Author s job title Specialist Nurse in Organ Donation Department Tissue donation. Comment / Changes / Approval. Initial version for consultation

Transcription

1 Document Control Title Policy Author Directorate Anaesthetics, Theatres, Critical Care, Cancer Services, Patient Access & Therapies Version Date Issued Status th Draft June th Jan V2 12 Author s job title Specialist Nurse in Organ Donation Department Tissue donation Comment / Changes / Approval Initial version for consultation Initial version for consultation 1.0 Dec 13 Final Final Version for Publishing st Dec Final Dec Final 2017 Main Contact Specialist Nurse for Organ Donation ICU level 3 North Devon District Hospital Raleigh Park Barnstaple, E31 4JB Lead Director Medical Director Superseded Documents Tissue donation Policy v2.0 Issue Date December 2017 Review and update as per 3 year review. Includes version 2.0 of procedure flowchart. Approved at Quality Assurance Committee and Published on Bob. Updated wording since the implementation of the National Referral Centre (NRC) Tel: Internal 2708 Review Date Review Cycle November 2020 Three years Consulted with the following stakeholders: (list all) Representatives of clinical staff groups via the Organ Donation Committee Approval and Review Process NDDH Organ Donation Committee Local Archive Reference G:\Public on Nddhcluster Local Path Directorate Management, Division of Anaesthetic, Theatre, Critical Care etc., Meetings, Trust Donation Committee Filename Policy v Dec 2017 (update).doc Policy categories for Trust s internal website (Bob) Location(s) on Bob Tags for Trust s internal website (Bob) Cornea, eye, donation, heart Valve. Retrieval, organ donation General\ Policy\ Policy v3.0.docx Page 1 of 7

2 CONTENTS Document Control Introduction Definitions Responsibilities... 3 Medical and nursing teams at all grades:... 3 Role of the Tissue Donor Co-ordinator (NRC):... 4 Qualified Tissue Retrievers:... 4 Ward/Unit Managers: TISSUE DONATION Flow chart for procedure following death Monitoring Compliance With and the Effectiveness of the Policy Subsection... 6 Process for Monitoring Compliance and Effectiveness... 6 Standards/ Key Performance Indicators Equality Impact Assessment Associated Documentation (Optional) Introduction 1.1. This document sets out Northern Devon Healthcare NHS Trust s system for Tissue Donation It provides a robust framework to ensure a consistent approach across the NDDH site, and supports our statutory duties as set out in the NHS Constitution North Devon Healthcare NHS Trust recognises the potentially sensitive issues that surround the donation of tissue (eyes and heart valves) following death. It acknowledges the need to ensure responsive handling of the situation, providing support and guidance to relatives and patients The purpose of this document is to ensure adherence to the Human Tissue Act (2004), the Human Tissue (Quality and Safety for Human Application) Regulations 2007 and the Human Tissue Authority Codes of Practice The policy applies to all clinical Trust staff Implementation of this policy will ensure that: That all staff are aware that donation of eyes and/or heart valves is an option within the North Devon Healthcare NHS Trust. The understanding of patients and their families regarding their rights and wishes to donate tissue is improved. A framework of guidance, training and support exists for staff providing care to patients and relatives when the question of tissue donation arises. General\ Policy\ Policy v3.0.docx Page 2 of 7

3 1.6. In addition to the statutory responsibilities set out in section 1.2, the Trust must have signed a Third Party Agreement covering tissue retrieval with a HTA licensed tissue bank such as the CTS Bristol Eye Bank and Bristol Heart Valve Bank. Professional guidance is provided by the Royal College of Ophthalmologists Guidelines on Eye Retrieval, and the UK Hospital Policy on Definitions 2.1. HTA Human Tissue Authority 2.2. CTS Corneal Transplant Service 2.3. NRC National Referal Centre for tissue donation 3. Responsibilities Medical and nursing teams at all grades: It is the responsibility of all nursing and/or medical staff to raise the option of tissue donation, sensitively with the patient or family following the guidence given in the deceased patient form. This is also part of the end of life care pathway. The tissue donation option is a documentation requirement on the Care of the Deceased patient form. It is expected that documentation is clearly completed to ensure compliance with trust policy and national documentation standards. Page the National Referral Centre (NRC) to refer the patient and provide all clinical details required. If this is out of hours, a message must be left stating the hospital, department, patient name, and contact number. If consent prior to death is established i.e. the patient is on the Organ Donor Register or carrying a donor card, the deceased person s relatives or those close to them should be told of the deceased person s decision. According to the Human Tissue Act 2004, the stated wishes of the deceased should take precedence over those of the family, but there may be exceptional circumstances where this is considered insensitive and inappropriate. To understand that Tissue donation is an integrated part of end of life care. General\ Policy\ Policy v3.0.docx Page 3 of 7

4 Role of the Tissue Donor Co-ordinator (NRC): Taking consent for donation in accordance with: Management of the deceased donor family donation conversation (MPD/MED/CM/051/03) ratified by the HTA (August 2006). The Human Tissue Act (2004) states that documented/evidenced consent must be obtained prior to the removal, storage and use of human tissue or organs. Responsible for ensuring the eye retrieval is in line with this policy and procedure, UK Transplant Guidelines/Protocols, Human Tissue Authority codes of practice, and the Third Party Agreements with the CTS Bristol Eye Bank and Bristol Heart Valve Bank. Providing liaison with the eye retriever, mortuary staff, ward staff and tissue banks on all matters related to tissue donation. Will contact the patients GP for further health history. Contact the coroner to ascertain permission where a coroner is involved (e.g. Post Mortem cases). Implementing a strategy for staff/public education and support in relation to tissue donation. Representation on the Trust Donation Committee. Provide pager service for referrals and advice. Office hours are 08:00-20:00. Out of hours messages are reviewed each morning. Qualified Tissue Retrievers: Responsible for ensuring the eye retrieval and the heart retrieval is in line with this policy and procedure, UK Transplant Guidelines/Protocols and Human Tissue Authority codes of practice and the Third Party Agreement with the CTS Bristol Eye Bank and Bristol Heart Valve Bank. Ward/Unit Managers: Acting as a patient advocate and ensuring that their decision regarding tissue donation are fulfilled whenever possible. Ensuring tissue donation is a usual part of end of life care. To monitor the training needs of the staff and provide adequate staff education to facilitate promotion of tissue donation in their ward area. To ensure Procedure for is brought to the attention of staff and that protocols are in place for the procedure to be implemented. General\ Policy\ Policy v3.0.docx Page 4 of 7

5 4. TISSUE DONATION Flow chart for procedure following death Patient dies YES a listed Contraindication. Do not refer for tissue donation Document your actions on notice of death form and in patient s notes. Does patient have any of the following contra-indications? HIV, Hep B/C, CJD, Dementia, Alzheimer s, Myeloma, Lymphoma, Leukaemia, Parkinson s, MS Patient not registered on ODR, Enquire if patient carried a donor card. No listed Contraindication. Check if the patient is on the organ donor register (ODR). Open 24hrs Call: Patient has registered on ODR Family Decline the option tissue donation Offer the family the opportunity to discuss tissue donation with the specialist nurse BEFORE the family leave the ward /dept. or over the phone if family not present in NDDH. Inform family that patient is on the ODR Family agreed to discuss tissue donation with the specialist tissue nurse Ensure that: The family are aware that the specialist tissue donation nurse will contact them at home. Check the family s contact numbers are recorded and correct. Refer patient to specialist tissue nurses: 24 hr Pager: You will need; patient s details, family contact details, admission hx, pmhx, time and date of death, GP details, name of certifying doctor, will patient require post mortem. Document outcome on deceased patient record notice of death form and in patient notes TISSUE DONATION OCCURS WITHIN 24 HRS OF DEATH: THEREFORE PLEASE BEGIN THIS PROCESS AS SOON AS POSSIBLE AFTER THE PATIENT S DEATH, TO INCREASE THE LIKELIHOOD OF A SUCCESSFUL DONATION General\ Policy\ Policy v3.0.docx Page 5 of 7

6 5. Monitoring Compliance With and the Effectiveness of the Policy Subsection Process for Monitoring Compliance and Effectiveness 5.1. Monitoring compliance with this policy will be the responsibility of the Lead Tissue Donor Co-ordinator for the South West. This will be undertaken by quarterly audits Numbers of tissue donor referrals including both proceeding and non proceeding donors Audit data will be reviewed at every trust Organ Donor Committee meeting Audit details and reports will be provided as required by NHSBT 5.3. Where non-compliance is identified, support and advice will be provided by the Tissue Donor Co-ordinators to improve practice. Standards/ Key Performance Indicators 5.4. At present there are no national key performance indicators; however the South West Tissue donation lead will audit and report to the organ donation committee quarterly- Numbers of tissue donor referrals including both proceeding and nonproceeding donors. 6. Equality Impact Assessment Table 1: Equality impact Assessment Group Age Disability Gender Gender Reassignment Human Rights (rights to privacy, dignity, liberty and nondegrading treatment), marriage and civil partnership Pregnancy Maternity and Breastfeeding Race (ethnic origin) Religion (or belief) Sexual Orientation Positive Impact Negative Impact No Impact Comment General\ Policy\ Policy v3.0.docx Page 6 of 7

7 7. Associated Documentation (Optional) Human Tissue Act (2004), the Human Tissue (Quality and Safety for Human Application) Regulations 2007 and the Human Tissue Authority Codes of Practice General\ Policy\ Policy v3.0.docx Page 7 of 7