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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”
University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.
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
University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.
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)
University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.
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
University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.
Accepted:
University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.
• 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
