Director of anesthesiology for liver transplantation: Existing practices and recommendations by the united network for organ sharing


  • The Liver Transplant and Anesthesia Consortium surveys were funded by the Department of Anesthesiology at Vanderbilt University.

Address reprint requests to M. Susan Mandell, M.D., Ph.D., Department of Anesthesiology, University of Colorado Health Sciences Center, 12631 East 17th Avenue, Academic Office One, Aurora, CO 80045. Telephone: 303-724-1760; FAX: 303-724-1761; 724-1760; E-mail:


A new Organ Procurement and Transplantation Network/United Network for Organ Sharing bylaw recommends that all centers appoint a director of liver transplant anesthesia with a uniform set of criteria. We obtained survey data from the Liver Transplant Anesthesia Consortium so that we could compare existing criteria for a director in the United States with the current recommendations. The data set included responses from adult academic liver transplant programs before the new bylaw. The respondent rates were within statistical limits to exclude sampling bias. All centers had a director of liver transplant anesthesia. The criteria varied between institutions, and the data suggest that the availability of resources influenced the choice of criteria. The information suggests that the criteria used in the new bylaw reflect existing practices. The bylaw plays an important role in supporting emerging leadership roles in liver transplant anesthesia and brings greater uniformity to the directorship position. Liver Transpl 19:425–430, 2013. © 2013 AASLD.


American Society of Anesthesiologists


continuing medical education


Centers for Medicare and Medicaid Services


Liver Transplant Anesthesia Consortium


Organ Procurement and Transplantation Network


United Network for Organ Sharing.

The Membership and Professional Standards Committee of the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) has approved a new bylaw recommending that each transplant center appoint a director of liver transplant anesthesia.[1] This change is in response to evidence that anesthesiologists significantly influence liver transplant recipient outcomes and resource utilization but do not have uniform liver transplant experience or education.[2, 3]

The final rule for designated transplant program requirements (OPTN part 121.9/42 CFR 121) does not require anesthesiologists to have or maintain any experience in the field of liver transplantation.[4] The aim of the new bylaw is to ensure that 1 individual at each center has expertise in the perioperative care of liver transplant patients. Therefore, minimum requirements were developed for the directorship position.

Using the current OPTN/UNOS criteria for a primary liver transplant surgeon as a template,[5] a transplant committee within the American Society of Anesthesiology developed requirements. These were incorporated directly into the OPTN/UNOS bylaws. The recommendations are as follows: (1) certification by the American Board of Anesthesiology or a foreign equivalent; (2) anesthesia care for at least 20 liver transplant recipients within the previous 5 years or 10 cases in the previous 5 years if the director candidate has additional fellowship training in critical care medicine, cardiac anesthesia, or liver transplantation; and (3) at least 8 continuing medical education (CME) credits in liver transplant–related activities over the previous 3-year period.

The administrative responsibilities included in the American Society of Anesthesiologists (ASA) committee recommendations are as follows: the director or a designee should participate in candidate evaluation and selection; transplant morbidity and mortality conferences; and the development of written, evidence-based perioperative and intraoperative guidelines for liver transplant patient care.[6]

Before the bylaw was adopted, a public comment questionnaire asked OPTN/UNOS member institutions whether the proposed criteria reflected current practice at their institutions.[7] Although this type of input provided some information, additional data were needed to fully address the question. Using a data set that could be analyzed for descriptive content and sample representation, this study describes directorship practices before the bylaw proposal. We obtained this information from the Liver Transplant Anesthesia Consortium (LTrAC), a group of anesthesiologists who conducted sequential surveys of US and international liver transplant anesthesia practices. We extracted survey results about directors of liver transplantation in the United States to determine the similarity between proposed and existing directorship practices.


LTrAC and Survey Instruments

LTrAC survey results have been published previously, and the methods of survey development, data collection, and analysis have been described.[3] Institutional review board approval was granted by Vanderbilt University Medical Center. The surveys were distributed electronically to all adult liver transplant programs in good standing with UNOS between 2006 and 2008. Data collection was closed in 2009.

Data Preparation

Completed surveys were electronically transferred to the Department of Biostatistics at Vanderbilt University for analysis. Responses to all questions containing the phrase “director of anesthesia for liver transplantation” were retrieved. Additional questions were reviewed for content by 2 members of the study team (M.S.M. and A.W.); upon consensus, questions containing additional information regarding the director's scope of practice were coded for analysis. The first survey (101) and the last survey (301) contained questions relevant to directors of transplant anesthesia.

Study Population and Survey Methods

The study populations consisted of adult liver transplant centers in the continental United States that were certified by the Centers for Medicare and Medicaid and were in good standing with UNOS.[1] Anesthesia practices were considered academic when they were governed by an accredited school of medicine and private when they were self-governing and were not associated with a medical school.

Liver transplant programs were categorized according to volume; the actual numbers were confirmed by data from the Scientific Registry of Transplant Recipients.[11] Programs were divided into large (>100), medium (50–99), and small ones (10–49) according to the annual number of liver transplants. These definitions were compatible with previously published studies.[8, 9]


Survey Sample

There were 119 certified centers in good standing when the surveys were distributed. Centers performing only pediatric transplants (n = 21) or handling fewer than 10 cases per year over a 3-year period (n = 10) were excluded from both surveys. Five centers undergoing reorganization were also excluded from the study: 3 during the 101 survey and 2 during the 301 survey. The number of academic centers increased from 59 to 61 in the time interval between the 101 and 301 surveys. One of the 3 reorganizing programs and a second private practice program changed to academic practice. The majority of the programs included in the study were academic (69% for the 101 survey and 71% for the 301 survey).

Completed LTrAC 101 surveys were received from 42 of the 59 academic centers (71%) and 3 of the 26 private practice groups (11%). Private practice groups were excluded from further analysis because of the poor response rate. The 301 survey response rate was 67% (41/61). The 2 new academic centers did not respond to the LTrAC 301 survey. One large center that participated in the LTrAC 101 survey also failed to respond to the 301 survey. There were 24 small, 23 medium, and 12 large volume academic centers that participated in the 101 survey (Table 1). The response rates based on center size were similar for the 101 and 301 surveys. The data from the LTrAC surveys were not accessed before or during the development of the OPTN/UNOS criteria for a director of anesthesia for liver transplantation.

Table 1. Academic Center Response Rates to the LTrAC 101 and 301 Surveys
Academic CentersLTrAC 101LTrAC 301
  1. NOTE: Response rates were stable for the 2 surveys. There were 2 new medium academic centers during the LTrAC 301 survey; one had changed from private practice, and the other was previously closed for reorganization. Neither center responded to the 301 survey. One large center did not respond to the 301 survey. This dropped the overall response rate to 67%. However, 41 of the 42 centers that responded to the LTrAC 101 survey also responded to the 301 survey.

All42/59 (71%)41/61 (67%)
Small14/24 (58%)14/24 (58%)
Medium19/23 (83%)19/25 (76%)
Large9/12 (75%)8/12 (67%)

Description of a Director of Anesthesia for Liver Transplantation: 2006–2009

All responding academic programs had a director of anesthesia for liver transplantation. Chairs for departments of anesthesiology appointed the directors at 87% of the programs surveyed; the remaining directors were appointed by the hospital administration (8%) or transplant surgeons (5%). The appointment was permanent at 97% of the centers. In 2006, the directors held their position for an average of 6.5 years (range = 1–20 years).

Few programs (38%) used written institutional criteria to describe the directorship position. Written criteria were more commonly used in small-volume centers (58%) versus medium- (28%) and large-volume centers (38%). Centers showed little change in this pattern over time. Only 8 programs reported a change in the criteria before or during the survey; 4 programs introduced criteria for the director, and another 4 programs eliminated criteria. A minority (20%) of the centers that did not require specific qualifications planned to introduce written criteria. New qualifications were being developed at 24% of the medium-volume centers, at 6% of the large-volume centers, and at none of the small-volume centers.

Unstructured comments from directors at 4 centers specified that they would not use criteria for the directorship position unless it was mandated by a governing agency. Directors from 3 additional centers without written qualifications reported that the directors at their institutions had to provide proof of previous liver transplant experience.

Comparison Between Existing Practices and UNOS/OPTN Recommendations


Most directors were board-certified by the American Board of Anesthesiology or a foreign equivalent. Two directors at medium centers were board-eligible. No director completed a fellowship in liver transplantation, and no program required additional certification in an Accreditation Council for Graduate Medical Education–approved program other than anesthesiology.[11] Additional qualifications requested by institutions for the directorship position included a range of activities: documented leadership and administrative skills, transesophageal echocardiography certification, and formal research training.

Case-Volume Requirements

Only 4.3% of all centers required a specific number of liver transplant cases for a person to qualify as director; this was primarily at medium (6%) and large centers (6%). The number of required cases varied with the center, and there was little association with center size. These centers required a set number of cases for a person to be appointed director. No center requested a specific case volume over a 5-year period.

Most surveyed programs (82%) requested that the director have postgraduate liver transplant experience. Additional case-volume experience was obtained at 42% of centers through visits to another transplant center to observe intraoperative care. Small centers used this approach most often (91%).

The transplant centers without written case-volume criteria requested postgraduate experience in cardiovascular anesthesia (67%), and up to 57% asked for additional intensive care training for a person to be appointed director. Cardiovascular experience was used at 86% of small centers and at none of the medium or large centers.

CME Credits

All directors earned CME credits in the field of liver transplantation on a yearly basis. The number of CME credits earned varied according to the center size. Just more than half of the directors (53%) at small centers earned up to 5 credits, whereas 50% at large centers earned 6 to 10 credits each year. The numbers of CME credits that directors at medium centers earned were evenly distributed between 1 to 5 (35%), 6 to 10 (33%), and >10 (31%). In contrast, directors at only 26% of small centers and 19% of large centers earned more than 10 CME credits each year.

Administrative Tasks

Transplant Selection Committee and Patient Assessment

Directors attended transplant patient selection committees at 65% of responding centers. Even though attendance was more common at large centers (75%), only 29% were present for more than half of the meetings (Table 2). Fewer directors attended at medium (67%) and small centers (57%). Only 20% of directors at small centers and 11% of directors at medium centers were present at more than half of the meetings. Attendance was associated with the provision of protected time for this activity in large centers (38%) versus small (25%) and medium centers (20%). In contrast, there was no association with the frequency with which anesthesiologists performed consultations for transplant candidates. Consults were performed for at least 75% of transplant candidates, and this occurred most often at medium centers (40%) versus large (30%) and small centers (16%).

Table 2. Participation in Administrative Tasks For the Director of Liver Transplant Anesthesia at Academic Centers
Center SizePatient Selection Committee AttendanceAttendance > 50%Resident RotationJournal ClubGrand RoundsMultidisciplinary Morbidity and Mortality RoundsParticipation in Morbidity and Mortality RoundsProtected Time
  1. NOTE: Directors reported attending the multidisciplinary patient selection committee at 65% of the 61 academic centers included in the study. However, only 18% attended more than 50% of all meetings. Similar numerical trends were observed for protected administrative time and attendance at more than 50% of meetings. Centers had additional educational activities in liver transplantation, including resident rotations, journal clubs, and block time for the presentation of liver transplant topics during grand rounds. Only 71% of all centers had multidisciplinary morbidity and mortality rounds in which anesthesiologists could participate. Directors at 51% of these centers participated in the multidisciplinary rounds; more did so at large centers (78%) versus medium centers (53%) and small centers (30%).

All (n = 61)65%18%26%18%20%71%51%25%
Small (n = 24)57%20%18%9%7%44%30%25%
Medium (n = 25)67%11%29%26%25%79%53%20%
Large (n = 12)75%29%31%19%34%90%78%38%
Education and Quality Improvement

Interdepartmental morbidity and mortality transplant rounds were reported at 71% of the study centers; this mostly occurred at large (90%) and medium centers (79%; Table 2). Only 44% of small centers reported interdisciplinary morbidity and mortality transplant rounds. Overall, anesthesiologists at 51% of centers participated in these rounds (78% at large centers, 53% at medium centers, and 30% at small centers).

Approximately half (56%) of liver transplant anesthesia teams performed independent quality reviews of their cases; this occurred most at large (75%) and small centers (67%) and least at medium centers (39%). It was rare (21%) for anesthesiologists to receive any formal feedback from the surgeons or the hospital regarding quality assurance or performance.

Educational Activities

Liver transplant–related educational activities in departments of anesthesia were uncommon. Only 18% of the responding centers incorporated liver transplantation into a journal club, and only 20% had block time for transplantation during grand rounds (Table 2). Anesthesia residents at only 26% of all responding centers participated in a structured liver transplant educational activity such as a clinical rotation. Some of these activities were associated with the size of the center; most activities occurred in large centers, and they occurred least at small centers (Table 2). Three centers reported having an anesthesia postgraduate fellow. The majority of the centers (80%) did not report any additional educational/quality assurance activities in the field of liver transplantation.

Written Protocols

Overall, 80% of the institutions reported having some form of patient care protocol developed by anesthesiologists. Protocols for preoperative assessments were present at 65% of all study sites. These were most common at medium (79%) and large centers (66%) and least common at small centers (48%). There were anesthesia protocols for obtaining laboratory results at 31% of all centers; the proportions ranged from 25% (at small centers) to 33% (at medium centers) to 34% (at large centers). Protocols for early extubation were recovered from 27% of the sites.


The LTrAC data show that the UNOS/OPTN bylaw recommendations for directors of anesthesia for liver transplantation are similar to existing practices at most academic adult liver transplant centers. All responding centers already had 1 individual identified as the director. Although few programs had formal criteria, most requested additional knowledge and experience in liver transplantation or related high-acuity care. The administrative tasks of directors were also similar to the bylaw recommendations and included candidate assessment and selection and quality improvement. We suggest that the new bylaw does not introduce new practices. Rather, it supports the emerging leadership in liver transplant anesthesia and brings greater uniformity to the directorship position. The primary focus of the directorship position in the future will be compliance with the existing bylaws.

There were 85 centers included in the 101 survey and 86 in the 301 survey. The inclusion criteria were aimed at minimizing the influence of factors with nonrandom effects on anesthesia practices.[12] Pediatric centers (n = 21) were excluded because of differences in physician certification and hospital credentialing. Centers not accredited by the Centers for Medicare and Medicaid Services (CMS) were excluded because they did not share the same performance requirements as accredited centers (42 CFR 482.74).[4] These factors may have influenced the choice of anesthesia providers and/or their organizational structure.

The 11% response rate of private practice groups limited the conclusions of this study to academic practices. A minority of the overall sample was lost because 69% to 71% of the potential sites were academic practices. Therefore, our final sample was purposive according to the demographic characteristics and comparative response rates that emerged during the study. The overall response rate to the surveys was close to 73%, the rate required for significance (P = 0.05) in the analysis of smaller sample sizes.[13] This suggests that our findings are representative of the population studied.

There was an inadequate respondent rate (11%) from private practices that cared for liver transplant recipients. It was, therefore, impossible to determine how many of these programs had a director of anesthesia. Furthermore, this study could not determine the similarities or differences between private practices and the UNOS/OPTN bylaws. The low response rate of private practices versus academic centers led us to speculate that private practice groups were less organized and probably had fewer directors. This will require further study.

We segregated the data according to case volume because there is a relationship between resource utilization and the choice of practices,[14] and it is a commonly used metric for the analysis of transplant center data.[15] Response rates varied from 83% for medium centers to 75% for large centers and 58% for small centers. Although quality or choice of care was not associated with the physician survey response rate, lower response rates from small-volume centers increased the risk of sampling bias in this group.[16]

There have been few national leadership strategies for liver transplant anesthesia. Organization by the ASA and UNOS/OPTN to identify directorship criteria is one of the first structured and cooperative efforts. At the time of the survey, there were no UNOS recommendations regarding a directorship position. However, directors of liver transplant anesthesia were present at all adult academic centers surveyed, and most were appointed by chairs of departments of anesthesia (87%). This suggests a grass-roots effort by academic departments of anesthesia to optimize the quality of care by using a leadership model. The findings concur with our previous study showing a self-directed trend to subspecialization in the field of liver transplantation.[3]

Our data indicate that a national consensus has not been reached regarding the criteria for directors. Differences in qualifications were often associated with case volume. For example, 86% of small centers used cardiovascular experience, whereas none of the medium and large centers did. Small centers also sent more directors to external centers to obtain experience. These differences suggest that some center-specific anesthesia practice patterns are not random and may be driven by inequities in access to resources used to gain knowledge and experience.[17]

The inclusion of administrative tasks in the recommendations for directors differs from the recommendations for other UNOS/OPTN physician leadership positions. The ASA included these tasks after evidence suggested that consolidated anesthesia liver transplant teams had better recipient outcomes.[2] The study reported additional educational activities and interdisciplinary communication as key factors in improving the quality of care.

Evidence from other studies has shown that consensus building increases the uniformity of medical practice,[18] whereas compliance with established guidelines or recommendations is related to oversight.[19] The diversity of practices observed in our study leads us to hypothesize that consensus building may benefit quality improvement in liver transplant anesthesia. This would require a consolidating process to define the position of director. It is likely that guidance from a national transplant organization would facilitate leadership development. The experience of other transplant specialties indicates that leadership models in liver transplant anesthesia will make compliance easier to institute and monitor.

The new bylaw recommendations are aligned with the National Quality Strategy initiative to improve health care quality, value, and outcomes that was submitted to Congress in 2011 as a mandate of the Patient Protection and Affordable Care Act.[20] The bylaw recommendations also meet the 2010 CMS transplant center conditions of participation for a comprehensive quality assessment and performance improvement program.[21]

Elements of the UNOS/OPTN director recommendations that meet the National Quality Strategy and conditions of participation include leadership, accountability, and multidisciplinary care coordination. The new bylaw contains quality process, outcome measurement, evaluation, and feedback; evidence-based protocol implementation; certification and CME; and regulation. These are also integral goals of CMS requirements and the National Quality Strategy initiative. The bylaw recommendations should, therefore, improve patient safety.

Overall, our data demonstrate that the UNOS/OPTN bylaw recommendations for directors of anesthesia for liver transplantation are reasonable and reflect practices at the majority of adult transplant centers. Although the recommendations are possible to institute at most sites, the data suggest that there are some nonrandom barriers influencing the choice of directorship criteria. These appear to be related to the resources that individual departments of anesthesia have or are willing to offer. This highlights the need for national consensus building to support the growth of anesthesia liver transplant leadership models and to unify criteria for the directorship position. Previous experience in the field of transplantation shows that guidance and oversight promote consensus building and compliance. This has been successful in other UNOS/OPTN leadership models.


The authors thank Russell Wiesner, M.D. (Mayo Clinic, Rochester, MN), and Richard Freeman, M.D. (Dartmouth University, Hanover, NH), for their work in introducing bylaws for liver transplant anesthesia practice.