FEBRUARY 1998, VOL 67, NO 2

P R A C T I C A L I N N O V A T I O N S

Function and impact of an OR donor-transplant committee

ultiple organ procurement surgery can be lengthy and stressful. Understanding the

care process and being able to guide intraoperative practice can be a rewarding, rather than intimidating, experience that results in more desirable outcomes.

The main OR at the Ottawa Civic Hospital, Ottawa, has 12 theaters that involve all surgical specialties with the exception of cardiac procedures. With the increased public awareness of organ donation, OR staff members have seen an increased number of organ donations. Originally only kidneys and corneas were recov- ered, but now liver, heart, lungs, pancreas, and bone donations are included.

Multiple organ recovery is done on all shifts. Most staff members rotate on these shifts so the same nurses are not always involved with these procedures. The organization of the intraoper- ative process involves on-site sur- gical staff members as well as vis- iting surgical teams from Canada and the United States. Each sur- geon brings his or her own unique techniques and instruments.

Seven years ago, preparing care for the first donor patients was dif- ficult. At that time, the amount of equipment and instruments required was excessive and incon- sistent. Nurses involved in the pro- cedures found them stressful not only because of the circumstances surrounding the often tragic histo- ries of the patients, but also the

time required to gather equipment and prepare the large setup.

In 199 1, OR nurses at Ottawa Civic Hospital decided to form a committee to formally coordinate and give continuity to nursing practice in the intraoperative phase of the donor process. Through the committee’s involvement, the qual- ity of patient care is monitored and regulated, and methods to simplify care are explored. The group meets monthly or as required to resolve problems. Any concerns are direct- ed to the committee members, and issues are brought back to the group. The group provides guid- ance for staff members and deals with problems as they arise. The main OR donor-transplant commit- tee is instrumental in guiding the clinical, management, and educa- tion functions to simplify intraop- erative patient care. The interaction of these components is illustrated in Figure 1. This article addresses

KARIN PAGE, RN, BNSC, CPN(C), i.s an OR staff nurse, Sunnybrook Health Science Center, Toronto. At the time this article was written, she was educator, OR, Ottawa Civic Hospital.

BEVERLEY HEENAN, RN, CPN(C), is a staff nurse, Ottawa Civic Hospital. At the time this article was written, she was a general surgep theater charge nurse.

SANDRA PILGRIM-STARK, RN, CPN(C), is an OR staff nurse, Ottawa Civic Hospital. At the time this article was written, she was a thoracic theater charge nurse.

the management of the clinical organ recovery process.

CLINICAL CHANGES One of the committee’s most

significant clinical functions was to develop a single, computerized preference sheet to provide consis- tency in preparation for patient care. When a multiple organ retrieval procedure is booked, this sheet is obtained from the comput- er bank. In the event of computer failure, a binder notebook is avail- able that contains a copy of the preference sheet. This list also has a tear-off donor checklist that nurses can refer to when setting up the procedure. This checklist addresses

procedure booking and associated events, procedure setup, procedures for patient arrival, information required for OR admission, anesthesia protocols, staff member roles, procedures for patient after- care, and procedures for transfer to the morgue. The checklist is used as a

worksheet to simplify the planning stage (Table 1). After the proce- dure is completed, this checklist is discarded.

Another problem in the past was difficulty maintaining inven- tory on items required for the pro- cedures. No staff member was specifically designated to check stock. There was no consensus on the number of stock items

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contained in one pan (Table 2). The com- mittee’s role in revising the content of the pans was to survey the nurses and sur- geons and to liaise with the CPD. The com- mittee decided that visiting surgeons may add their own instruments to the pans at their preference.

The amount of equipment and additional supplies origi-

Figure 1 The OR donor-transplant committee Simpli- fies patient care processes, regulates quality, and coor- dinates practice by guiding clinical, education, and management functions.

required or the standard storage area for these specific items. Each time a procedure was booked, the list of equipment needed for the procedure changed.

Developing the donor cart was a means of simplifying the proce- dure with respect to immediate availability of regular stock items. The donor cart is kept in the cen- tral processing area and contains specialized organ packaging sup- plies and other items (Figure 2). After the cart has been used, all items except a few specialty items are restocked by the Central Pro- cessing Department (CPD) staff members. The bone harvesting, liver perfusion, and pancreatic kits are supplied by the organ donor coordinator.

were required to complete the setup. The instruments used for multiple organ retrievals now are

Previously four instrument sets

naily required was reduced (ie, three per-

fusion tables to one). A donor medication box was established to contain all non-narcotic med- ications needed by anesthesia care providers. The committee also ensured the proper perfusion solutions and slush machines were available.

MANAGEMENT INlTlA TIVES

tee comprises a maximum of six volunteer RNs, one orderly, one clinical manager, one clinical edu- cator, and one organ donor coordi- nator. Cardiac OR staff members and surgeons from all specialties act as consultants to the commit- tee. A chair and secretary are elected annually from the six member nurses. Appointments are for one year to provide consisten- cy and an opportunity for other staff members to join. These guidelines are listed in the com-

The donor-transplant commit-

mittee’s “terms of reference,” which outline the purpose of the committee and the roles of the various members. For example, the role of the chair includes call- ing meetings and setting agendas and the role of the clinical manag- er includes functioning as facilita- tor when required.

Teamwork is emphasized and all OR staff members have the chance to provide input on any issue. The committee has long- standing liaisons with other hos- pital staff members, donor-trans- plant physicians, and transplant coordinators. The OR donor- transplant committee also is rep- resented on the main hospital transplantation committee.

Initially, differentiation of role responsibilities between the peri- operative nurses and the organ donor coordinator, allied health care workers, the CPD, and the OR business office was confusing. Several responsibilities seemed to overlap, and documentation was duplicated. The committee direct- ed role development by coordinat- ing discussions with all personnel and by designing procedures and checklists to provide guidance.

The role of the organ donor coordinator (ie, an RN with a criti- cal care background) involves interacting with the donor and donor family members and preop- erative coordinating of organ donor programs and surgeons. Intraoperatively, the coordinator completes specific organ docu- mentation, assists in packaging organs, and arranges for their transportation. The OR nurses coordinate specific surgical requirements, including scrubbing and circulating. In this way, the organ donor coordinator and OR staff members function in their areas of expertise and provide

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quality patient care. When this article was written,

the Ottawa Civic Hospital OR did not exclusively hold a theater for emergency procedures. The com- mittee supported the development of booking and scheduling poli- cies to accommodate elective patients delayed by the often lengthy multiple organ donor cases. Patients scheduled for spe- cific services may be "bumped" on a rotating basis, but the proce- dures are not canceled. Interdisci- plinary cooperation and commu- nication is essential.

fied the patient care process by developing procedures for trans- porting patients from the morgue specifically for bone recovery and by revising enucleation policies. Working with the CPD, pharma- cy, and the OR assistants has simplified the flow of instruments and supplies. The OR business office also plays a role in the administrative activity of the donor process by providing infor- mation and placing orders for required instruments and supplies.

This administrative portion is accomplished in consultation with the organ donor coordinator as a liaison to other units in the hospi- tal. Originally, the organ donor coordinator was not present during organ recovery; however, the committee and the coordinator decided to work together toward the coordinator's currently more active role in the OR.

Recently, the group has simpli-

EDUCATION The committee uses literature

to develop the education function of the group. A literature search is done monthly to update the com- mittee members on current issues. Minutes from committee meetings and pertinent journal articles are

available to all staff members, which provides other education resources about organ donation.

The com- mittee also designs kardex- es for staff members, which are sum- maries of the donor process from OR book- ing to transfer to the morgue. They are readi- ly available at the main OR control desk and are used as education tools for both new and experi- enced staff members.

Education

Table 1 CHECKLIST FOR PERIOPERATIVE NURSES

I. Receive bookina from donor coordinator

Confirm time of procedure Obtain list of organs to be recovered and teams to be expected

II. Obtain computerized procedure preference sheet and send to central processing department Ill. Call housekeeping to request large container of ice on wheels

IV. Notify on-call staff members as required

V. Set up the procedure in largest or orthopedic room if takina bone

Bring defibrillator into room 0 Check perfusion solution availability

Ensure slush machine is set up by scrub person os soon as possible

VI. When patient arrives, complete admission procedure Verify operative consent Verify death certificate Ask orderly to pick up blood after transferring patient to OR table Confirm if autopsy is to be done or if coroner hos requested notification at the end of the procedure

VII. Remind anesthesia care providers to obtain blood samples from patient to accompany organs as required

sessions on topics such as VIII. Count, prep, drape, and begin procedure

organ packag- IX. Complete intraoperative nursing care kg protocols Document introoperotive procedures are Provided to Assist with organ perfusion OR staffmem- Assist with organ packaging hers on a r%U- 0 Assist donor coordinator as required lar basis.

X. Perform postprocedure death protocol Another com- ponent to staff Count instruments member educa- Provide patient aftercore and offer emotional support tion involves for the family holding rounds to review par-

Call security for transfer to morgue as required Send chart to hospital records deportment

ticular case his- tories. These rounds are scheduled during regu- lar inservice program times or as part of an annual education review day and involve OR and OR relat- ed staff members. The case histo- ries are presented by the organ donor and recipient coordinators.

On occasion, recipients are in attendance to provide periopera- tive staff members with a broader view of donor and transplant activity and patient outcomes.

Every year the committee, along with the hospital organ

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Table 2 ORGAN DONOR S W

Retractors

Figure 2 The donor cart contains specialized packag- ing supplies and other requirements for multiple organ recovery procedures.

donor coordinators, sponsors an organ recipient tea. Former trans- plant patients and OR staff mem- bers gather to share experiences and provide feedback and support for each other. This contact with past organ recipients has been significant. The perioperative clinical nursing staff members provide positive feedback and gain a sense of completion and closure when talking to the organ recipients and attending rounds.

Caring for donor patients is difficult. It can be an emotionally demanding time when many ethi- cal issues arise. No staff members have ever refused to participate in organ recoveries, but at times nurses have been upset by the tragic natures of particular cases. One of the committee’s activities

was to meet with the hospi- tal pastoral care depart- ment to discuss the possibility of debriefing sessions for staff members requesting sup- port. Ethical issues often are personal to staff members;

2 Richardson retractors (fwo sizes)

Tissue forceps and instruments 2 short Debakey tissue forceps 1 extralong Debakey tissue forcep 2 Ramsay tissue forceps 2 toothed Adson tissue forceps 2 smooth Adson tissue forceps 2 Poole suction tips 4 scalpel handles (various sizes) 1 tonsil tip suction 2 electrosurgical instrument safely holsters Scissors

2 short metzenbaum scissors 2 long metzenbaum scissors 1 extra long metzenbaum scissors 2 straight Mayo scissors 1 curved plastic scissors 3 angled Debakey scissors

Instrument string 2 curved Debakey vascular clamps 2 Semb vascular clamps 2 Lee vascular clamps 2 angled Debakey vascular clamps 2 needle drivers 2 short lowers (ie, Lahey) 2 long lowers (ie, Lahey) 5 long Kelly clamps 5 curved hemostats 5 short Kochers 5 curved mosquitoes 10 blunt towel clips

*Sternal retractors and other instruments are added as required.

however, common themes of death, donor rights and dignity, and the value of transplantation are addressed by the committee and OR staff members through discussion, journal articles, and at the annual organ recipient tea.

Other health care workers also

are included in education sessions. The CPD staff members attend inservice programs that address changes in the donor cart and instrument pan contents required for the procedure. They also receive instructions on new items as needed.

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Perioperative nurses have the occasional opportunity to accompany surgeons to other hos- pitals to recover organs, which provides a learning experience for penoperative nurses in ORs of all sizes.

The OR donor-transplant com- mittee actively participates in public education through Donor Awareness Week in April of every year. The week is coordi- nated by the Multiple Organ Retrieval and Exchange Program of Ontario. In conjunction with the organ donor coordinator, donor-transplant committee members volunteer at an informa- tion booth along with organ recipients in the hospital’s main concourse. This provides an opportunity for the general pub- lic, as well as other hospital staff members, to increase their aware- ness of organ donation. The impact the committee has had on the patient care process, there- fore, has been significant.

SURVEYAND IMPACT Standards of patient care, such

as sterilization, draping technique, counting, and documentation, are routinely monitored for all surgical patients in collaboration with the quality improvement committee. Care of donor patients is monitored in the same manner; however, to evaluate the overall donor process outcomes, a retrospective survey of the main OR staff members was conducted in the spring of 1997.

All 83 nursing staff members

SUGGESTED READING

were offered a one-page question- naire; 33 were returned, indicating a 40% return rate. Staff members were asked to rate their perceived level of comfort in planning and implementing nursing care for the multiple organ donor patients three years ago when the donor- transplant committee began to implement changes, and now. The ratings included uncomfortable, somewhat uncomfortable, some- what comfortable, and comfort- able. The participants were asked to select items to which they attributed any change in degree of comfort; they also were given the opportunity to write comments.

The survey found that 25 respondents indicated an increase in comfort, eight respondents indicated no change, two of the eight that indicated no change already were at the highest comfort level, and three of the eight that indicated no change had no clinical exposure.

The 25 of 33 respondents (ie, 76%) who indicated an increase in perceived comfort attributed the following to the change:

organ donor coordinator involvement, simplification of the process, increased exposure, direct participation in commit- tee activities, and availability of relevant journal articles. All of these, with the excep-

tion of increased exposure, are

1996) 25-30.

due to the initiatives of the com- mittee. Other comments received included, “Keep the organ donor committee,” “Changes already have made it much easier,” and “Pleased with improvements.” Suggestions included adding more education sessions and implementing staffing changes to increase exposure for all staff members.

This small survey, because of the ex post fact0 design and obvi- ous lack of controls, may be weak in determining causality; however, to the committee and OR staff members, it has positively rein- forced nursing practice. Based on these results, more staff member teaching will be planned through- out the year and the committee will continue to support its objec- tives and consider taking on other clinical issues.

CONCLUSION Today, the multiple organ

recovery procedures in the OR at the Ottawa Civic Hospital are smooth and fairly predictable. Under the direction of the OR donor-transplant committee, the clinical process is simplified, edu- cation is focused, and nursing pol- icy and procedures are in place. Evaluation has shown the positive impact of this OR committee’s work. It is very rewarding for a committee to see all the various elements of care coordinate into a single seamless process, resulting in a successful organ recovery and a gift of life. A

Hibbert, M. “Stressors experienced by nurses while Morray, B H. “The lottery of life: Should organ transplants be used to even the odds?” Dimensions of CriticaE Care Naming 14 (SepternberlOctober 1995) 266-272.

Samartan, K. “Organ procurement surgery: What penoperative nurses can expect,” AORN Journal 58 (August 1993) 229-233.

caring for organ donors and their families,” Heart and Lung 24 (Septernber/October 1995) 244-252

Martinelli, A M. “Organ donation: Barriers, religious aspects,” AORN Journal 58 (August 1993) 236-251.

Molzahn, A E. “Organ donation: What do nurses know and believe?” The Canadian Nurse 92 (October

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