HRSA Transplant Center Growth and Management Collaborative: Best Practices Evaluation Report - September 2007

Because of the perpetual shortage of organs, transplant centers must be aggressive in soliciting, listing, and caring for patients and in accepting and rehabilitating organs. This aggressiveness is manifested in a variety of ways, reflecting the diverse needs of the various transplant centers visited. However, at each site visited, there was an emphasis on evidence-based aggressiveness; physicians and surgeons were willing to innovate and take risks, but only if such actions were grounded in sound scientific and medical research and only if such risks were rigorously monitored and reviewed to assess safety and efficacy.

The transplant centers visited employed aggressive patient and organ acceptance practices. By assessing patients and organs as a whole (instead of relying on heuristics), surgeons and physicians are often able to match the right organ to the right patient, even if the organ is marginal or the patient has multiple co-morbid conditions that could negatively impact the transplant procedure’s success. Furthermore, transplant doctors recognize that just as certain techniques can improve the functionality of an organ, patients with potentially exclusionary co-morbidities can be treated to a point where they are eligible for transplantation.

This aggressive approach applies to patient evaluation and management while on the waitlist. Using a variety of techniques, many of the sites we visited implemented processes to reduce the time from patient referral to patient listing. Transplant teams endeavor to build a robust waitlist, long and diverse enough to accommodate organ offers, but still manageable in length. While on the waitlist, patients receive attention from a variety of actors (e.g., physicians, nurses, social workers, financial coordinators) to ensure that they are physically, financially, and psychologically prepared for the transplant procedure.

In order to populate their waitlists, many transplant centers (particularly those in competitive areas) engage in proactive outreach and marketing. Representatives visit clinics and hospitals throughout the area to educate health workers and patients about their programs and transplantation as a possible treatment option, while transplant surgeons and physicians personally seek out community doctors to establish connections, maintain communication, and collaborate on patient care. Similarly, transplant center staff work with their local OPOs to offer trainings and procurement protocols and also share their organ acceptance criteria with those OPOs around the country that commonly have organs they wish to export.

Exhibit 5 summarizes the five key change concepts and related action items that correspond with Strategy/Driver 3: Aggressive Clinical Style.

Exhibit 5:
Strategy/Driver 3: Summary of Key Change Concepts and Action Items

Key Change Concept 3.1: Create high threshold for rejecting organ offers and potential recipients.

Aggressive patient and organ selection were commonly practiced throughout the transplant centers we visited. As one doctor explained to us, patient and graft survival rates do not tell the whole story: high survival may indicate that a center is not taking enough risks and that patients who could have benefited from transplants are dying on the waitlist. The surgeons and physicians to whom we spoke emphasized that an organ need not be pristine to be viable. Experienced transplant surgeons were often able to identify which defects were acceptable, which could be corrected, and which were, in fact, prohibitive. By integrating the best and most current medical evidence with their professional experiences, transplant surgeons have been able to expand the use of ECD and, more recently, DCD organs. Institutional support has facilitated this, as many administrators encourage their surgeons to travel to inspect organs prior to a decision on procurement. Also, transplant centers have made efforts to collaborate with local OPOs to improve procurement outcomes and to track organs that were rejected at one center, but ultimately utilized at another.

Similarly, transplant centers have been progressive in listing patients for transplantation. Transplant surgeons and physicians aim to evaluate patients holistically rather than relying on “rule-out” characteristics, which may not accurately reflect a patient’s ability to receive or thrive after a transplant procedure. Further, research has allowed programs to offer transplantation to a variety of patient groups previously considered inappropriate candidates. Centers are careful to review the newest and best research and to revise patient eligibility standards in light of advances that arise. Transplant physicians also aggressively treat patients who suffer from contraindications to transplantation in an effort to improve their condition to the point where they are eligible for listing.

Ultimately, transplant teams try to match specific organ to specific recipients. As one surgeon said, “there are no good or bad organs. There’s an appropriate organ at the appropriate time for the appropriate patient.” Such matching often requires an intention-to-treat analysis. That is, it is the responsibility of transplant doctors to consider how a patient will fare if he or she does not receive a specific organ or is not listed at all. Once such an analysis has been conducted, surgeons and physicians can more confidently gauge the appropriateness of listing a given patient or accepting a given organ.

Action Items

• 3.1a: Involve transplant surgeon in organ offer prior to turndown. While the initial organ offer may be made to transplant coordinators or other transplant center staff/providers, at several high-performing centers, no organ offers are rejected without the consent of a transplant surgeon. Surgeons have a comprehensive knowledge of their patients and are best equipped to gauge the appropriateness of an organ for any given patient, and therefore, be responsible for making the final decision regarding organ viability. Similarly, when declining offers of organs that do not meet their criteria, transplant surgeons may often explain under what conditions the organs might be accepted (e.g., a specific improvement in creatinine level or result of an echocardiogram) and ask to be contacted should this occur. Where implemented, this practice has led to an increase in organ utilization.
  
  
  
  • When a new chair of the liver transplant program joined the University of Washington Medical Center, he established a policy that requires his approval of all decisions to accept and reject offers of livers for transplantation. This has helped him to ensure that the center is not being overly conservative in rejecting organ offers, and he and others at the center attribute recent increases in the number of transplanted livers in part to this practice.
    
    
    
  • The University of California, San Francisco’s heart transplant program has implemented a similar policy, where the Surgical Director receives virtually all organ offers on his cellular telephone and proceeds to assess the organ’s viability based on real-time measurements.
    
    
    
• 3.1b: Reject organ offers only after you have confirmed that a suboptimal organ is not viable by visualizing (inspecting in-person) organs or confirming inconclusive or prohibitive test results. Several of the transplant surgeons interviewed for this report observed that while the description of an organ may seem prohibitive, only by inspecting the organ in-person and confirming relevant tests can the viability of the organ accurately be assessed in some cases. At many of the high-performing centers that we visited, transplant surgeons will travel to donor hospitals to assess an organ in-person, fully prepared to accept or reject it. Similarly, surgeons will ask for various tests or even perform them themselves in order to determine the damage to the organ and its potential to be rehabilitated.
  
  
  
  • At Duke University Medical Center, one of the heart transplant surgeons will confirm inconclusive or prohibitive test results before rejecting an organ offer. For example, he will not reject an organ based on one abnormal echocardiogram of an 18-year old donor. In a case like this, he would ask the OPO coordinator to repeat the echocardiogram and/or to catheterize the heart before rejecting the organ. Center staff believe that this determination to confirm that an organ is not viable before rejecting it has resulted in additional transplants being performed at the center.
    
    
    
  • If Duke University Medical Center’s physicians are unable to ascertain the viability of an organ remotely, the lung and heart programs will send surgical fellows to visualize donor organs. One surgeon said, “If you look, you’re going to get a much greater yield”, indicating that when surgeons travel to see organs, they often return with usable grafts. Rather than sending attending surgeons, the center sends surgical fellows to inspect the organs, reducing the surgeons’ burdens and allowing them time to prepare for a possible transplantation. Other centers will send attending surgeons to visualize the organs and conduct the procurements if they are viable.
    
    
    
• 3.1c: Work with OPO donation coordinators to “tune up” offered organs that are suboptimal yet have the potential to be viable for transplantation. Through interventional techniques such as hemodynamic management, hormone replacement therapy, and ventilator management, OPO staff can often rehabilitate non-pristine organs.³⁵ As such, transplant centers will communicate with OPOs in order to increase organ viability. This process may include care for the patient upon declaration of brain death and interventions performed on organs prior to procurement. For example, Duke University Medical Center’s lung and heart transplant programs create a high threshold for rejecting organ offers. One of the center’s lung transplant surgeons works with OPO coordinators to improve organ function so that organs not initially considered viable for transplantation become viable. For example, the surgeon works with the OPO coordinator to increase the PO2 level of a donor with a low PO2 level. The University of Washington Medical Center and Cleveland Clinic lung transplant programs engage in similar partnerships with their local OPOs.
  
  
  
• 3.1d: Continually take measured, evidence-based steps to push the envelope on organ acceptance criteria, including accepting ECD and DCD organs. Through careful application of clinical evidence, the transplant centers we visited are able to increase the number of organs they transplant. In some cases, organs are matched to specific patients whose conditions may make a given organ a better fit, while the severity of other patients’ cases may necessitate the utilization of less ideal organs. In other cases, surgeons and physicians may recognize opportunities to expand the definition of “viable,” realizing that organs traditionally labeled as “unfit” can yield strong outcomes.
  
  Underlying this approach is the belief that every organ (and every recipient) is unique and must be assessed in its own context, such as patient characteristics and needs. As one transplant surgeon at the University of California, San Francisco said, “there are no good or bad organs. There’s an appropriate organ at the appropriate time for the appropriate patient.” By relying on clinical evidence and documented and reviewed past experiences, surgeons and physicians have increased their use of ECD and, more recently, DCD organs.
  
  Further, there is some debate over how ECD organs are defined. Many feel that the criteria for classification are not wholly appropriate, stigmatizing many potentially viable marginal organs, while categorizing many other imperfect organs as SCD. Lastly, as one transplant physician at the University of California, San Francisco pointed out, because some ECD/DCD donors only yield one organ (e.g., liver in an older donor), transplant centers’ procurement costs may increase on a per-organ basis because other organs are not being procured to offset the cost, and the number of organs procured and transplanted per donor may decline.
  
  
  
  • Using emerging evidence, a surgeon at the kidney program at New York-Presbyterian Hospital developed a three-page memo formalizing and expanding the program’s acceptance criteria for marginal organs. This memo outlined those characteristics the surgeon believes are predictive of graft and patient survival (e.g., baseline renal function, organ function at time of recovery, organ anatomy, donor age, biopsy results, pump parameters, warm/cold ischemia) and described these characteristics’ limits. This objective set of criteria has allowed coordinators to better understand for what the surgeon is looking in a donor organ and has been followed by an increase in the number of DCD and ECD organs utilized by 450 percent and 771 percent, respectively.
    
    
    
  • Hahnemann University Hospital’s kidney program was able to increase its transplant volume by closely monitoring the outcomes and demonstrating the effectiveness of transplanting organs from older donors (i.e., age 60 and over) and from patients with acute renal failure. Today, patients receiving these types of organs comprise approximately 30 percent of Hahnemann’s kidney transplant cases.
    
    
    
  • New York-Presbyterian Hospital’s kidney transplant team will offer dual organ transplants to certain patients in the event that two organs with suboptimal nephron mass become available. While neither of the transplanted kidneys would provide sufficient functionality alone, in tandem, they offer adequate function for the patient.
    
    
    
• 3.1e: Plan transplant program budgets that account for an inevitable proportion of “dry runs” (e.g., traveling to visualize an organ and returning without one). Because of the importance of visualizing an organ before rejecting it, surgeons often travel to view borderline organs in order to render a decision on procurement. As the questionable viability of these organs is what prompts these visualizations, it is not unusual for such trips to result in the rejection of the organ in question. A transplant physician at Cleveland Clinic estimated that roughly 15-25 percent of trips end without procuring an organ.
  
  
  
  • Cleveland Clinic, Duke University Medical Center, and Mayo Clinic Jacksonville’s administrations understand the value of such visualization trips and build a number of “dry runs” into their budgets so as not to disincentivize such excursions and to increase the total number of organs recovered.
    
    
    
  • When procurement trips end with the rejection of the organ in question, Cleveland Clinic’s lung team meets the following day to discuss the details of the case and to determine what can be learned and applied from the experience.
    
    
    
• 3.1f: If an offered organ is a potential match for someone on your list, do not reject it simply because a surgeon from another center has to procure it; trust your colleagues at other centers. At the Cleveland Clinic, a pancreas surgeon recognized that, for various reasons (e.g., transportation time, multiple surgeries), he may not always be able to procure an organ himself. In such instances, he relies on his colleagues elsewhere to procure the organ for him, realizing that this compromise is preferred to rejecting an otherwise viable organ. He further noted that he has accepted and transplanted all the organs procured for him by other centers.
  
  
  
• 3.1g Monitor and work consistently on lowering ischemic and operating times to increase the viability and to reduce recipient complications. The chair of the Mayo Clinic Jacksonville’s transplant division believes that maintaining low ischemic times is critical to the successful transplantation of marginal organs, and the center assiduously monitors this variable. To minimize the time it takes to procure the organs, only experienced attending surgeons procure the organs. Similarly, this surgeon and his colleagues seek to minimize operating times to improve patient outcomes. To this end, they use anesthesiologists who are experienced in liver transplants and a dedicated nursing team. The Mayo Clinic Jacksonville has been able to reduce operating times to 3-3.5 hours, extubating patients sooner (reducing the risk of pneumonia) and preventing patients from entering the ICU post-transplant (lowering the risk of infection to these immunosuppressed patients). Shorter surgery times also result in quicker patient recovery times and shorter hospital stays. The transplant division monitors these variables and reviews them with individual surgeons to help them improve their times and resultant outcomes.
  
  
  
• 3.1h: In conjunction with OPO and other regional transplant centers, use data on whether organs that were rejected by the center were accepted for transplantation elsewhere to assess whether the center’s organ acceptance criteria and practices are too conservative. The Mayo Clinic Jacksonville conducts weekly calls with its local OPO and other transplant centers in its DSA to review the status of all organs that were placed by the OPO in the previous week. In advance of the calls, the OPO gathers data on whether organs rejected by the local transplant centers and exported to transplant centers outside the region were transplanted. This information helps Mayo Clinic Jacksonville and the other centers in its DSA to assess the appropriateness of their organ acceptance criteria and how consistently those criteria are being applied in making decisions about organ offers.
  
  
  
• 3.1i: Based on existing and emerging evidence, expand the envelope for accepting higher risk recipients (e.g., older patients, patients critically ill in the ICU, experiencing multiple system failure, suffering from nutritional failure, with HIV, and with body mass indices in excess of 40). Many of the centers we visited displayed a willingness to evaluate and list patients who had previously been deemed unfit for transplantation by other transplant centers. Relying on an evidence-based approach, these centers were able to establish protocols for properly caring for high-risk patients. These centers note that evaluating and listing higher-risk patients gives the patients the possibility of receiving a life-saving transplant procedure, and it also helps the centers to maximize the utilization of offered organs because it enhances the likelihood that they will be able to find an appropriate match for every organ.
  
  
  
  • The University of California, San Francisco’s liver transplant program pushes the envelope when it comes to patient acceptance. Based on existing and emerging evidence, the program evaluates and lists patients who may not be accepted at other centers, including those who are critically ill in the ICU, experiencing multiple system failure, suffering from nutritional failure, and have body mass indices in excess of 40.
    
    
    
  • Hahnemann University Hospital’s kidney transplant program was one of the first programs to offer transplants to HIV-positive patients suffering from end-stage renal disease by using organs from donors who engaged in high-risk lifestyles and were HIV-negative, but still in the window period. By monitoring and documenting results, the program was able to show that survival rates were comparable to those of other high-risk patients.
    
    
    
  • New York-Presbyterian Hospital’s kidney transplant program will offer transplants to highly sensitized patients, immunocompromised patients (e.g., those with HIV), and patients with hepatitis C.
    
    
    
  • Unlike many other centers, the Mayo Clinic offers liver transplants to patients suffering from cholangial cell carcinomas and has experienced strong results to date.
    
    
    
  • Cleveland Clinic’s lung transplant program offers transplants to patients suffering from hepatitis C (HCV). A retrospective study recently published from the Cleveland Clinic found no significant differences in the outcomes between those transplant recipients suffering from HCV and HCV-negative individuals.³⁶
    
    
    
• 3.1j: Treat reversible contraindications for transplantation in candidates not initially selected. Several of the transplant centers visited treat patients with contraindications for transplantation in order to make them eligible for the procedure. Additionally, pre-transplant care is aggressively provided to ensure that patients remain healthy enough to receive an organ should one become available.
  
  
  
  • The University of California, San Francisco’s liver transplant team will ablate liver tumors in an effort to help patients meet the Milan criteria for transplantation.
    
    
    
  • New York-Presbyterian Hospital’s cardiology team will use inotropes to regulate myocardial contractions as a bridge to transplantation.
    
    
    
• 3.1k: Expand living donor procedures, including living liver donor surgeries, through alternative/novel solutions such as paired exchanges (also known as “family swaps”), exchanges to the list, immunoglobulin therapy in the event of a positive cross-match, and desensitization in the event of ABO incompatibility. Organ shortages and local competition have pushed many transplant centers to focus on living kidney donations as a means by which to increase volume and serve more patients. Living kidney donations often yield healthier organs, shorter recipient wait times, and thus, improved patient outcomes. Additionally, living donors make available organs from deceased donors for other recipients. Therefore, many of the centers visited were aggressively and innovatively emphasizing their living donor programs.
  
  
  
  • In order to increase the number of living kidney donations, the University of California, San Francisco uses “creative solutions” to encourage living kidney donations including: 1) paired exchanges (also known as “family swaps”), where a relative or friend of one patient donates a kidney to another patient, whose relative or friend donates a kidney to the first patient; 2) exchanges to the list, where a relative or friend of one patient donates a kidney to someone higher on the list, while the first patient receives the second patient’s accrued wait time; 3) immunoglobulin therapy in the event of a positive cross-match; and 4) desensitization in the event of ABO incompatibility.
    
    
    
  • Despite the aggressiveness with which New York-Presbyterian Hospital pursues deceased donor organs, the hospital employs a highly rigorous and thorough living donor screening process. Physical and psychosocial assessments are performed in order to ensure that a donor is physically and emotionally fit to donate an organ. Further, potential donors and recipients are strictly separated throughout the process to allow potential donors to answer questions honestly and for evaluators to identify if a patient is being financially, emotionally, or otherwise coerced.
    
    
    
  • The kidney transplant team at New York-Presbyterian Hospital performs laparoscopic nephrectomies to minimize the invasiveness of the procurement procedure for donors.
    
    
    
• 3.1l: Review patient acceptance criteria regularly to determine if they are appropriate in light of emerging evidence about new therapies. As technologies change and more research comes to light, patient acceptance criteria may be subject to modification. Relying on outdated evidence or outmoded tools deprives patients of optimal care and hospitals of transplant revenues.
  
  
  
  • At the Cleveland Clinic, the lung transplant team holds an annual retreat where it reviews its inclusion/exclusion criteria for transplantation with the entire lung transplant team, including transplant surgeons, physicians, nurse coordinators, and other clinicians and staff.
    
    
    
  • Similarly, Duke University Medical Center’s lung transplant team participates in monthly off-site retreats to discuss and ultimately reach consensus on a variety of matters, including patient acceptance criteria. The team also uses this setting, which is free from distraction, to discuss the field of lung transplantation, and how new devices, techniques, and pharmaceuticals can contribute to its work.
    
    
    
• 3.1m: Institute no absolute “rule-out” characteristics; a patient should be evaluated as a whole, and, if possible, matched to an appropriate organ. Several of the surgeons to whom we spoke emphasized that each patient is unique and should not be judged definitively by pre-selected criteria. While some characteristics may complicate transplantation, a patient must be considered as a whole and doctors should not rely on absolute “rule-out” characteristics. Rather, surgeons should aggressively treat patients to prepare them for transplantation and then seek to match the right organ to the right patient. For example, with the arrival of a new Surgical Director, the University of Washington Medical Center’s (UWMC’s) liver transplant program reviewed its acceptance criteria and made a determination to no longer automatically reject patients who have recently used cigarettes. Additionally, rather than turning away those patients who do not abstain from alcohol use, UWMC sends these patients to a hepatologist and social worker. This allows UWMC to begin treating the patient and to work with him/her to quit drinking. If the patient can demonstrate abstinence from alcohol for 6 months, he/she can then be placed on the waitlist.
  
  
  
• 3.1n Use an intention-to-treat analysis to inform organ (and patient) acceptance criteria. Consider how a patient would fare without an organ when deciding whether or not to accept a marginal organ. Several surgeons with whom we spoke noted that while all transplants carry some risk, the risk of inaction also must be considered. New York-Presbyterian Hospital’s heart transplant team designed a method of measuring this. It developed a risk stratification model to determine which patients stand to benefit from transplantation. This quantitative and objective measure weighs the risks and benefits of transplantation against the risks and benefits of continued medical intervention.
  
  
  
• 3.1o When offered a heart or lung, ask about the availability of the other thoracic organs, as they have often not been placed and may match a patient on the waitlist. Cleveland Clinic has made it a practice of asking OPOs about the availability of other thoracic organs when offered a heart or lung. One transplant pulmonologist estimated that this has resulted in an additional organ about 10 percent of the time. However, this frequency has been reduced by the advent of DonorNet, OPTN’s electronic organ allocation program.
  
  

  
  Key Change Concept 3.2: Maintain preparedness by building, managing and optimizing your waitlist.

Effective management of transplant waitlists can have a profound impact on organ acceptance, patient waiting times, and patient outcomes. Transplant center staff stressed the importance of building a list that is large and diverse enough to accommodate incoming organ offers, without being so large as to hinder proper pre-transplant patient management. To facilitate the growth of the list, transplant centers have implemented a variety of practices to streamline the patient evaluation and listing processes. Upon listing, it is essential that transplant center staff follow patients to ensure that they remain medically, financially, and emotionally prepared for transplantation. At some institutions, patients near the top of the list (and thus most likely to receive an organ offer in the near future) are rigorously reviewed by transplant surgeons and their teams to ensure that they are ready for transplantation. Such reviews increase surgeon knowledge of the list and of specific patients, which allows for timely decisions on organ offers.

Action Items

• 3.2a: Monitor and continuously work on reducing time from referral to evaluation and from evaluation to listing of patients. Many of the transplant centers visited had streamlined the patient referral, evaluation, and listing processes. Such practices are beneficial to patients who may be apprehensive and eager to move forward in the process. Appointments are often clustered to reduce the number of trips patients must make to the hospital. Staff will also perform tests likely to exclude patients early on in the evaluation process to save ineligible patients time and emotional stress, to reduce the demand for limited diagnostic slots, and to reduce resource use and associated costs. Additionally, early listing of patients may lead to the transplant procedures being performed when the patients are healthier (prior to deterioration), which is associated with better outcomes.
  
  
  
  • The Mayo Clinic’s staff has studied and implemented Toyota’s Lean Manufacturing system to streamline processes for patients, reducing the time to make an appointment from 14 days to 2.5 hours and the wait-time for appointments from 45 days to 2-3 days, resulting in 8 percent more patients being evaluated.
    
    
    
  • The Cleveland Clinic aims to evaluate all patients within 2 weeks of their referral. The transplant center also aims to perform all tests during one visit (which may last multiple days), so that patients and families from outside of Cleveland do not have to make an excessive number of trips to the city. Additionally, there is cooperation and informal coordination among physicians at the Cleveland Clinic in an effort to place patients into the diagnostic slots required to determine transplant appropriateness.
    
    
    
  • By implementing division of labor among evaluation staff, identifying ineligible patients early on in the evaluation process, and procuring guaranteed slots in diagnostic labs, University of Washington Medical Center’s liver transplant program was able to reduce the time from patient referral to evaluation from 3 months to 30 days.
    
    
    
• 3.2b: Monitor the medical, financial and social status of all patients on the waitlist and help them to intervene where feasible to overcome barriers to transplantation. Even after patients have been found eligible for transplantation and added to a waiting list for an organ, they still may encounter a number of obstacles that would make them ineligible for transplantation by the time they reach the top of the list. For example, a patient’s condition may worsen, a patient with a history of substance abuse may resume risky behaviors, and a patient may lose his or her health insurance. Recognizing these possibilities, transplant programs employ pre-transplant coordinators, social workers, and financial coordinators to ensure that patients are maintaining their readiness for transplantation. At the high-performing transplant centers visited, these staff work closely with patients to help them address any barriers to transplantation that arise and to avoid future setbacks.
  
  
  
  • Both the Mayo Clinic and the Hospital of the University of Pennsylvania’s transplant centers employ dedicated transplant psychiatrists with an expertise in treating patients with chemical addictions. The psychiatrists help to manage patients while on the waitlist and provide insight into optimum holistic treatment.
    
    
    
  • New York-Presbyterian Hospital’s kidney transplant program temporarily inactivates patients when, upon periodic review, they are not transplant-ready. Upon inactivation, staff proceeds to work with these patients to improve their condition and, as appropriate, they are summarily reactivated. Center staff estimate that these reviews typically result in about 25 percent of the patients on the waitlist being temporarily deactivated.
    
    
    
  • Cleveland Clinic’s lung transplant team aims to evaluate patients on the waitlist every 8 weeks to assess their clinical state and to determine if additional diagnostic testing is required (e.g., heart catheterization). Patients with airway issues are discussed weekly by the transplant team to ensure optimal management. One physician went so far as to say that waitlist mortality is reduced when pre-transplant patients are carefully monitored.
    
    
    
• 3.2c: Schedule periodic “top-of-the-list” meetings to review the status of patients closest to transplantation to ensure that all tests are complete and all information is up-to-date. Because of the myriad challenges facing potential transplant participants, aggressive monitoring by transplant centers is an important mechanism by which to ensure the readiness of patients. Reviews of patient medical, psychological, and financial characteristics allow the transplant team to identify potential barriers and remedy them prior to transplantation.
  
  
  
  • New York-Presbyterian Hospital has dramatically reduced patient waiting time for kidneys and waitlist mortality by regularly reviewing candidates on the top of the waitlist by blood type, as well as those awaiting ECD organs, dual transplants, pediatric organs, and those with HCV in an effort to ensure that they are healthy and ready for transplantation should an appropriate organ become available.
    
    
    
  • The California Pacific Medical Center kidney transplant program also conducts a “top-of-the-list” review and re-evaluation of patients. Once a month, the program’s nurse coordinators, social workers, and financial coordinators meet to review the 30-40 patients that are near the top of the waiting list (within a year of transplantation). At this 2-3 hour meeting, the staff conduct a complete review of all the information about the patients’ readiness for transplantation and work with the patients to address any barriers.
    
    
    
  • The California Pacific Medical Center kidney transplant program also recently adopted an even more proactive approach to clearing patients for transplantation. The program conducts full re-evaluations of patients as they near the top of the list. Program staff believe that these re-evaluations, many of which are performed at the center’s satellite clinics, have helped them avoid situations where an organ offer must be declined for a patient at the top of the list because the patient is not ready for transplantation.
    
    
    
• 3.2d: Know your waitlist; ensure that surgeons who receive organ offers have access to up-to-date, accurate information about waitlisted patients. Because of the uniqueness of each patient and each organ, an in-depth knowledge of the waitlist is essential for surgeons to properly consider organ offers. Such familiarity facilitates time-sensitive decisions, particularly in matching marginal organs to patients.
  
  
  
  • The Surgical Director of the Mayo Clinic’s liver transplant program reviews the center’s waitlist, as well as the DSA list, to predict which patients are likely to be made offers and to determine which organs would best accommodate them. Additionally, the liver transplant team has remote access to the waitlist and to patient information so that data can be accessed as soon as an organ offer is made.
    
    
    
  • The University of Washington Medical Center, the California Pacific Medical Center, and many of the other transplant centers visited have implemented information technology systems that allow surgeons to securely access data about pre-transplant patients remotely. These systems allow surgeons to access up-to-date information about all their waitlisted patients when they receive calls with organ offers during off hours.
    
    
    
• 3.2e: Build and maintain the waitlist to a size that is manageable, yet includes sufficient patient diversity to enable identifying appropriate matches for most offers of viable organs. Maintaining their waitlists at an optimal size is a challenge for many transplant programs. If the list is too short, programs may find that they cannot accept offered organs because there is not sufficient patient diversity on their lists for them to identify an appropriate match. If the list becomes too long, pre-transplant care may be compromised.
  
  
  
  • The abdominal transplant team at the University of Washington Medical Center recognized that it could not substantially grow its program without expanding its waitlist. As one surgeon put it, “having a robust list allows us to be able to place that organ into the appropriate patient.” To accomplish this, the transplant program critically assessed its patient acceptance criteria and, according to the best available evidence, expanded it.
    
    
    
  • Transplant surgeons at the Cleveland Clinic also aim to have a diverse waitlist and have expanded their patient acceptance criteria to include patients with hepatitis C and HIV. In addition to making the opportunity available to these patients for a lifesaving transplant procedure, this expanded waitlist helps the Cleveland Clinic to maximize the use of offered organs.
    
    
    
• 3.2f: Develop a defined process for ECD consent. Several transplant surgeons voiced a desire for the development of a defined process by which to gain patient consent for the transplantation of ECD organs. While consent is currently required, there is no set procedure for attaining it and surgeons feel that the process could be more efficient with such protocols in place.
  
  
  

  Key Change Concept 3.3: Reach out and collaborate with referring community and professional staff.

Transplant physicians at the centers visited recognized the important role referring physicians play in the pre- and post-transplant care provided to patients and are eager to work collaboratively with these doctors to ensure that this care is delivered as efficaciously as possible. Transplant physicians are quick to reassure community doctors that they do not “steal” patients, but rather, seek to serve as resources to referring physicians. To this end, they make themselves and their transplant coordinators available to referring physicians at all times and aim to provide information to them in a timely manner. At some transplant centers, staff used their transplant expertise to develop protocols outlining care for transplant patients, working with referring physicians to implement them. Transplant centers also seek to share their successes with physicians in the community, celebrating their strong outcomes and the role community doctors and their staff played in achieving them. These outreach efforts help transplant staff build constructive relationships with the referring community, improve patient care, and, ultimately, increase patient referrals and transplant center volume.

Action Items

• 3.3a: Develop and disseminate protocols for pre- and post-transplant care for referring physicians in the community. Referring physicians often play an important role in preparing patients for transplantation and in caring for them after the procedure. However, as many referring physicians are not transplant experts, they may not be aware of the most recent advances in pre- and post-transplant care. Recognizing this, the University of Washington Medical Center’s liver transplant program developed post-transplant protocols for referring physicians, which include guidelines for required labs and patient education and ensure standardized and appropriate care. The program also sends letters to referring physicians when their patients are first added to the waitlist to provide them guidance on how they can help manage patients’ care before the transplant procedure.
  
  
  
• 3.3b: Encourage transplant surgeons and physicians to personally reach out to referring physicians in the community to educate them about pre- and post-transplant care and to facilitate collaboration on lifelong care of recipients post-transplant. Transplant centers recognize that referring physicians play an important role in caring for patients before and after transplantation and that it is crucial for these physicians to be kept up-to-date on standards of care. As such, transplant physicians at the University of Washington Medical Center and the Mayo Clinic seek to actively partner with referring physicians in an effort to ensure that proper care is delivered and to demonstrate to community doctors that the care is truly collaborative. Additionally, a commonly cited fear of referring physicians is that they will “lose” their patients permanently to the transplant center. Assuaging these fears is an important way to encourage the referring of sick patients. Transplant physicians are able to accomplish this by partnering with referring doctors, maintaining open communication throughout the process, and by responding to questions in a timely manner. As one Hahnemann University Hospital staff member pointed out, failure to do this may negatively affect referral patterns, particularly if a hospital builds an unfavorable reputation in this area. However, if successfully done, referrals can increase substantially.
  
  
  
• 3.3c: Provide 24/7 phone lines through which referring physicians can access a physician or coordinator to ask questions about pre- and post-transplant care for their patients. In order to address patient issues and to actively include referring physicians in the transplant process, a transplant center should provide these doctors with access to physicians or coordinators at all times. Stanford and the University of Washington Medical Center keep clinical staff on call to handle such inquiries, a practice that builds credibility and trust and, in addition to improving patient care, may increase referrals.
  
  
  
• 3.3d: Send annual report cards to referring centers and physicians, highlighting outcomes and the contributions of specific referring parties. The Cleveland Clinic mails out annual report cards to referring hospitals and practices in an effort to inform these institutions and individuals of the role their partnership with the transplant center has played in helping patients. These mailings also serve to advertise the Cleveland Clinic’s high outcomes and can double as promotional materials for potential payers. Similarly, upon patient discharge, University of Washington Medical Center sends letters to referring physicians promoting its outcomes and referrals.
  
  
  

  Key Change Concept 3.4: Partner with OPOs to implement best practices.

While the extent to which transplant centers rely on their local OPOs for organs is highly variable, they are almost uniformly benefited by improvements in local OPO performance. Many transplant programs offer their expertise to their local OPOs by developing protocols, holding trainings, and offering support on issues that may arise. Additionally, some centers use their OPOs to organize meetings and facilitate communication with other local transplant centers, while others reach out to more distant OPOs with high organ export rates.

Action Items

• 3.4a: Collaborate with OPO donation coordinators and critical care specialists on best practices in managing organ donors from declaration of death to organ recovery; provide regular refresher training and training for new coordinators. The success of an organ transplant program is intimately tied to its local OPO. Patient management, timely and accurate organ recovery, and clear communication can increase the number and quality of organs provided to a hospital, and, as a result, the outcomes of its patients. This can be accomplished by offering training sessions and protocols to OPO staff and by maintaining open communication between the transplant center and the OPO. For example, the University of Washington Medical Center’s lung transplant program works with the OPO in its DSA to ensure that donors are being managed in a way that does not compromise the function of the lungs. One of the center’s transplant surgeons provides occasional trainings on management of lungs in organ donors for OPO donation coordinators. He trains new coordinators and offers refresher trainings and is available to answer questions as needed.
  
  
  

  Key Change Concept 3.5: Actively market program to increase referrals and organ offers.

While superior outcomes may attract some patients, high volume and high growth transplant centers have figured out that aggressive outreach and marketing is often necessary to sustain growth. General education sessions held at local health centers and clinics are often an effective way to draw patient and physician attention to a transplant center and its strong outcomes. Further, transplant physicians and surgeons will engage referring physicians in an effort to get them to consider transplantation as a possible treatment modality for appropriate patients. These interactions also foster trust and enable communication, often leading to patient referrals and collaborative care. Outreach can also be aimed directly at patients, particularly if a patient does not think his or her physician is open to the idea of transplantation. Lastly, some centers work to educate OPOs outside their service area about their organ acceptance criteria in an effort to increase imported organ offers.

Action Items

• 3.5a: Market to referring providers through general education sessions about transplantation in the community. Both expanding and established transplant programs emphasized the importance of creating awareness among providers of their transplant programs and their strong outcomes, as well as of the use of transplantation as a possible treatment modality.
  
  
  
  • California Pacific Medical Center’s kidney transplant program sends teams to dialysis centers, satellite clinics, community offices, and other health facilities around the Bay Area to provide general education regarding transplant options.
    
    
    
  • Staff at both the Hospital of the University of Pennsylvania and Hahnemann University Hospital, which run similar outreach sessions, stressed that, while they would prefer that patients be referred to their respective hospitals, of paramount importance is that patients are referred somewhere for transplantation and receive the care they need.
    
    
    
  • The Cleveland Clinic lung transplant program offers education at rehabilitation centers because many potential transplant patients meet post-transplant patients in these settings and learn about lung transplantation from these patients.
    
    
    
• 3.5b: Reach out to referring physicians in the community to increase awareness about transplantation as an appropriate treatment modality for challenging/difficult cases about which there may be misconceptions that transplantation is still experimental. Outreach is an effective tool because referring physicians may not be able to follow all of the advances in transplant medicine and may have misconceptions regarding their patients’ appropriateness for the procedure, when to refer a patient for transplantation, and how to best treat patients post-transplant. By educating community physicians about the advances in and possibilities of transplantation, more patients can get the care they need, while transplant centers are able to improve their volume.
  
  
  
  • Because of its proximity to many rural areas, the Cleveland Clinic’s lung transplant program sends pulmonologists out into the field to educate community physicians about the potential benefits of transplantation and its appropriateness as a treatment modality. This is particularly useful in the case of conditions in which transplantation has recently emerged as a treatment option as many referring physicians may not be aware that their patients are now eligible for transplantation. Cleveland Clinic also educates referring physicians regarding timeliness, as many patients, such as those with pulmonary fibrosis and pulmonary emphysema, should be referred much earlier in the progression of their disease than they usually are.
    
    
    
  • The University of Washington Medical Center has been able to manage its workload and resource utilization through education because inappropriate referrals have been reduced as a result of increased education of referring physicians.
    
    
    
• 3.5c: Encourage transplant surgeons and physicians to reach out personally to community providers to establish relationships, build trust, and communicate that the transplant center is committed to partnering with them to care for their patients. While nurses frequently lead outreach events, physicians and surgeons can play an important role in the process as referring physicians are sometimes more receptive to fellow doctors. Further, many of these interactions must occur outside of the context of outreach events.
  
  
  
  • The Surgical Director of the University of Washington Medical Center’s lung transplant program has been particularly involved in outreach efforts to referring physicians, stressing transplantation as a treatment modality for end-stage lung disease to “anyone who would listen,” at every referring hospital in the area. In addition to making referring physicians more aware of the benefits of transplantation, these personal overtures demonstrate the center’s seriousness about transplant medicine, as well as their commitment to collaborative care with community physicians. Lastly, the relationships these interactions yield help to steer referrals to the hospital.
    
    
    
  • The kidney and liver transplant surgeons at the Hospital of the University of Pennsylvania (HUP) actively market their programs to community physicians by inviting them to attend dinner meetings 1-2 times per week. During these meetings, the surgeons discuss the services offered by HUP’s transplant programs; the patient evaluation process; the expanded patient acceptance criteria that are used to allow patients, including those with co-morbid conditions, to benefit from transplantation; and the role of community physicians in helping to care for patients before and after the transplant procedure. These proactive outreach efforts have increased the patient referral base from community physicians by an estimated 20 percent.
    
    
    
• 3.5d: Send kidney outreach teams to community dialysis centers to reach patients who may be eligible for transplantation, but have not been referred to a transplant center for evaluation; create and distribute self-referral forms for dialysis patients. For kidney transplants, dialysis centers are an important venue where transplant programs can conduct outreach. Staff at one transplant center estimate that only 15 percent of dialysis patients are on kidney transplant waitlists, while they believe that 50-60 percent may be eligible.
  
  
  
  • California Pacific Medical Center employs a team of six full-time nurses who conduct outreach to patients and providers in dialysis centers across Northern California. The Center’s first outreach coordinator had a background in acute dialysis. She reported that when she began in her role as an outreach coordinator, she went to every dialysis center in the region during every shift and attempted to develop relationships with all the staff and providers. When new dialysis centers opened, she would go to their opening and bring a plant or another form of gift from the center. Over time, she gained the trust and respect of the dialysis centers and the local nephrologists and found that they were more willing to refer patients to California Pacific Medical Center. The center attributes much of the growth in its kidney transplant program to having dedicated outreach coordinators.
    
    
    
  • Hahnemann University Hospital’s kidney transplant program created a self-referral form for patients who feel their doctors are not receptive to the idea of transplantation. These patients can schedule evaluations with the transplant team themselves to assess the appropriateness of the procedure.
    
    
    
  • In 2003, the Hospital of the University of Pennsylvania (HUP) hired a full-time transplant network coordinator who, along with a transplant nurse coordinator, regularly travels to dialysis centers in the region and conducts educational sessions for patients, staff and providers on kidney transplantation and how patients on dialysis can benefit from the procedure. Since 2003, this effort has increased the number of patients referred to the kidney transplant program by an estimated 30 percent.
    
    
    
• 3.5e: Educate OPOs outside service area about the center’s organ acceptance criteria to boost organ imports. Those transplant programs with reputations of being aggressive are able to further increase their volumes as non-regional OPOs may be more likely to call them when trying to export an organ. OPOs that are aggressive in their placement of organs will often go to their “hot list” of aggressive centers when they have exhausted all other options under the allocation system. These OPOs have found that when they believe they have an organ that may be viable, it is worth taking the time to make a few extra calls to the more aggressive centers that may be able to find a match for the organ on their list. To encourage these calls, some of the aggressive transplant centers are reaching out to the OPOs outside their DSAs to build relationships and to let them know that they would welcome these calls. As one administrator at the Hospital of the University of Pennsylvania said, “we need to convey that [we are] hungry. We have a reputation of saying yes.” Surgeons at the University of Washington Medical Center have also reached out to OPOs down the West Coast to update them on innovations and the addition of new surgeons. This outreach signals the program’s willingness to accept calls from OPOs about organs for which they are unable to find an appropriate match elsewhere.
  

³⁵ Wood KE, Becker BN, McCartney JG, et al. Care of the potential donor. N Engl J Med 2004;351(26):57-66.
³⁶ Sahi H, Zein NN, Mehta AC, et al. Outcomes after lung transplantation in patients with chronic hepatitis C virus infection. The Journal of Heart and Lung Transplantation 2007;26(5):466-71.