Study and document into LL notes
Y / N
Set up Lidco Monitor
Y / N
Run ISTAT simulator and controls Y / N
Complete Physical Assessment & document in LL
Y / N
* Eighth & Ninth Hours* Date/Time _______________
Enter Consent & med/soc into LL
Y / N
Complete in LL: NOK, Donor Demographics, Admission Course, Med Standards Checklist, Med/soc
UNOS, Labs, Urinalysis, Hemodynamic (except meds section and I&O section), cardiac Evaluation
EKG, Pulmonary Evaluation CXR
Y / N
Complete initial referral page of LL
Y / N
Upload into Donornet
Y / N
*Tenth & Eleventh Hours* Date/Time _______________
Complete first page of Donornet, add coags to lab section, verify u/a transferred over, copy & paste
toxicology screen to lab section, copy and paste EKG to tests section
Y / N
Fax EKG image to DRC and notify them to run lists
Y / N
Complete in LL: Hemodynamic meds section and I&O section
Y / N
Complete meds tab in Donornet
Y / N
Notify DRC that Donornet is ready for placement
Y / N
Complete Heart and Lung evaluation with an O2 challenge
Y / N
Obtain new labs from the ISTAT
Y / N
*Twelfth Hour*
Date/Time _______________
Notify Eye Bank if other than CORE
Y / N
Call OR with a heads up, establish who will contact anesthesia
Y / N
Page 2
CORE Form D-2 1/3/97, 6/5, 7/25, 8/5, 8/27, 7/10/98, 3/23/00, 3/7/01, 10/2/01, 3/03,
7/04, 7/05, 2/08, 11/08, 4/09, 11/5/09, 5/19/10, 12/13/10, 12/20/10, 6/29/11
LOCAL ORGAN DONOR CHECKLIST
Call Medical Examiner & document in LL then complete Medical Examiner Form
Y / N
Call Funeral Home & document in LL
Y / N
Call Kurt with hand & PHBI evaluation
Y / N
Set up transportation for teams if you are at a non-local hospitaL
Y / N
Update AOC and request permission to order a bronch and echo
Y / N
*Thirteenth & Fourteenth Hours* Date/Time _______________
Run ISTAT simulator when needed (every 8 hours)
Y / N
Obtain new labs
Y / N
Put Echo and bronch results in LL & donornet and begin heart & lung placement
Y / N
Update Vitals in LL & Donornet
Y / N
Call OR to set OR time and verify anesthesia is aware, request slush machines, bronch cart, and
defibrillator with internal paddles
Y / N
*Fifteenth Hour*
Date/Time _______________
Complete Paper Chart: Don't forget to fill out Op notes and Heart & Lung triplicate forms if needed
Y / N
Once organs are placed order any necessary organ preps
Y / N
Complete Organ Information tab in LL
Y / N
*Sixteenth Hour* Date/Time _______________
Obtain OR blood, urine culture, blood cultures, and Medical Examiner specimens
Y / N
Call DRC to discuss which organs & research projects are being recovered, who is recovering, and verify
transportation has been set up for all teams
Y / N
Conduct a meeting with the OR staff and change into hospital scrubs or a bunnysuit
Y / N
*Seventeenth Hour*
Date/Time _______________
Complete CCM form
Y / N
Complete Hypothermia Workbook
Y / N
Make sure Vitals, Labs, and I&Os are up to date
Y / N
Make sure U/A & CXR are within UNOS Time requirement
Y / N
Obtain Tissue # from DRC
Y / N
*Intra-op* Date/Time _______________
Review paperwork with surgeons (ABO, Consent, Med/Soc, Serologies, Pronouncement)
Provide Anesthesia with paperwork (request copy of their record after xclamp)
Timeout #1
Moment of Silence
Fill out pre-printed labels and label OR blood & cultures
Obtain signatures from Recovery Coordinator (Checklist and Signature page)
Timeout #2 (Heparin, blood cultures, ME specimens)
Complete Intra-Op
Complete Kidney Anatomy
Obtain physician signatures (Op note, signature page, coroner book)
Fax any necessary paperwork to DRC (DCD form)
Copy Op notes and place original in patient medical record
Return medical record & obtain signature
Ensure all papers are in the paper chart
Ensure all of LL is complete (Don't forget Tissue demographics page for tissue/cornea donors)
Page 3
CORE Form D-2 1/3/97, 6/5, 7/25, 8/5, 8/27, 7/10/98, 3/23/00, 3/7/01, 10/2/01, 3/03,
7/04, 7/05, 2/08, 11/08, 4/09, 11/5/09, 5/19/10, 12/13/10, 12/20/10, 6/29/11
LOCAL ORGAN DONOR CHECKLIST
Leave Funeral Home packet, belongings, & specimens with the body (and Coroner book in WV)
Clean OR
Transport body to the morgue
Contact ME or Funeral Home on a recorded line
Update AOC with outcome of OR
Notify DRC when you are leaving the hospital
Page 4
CORE Form D-2 1/3/97, 6/5, 7/25, 8/5, 8/27, 7/10/98, 3/23/00, 3/7/01, 10/2/01, 3/03,
7/04, 7/05, 2/08, 11/08, 4/09, 11/5/09, 5/19/10, 12/13/10, 12/20/10, 6/29/11