The AJT Report
The AJT Report
This month, we look at a variety of ways transplant centers are coping with the increased volume and complexity of organ offers. Also this month, we look at six OPTN/UNOS proposals open for public comment.
News and issues that affect organ and tissue transplantation
Organ Offer Management
Transplant centers cope with the growing complexity of organ acceptance
With the communication of organ offers becoming so voluminous and complex, the days of someone just receiving a phone call and taking care of it are over. There are a variety of ways transplant centers are coping with problems related to staff burnout and escalating budgets.
According to Barry Marshall, a senior consultant with the national firm Transplant Management Group, based in Mandeville, La., the vast majority of transplant centers have coordinators take the call from their organ procurement organization (OPO). “The exclusionary criteria for organ acceptance is pretty cut and dried,” he says. “Most programs have upper and lower limits for everything associated with that organ. There is no reason a trained transplant coordinator can't at least take that first call and know that if you're getting an offer for an 85-year-old kidney for a 14-year-old recipient, the exclusionary criteria requires a ‘no thank you.”’
Nanci Flores, director of transplant services at the University of California, Los Angeles (UCLA) says her center has traditionally used nurse transplant coordinators, previously on an on-call basis and now with a new shift schedule. Issues of both staff burnout and financial constraint have influenced UCLA's organ offer management. In the past, staff complained of burnout. To save money, about six years ago nurses were moved from hourly and overtime pay to exempt, salaried positions. Then UCLA developed “call teams,” which included five salaried coordinators working 24-hour shifts with the flexibility to split shifts. While the abdominal teams accepted the new concept, the heart and lung programs opted to retain the old on-call system.
“It was a huge change and not an easy one to make,” Flores says about the call teams. “The surgeons complained a lot, but once they got used to it and [as] they've gotten to know the nurses taking the calls, it's working. We make call team members come in once a month for staff meetings. Sometimes we bring them in to meet OR staff, or we'll have them go out with the teams.”
Marshall says that some of the smaller programs he has worked with use surgeons to take the calls. “But it really depends on the medical site, who the director is and how they feel about it.”
One such center is Newark, De.-based Christiana Care Health Services, where S. John Swanson, III, MD, says the center's two transplant surgeons take the calls “because we know the nuances and can often make a final decision on acceptance. Ultimately, the decision rests with the physician and the OPO will call us anyway.”
However, Dr. Swanson is concerned about the numerous calls received during the night. “DonorNet has changed notification and everybody is called for every donor,” he says. “It's a major problem; we can get several calls a night and our patients may not even be in the top 10 for the offer.”
An In-House OPO
The University of Wisconsin Health Center in Madison is one of a handful of transplant centers with its own OPO. Dina Steinberger, interim executive director of the University of Wisconsin organ and tissue donation, cites several in-house benefits of the program, including a self-deploying recovery team on-call at all hours, a partnership with bedside nurses and doctors for donor management, integrated electronic health records and a common culture with a sense of ownership and accountability.
A little more than a year ago, the center decided to change to a 12-hour shift staffing model to deliver consistent, high-quality care to patients and families and to alleviate coordinator burnout, says Steinberger. “Published studies have shown that OPOs are challenged with retaining clinical staff, with two years the average,” she says. Now, new staff trained in the shift model say they like it.
- Transplant centers have adopted a variety of ways to cope with the increased volume and complexity of organ offers.
- Most centers use coordinators, some have surgeons take the call, a few operate their own OPO and others outsource to third parties.
Outsourcing to Third-Party Companies
Many centers may be unaware of a new trend in organ offer management: third-party companies who take the call and, if needed, set up the logistics of transportation, staffing and OR booking. Two of these companies are Buckeye Transplant Services in Glandorf, Ohio, and Transplant Coordinators of America (TCOA), based in Mt. Pleasant, S.C. They offer 24/7 and night/weekend/holiday coverage.
“When we started our services in 2008, transplant surgeons fielded the offers,” says Jeff Arrington, CEO of Buckeye Transplant Services. Now, physicians aren't contacted for every offer. Rather, the organization uses a flow chart from the center to thoroughly vet the organ and order more testing as needed before waking the surgeon in the middle of the night. “One of the compliments we get is that we're becoming part of the transplant center's culture and are seen as part of the team rather than a third-party outsource agency. We do that by keeping the same two or three coordinators on call for a particular center,” he says.
As the complexity of organ allocation increases, OPOs are challenged when the utilization of organs is not maximized. Ef.ciency can be lost with marginal organs.
TCOA, which has been in operation for approximately seven years, says that outsourcing services amount to a financial savings of 15% to 20% over staff retention. According to James Schiller, TCOA's chief marketing officer, the primary reasons transplant centers seek his organization's services are finances and staff burnout.
A recent new TCOA client is the Tulane Transplant Institute in New Orleans, where Barry Marshall is vice president of service lines and business development. Previously, Tulane utilized designated on-call coordinators, many of whom worked from their homes. Then, for financial reasons, they started looking at options regarding overall staffing. “One of those was to outsource call coverage and still maintain the same level of service. For us, the cost savings has been about 20% to 25%,” he says.
As the complexity of organ allocation increases, OPOs are challenged when the utilization of organs is not maximized. Although organ allocation works well for perfect organs, efficiency is lost with marginal organs, says Susan Stuart, president of the Association of Organ Procurement Organizations (AOPO).
Stuart references examples from the research of the Organ Procurement and Transplantation Network (OPTN) Effective Screening Working Group (ESWG), which found that surveyed transplant programs recognized the importance and impact of updating and adjusting recipient acceptance criteria for expanded criteria donor, donation after cardiac death and import offers. However, very few programs made any adjustments. “Regardless of who is making or taking the calls, flawed recipient listing criteria end up unnecessarily and significantly extending the allocation process, frustrating OPO and transplant program staff, leading to burnout and increased cost and, more importantly, wasting organs,” says Stuart.
In addition to several analyses conducted by the OPTN/United Network for Organ Sharing (UNOS) research department and the ESWG, a 2009 study published in the American Journal of Transplantation found that although offer-acceptance tools were available through UNOS, the system was not being efficiently utilized.
UNOS Screening Tools
“Feedback from transplant centers suggests that many still want to see every offer, to avoid missing the ‘diamond in the rough’,” says Joel Newman, who is the assistant director of communications for UNOS. Additionally, the screening tool limitation of one dimension at a time has been a challenge. For example, a center may screen out offers of donors older than age “X,” but might be interested in a donor age “X + 1” if everything else is acceptable, he says.
Nonetheless, there are tools available from UNOS to help centers better define their acceptance criteria and limit the number of offers to those that might best fit their patients. Ellie Willard, UNOS Organ Center supervisor, says UNOS staff are available to help transplant centers utilize these screening tools.
OPTN/UNOS Seeks Public Comment on Proposals by December 6
OPTN/UNOS HAS RELEASED SIX PROPOSALS for public comment. The comment period ends December 6, and the earliest that any of these proposals will be finalized and potentially voted on by the OPTN/UNOS board of directors is in June 2014.
- Establish minimum requirements for living liver donor follow-up: Transplant programs would be required to report specific fields on the Living Donor Follow-Up form at required postoperative reporting periods (six, 12 and 24 months).
- Require UNet registration of all living donor organ candidates prior to transplant: All candidates for living donor transplants would be added to the waiting list before their transplant.
- Patient notification of lack of transplant functional inactivity: Through a requirement for patient notification, candidates and potential candidates could learn about a program's activity levels, allowing the patient to make informed decisions about whether to move to another, more active program.
- Modify deceased donor testing requirements: This proposal seeks to modify current deceased donor testing requirements based on updated testing kit availability and laboratory practice, and also to clarify any points of confusion for the OPO community.
- Histocompatibility policy rewrite: The Histocompatibility Committee recommends a comprehensive review of the OPTN policies governing histocompatibility testing to better align OPTN testing requirements with federal regulations and to eliminate outdated or inadequately addressed sections of the current policies required by histocompatibility accrediting agencies.
- Revise the current method of flagging for transplant program posttransplant performance reviews: The purpose of this proposal is to better identify those transplant programs that may be underperforming in the area of patient and graft survival.