Best Practice

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The Wait of a Lifetime
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HRSA Organ Donation Transplantation
Breakthrough Collaborative Initiative
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Best Practice 1Involve Senior Leadership to
Advocate Donation as the Mission
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• Wed. Senior Leadership Meeting
• Report Out
• Dr. Tony DAlessandro

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Involving Senior LeadershipNursing Patient
Care ServicesDianne M. Danis, RN,MSDirector,
Nursing Practice InnovationUniversity of
Wisconsin Hospital Clinics
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Joint Commission 10Cs

• Commitment of leadership
• Champion for the cause identified
• Culture of priority for organ donation created
• Collaborative effort with OPO
• Communicate organ donation opportunities rapidly
  to OPO

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Joint Commission 10Cs

• 6. Check progress through dashboard
• 7. Conversion rate monitored improved
• 8. Counsel potential donor families effectively
• 9. Clarify policies procedures infrastructure
• 10. Criteria established for DCD

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Commitment Championship

• Sr VP Nursing Patient Care Services Nursing
  Executive Council identified need for increased
  efforts to support donation
• Small director steering group established to
  discuss issues identify solutions
• Director of Nursing Practice Innovation
  identified as point person champion

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Collaborative Effort

• Joint meetings initiated with nursing steering
  group and OPO representatives
• Meetings now include MTF representative as well
• New designated requestor training program jointly
  developed coordinated
• Collaborative Nursing Grand Rounds presented
  March 21
• Currently looking at data collection reporting

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Counsel Families Effectively

• Designated Requestor role restricted to RNs from
  high-occurrence units, nursing coordinators,
  social workers, OPO staff
• Initial training is 4-hour course taught by OPO
• Trained requestors are entered into nursing
  database coordinators assist in identifying
  requestors when necessary
• Brief annual updates are planned
• After action reviews

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Clarify Infrastructure

• Development of guidelines for identifying
  designated requestor
• Development of course curriculum
• Key concepts integrated into orientation
• Report of Death form in development
• Current focus on streamlining M/T process

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Reflections

• What is it about this work?
• How to engage senior leadership?

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Best Practice 2Practice Early Referral by
Establishing Clinical Triggers
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Best Practice 2 Early Referral and Rapid
Response Establishing Clinical Triggers
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Clinical Triggers

• A Mechanically Ventilated Patient with a Severe
  Brain Injury-
• For Whom a Physician is Evaluating for Brain
  Death
• A Patient with a Glasgow Coma Scale (GCS) of 5
  or less
• For Whom a Physician has Ordered Life Sustaining
  Therapies be Withdrawn

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How Clinical Triggers Improve the Organ Donation
Process

• Clarifies when to notify the OPO
• Ensures timely notification to the OPO
• Allows for ongoing communication and
  relationship building between the patients
  family, hospital and OPO before requesting organ
  donation

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Model for Improvement
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Model for Improvement3 Key Questions

• 1. What are we trying to accomplish?
• 2. How will we know if a change is an
  improvement?
• 3. What changes can we make that will result in
  improvement?

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Process for Testing ChangesPlan-Do-Check-Act
Planplan the change to be tested Docarry out
the plan, make observations, record
data Studyanalyze data, summarize what was
learned Actplan implementation or plan next cycle
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Addition of Clinical Triggers to the Electronic
Trauma Flow Sheet

• Paula Vogt, RN
• Aspirus Wausau Hospital
• UWHC-OPO

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• Effective Question for the Audience
• Dennis Wagner

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• WOW!
• HOW?

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• WOW!
• What changed for the better? (possibility)
• HOW?
• What is the driver of that change?
• (opportunity)

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• Question to run on
• What is the actionable insight
• you are taking from these best practice
  presentations?

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Best Practice 3Identify Donation Champions
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Best Practice 3Identify Donation Champions

• Kristina Engeseth
• UW Health Organ Procurement Organization

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Best Practice Definition

• Identify and support organ donation champions at
  various hospital levels include team leaders who
  are willing to be called upon to overcome
  barriers to organ donation in real time

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Who are Organ Donation Champions?
Community members, donor family representatives,
recipients and representatives from all levels of
professional staff

• Hospital senior leadership
• Physician representatives
• Nursing representatives
• Social work
• Pastoral care

• Respiratory therapy
• Laboratory
• Quality improvement
• Pre-hospital care providersEMT/Paramedic,
  transport

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Who are Organ Donation Champions?

• Committed to promoting proactive advocacy for
  organ donation into personal and institutional
  goals
• Common goal of identifying best practices and
  incorporating them into institutional policies
  and practices

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What is the Role of an Organ Donation Champion?

• Advocate organ donation
• Link the hospital to the OPO and other recovery
  agencies
• Facilitate the process of organ donation and help
  overcome barriers

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What is the Role of an Organ Donation Champion?

• Committed to
• The goal of every donation opportunity, every
  organ, every time
• Making best practices common practice by being
  the go to person
• Using the Model for Improvement to implement
  change

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Best Practice ShowcaseOrgan Donation Resource
Team

• Sue Olson, RN
• Gundersen Lutheran Medical Center
• Rita Roberts, RRT, RN, CCRN
• Gundersen Lutheran Medical Center

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Why?

• Organ donation is an infrequent and unique
  opportunity
• 13 organ donors at Gundersen Lutheran Medical
  Center in 2006
• Beneficial to have staff that are experienced in
  organ donor management
• There are always ways to improve the donation
  process
• Support our donor families
• Support our staff

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Why?

• The donor family benefits when we work together
  to create an integrated process not dependent on
  individuals
• Recognized that staff also benefits from an
  integrated process
• Strong commitment to every donation opportunity,
  every organ, every time

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First Steps

• Developed vision for team
• Met with ICU Manager to garner support and
  commitment
• Recruited experienced ICU staff
• ICU Manager met with VP to secure approval for
  team
• Meeting with HR Department to develop
  compensation package

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Benefits

• Specially trained and experienced staff assisting
  with the care of every potential organ donor
• Timely implementation of hospital organ donor
  guidelines and OPO orders
• Experience/educational opportunities for staff
• Increased staff satisfaction
• Increased number of organs recovered and
  transplanted per donor

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Measurement Strategy

• Time from
• Verbal consent to written consent
• Verbal consent to brain death declaration
• Written consent to brain death declaration
• Consent to transfer of charges to OPO
• Written consent to OR
• Donor management goals
• BD donors on multiple pressors to be started on
  T4 protocol
• pH 7.45
• Na
• EF 50 (final echo at least 2 hours after brain
  death)
• Inotropes
• Dopamine 5 mcg or less
• No levophed
• Neosynephrine 50 mcg or less
• Organs recovered and transplanted per donor

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What Did We Learn?

• Support is needed from staff at all levels
• Bedrock belief in organ donation process
• Advocacy for every organ donation opportunity,
  every organ, every time
• Financial support
• Team allows for collaborative practice and
  integrated process within entire organization
• Staff and donor families are better supported
• Organ donation is such an unique opportunity for
  everyone
• Team structure allows for experience and support
  to always be available

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Thank You!

• Contact Information

Sue Olson smolson2_at_gundluth.org
Rita Roberts rjrobert_at_gundluth.org
Kristina Engeseth kengeseth_at_uwhealth.org
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Best Practice 4After Action Reviews
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CONDUCTING AFTER ACTION REVIEWS

• Sue Hamilton, RN
• UW Health Organ Procurement Organization
• Dena Jarog, CNS, PICU
• St. Joseph's Childrens Hospital Marshfield

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What is an AAR?

• After Action Review (AAR)
• Brings hospital staff and OPO staff together to
  discuss a completed donation case or situations
  warranting a debriefing
• Has been identified as a National Best Practice
  for increasing donation rates

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Facilitator
OPOStaff
HospitalStaff
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After Action Review FrameworkNo project is
complete until it has been reviewed and its
lessons learned Nancy Dixon

• 1) What did we set out to do?
• 2) What did we actually do?
• 3) What have we learned?
• 4) What are we going to do?
• 5) Who are we going to tell?

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Implementation Has Ledto SUCCESS!

• Best practices are spread real time
• OPO and hospital staff are actively involved and
  relationships are stronger
• Positive outcomes for families making end of life
  decisions
• All teach/all learn environment is strong and
  healthy

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Ensure SUCCESS

• Offer AAR in real time
• Conduct AAR within 1-2 weeks of case
• Frame AAR as a positive experience allowing all
  participants to share thoughts
• Identify hospital partner to assist in
  facilitating
• Use standard form to record results
• Set up teleconference line
• Follow-up on action items and share learning
  points

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OPO Perspective

• Donation Outcomes
• Opportunity to share updates on recipients and
  donor families
• Clinical Staff
• Emotional component of reconnecting
• Builds rapport between hospital and OPO staff
• Allows time to offer support
• Hospital Services Staff
• Effectively facilitates AAR
• Responsible for documentation
• Plan for follow-up on action items

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Hospital Perspective

• AAR identifies challenges and opportunities for
  improvement
• Hospital / OPO / Combined issues
• Timeliness
• St Josephs Hospital is committed to the Tuesday
  morning following a case
• All Teach, All Learn
• True collaborative style, learn together
• Safe environment
• Open communication

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Hospital Perspective

• Reflect and Debrief
• Unresolved challenges and feelings of frustration
  are not brought into the next donation
• Celebrate!
• Positive outcomes of organs transplanted

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Special Thanks to
YOU!
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• Effective Question for the Audience
• Dennis Wagner

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• Question to run on
• What is the actionable insight
• you are taking from these best practice
  presentations?

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Best Practice 5Create an OPO Hospital
Presence,In-House CoordinatorModel
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Best Practice 5Create an OPO/Hospital Presence,
In-house Coordinator Model

• Dina Steinberger, PA-C

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Definition

• Integrated and flexible organ donation team
  identifies and uses the strengths of all the OPO
  and hospitals players in a well-defined donation
  process
• Assumes stewardship for well-defined family
  support
• Availability real-time
• Accountability for achieving high outcomes
• Established communication system to get the
  right people, right place, right time

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In-House Coordinator Model

• Life Gift, Houston 1996
• 2 FT nurses in 2 Level 1 trauma centers
• Fully integrated into hospital operations
• High visibility continuous education, increased
  early referrals, immediate problem-solving
• Meet regularly with hospital staff to review
  cases and organ donation performance
• Profiled as a best practice during HRSA Organ
  Donation Breakthrough Collaborative initiative
• Various adaptations of IHC model nationally

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Donor Hospital PerspectiveThedacare In-house
Coordinator Model

• Peg Grambsch, RN
• Theda Clark Medical Center
• Judy Struble, RN
• Appleton Medical Center

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Development of the Role

• Became aware of best practice from the
  collaborative
• Developed goals, responsibilities and a vision
• Proposed concept to senior management
• Developed a timeline and job description
• Continued meetings with senior leaders
• Provided data of other hospitals outcomes
• Approval from senior management

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Key FunctionsA Day-in-the-Life of an IHC

• Daily follow-up on referrals
• Real-time data collection
• Problem-solving and customer service
• Continuous education of staff and physicians
• Maintain regulatory requirements
• Update policy and procedures
• Implement collaborative best practices
• Community education

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Improvements

• Epic Access for OPO Coordinators
• Real-time, web access to patients medical record
• Training
• Referral Sheet Process
• Real-time chart reviews
• Decreased telephone time

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Benefits of the Role

• Increased family support
• Dedicated, expert donation resource available to
  staff and physicians
• Real-time problem-solving
• Real-time chart reviews
• Promoting donor awareness in the community
• Regulatory compliance

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What we have learned

• Effective family support is critical to achieving
  high donation outcomes
• Incorporating Dual Advocacy techniques
• Even when there is a process in place, every
  donation experience is different
• Maintain continuous collaboration with various
  donation organizations (OPO, tissue, eye)
• Dashboard is an helpful tool to monitor and
  identify areas for improvement (ex. Clinical
  triggers)
• Real-time problem-solving is the best solution

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Best Insights

• Work with senior leadership to establish the
  goals and vision for donation at your hospital
• Regularly discuss your dashboard results with key
  leaders
• Continue to identify and test best practices to
  improve those results
• Involve staff and physician champions from key
  areas
• Develop an effective family support process

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Best Practice 6Implement Donation After
Cardiac Death
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Best Practice 6Implement Donation After
Cardiac DeathJill Ellefson, Manager of Hospital
Services
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Donor Family PerspectiveSue Dillon
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Donation after Cardiac Death (DCD) versus
Donation after Brain Death (DBD)

• DBD
• Severe injury from trauma,CVA, or anoxic event
• Meets Brain death criteria
• Clinical exam
• Confirmatory exam
• Brain death declaration by physician
• Organ recovery begins after declaration of death
• Patient on ventilator until organs recovered

• DCD
• Severe injury from trauma,CVA, or anoxic event
• Does not meet criteria for brain death
• Cannot survive without mechanical ventilation
• Family and doctor elect to withdraw life support
• Withdrawal of life support in OR or ICU
• Cardiac death declared after 5 minute observation
  period
• Organ recovery begins after declaration of death

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National Increase in DCD Donors 2006 vs. 2005

• Donor Increase 15.5
• Organs Recovered Increase 14.9
• Organs Transplanted Increase 24.0
• Organs Transplanted per Donor
• 2006 2.11
• 2005 1.97
• 13 DSAs saw a decrease in DCD donors recovered
  8.0 to 80.0
• 6 DSA saw no change
• 29 DSAs saw an increase 2.0 to 600.0
• (These categories include only DSAs with at least
  one DCD donor recovered in both 2005 and 2006)
• 54 DSAs have recovered at least 1 DCD donor in
  2006
• Range 1 to 66

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Donation After Brain and Cardiac
DeathUniversity of Wisconsin Experience
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Number of Transplants from DCD DonorsUniversity
of Wisconsin

• Type of Transplant Number of Transplants
• Kidney (1984) 602
• Liver (1993) 71
• Pancreas (1993) 54Lung (1993)
  24
  
  
• Total Transplants 751

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Hospital Perspective

• Jeannine Zuba, Neuro Trauma ICU Manager
• Amy Kroos, RN
• Victoria Farkas, RN
• OSF Saint Anthony Medical Center
• Rockford, IL

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Path to Donation after Cardiac Death

• BSN student leadership project
• Capture patient population with poor prognosis
  but did not progress to brain death
• Collaborative Conference educated and inspired
• JCAHO standard
• Increase organ retrieval by 5

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Path to Donation after Cardiac Death

• Jan. 2006 Policy Development
• Research
• Collaboration with UW
• Jan. 2006 Aug. 2006 Multidisciplinary Team
• Nursing, UW, Trauma Physicians, Hospitalists
• OR, RT, Pastoral Care, ED, Social
  Services

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Path to Donation after Cardiac Death

• April 2006 September 2006 Education
• Ethics Committee
• UWs DCD pamphlet
• Net Learning
• Poster Studies
• Mentorship Lecture
• Unit Champions
• Physician Champions
• M.D. Education
• UW Inservicing
• Policy effective September 1, 2006

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First DCD Case September 13, 2006

• 48 y/o Male Blunt Head Injury S/P Fall
• SAH, SDH, GSC 4 on arrival
• Complex medical history
• Admitted 9/12/07 0035
• DCD 9/13/07 1444
• Did not progress to Brain Death
• Consent per mother

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First DCD Case September 13, 2006

• Family did not accompany patient to the OR
• OPO arrived at facility at 1230 on 9/13/07
• OPO supported team effort throughout procedure
• Patient expired within 5 minutes of extubation
• Organs recovered
• Both Kidneys
• Liver
• Pancreas islets

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After Action Review 9/15/06

• What went well?
• OPO coming early to prepare
• Teamwork
• M.D. cooperation
• OR staff
• Prayer by chaplain in OR
• Amy and Jeannine on-site
• Excellent Education
• Professional demeanor
• Rapport and care for family

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After Action Review 9/15/06

• Opportunities for improvement
• R.T. education (October 11, 2006)
• Improve time when M.D. needed for declaration
• Labs were not done within 6 hours of incision
• Noteworthy
• DCD tool not completed due to respiratory status
• Organ Procurement technique surprise to staff

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Positive Result from DCD

• Organ Donation Committee
• Professional growth
• Provided additional options for families staff
• Increased relationship with OPO
• Multi-disciplinary relationships

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Organ Tissue Donation Beyond

• Continued Education
• First Person Requestor Training
• Donor Management Education
• Ancillary education
• Algorhythms
• Monitor Quality Improvement
• Increase hospital and community awareness

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• Effective Question for the Audience
• Dennis Wagner

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• Question to run on
• What is the actionable insight
• you are taking from these best practice
  presentations?

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DSA Recognition
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Hospitals Recognized for High Conversion Rates

• Overall, 25 out of 29 hospitals in the DSA
  achieved the national goal of a 75 conversion
  rate!

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Data Collection

• Data collection was for rolling 12-month periods
  between January 2005 and February 2007. The
  following hospitals achieved a 75 conversion
  rate
• Adjusted Conversion Rate The number of actual
  donors divided by the number of eligible donors.
  DCD donors are added to both the numerator and
  denominator.

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Agnesian HealthcareSt. Agnes HospitalFond du
Lac
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Appleton Medical Center
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Aspirus Wausau Hospital
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Aurora Baycare Medical CenterGreen Bay
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Aurora Medical CenterOshkosh
96
Beaver Dam Community Hospital
97
Beloit Memorial Hospital
98
Fort HealthCareFort Atkinson
99
Franciscan Skemp Health CareLa Crosse
100
Gundersen Lutheran Medical CenterLa Crosse
101
Luther HospitalEau Claire
102
Marquette General Hospital
103
Mercy Health SystemJanesville
104
Mercy Medical CenterOshkosh
105
Meriter HospitalMadison
106
OSF Saint Anthony Medical CenterRockford
107
Riverview Hospital AssociationWisconsin Rapids
108
Sacred Heart HospitalEau Claire
109
St. Josephs HospitalMarshfield
110
St. Marys Hospital Medical CenterGreen Bay
111
St. Marys Hospital Medical CenterMadison
112
St. Vincent HospitalGreen Bay
113
Swedish American HospitalRockford
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Theda Clark Medical CenterNeenah
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University of Wisconsin Hospital and
ClinicsMadison
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Congratulations for Your Life-Saving Work!
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Large Hospitals Winning Medals of Honor for 75
Rates

• May, 2005 185
• October, 2006 371

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Your Donation Service Area Wins Major National
Award
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The Wait of a Lifetime