Elizabeth Friddell
Site SurveyorUNOSSeptember 2024
IN THIS ISSUE 2
The Alliance
Insight Series
The Alliance insight series offers critical resources for stakeholders across the donation and transplantation continuum. For each topic, you can find related action items, tools, and references.
The Alliance Insight Series
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SEPTEMBER 2024 | ISSUE 2
Background
In August 2022, the OPTN aligned its policies with the U.S. 2020 Public Health Service (PHS) Guideline for assessing all transplant candidates for Hepatitis B vaccination.
Education
| POLICY INTERPRETATION | OPTN POLICY 15.2: CANDIDATE PRE-TRANSPLANT TESTING REQUIREMENTS | ||
|---|---|---|
| WHAT | WHEN | REMINDERS |
| Part of medical evaluation prior to transplant | The assessment of HBV vaccination status (i.e., review of vaccination records, titers) must be explicitly stated in the medical record. |
| HBV: Hepatitis B Virus | ||
Action
1. Improving Compliance Through Process
a. Leveraging EMR tools to create standardized documentation
- EPIC: Use of Smartphrase including HBV vaccination history, HBV titer results, patient vaccination status, and rationale mirroring TIEDI reporting fields
- Matching Epic deferral immunization nomenclature with TIEDI options.
2. Improving Compliance Through Monitoring
a. Creation of check list tasks and tracking report in Epic- can be utilized by coordinators and quality team to track compliance.
b. Auditing by transplant quality teams including reporting out on compliance rates and educating when noncompliance is noted.
Lessons Learned on the Journey Toward Compliance
Be aware of what kind of HBsAb testing (quantitative vs qualitative testing) is being ordered. Quantitative testing is often preferred as numerical value will better illustrate the level of immunity.
HBV vaccination series completion is dependent on the product that is received. Any supporting documentation supporting completion of vaccination series should include information regarding all doses of vaccination.
TIEDI Reporting Requirements
| TIEDI FORM | ||
|---|---|---|
| TIEDI FORM | WHAT TO REPORT | WHERE TO REPORT |
| Transplant Recipient Registration (TRR) | Assessment of HBV Vaccination Status Prior to Transplant for All Recipients |
If a patient has received a full Hepatitis B vaccination series prior to transplant, select Yes. If unknown, select UNK. If ‘No’ is selected, select the reason from the list:
Other, specify: Select this option if series is still in progress of completion & indicate “series still in progress.” This option may be used for any other reason that is not listed in options above. |
OPTN Survey Readiness
1. Provide documentation that:
- An assessment (and date of assessment) of the need for HBV vaccination prior to transplant and reason for not initiation or completing HBV vaccination series (if indicated)
- Vaccination status prior to transplant in medical records is consistent with the vaccination status reported in TIEDI
Tools & Resources
- OPTN policies to align with 2020 U.S. Public Health Service Guideline – Toolkit
- CDC PHS Guideline
- CDC Guidelines for Organ Transplants
- OPTN Policies and Evaluation Plan
- Notice of OPTN Policy Changes
- PHS – FAQs
- Lab testing FAQs
- UNOS Connect: search for the PHS Playlist
- CDC Vaccination Schedule 2024
- Hepatitis B Foundation – Vaccination Schedule and Guidelines
A SPECIAL THANKS TO THIS ISSUE’S CONTRIBUTORS
We would like to express our sincerest gratitude for our contributors’ tireless efforts on making Transplant Quality Corner a reality. Their dedication and expertise have been an invaluable contribution to the successful launch of this project. We are incredibly grateful for all their hard work and commitment.
Tamika Watkins
Disease Transmission Advisory CommitteeUNOSA SPECIAL THANKS TO THE TRANSPLANT QUALITY CORNER WORKGROUP
Denisia Chen
RN, CHC, CPCTransplant Regulatory Compliance SpecialistStanford Medicine Children's Health
Abbey Olsen
MSN, RN, CCRNTransplant Quality ManagerUniversity of Utah Hospital
Deepa Kurup
RN, MSN/MBA, LSSBB, CPHQSenior Director, Center for TransplantationUC San Diego Health System
Melissa Robinson
Quality & Safety Director, Transplant Institute Loma Linda University Medical Center
Jenna Lawson
MSSenior Quality and Patient Safety AdvisorVanderbilt University Medical Center
Hellen Oduor
Quality DirectorMethodist Dallas Medical Center
Lindsay Smith
RN, MSNTransplant Quality DirectorVanderbilt University Medical CenterFEEDBACK
If there is content you feel that should be added or was lacking, we would like to hear from you. Positive feedback on what is working for you, is also welcomed. Thank you for taking the time to provide us with your feedback.