University of Minnesota Health Donor Screening Program Region 7 Education Meeting 2/13/14 Dr. Gail...

University of Minnesota Health Donor Screening Program

Region 7 Education Meeting 2/13/14

Dr. Gail Frankle DHN, RN, CPTC Sr. Director Transplant Services, University of

Minnesota Health

Timeline• Era 1 3/13-7/13

“ No dedicated screening program”• Era 2 8/13-12/13

“ Single surgeon (lung) dedicated screening” 12/13 first OCS Breathing Lung -Inspire

New Leadership in place and process improvement• Era 3 1/14-4/14 “ No dedicated screening program”

1/14 Second OCS Breathing Lung - Inspire 1/14 first OCS Breathing Lung - Expand

• Era 4 5/14- 10/14 “ Dedicated screening program”

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The UMH Experience prior to Dedicated Screening Program

• Feb ‘13 – July ‘13 - 199 primary offers, 5% Utilization rate, 21% Underutilization rate, 10 transplants

• Fewer number of surgeons on staff• Less time to dedicate to screening and

working up offers• Donor Screening ERA

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Role of the Donor Coordinators

• May 2014 - 3 dedicated donor screeners (combined H/L)

• 24 hour call: firefighter’s schedule• Advanced* screening of all imports, local cases• Transplant coordination• Quality/Audits/Reporting• Clinical research

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

ERA 5: …and beyondHighlights

• Oct ‘14 – Jan ‘15: 48% turn down rate, 6% Underutilization rate, 15% Utilization rate, +/- 17 (21 transplants)

• December ‘14 – 22% Utilization rate (peak)• January ‘15 – Zero send outs, 6 transplants

(UMN list diminished to 13 PTR for most of month, zero AB/B PTR; far fewer offers)

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Era by the numbers

UNOS coding Valid code(s) – 801, 802, 803, 810, 812, 830, 831, 837, 898

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Coding, de-coded

• 801 – PTR ill, refused txp

• 802 – laterality

• 803 – transplanted, in progress

• 810 – cross match +

• 812 – No serum avail

• 830 – Quality

• 831 –inappropriate size

• 837 – Organ-specific issue

• 898 – Free text

PTR requires laterality not offered by OPO, poor quality of affected lung influences primary PTR compatibility

Positive virtual/prospective deemed incompatible by Immunology Director/Surgeon

OPO unwilling/unable to send blood for sensitized PTR requiring PXM

Donor Quality; 830 vs. 837 (affect underutilization rates)

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

802

• PTR requires different laterality than offered• Unilateral lung disease (PNA) which affects primary

PTR compatibility– Requires BSL or RL however donor CT Chest

reveals significant RL pneumonia– List screened for PTR able to take LL

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

830

• Quality of the donor, in whole is not acceptable by UMH standards– Non-primary CNS CA, MSOF, combination of factors

(bronch, CXR, etc.)• Age not a factor; each offer gets assessed based on number of

factors• Social history not applicable• Single r/o finding receives 837• Requires audit; coordinator sends specifics of turn-down for

monthly reporting. Sent-out?

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

898

• Factors such as unable to make family-driven OR time

• Offer made from OR (declined by recovering team)

• DCD w/low likelihood of rapid death• Specific issue communicated by surgeon• Rarely used

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Codes & ReportingMaster spreadsheet maintained daily:

PY, transplanted, 831, 830/837, 898/other, surgeon phoned, list exhausted, sent out, and comments tracked

End-of-month reporting generated from Master spreadsheet

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health (local) Screening Flowchart

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health (import) Screening Flowchart

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Size: does it fit? Do we need it to fit?

• Predicted/actual Total Lung Capacity• Lung measurements• Height• PTR disease process (Obstructive vs.

Restrictive disorders)• Severity of illness (LAS), Class II antibodies and

cut-downs?

Know your list!University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Assessing for Quality

• Gas exchange – p:f assessment on conventional vent settings, alveolar recruitment, unfairly extrapolating ARDSnet data?

• Imaging – CXR (pna/edema), CT chest w/lung windows, bronchscopy

• Active infection – gs/cx, WBC, antibiotics• DCD rapid death evaluation• Unilateral disease? Know your list!• UMN DLQI *• OCS• PTR influences feasibility of offer? Logistics, OCS University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

HLA• Immunology director paged w/primary import offer• Virtual vs. Prospective (critical elements at time of transplant)

– Extra serum sent to lab on all local cases; prospective started on expected PTR*

– Retrospective cross match on Virtuals• Class II: DQ, DR, DPB – availability of testing?• MFI > 3000 (final decision made by surgeon with HLA director

recommendations)• Pitfalls: IVIG therapy, false positives/noise

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Donor Management

• May request vent changes, diuresis, antibiotics, etc.• Constant assessment post-therapy– Q4° CXR, p:f on pure O2, serial bronch

• Time? Bacterial meningitis, resolving pneumonia• Frequent communication w/OPO coordinator

paramount!

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Presentation to surgeon

• Synopsis of case• Accepts or• Declines offer

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Accepted:

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• Donor OR is set• Pt. contacted for verification– Admitted to UMMC

• LifeSource contacted for transportation• Organ Recovery team notified• Pt. is admitted– Unit is notified– Special Instructions given if needed

• UMH OR notified• Blood Bank notified• Immunology notified for retrospective XM• Staff, Cardiologists/Pulmonologists notified• Organ Research notified• OR Implanting team notified• Provide ongoing communication with all parties

involved in Xplant• Notifications– EPIC documentation– Email notification sent– UNOS delisting

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

SLEEPSLEEPSLEEPSLEEPSLEEPSLEEPSLEEP

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Dr. Gail Frankle DHA, RN, CPTCSr. Director Transplant ServicesUniversity of Minnesota Health

612-614-8910dfrankl1@fairview.org