Variability in clinical triggers for organ donation referrals

In organ transplantation, regulatory efforts have mainly targeted Organ Procurement Organizations (OPOs) and transplant centers, while donor hospitals-crucial to the donation process-have remained under-examined. As the first point of contact for potential donors, these hospitals lack standardized criteria for when and how to refer patients to OPOs, creating variability that can delay referral and reduce organ availability. This viewpoint focuses on clinical triggers: the physiological criteria that prompt hospitals to notify OPOs of potential donors. While CMS requires donor hospitals to maintain written agreements with their designated OPOs and to inform the OPO of deaths and "imminent deaths," there is no national standard defining which bedside clinical criteria should prompt timely notifications; most hospitals defer to their local OPO for guidance. We analyzed clinical triggers from 55 of 56 U.S. OPOs and found marked inconsistency. Glasgow Coma Scale thresholds were used by 69.1%, and brainstem reflexes by 54.6%, with wide variation in both. Fewer than half addressed family discussions, and notification windows ranged from immediate to 240 min. These discrepancies reflect a critical bottleneck in the donor identification process. Standardizing clinical triggers and instituting a referral-based performance metric framework may improve metrics, thereby enhancing early donor identification, reducing missed referral opportunities, enhancing organ recovery, and reducing waitlist mortality. As scrutiny of OPOs and transplant centers increases, improving donor hospital practices is essential to optimizing the transplant system.