Improving Your Death Referral Notification

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Improving Your Death Referral Notification

• Donna Morales RN
• St. Johns Hospital and Health Center
• Annette Gonzalez MBA/HCM
• OneLegacy

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Objectives

• Review CMS Mandates for donation
• Introduction of Tissue Dashboard data
• Case Review
• Recommendations

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CMS Mandates

• Every death be reported to your Organ Procurement
  Organization (OPO)
• OneLegacy
• Deaths to be reported in a Timely Manner
• Determined to be within 1 hour of death
• Hospital staff is not to approach for donation
  unless they are a Trained Designated Requestor

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Tissue Dashboard

• Referral Compliance PE 100
• Referrals from hospital to OneLegacy
• Hospital cardiac deaths
• Timely Referrals PE 100
• Referrals Made
• Tissue Donor information

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St. Johns Health Center Case Review
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Getting Started

• Hospital identified their donation liaison
• Met with both of OneLegacys hospital reps
• Organ- Hospital Services Coordinators (HSC)
• Tissue- Tissue Hospital Services Specialists
  (THSS)
• Reviewed organ and tissue dashboards
• Reviewed hospitals referral process

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Hospital Evaluation

• Organ Donation
• Not a lot of potential
• Tissue Donation
• All deaths were being called in
• Referral timeliness could be improved
• Donation numbers could potentially improve with
  timeliness

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Referral Timeliness Assessment
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• Reviewed January to September 2008
• Referral Timeliness averaged 73
• Verified OneLegacys data with hospitals death
  log for accuracy
• Discovered that House Supervisors made all
  referrals

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Action Plan
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Monthly Meetings

• Reviewed Dashboards
• Discussed issues and resolutions
• Revised Policy and Procedures
• Updated hospitals Referral Log
• Used Referral Guidance Document
• Hospital development plan

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Hospital Development

• Staff educated to notify House Supervisors ASAP
  of a death
• House Supervisors were educated of Timeliness
  performance expectation
• Units compared their own dashboards to OneLegacys

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Clinical Trigger Card

• Bullet Card promoted during unit inservice
• Decide where to put them up
• Promotes Awareness
• Phone stickers useful as well

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Hospitals Referral Log

• OneLegacy Sheet
• Modified using OneLegacys Referral Guidance
  Document
• Helps keep track that every call is made
• Write names of people that have been spoken to
• Any additional notes- transfers, pending cases,
  etc.

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Results

• Improvement in Referral Timeliness
• January September 73 Q1 - Q3
• October December 96 Q4
• 2008 Average 79
• 2009 Average 100 Q1
• In 2008, 33 of Tissue Donors came from Q4

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Where Are We Now?

• Meet as needed
• Email and review dashboards monthly
• Open communication
• Scheduled to inservice staff twice a year

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Getting Started at Your Hospital
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• Identify your hospitals donation liaison
• Meet with your OneLegacy hospital reps
• Organ- Hospital Services Coordinators (HSC)
• Tissue- Tissue Hospital Services Specialists
  (THSS)
• Email Clinique Burrell cburrell_at_onelegacy.org to
  be referred to your OneLegacy reps

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• Review organ and tissue dashboards
• Update hospitals donation Policies Procedures
• Implement a Hospital Development Plan
• We are here to help!

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Thank you!