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Proposal to Require Extra Vessels Disposition Reporting to the OPTN in Five Days of Transplant or Disposal

Sponsored by the Operations and Safety Committee (OSC)

Phillip C. Camp, Jr, MD – Chair

Jean Davis – Vice Chair

Spring 2012

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Importance of Extra Vessel Data Tracking spread of disease

2004 - Rabies transmission through extra vessel transplant

2009 – HCV transmission through extra vessel transplant

Care and Follow up of Recipients New clinical information related to donor disease

identified post transplant; and Communicate new information – can affect outcomes - care or treatment of recipients; can save lives

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Extra Vessels Data Collection Extra vessel data collection differs from solid organs

due to timing of use, storage, and possible disposal at a later time.

OPOs list in DonorNet extra vessels sent with each organ

Transplant centers report extra vessels used for transplant • at waiting list removal (with vessel donor ID) or later

using Vessel Use Report.• may also report extra vessels use or disposal via fax

or email to UNOS Data Quality.

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Extra Vessels Disposition Reporting Data

Cases Where Vessels Reported Recovered and Sent with Deceased Donor Kidney, Liver, Pancreas, or Intestine During 2008 - 2010

*Data as of June 17, 2011.

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Vessel Disposition Reported at Waiting List Removal or by Fax. Transplants 1/2011-11/2011:

Over 3,000 (11.8%) recipients have “vessels used?” equal to “unknown”. Over 400 (40.7%) PA or KP transplants had “vessel used?” equal to No.

WERE EXTRA VESSELS USED IN THE TRANSPLANT PROCEDURE:

Total (ALL)Unknown No Yes

N % N % N % NTransplanted organ

427 11.1 3,413 88.5 17 0.4 3,857Thoracic

Intestine5 4.0 44 35.5 75 60.5 124

Kidney1,630 10.6 13,709 88.9 74 0.5 15,413

Pancreas/KP170 16.9 410 40.7 428 42.5 1,008

Liver872 14.9 4,547 77.9 421 7.2 5,840

Total (ALL)3,104 11.8 22,123 84.3 1,015 3.9 26,242

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Policy Proposal - 5.10.2 Vessel storage

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Operations and Safety Committee Activity Updates

Spring 2012

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Patient Safety Planning Development Subcommittee

Review trends and patterns of safety events reported to the OPTN and disseminate information for process improvement:

• Quarterly Patient Safety Newsletter;• Enhancement to safety situation reporting data

points;• Encourage Best/Successful Practice reporting;• Quick Reference Guide to Reporting Safety

Events to the OPTN.

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ABO Verification Develop a matrix to document critical points in the

processes of ABO checks and verification

Assess current policy language to create symmetry and clarity were possible:• Separate determinations vs. separate occasions;• Prior to incision, prior to donation, prior to implant – are

these appropriate time measures for safe practice?• confirmation vs. verification

Develop standardized documentation tool for ABO verification

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Organ Tracking and Traceability

Assessing standardized coding system (ISBT 128)• Labeling• Barcoding• Tracking/Traceability

Feasibility study of coding system (ISBT 128)• Benefits and risks• Security of information• Cost savings or additions• Efficiencies gained? • Enhanced patient safety?

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Transportation Failures and Near Misses

Annual review of Organ Center data

Enhancement of data points being proposed to the Patient Safety electronic reporting system in UNetSM

Poster accepted for ATC on Organ Center data

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Questions?