The Multidisciplinary Team. The Kidney Donor Surgical Team Benefits and Challenges. New Initiative: The Center for Living Donation

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Posy Todd
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The Recanati/Miller Transplantation Institute at The Mount Sinai Medical Center Recanati Miller Transplantation Institute: The Center for Living Donation Support for the Donor Through All phases of

It is one of the nation s leading academic transplant centers providing comprehensive care to those with end stage organ failure.

Our first laparoscopic live donor kidney transplant was performed in 1996. Our liver transplant program began in 1988 when the founder, Dr. Charles Miller and Dr.

In 1998 we did our first adult-to-adult living donor liver transplant.

improve long-term survival of transplant recipients Calling on our many years of experience, we continue to provide lifelong partnerships with our patients, their families and referring physicians.

New Initiative: The Center for Living Donation In April 2010, RMTI developed a separate Center within the Transplant Institute to care for live donors We believe that live donor care is a new

wellness through the latest medical advances, comprehensive evaluation, support and education, before during and after donation.

those who have been donors To improve patient and graft survival of transplant recipients through the benefit of live donation To provide patient and professional education about live donation and

1 The Recanati/Miller Transplantation Institute at The Mount Sinai Medical Center Recanati Miller Transplantation Institute: The Center for Living Donation Support for the Donor Through All phases of Donation The Mount Sinai Medical Center is known internationally for its innovation in research, education and clinical care. It is one of the nation s leading academic transplant centers providing comprehensive care to those with end stage organ failure. Our transplant program began in 1967, as one of the first kidney transplant programs in the northeast. We have performed pancreas transplant since Our first laparoscopic live donor kidney transplant was performed in Our liver transplant program began in 1988 when the founder, Dr. Charles Miller and Dr. Myron Schwartz performed the first liver transplant in New York State. In 1993, we performed the first pediatric live donor transplant in the state. In 1998 we did our first adult-to-adult living donor liver transplant Very public death of a live liver donor RMTI researchers are working independently and collaboratively to improve organ preservation, reduce rejection, minimize surgical complications and improve long-term survival of transplant recipients Calling on our many years of experience, we continue to provide lifelong partnerships with our patients, their families and referring physicians. Our mission is to provide exemplary medical and surgical care in a compassionate and individualized setting, a hallmark of the RMTI. New Initiative: The Center for Living Donation In April 2010, RMTI developed a separate Center within the Transplant Institute to care for live donors We believe that live donor care is a new subspecialty of transplant that requires expertise different than recipient care Mission: To provide quality health care to potential and actual live organ donors in an environment focused on wellness through the latest medical advances, comprehensive evaluation, support and education, before during and after donation. The principal goals and objectives: To create an enhanced independent donor advocacy team (IDAT) To provide comprehensive patient focused medical and psychiatric care to promote long term wellness to those who have been donors To improve patient and graft survival of transplant recipients through the benefit of live donation To provide patient and professional education about live donation and long term health of donors To advance the science of living donation through innovation and outcomes research The Center for Living Donation Assumptions The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. Consensus Statement of the Live Organ Donor : JAMA, December 12, 2000-Vol 284, No.22 The Heath Care Team designated to the care and wellbeing of all potential and actual live organ donors has an obligation to provide sound ethical judgment, latest scientific technologies, comprehensive clinical expertise, education and emotional support in a patient friendly environment. The Multidisciplinary Team The Kidney Donor Surgical Team Benefits and Challenges Three Live Donor Coordinators Liver PKD Non-directed Designated Live Donor Social Worker (IDA) Designated Administrative Staff and Data Coordinator Financial Coordinator Psychiatrist Nutritionist Nurse Practitioner Hepatologists and Nephrologists Surgeons 1

Policy and Process Review Goal: Donor Safety Rapid Recognition and Response Revised the

documents Translated them into foreign languages Revised the postoperative management and

staff Developed a rapid recognition and response process Began weekly and monthly meetings

team( process and patients) Donor selection committee Weekly IT meetings Monthly meeting with

based communication Identification of educational needs requiring dissemination Motivation

members Restricted Use of the Weck Hem-o-loc Clip Process of referral for live donation

for review in the future In preparation for UNOS Live Donor Kidney Survey and to change

2 Policy and Process Review Goal: Donor Safety Rapid Recognition and Response Revised the selection and evaluation process Updated all patient and staff education and consent documents Translated them into foreign languages Revised the postoperative management and follow-up process Moved hospitalized donors to a central location and inserviced the entire staff Developed a rapid recognition and response process Began weekly and monthly meetings with team Created Live Donor Education Supplement Communication Weekly meeting with donor team( process and patients) Donor selection committee Weekly IT meetings Monthly meeting with donor and recipient team Quarterly policy and procedure meeting with surgeons Electronic/Web based communication Identification of educational needs requiring dissemination Motivation for Staff Education about Live Donation Monthly Educational Supplement to ALL Transplant team members Restricted Use of the Weck Hem-o-loc Clip Process of referral for live donation Process for reassessment of infectious risk prior to Live donor surgery Posted on Intranet for review in the future In preparation for UNOS Live Donor Kidney Survey and to change Culture about live donation Posted all new policies Quiz to highlight important new changes Contest to encourage participation 2

LIVING DONOR REGISTRATION IN UNET -Benchmark 100% ABO X2 VERIFICATION Evaluation ABO X2 VERIFICATION PRIOR TO OR PRESENCE OF AN ILDA NOTE IN CHART Kidney -note in chart 100% 100% 100% x 100% 100%

3 LIVING DONOR REGISTRATION IN UNET -Benchmark 100% ABO X2 VERIFICATION Evaluation ABO X2 VERIFICATION PRIOR TO OR PRESENCE OF AN ILDA NOTE IN CHART Kidney -note in chart 100% 100% 100% x 100% 100% 100% x 100% 100% x Kidney -evaluation 30% 100% 100% x 100% 100% 100% x 100% 100% x DOCUMENTATION OF FOLLOW UP PLAN PRE-DONATION LIVING DONOR KIDNEY ~ Donor Evaluations 83% 100% 100% x 100% 100% 100% x 100% 100% x Donors 0% 100% 100% x 100% 100% 100% x 100% 100% x NUTRITION SCREENING PRIO TO LIVING DONOR~ SIGNED CONSENT TO BEGIN EVALUATION ON ALL DONOR EVALS SIGNED "MAKING AN INFORMED CHOICE FOR SURGERY" Kidney 0% 71% 100% x 100% 100% 100% x 100% 100% x FOLLOW UP VISITS SCHEDULED/DOCUMENT SUFFICIENT ATTEMPTS Kidney x x 65% x 100% 100% 100% x 100% 100% x FOLLOW UP VISITS CAPTURED ALL REQUIRED DATA ELEMENTS Kidney x x 100% x 100% 100% 100% x 100% 100% x UNOS DATA SUBMISSION - Benchmark 95% within 90 days Encouraging Donor Follow-up Remove disincentives to follow-up Cost Multiple ways to follow-up Capture data with each interaction Switch in paradigm: Follow-up is health promotion not identification of disease Nursing focus Establishing relationships with team Added a 6 week follow-up visit NP, Dietitian, Social worker Referral to fee for service primary care clinics if uninsured Policy on follow-up appointments Data Submission Compliance Total Expected: 189 Total Received to Date: 189 Total Received in Compliance: 189 Total Received Late: 0 Compliance Percentage: % Still Expected: 0 2% 2% Compliance Report Living Donor Follow-Up Records - Kidney for period from: 7/1/2010-3/31/ % 27% Seen in transplant center Updated by other health care facility Not seen Record Status 6 months 1 year 2years TOTAL LD seen in transplant center LD status update by verbal or written communication between transplant center and donor LD status update by other health care facility LD status update via other source Not seen TOTAL Verbal or written updated Update via other source 44% Ensuring Quality QAPI QAPI process specifically for live donor program Reporting structure to organ specific programs Quarterly reports of M&M Weekly DRC discussion: New evaluations Deferred donors Upcoming surgeries Recent surgeries Follow-ups Patient complaints Quality Issues Process Indicators Pre Registration in UNET IDA note ABO x2 prior to OR Informed consent Surical consent Peri Donor /recipient ready for OR ABO at donation Post Follow-up visit captures all elements Clinical Outcome Indicators Pre Full Medical Clearance pre donation Peri Aborted procedures Conversion from lap to open Post Death Readmission in 7 days Readmission in 30 days Complications CAP Audit Data Tracking LIVING DONOR - KIDNEY 2010 JULY AUG SEPT Q3 OCT NOV DEC Q JAN FEB MAR Q1 The Center for Living Donation New Initiatives TOTAL LDR 100% 100% 100% x 100% 100% 100% x 100% 100% x TOTAL LDF 100% 100% 100% x 100% 100% 100% x 100% 100% x 3

Mentorship Program Qualifications of a Mentor Mission Statement: To provide every potential donor a comprehensive

donation process Better understand risks and benefits to live donation Have the ability to ask questions in a non

be a donor to a pediatric patient or adult Must be compliant with follow-up.

complete orientation to include: Hospital volunteer training Optional OPO training Mentorship one day education

Donor Nurse Donor champions on the nursing unit to mirror to goals of the IDAT.

Begin by volunteering Rotate to the Out Patients Practice to observe the IDAT performing a donor evaluation

improvement LEARNING OBJECTIVES List the components and purpose donor evaluation Discuss Impact of the regulatory

team approach List short and long term medical and psychosocial complications Empathize with the potential and

4 Mentorship Program Qualifications of a Mentor Mission Statement: To provide every potential donor a comprehensive medical and psychosocial evaluation including the ability to meet with a person who has gone thru the donor experience. During the donor evaluations process, the potential live donor will have the opportunity to meet and talk with a donor who has gone through donation. At the end of the meeting with the donor mentor, the donor candidate will: Identify from a donors point of view the donation process Better understand risks and benefits to live donation Have the ability to ask questions in a non threatening environment to someone who has gone through the process Better understand what to expect during the post operative course. Understand that everyone s donation experience is different Have an advocate outside the medical profession to call as questions and concerns come up. Qualifications for Mentorships: Donors must be 6 months post donation and recovered without unresolved issues Can be a donor to a pediatric patient or adult Must be compliant with follow-up. Must interview with member of IDAT prior to consideration Must have free time to participate in program Must complete orientation to include: Hospital volunteer training Optional OPO training Mentorship one day education seminar Quality Improvement In Living Donation Designated Donor Nurses Implementing the DDRN Program Designated Donor Nurse Donor champions on the nursing unit to mirror to goals of the IDAT. Care for and advocate for live donors during the in patient stay serve as a resource to their colleagues. Begin by volunteering Rotate to the Out Patients Practice to observe the IDAT performing a donor evaluation (2-days) One on One education Participate in donor selection meeting Observe the surgery Ongoing Quality improvement LEARNING OBJECTIVES List the components and purpose donor evaluation Discuss Impact of the regulatory aspects of living donation Discuss the role of the Registered Nurse in donor advocacy Identify the benefits of the team approach List short and long term medical and psychosocial complications Empathize with the potential and actual live donors in regards to the magnitude of the decision needed to be made and the feels afterwards regardless of whether they were able to donate. Describe the importance of pain management Currently have 4 trained (3 day shift, 1 night) Presented Concept at Nursing Grand Rounds Exhibited a Poster during Nurses Week 2011 Goal to have all nurses on floor trained Obtaining CME Wellness Newsletter Donor Recognition Event April 4, 2011 Tri-annual newsletter for living donors Updates about the center In the News Healthy Tips Recipes Mock Tails Patient stories Nurses Note Meet the Team Upcoming events 4

Health Promotion Donors are healthy people but Mirrored after the Breast Cancer Program Offered to all donors within the first year of recovery Nutrition,

existing RMTI research on Live donors Identify deficits in the literature: Psychosocial outcomes in live donors Altruistic donation/paired donation Long

goals and constraints of the Center for Living Donation The steering committee meets every two months to discuss goals and direction and review protocols.

Support groups Health related topics Goals of the Center for Living Donation In-Patient Unit designated to the care of the live donor Support Services for

5 Health Promotion Donors are healthy people but Mirrored after the Breast Cancer Program Offered to all donors within the first year of recovery Nutrition, stress management, exercise, emotional support and networking Live Donor Research Steering Committee Research is a Key Goal Within the Center Review existing RMTI research on Live donors Identify deficits in the literature: Psychosocial outcomes in live donors Altruistic donation/paired donation Long term outcomes liver and kidney Informed consent Develop a process for Investigators to present research ideas and develop into approved studies within the goals and constraints of the Center for Living Donation The steering committee meets every two months to discuss goals and direction and review protocols. Lecture Series Current: Every thing you need to know about Kidney Donation Everything you need to know about Liver Donation How to ask for The Gift Future Support groups Health related topics Goals of the Center for Living Donation In-Patient Unit designated to the care of the live donor Support Services for the inpatient stay Improving donor follow-up and health Public and Professional Education Increasing the Knowledge of the The Donor Experience thru live donor outcomes research 5

Core Competencies. for the Clinical Transplant Coordinator

Core Competencies. for the Clinical Transplant Coordinator Core Competencies for the Clinical Transplant Coordinator Assumption Statements This document outlines the core competencies for practitioners/coordinators in the field of clinical transplantation. These