The Role of the Hospital Liaison
Work with a Donation Program Coordinator
- You will work with your Lifeline of Ohio Donation Program Coordinator to:
- Follow up on any missed/delayed organ (imminent) or cardiac referrals
- Create a strategic plan that will help identify ways that we can improve the opportunity for donation in your facility
- Must be updated in conjunction with your Donation Program Coordinator on an annual basis and referenced regularly to ensure we are meeting our agreed upon goals
- Assist in the creation of a Donation Council, if applicable, and the scheduling of regular meetings with key advocates within the hospital
- Scheduling education to ensure all staff are familiar with the donation process
- Help to enhance the donation culture within your hospital
- Create and/or facilitate the revision of your hospital policies as it relates to donation
- Assistance in locating appropriate contacts for acquiring the monthly hospital death list, as needed, so it can be reviewed by the OPO to ensure all deaths are referred to the OPO’s referral center (DSS)
- Assist in the completion of Medical Record Review should our OPO not have EMR access
- Real time assistance with organ, eye and/or tissue recovery needs or issues
- Arranging After Action Reviews after an organ recovery with key hospital contacts to ensure any concerns are addressed and collaboration is maintained
- Assist in the distribution of survey links to hospital staff following cases so we can ensure we are meeting your hospital’s needs and addressing any concerns
- Assist in coordinating hospital leadership attendance during annual scorecard meetings, when applicable
Make a Larger Impact in Your Facility
Organ Case Follow up
Staff Letters: Following every organ recovery, a letter will be provided to the hospital liaison thanking the staff that assisted in the recovery and updating them on what organs were able to be transplanted and how many lives were saved through the gifts of donation.
After Action Review: Coordinated by the hospital liaison, this is a time to meet with staff who were involved in an organ recovery and discuss what went well and any concerns the hospital staff or OPO may have. This helps to ensure any concerns are resolved so that future organ recoveries do not experience the same hurdles.
HRSA Hospital Campaign: Hospitals big and small are invited to join the HRSA Hospital Campaign which typically begins each fall. Become a part of the initiative that has encouraged more than 552,000 Americans to become organ, eye and tissue donors since 2011, and help build a donation-friendly culture in your hospital using the free tools and resources.
An Honor Walk is a ceremonial event to commemorate a patient prior to organ donation. The event typically takes place as the patient is transported to an operating room prior to organ procurement.
Honor walks need to be coordinated by hospital staff to ensure hospital safety and privacy protocols are taken into consideration.
A policy is recommended to ensure a smooth transport into the OR.
If you are interested in implementing an Honor Walk, please see our checklist here.
Access donation data and statistics using either of these websites:
Background Information: Located in Richmond, Virginia, the United Network for Organ Sharing (UNOS) is a non-profit, scientific and educational organization that administers the nation’s only Organ Procurement and Transplantation Network (OPTN), established by the U.S. Congress in 1984. Through the OPTN, we:
- collect and manage data about every transplant event occurring in the United States
- facilitate the organ matching and placement process using UNOS-developed data technology and the UNOS Organ Center
- bring together medical professionals, transplant recipients and donor families to develop organ transplantation policy
All About Lifeline of Ohio
Donation Legalities and Compliance with Federal Regulations
Uniformed Anatomical Gift Act (1968)
The Uniform Anatomical Gift Act (UAGA or the Act) was passed in the U.S. in 1968 and has since been revised in 1987 and in 2006. The Act sets a regulatory framework for the donation of organs, tissues, and other human body parts in the U.S. The UAGA helps regulate body donations to science, medicine, and education.
The HIPAA Privacy Rules grant an exemption to the patient authorization requirements for OPO groups for the limited purpose of procuring organs — which includes deceased organ, eye and tissue donation and transplantation services.
CMS Compliance/Joint Commission Federal Rule 5 Components for Hospitals
- Call on every death within 60 minutes
- Call on every imminent death upon patient meeting established triggers for imminent death
- Effective requestors who are formally trained in the donation request process
- Completion of Medical Record Review by OPO to capture any missed or delayed referrals and provide education to hospital staff following completion
- Agreements with organ/tissue/eye recovery agencies
- Approach families in a sensitive and caring manner
Dead Donor Rule
The “Dead Donor Rule” (DDR) lies at the heart of current organ procurement policy.  It is not a legal statute; rather, it reflects the widely held belief that it is wrong to kill one person to save the life of another. On those grounds, an organ donor must already be dead before vital organs are removed. The DDR is therefore an ethical norm: vital organs may be removed only after the organ donor is dead. The Uniform Determination of Death Act (UDDA) assures patients, families, physicians, and other health professionals that a patient who is brain dead is in fact dead, so the combination of this policy with the DDR makes the recovery of organs for life-saving transplantation legally and ethically acceptable.
Clinical triggers are agreed upon parameters set by both the hospital and the OPO, per their agreement, that initiates a notification call to alert the OPO of a possible donor. Clinical triggers are written into hospital policy to help hospital staff caring for patients know when it is appropriate to notify an OPO of a patient.
Imminent Death (Potential Organ Donation) Clinical Triggers
Notify an OPO of all ventilated patients within 60 minutes of meeting ANY condition listed below, regardless of age or diagnosis:
- Any GCS with anticipated family meeting to discuss
- Terminal de-escalation of care (code status change, vasopressors, etc.)
- End of life
- GCS 5 or less off paralytics
- Family initiates donation conversation
Cardiac Death Trigger
Call within 60 minutes of Cardiac Time of Death (CTOD)
- Please refrain from mentioning donation or Lifeline of Ohio to the family
- Lifeline of Ohio will evaluate all donation potential and huddle with the care team prior to any family discussion
- Please call any time Brain Death testing is considered
- WAIT before you extubate
iReferral – An online tool which allows for submission of notifications to be made using the OPO portal instead of calling Lifeline of Ohio. Contact your Donation Program Coordinator to learn if your facility currently uses this program, or how you can explore the process of implementing this tool hospital wide.
The Lifeline of Ohio Team
It takes a lot of team members to facilitate the gift of donation. Meet our clinical teams and learn more about how each member contributes to the work of saving and healing lives.
Donation Program Coordinator
- Responsible for cultivating working relationships with key hospital staff in your facility to encourage strong engagement in donation recovery efforts
- These individuals work with hospital liaison(s) directly to:
- Develop an annual Strategic Plan with the facility, highlighting goals of performance
- Provide real-time support for active cases and ensure timely follow-up and resolution of any concerns
- Prepare and present analytics on key donation metrics to all levels of hospital leadership
- Provide education to hospital partners and their staff
- Contribute to the development and improvement of department policies, processes and procedures
Donation Support Services (DSS) Coordinator
- These team members can work either in our main office in Columbus, Ohio or in their home office.
- Receive all referrals via phone or electronically via our iReferral portal
- For all individuals who have the potential to donate organs (heart-beating referrals), the team member documents and dispatches clinical team members to the hospital for further evaluation.
- For all individuals who have the potential to donate tissue (cardiac death referrals), staff are trained to approach potential donor families with compassion and sensitivity for tissue and eye donation.
- DSS Coordinators are responsible for completing a notification form for tissue donors.
- If the patient is not a registered donor, they will complete an Authorization form.
- After notification and/or authorization is complete, the donor family will also complete a medical/social questionnaire called a DRAI.
- The DRAI is a medical/social history questionnaire and is similar to what you would complete when donating blood and can determine suitability for donation.
- These team members coordinate the recovery of tissues and/or eyes in conjunction with our tissue processors and eye bank partners.
- Following donor family authorization, transportation of the donor may be arranged by the DSS Coordinator to an offsite location for tissue recovery.
- Following recovery, these team members can also coordinate the transport of the donor to the funeral home.
They assist in the aftercare of our donor families by preparing and mailing tribute boxes to be sent to the funeral home commemorating their loved one for becoming a hero of donation.
Family Services Coordinator (FSC)
- Responsible for approaching the families of potential donors with compassion and sensitivity both onsite and in some cases over the phone
- If a patient is registered as a donor, the FSC will complete a notification for the Donation of Organs and/or Tissues form.
- If the patient is not a registered donor, they will complete an Authorization for Organ and/or Tissue Donation form.
- Completes a medical/social questionnaire called a Donor Risk Assessment Interview (DRAI) with the donor’s legal next of kin
- The DRAI is similar to what you would complete when donating blood and can determine suitability for donation.
- The FSC remains a resource and support for the donor family throughout the donation process and connects the family with our bereavement services team so they can access support resources available to them.
- Responsible for performing initial evaluations for organ donors on site
- These individuals also work with our Donation Support Services (DSS) team to receive phone calls and to evaluate referrals.
- They assist the DSS coordinators and the ORC team as needed.
Organ Recovery Coordinator (ORC)
- This team member works onsite at your facility, working directly with providers and staff to medically manage the potential donor and ensure organs are viable for recovery and transplantation
- Coordinates organ matching, OR time and all logistics during recovery including incoming transplant teams
- Utilizing the United Network for Organ Sharing (UNOS) database, ORCs facilitate the matching of organs to appropriate recipients.
- Maintains preservation of organs during and after the organ recovery process in collaboration with surgeons, ORCs and hospital staff to maximize organ viability for transplantation
- Maintains solid organ preservation, either with cold storage or mechanical perfusion, after recovery until the time of transplantation and/or export of the organ(s) occurs
- Assures aseptic technique is used during the set-up, recovery, and packaging processes
- Prepares organ(s) for export for transplant and/or research
More Resources from Lifeline of Ohio
Below you will find resources for our Placenta Donation program, Bereavement Services department and our Faith Outreach. Each of these webpages offer robust materials to use in your hospitals.