JCAHO Revises Standard for 2007!
The Joint Commission has approved revisions to standard LD.3.110 that address organ procurement and donation. These revisions, effective January 1, 2007, are applicable to critical access centers and hospitals. Below are the major revisions to the standard. For a copy of the complete standard, please reference the 2007 Comprehensive Accreditation Manual for Hospitals published by JCAHO.

Standard LD.3.110 revisions:
Rationale for LD.3.110 (Critical Access Hospitals, Hospital)
Leadership’s commitment to creating a culture conducive to organ donation can have significant impact on the overall success of the hospital’s organ procurement efforts. The elements of performance in Standard LD.4.200 apply to all potential organ donors. This includes any individual who has been determined medically suitable for donation by the organ procurement organization (OPO). If the hospital has the necessary resources to support the recovery of organs after cardiac death, non-heartbeating donors are included in the organ procurement effort.

4. The OPO is notified of a patient who has died, or whose death is imminent, in the following ways:

• In accordance with clinical triggers defined jointly with hospital medical staff and the designated OPO
• Within time requirement jointly agreed to by the hospital and designated OPO (ideally within one hour)
• Prior to the withdrawal of any life-sustaining therapies including medical or pharmacological support

12. The organization works with the OPO and tissue and eye banks to do the following:

• Review death records to improve identification of potential donors
• Ensure that the necessary testing and placement of potential donated organs, tissues, and eyes takes place in order to maximize the viability of donor organs for transplant and maintain potential donors while preliminary suitability is determined.
• Educate staff about donation issues
• Develop a donation policy that addresses opportunities for asystolic recovery, based on an organ potential for donation that is mutually agreed upon by the designated OPO, hospital, and medical staff.