Expedited Placement of Livers OPO Committee

What problem will the proposal solve? Current OPTN policies do not address expedited placement This absence of policies create: Lack of transparency about how expedited placement currently works OPOs and transplant hospitals have no formal guidance; perform inconsistently Candidates have inconsistent access to organs Expedited organ placement has been an important part of organ allocation for many years. Organ procurement organizations (OPOs) use this method to quickly place organs that are at risk of not being used for transplant. Expedited placement is not currently addressed in OPTN policies This creates a lack of transparency, lack of formal guidance for OPOs and transplant hospitals, and inconsistent access to organs for candidates that need a lifesaving transplant.

What are the proposed solutions? Create a system for expediting liver offers Focus initially on expedited offers following “in-OR” turndowns 70% of OPOs have at least one expedited placement reviewed by the MPSC each year 60% of liver expedited placements reviewed were associated with intra-operative turndowns The solution is to create a system for expediting liver offers This will focus initially on expedited offer following in-OR turndowns

What are the proposed solutions? Transplant hospitals must “opt-in” to receive expedited liver offers OPOs will have criteria to initiate expedited liver offers Transplant hospitals must accept offers within 20 minutes in order to be eligible to receive the liver The proposed solutions are to create policies that establish requirements for the expedited placement of livers. Transplant hospitals will be required to “opt-in” in order to receive expedited liver offers There is criteria for when OPOs can initiate expedited liver placement Transplant hospitals must accept offers within 20 minutes in order to be eligible to receive the liver

“Opt-in” Criteria for Transplant Hospitals Transplant hospitals must agree to allow any procurement team to recover the liver if necessary Enter the following criteria for each type of donor (DCD and/or DBD) Minimum and maximum age Maximum body mass index (BMI) Maximum distance from the donor hospital to transplant hospital Minimum and maximum height Percentage of macrosteatosis Minimum and maximum weight Here is the criteria that transplant hospitals need to submit in order to opt-in. Due to the urgency created by a late turndown, transplant hospitals must agree to allow any procurement team to recover the liver if necessary. The reason for this is that the hospital that will receive the offer might not have time to send a team to recover the organ. These additional criteria need to be submitted for each type of donor from which the transplant hospitals is willing to accept expedited liver offers.

Criteria for OPOs to initiate expedited liver offers OPOs can make expedited liver offers if they meet both of these conditions: 1. The donor has entered the operating room or in the case of a DCD donor, withdrawal of life sustaining medical support has been initiated, whichever occurs first 2. The host OPO or Organ Center is notified by the primary transplant hospital that the primary potential transplant recipient will no longer accept the liver Here is the criteria for when OPOs can initiate expedited liver offers The donor has entered the operating room, or for DCD, if withdrawal of life sustaining medical support has been initiated The primary center has notified the host OPO or Organ Center that they can no longer accept the liver

OPOs - Sending Expedited Liver Offers OPOs must enter the following information before sending electronic expedited liver offers: Date and time donor entered the operating room (or life sustaining medical support was ) Date and time transplant hospital notified the host OPO that they can no longer accept the liver offer. Reason the primary potential transplant recipient refused the liver OPOs must make expedited liver offers using the expedited liver match run Prior to sending electronic offers, OPOs must provide the date and time the donor entered the OR, when they were notified by the primary transplant hospital and the reason for the organ offer refusal. OPOs must also use the expedited liver match run to send offers.

Responding to expedited liver offers Transplant hospitals must accept expedited liver offers within 20 minutes to be eligible to receive the liver At the end of the 20 minute timeframe, the liver will be placed with the candidate with an acceptance that appears highest on the match run Transplant hospitals must accept offers within 20 minutes in order to be eligible to receive the liver Once the 20 minutes timeframe has elapsed, the host OPO must place the liver with the candidate with an acceptance that appears highest on the expedited match run.

Additional policy modifications 5.4.C: Liver Offers – Added language to reference Policy 9.10.B: Expedited Liver Offers 5.6.B: Time Limit for Review and Acceptance of Organ Offers – Added language to clarify that the acceptance time limit for expedited liver offers is 20 minutes instead of the 30/60 minutes in this policy There were several modifications to existing policies, highlighted by the following changes: 5.4.C: Liver Offers – This policy currently addresses when an initial liver offer can be re-executed. Since expedited placement will require a new match run type, language was added to reference Policy 9.10.B: Expedited Liver Offers. 5.6.B: Time Limit for Review and Acceptance of Organ Offers – Since the proposed time limit to accept expedited liver offers is 20 minutes instead of the 30/60 minutes outlined in this policy, the Committee is proposing language stating that this policy does not apply to expedited liver offers.

How will members implement this proposal? Explain the conditions appropriate for expedited liver placement Educate their staff on required information related to sending expedited liver offers Policy requirement to use expedited match run OPO staff should be able to: Explain the conditions appropriate for expedited liver placement Educate their staff on required information related to sending expedited liver offers Understand the policy requirement to use the expedited match run

How will members implement this proposal? Transplant Hospitals Must enter acceptance criteria on a candidate-by-candidate basis in order to receive expedited liver offers Develop processes that allow quick review of expedited liver offers within the 20 minute time limit Transplant hospitals must: Enter acceptance criteria on a candidate-by-candidate basis in order to receive expedited liver offers Develop processes that allow for a quick review of expedited liver offers within the 20 minute time limit

How will the OPTN implement this proposal? System programming changes include: Adding new fields to Waitlist and DonorNet to allow transplant hospitals and OPOs to enter the required information Creating a new match run type for expedited placement This proposal will require system programming changes which will include: Adding new fields to Waitlist and DonorNet to allow transplant hospitals and OPOs to enter the required information Creating a new match run type for expedited placement

OPO Transplant Center Work Group Roster Jennifer Prinz Diane Brockmeier Lori Brigham Jennifer Muriett Jeff Orlowski Nikole Neidlinger, MD Transplant Center Will Chapman, MD David Foley, MD Shimul Shah, MD Richard Cummings Shawn Pelletier, MD Ryo Hirose, MD Here is the work group roster – as you can see, we have good representation from both OPOs and transplant centers.

Questions?