Federal Regulations

The process of identifying potential donors begins with hospital staff. All patients at risk for imminent death or who have just died must be promptly referred to the OPO. Evidence suggests that as many as 27% of potential donors are lost because they are not identified.16

The Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (42 CFR Part 482.5) require that hospitals refer ALL imminent deaths and deceased patients (actual deaths) to their OPO within 1 hour. Patients who meet the criteria for imminent death must be referred within one hour after the relevant clinical triggers have been reached. All actual deaths must be referred within one hour to preserve the opportunity for tissue and cornea donation. This requirement has reduced the loss of donors due to non-identification and non-referral by 40 percent.14 16 Nevertheless, 16 percent of all potential organ donors are still not identified.14 Timely identification and referral of potential donors not only preserves the opportunity for donation, but also allows for appropriate donor family support and optimum donor management.