Introduction: Accurate assessment of opportunities for donation after circulatory death (DCD) is needed to grow the pool of available organs for transplant. While accurately ruling in a candidate is often examined in the context of transplant center and donor hospital resource preservation, less focus is placed on the opportunities missed in the pursuit of accuracy. We describe a performance improvement effort aimed at reducing the number of patients incorrectly “ruled-out” for donation. 
Method: Potential DCD referrals were defined as ventilated patients referred to our organ procurement organization (OPO) and found to be eligible after medical screening.  In the last 3 years, our OPO screened 2,017 medically suitable potential DCD donors for likelihood of progression to death within a120-minute timeframe. Overall, 75% (1,513) of the patients deemed candidates by our team ultimately passed within the DCD timeframe. In that same period, 16% (n=358) of patients that were ruled out based on neurologic function did expire in the DCDD timeframe, representing missed opportunities to expand the donor pool.  
Results: The decision to proceed with DCD lies with our clinical director on call (CDOC). This role was historically a 24 hour on-call shift for existing leadership team members, who juggled their primary role with referral screening and case management. From 1/1/2021 – 1/31/2023, 19% of the patients ruled out for DCD were incorrectly excluded. To reduce multitasking and enhance screening quality, a second CDOC was added during high volume hours on weekdays for referral screening. This CDOC was still often a manager, and for the 6 months this model was in place the incorrect DCD rule out rate improved to 14%.  In August 2023, a full-time CDOC model was implemented.  These team members had no obligations outside of the call schedule and would cover all case and referral activity (2 CDOCs per shift.) From 8/1/2023 – 10/31/2024 the incorrect DCD rule out rate further improved to 12.7%. Based on feedback from CDOCs, referral CDOCs were added to weekends and holidays, leading to improved daily coverage. From 11/1/2024 – 5/31/2025, the rate of incorrect DCD neuro rule outs has declined to 8% in our current configuration.
Conclusion: While correctly assessing patients that will expire within a timeframe for DCD is necessary to ensure resources are efficiently expended, it cannot be at the expense of expanding the donor pool. Ensuring OPOs focus not only on correctly ruling in, but also on accuracy in ruling out can ensure opportunities for lifesaving transplants are maximized. Reducing multi-tasking, ensuring ongoing monitoring and screening of patients for whom neuro status may quickly deteriorate, and close analysis of performance data are strategies that have helped our OPO grow the number of donors in our community. If our current performance were applied retroactively from 1/1/2021 – 10/31/2024, an additional 172 donors may have been realized.