“Life Saving Results” October 29-30,2015

Jonette Strothcamp

Family Liaison

Hospital Services

Fisher,

Kidney Recipient

Mid America Transplant Services

• Not for Profit

• Procurement of vital organs, tissues, and eyes

• Medicare approved and funded

• Professional and Public Education

• Donor Family Support Services

• Incorporated in 1974

• Located in St. Louis, MO

• Serves Eastern MO, Southern IL,

and Northeast AR

MO

IL

AR

Mid-America

Transplant Services

All About MTS

• Organ procurement organization (OPO)

• 58 OPO’s in the nation

• One of 3 that is an eye bank and tissue bank

• First to have operating room in-house (we now have 3 in our facility)

More About MTS

• Home office is in St. Louis, MO

• 3 satellite offices

– Springfield, MO

– Cape Girardeau, MO

– Jonesboro, AR

• Just over 100 employees

• In the MTS service area there are: – About 112 Hospitals

– 4 Transplant Centers

• Transplant Centers are responsible for the medical

care of the recipient – OPOs focus most on the donor families

Hospitals and Transplant Centers

TJC (The Joint Commission) Guidelines

• Signed agreement with MTS

• Report all deaths to MTS

• Hospital has designated requestors trained by MTS

• Required documentation in patient's chart

• Death record reviews

Regulations

CMS Ruling 42 CFR Part 482 (1998) • Mandatory reporting of all deaths • Donation must be offered to families • Only designated requestors approach families for

consent • Mortality chart reviews by MTS

Regulations

2008 Missouri Uniform Anatomical

Gift Act UAGA Senate Bill 1139

• Effective August 28, 2008

• Establishes First Person Authorization

• Changes Hierarchy for Authorization

Donor Registry

Three Possible Approaches to Tissue Donation

1. Not on Registry

NOK must give authorization

2. Intent Registry

NOK must give authorization

3. 1st Person Registry or Authorization

Authorization Already Given

NOK not approached

Tissue Donation

• Saphenous Vein

• Heart Valve

• Skin

• Cartilage

• Eye

• Bone

• Tendons

• Fascia

Bill,

Bone recipient

Who Can Donate Tissue?

• No Medical History of:

– Current sepsis

– Current cancer

– Communicable diseases

• Age Criteria

Family Issues

• No cost

• No disfigurement

• Open casket funeral

• All questions answered

Communication Center

• Checks donor registry

• Determines suitability for

potential tissue donors

• Obtains release from

ME/Coroner

• Facilitates donation logistics

• Staffed 24/7

• Triages all tissue and organ referrals

When to Call

Organ referrals

• Neuro injury on vent

• GCS <5

• <80 years of age

• Prior to withdrawal of ventilator

• Before or less than one hour after Brain Death Exam

Tissue referrals

• Impending death

• Prior to approaching

family

• Within one hour of

cardiac death

On-Site at Hospital

• MTS Coordinator introduces self to staff

nurse & physician

• Evaluate chart for donor eligibility

• Check bundle values

• FSS introduces to Chaplain

• MTS staff to organize “Huddle”

Individual Bundle Metrics

• SBP: > 100 (mmHg) [or < 100 if MAP > 60]

• CVP: 5 – 10 (mmHg) [or < 5 if SBP “Met”]

• Glucose: 65 – 200 (mg/dL)

• pH: 7.25 – 7.45

• Temp: 96.8 – 99.6 (°F)

• Urine Output: > 0.5cc/kg/hr

• Na: < 160 (mmol/L)

• Lactic Acid: WNL

Establishing Brain Death

• Brain death occurs when all blood flow to the

brain and brain stem stops, causing death to all

brain cells.

• Irreversible

• Mechanically maintained “vital functions” are

not an indication of life

• Etiology: CVA, Head Trauma, Anoxia

Establishing Brain Death

• Refer to Hospital policy

• How is Brain Death (BD) determined?

– Bedside clinical exam

– Apnea test

– Confirmatory test

Defined Process for Improving

Conversion Rates

• Timely referral

• Family given grave prognosis

• BD declaration in timely manner

• Family understands brain death

• Family approached at right time

• MTS FSS part of collaborative approach

• Consistent message given by care team

When Should The Family Be

Approached?

• After death is understood by the family

• When family is asking “What’s Next?”

PLEASE WAIT FOR MTS FAMILY SUPPORT COORDINATOR FOR

POTENTIAL VITAL ORGAN DONORS

Collaboration

• Physician - Clear understanding of brain

death

• Pastoral Care - Minister to family’s needs

• Nurses - Support families needs, reinforce

message

• MTS FSS - Answers questions, supports

family, consent and Medical/Social History

General Evaluation

• Past Medical/Social

History

• ABO

• Height/Weight

• Fluid and Electrolyte

status

• Hemodynamics

• Review of Culture

Results

• Serologies

• Brain Death

Documentation

• Consult Medical Director

Donor Management

• Potential Complications – Hypotension

– Pulmonary Deterioration

– Hypothermia

– Diabetes Insipidus

Management

Hypotension • Etiology

– Loss of Vascular Tone

• Nursing Intervention

– Administer Crystalloids, Colloids, Blood Products

– Vasopressors

– Hormonal Resuscitation

• Continuous Hemodynamic Monitoring

Management

Pulmonary Deterioration

• Etiology – Pulmonary Edema, Atelectasis, and Aspiration

Pneumonia

• Interventions – Good Pulmonary Toilet

– Bronchoscopy

– Chest X-Ray

– Ventilator Settings

– ABG

– Sputum Culture and Gram Stain

– Antibiotics

Management Hypothermia • Etiology

– Loss of the hypothalamic thermostat

– External causes

• Intervention

– Increase room temperature

– Hypothermia blanket, heating lamp

– Warm IV fluids

– Warm and humidified ventilation

Management

Diabetes Insipidus

• Etiology – Loss of the pituitary gland function, resulting in

loss of circulating ADH

• Nursing Intervention – Match hourly urine output plus 50cc of IVFs (1/4

or ½ NS)

– Administer DDAVP 0.5-2.0 mcg IVP

– Close monitoring of serum Na+ and K+

Organs Currently Being

Transplanted

Heart

Small

Intestine

Lungs

Liver

Kidneys

Pancreas

Heart Evaluation

• EKG

• Echocardiogram

• Labs

– CPK with mB, Troponin

• Swan Ganz

• Cardiac Catheterization

Lung Evaluation

• Current Chest X-Ray

• ABG

• O2 Challenge – 100% FiO2, 5.0 PEEP for 20

minutes

– PO2 > 300 lung calls are made

• Lung Measurements

• Bronchoscopy

• Sputum Gram Stain

Liver and Small Bowel Evaluation

• Labs – PT, PTT, ALT, AST, GGT, Alk

Phos., Total and Direct

Bilirubin, Electrolytes

• Liver Biopsy in Unit

• Abdominal Trauma – X-Rays as needed

Pancreas Evaluation

• Labs

– Amylase, Lipase,

Electrolytes, HgbA1C

• Blood Sugars Through

Course of Admission

Kidney Evaluation

• Labs

– BUN, Creatinine, and

Electrolytes

• Urine Output

• Urinalysis

United Network of Organ Sharing

• Federally contracted regulatory agency

• All Donors and Recipients are registered

• Transplant Centers and OPO’s must be

members

• Principles of Allocation – ABO/Size Match

– Geographical / Logistics

– Time Waiting

– Severity of Illness

– Kidneys – HLA Match

– Age is a Factor for Pediatric Donors

Organ Allocation

Organ Allocation

• Transplant centers are contacted electronically

• Review all donor information online

• Accept or decline organ based on recipient needs

• Contact MTS coordinator for further information, additional tests, and to coordinate organ recovery

Final Organ Allocation

• Recipients are matched prior to going to the operating room

• OR time must be coordinated with all centers involved

• Some recipients require crossmatches or may come from some distance away

• OR time is set when EVERYONE is ready

Moving Back to MTS

• Ability to perform Cardiac

Cath’s, Echocardiograms, Labs – Decreased time in ICU

• Most procurements occur at

MTS OR – Cost Containment

– Avoids limiting hospital OR

resources

Organ Recovery

• Organ dissection

• Cross clamp/Preservation

• Heart recovered first followed by Lungs, Liver,

Kidney’s and Pancreas

• If small bowel is taken it is usually procured after

the liver

Donor Family - AfterCare

• Immediate Aftercare – Informational Packets for Organ and Tissue Donor

Families

– Donor Medals

– Sympathy Cards

– Initial Family Thank You Letter

• Follow Up Correspondence – 1 year scheduled mailing program

– Solace Newsletter published three times per year

• Ongoing Support – Correspondence between Donor

Families and Recipients

– Memorial Ceremonies

– Special Education Seminars

– MTS Website

Donor Family - AfterCare

Donor Family Satisfaction is High

9.75

9.78

Satisfaction

with Decision

to Donate

Likelihood to

Make Decision

to Donate

Again

Scale of 1-10