Transplant Team Members Research Articles

Ethical challenges in organ transplants for refugees in a healthcare system.

Several ethical issues are associated with providing living organ transplantation services, and there is limited information on these issues faced by the teams providing service to refugees or asylum seekers. To determine the challenges healthcare professionals face in organ transplant centers providing services to Syrians under temporary protection status and discern whether these difficulties align with ethical issues in living organ transplantation. This study employed a qualitative design and conducted individual semi-structured, in-depth interviews with 18 transplant team members in Istanbul between September and November 2022. Data analysis was based on Braun and Clarke's thematic analysis. The participants comprised 18 healthcare professionals, including 6 physicians and 12 nurses working in organ transplant teams in Istanbul. The University's Ethics Committee provided approval. Participants were informed regarding confidentiality and signed an informed consent form. Three themes emerged from the data on ethical issues faced by organ transplantation services to Syrians: (a) beneficence or double equipoise, (b) autonomy, and (c) justice. Transplant teams experience problems related to preserving double equipoise in the provision of living donor organ transplantation because of language barriers, poor socioeconomic conditions, and cultural factors, which increases transplant teams' individual and indirect social burden. Although problems arise from the language barrier when obtaining informed consent in the autonomy theme, institutional and national policies in preventing donor abuse have a comforting effect. Health workers had the least problems with the justice theme, wherein national health policies are determined. Fewer issues related to autonomy and justice were reported in providing organ transplantation services to Syrians, with the most intense reported issues being maintaining double equipoise. The results revealed the need to develop institutional, national, and international policies with individual solutions to prevent difficulties healthcare professionals face in this process.

Caregivers' and providers' perspectives of social and medical care after pediatric liver transplant: Results from the multicenter SOCIAL-Tx study.

Disparities exist in pediatric liver transplant (LT). We characterized barriers and facilitators to providing transplant and social care within pediatric LT clinics. This was a multicenter qualitative study. We oversampled caregivers reporting household financial strain, material economic hardship, or demonstrating poor health literacy. We also enrolled transplant team members. We conducted semistructured interviews with participants. Caregiver interviews focused on challenges addressing transplant and household needs. Transplant provider interviews focused on barriers and facilitators to providing social care within transplant teams. Interviews were recorded, transcribed, and coded according to the Capability, Opportunity, Motivation-Behavior model. We interviewed 27 caregivers and 27 transplant team members. Fifty-two percent of caregivers reported a household income <$60,000, and 62% reported financial resource strain. Caregivers reported experiencing (1) high financial burdens after LT, (2) added caregiving labor that compounds the financial burden, (3) dependency on their social network's generosity for financial and logistical support, and (4) additional support being limited to the perioperative period. Transplant providers reported (1) relying on the pretransplant psychosocial assessment for identifying social risks, (2) discomfort initiating social risk discussions in the post-transplant period, (3) reliance on social workers to address new social risks, and (4) social workers feeling overburdened by quantity and quality of the social work referrals. We identified barriers to providing effective social care in pediatric LT, primarily a lack of comfort in assessing and addressing new social risks in the post-transplant period. Addressing these barriers should enhance social care delivery and improve outcomes for these children.

Multidisciplinary and multidimensional approaches to transplantation in children with rare genetic kidney diseases.

In this review, we describe the multidisciplinary, multidimensional care required to optimize outcomes for pediatric transplant recipients with rare genetic kidney diseases. Transplant success, recipient survival, and improvement in quality of life depend on collaboration between patients, families, and a team of specialists with medical, as well as nonmedical expertise. A multidisciplinary transplant team composed of experts from medicine, surgery, nursing, nutrition, social services, transplant coordination, psychology, and pharmacology, is now standard in most transplant centers and is critical to the success of a transplant. In addition to these professionals, other specialists, such as cardiologists, urologists, geneticists, metabolic disease specialists, occupational therapists, case management, child life, chaplain, and palliative care services, have a crucial role to play in the preparation, surgery, and follow-up care, especially when a pediatric patient has a rare genetic disorder leading to renal involvement, and the need for transplantation. In order to describe this multidisciplinary care, we divide the genetic renal diseases into five subgroups-metabolic and tubular disorders, glomerular diseases, congenital anomalies of the kidney and urinary tract, ciliopathies including cystic diseases, and miscellaneous renal conditions; and describe for each, the need for care beyond that provided by the standard transplant team members.

An international survey of allied health & nursing professionals during the COVID-19 pandemic: Perspectives on facilitators of & barriers to care.

Allied health and nursing professionals (AHNP) are integral members of transplant teams. During the COVID-19 pandemic, they were required to adapt to changes in their clinical practices. The goal of the present study was to describe AHNP perceptions concerning the impact of the pandemic on their roles, practice, and resource allocation. An online survey was distributed globally via email by the International Pediatric Transplant Association to AHNP at transplant centers from September to December 2020. Responses to open-ended questions were collected using an electronic database. Using a thematic analysis approach, coding was conducted by three independent coders who identified patterns in responses, and discrepancies were resolved through discussion. The majority of respondents (n=119) were from North America (78%), with many other countries represented (e.g., the United Kingdom, Europe, Australia, New Zealand, South Africa, and Central and South America). Four main categories of impacts were identified: (1) workflow changes, (2) the quality of the work environment, (3) patient care, and (4) resources. Participants indicated that the pandemic heightened existing barriers and resource challenges frequently experienced by AHNP; however, the value of team connections and opportunities afforded by technology were also highlighted. Virtual care was seen as increasing healthcare access but concerns about the quality and consistency of care were also expressed. A notable gap in participant responses was identified; the vast majority did not identify any personal challenges connected with the pandemic (e.g., caring for children while working remotely, personal stress) which likely further impacted their experiences.

Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation

Advances in maintenance immunosuppression over the past three decades have improved solid organ transplantation outcomes dramatically. Uninterrupted access to immunosuppression is paramount to minimize rejection and maintain allograft and patient survival. There is no standardized approach to maintenance immunosuppression management. Agents used vary based on transplanted organ, center-specific protocol, provider expertise, insurance formularies, ability to cover co-pays, recipient characteristics and tolerability. Published data reflects this heterogeneity. Despite this limitation, maintenance immunosuppression usage cross pollinates between organ groups with standard of care agents often being used off-label, making medication access a challenge for many transplant recipients. A multidisciplinary panel of American transplant clinicians was formed to review published literature on maintenance immunosuppression with the goal to formulate consensus recommendations for their use in specific organ groups. These consensus recommendations are intended to provide transplant clinicians with a summary of literature on maintenance immunosuppression in the modern era and to support transplant team members working to secure medication access for patients.

Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and International Society for Heart and Lung Transplantation: An executive summary.

Advances in maintenance immunosuppression over the past three decades have improved solid organ transplantation outcomes dramatically. Uninterrupted access to immunosuppression is paramount to minimize rejection and maintain allograft and patient survival. Agents used vary based on transplanted organ, center-specific protocol, provider expertise, insurance formularies, ability to cover co-pays, recipient characteristics and tolerability. Published data reflects this heterogeneity. Despite these obstacles, the information about maintenance immunosuppression use cross pollinates between organ groups with standard of care agents often being used off-label, making medication access a challenge for many transplant recipients. A multidisciplinary panel of American transplant clinicians was formed to review published literature on maintenance immunosuppression with the goal to formulate consensus recommendations for their use in specific organ groups. These consensus recommendations are intended to provide transplant clinicians with a summary of literature on maintenance immunosuppression in the modern era, and to support transplant team members working to secure medication access for patients.

Successful kidney transplantation from a deceased donor with severe COVID-19 respiratory illness with undetectable SARS-CoV-2 in donor kidney and aorta

To the Editor: Kidney transplantation (KT) from coronavirus disease 2019 (COVID-19) donors were avoided due to concerns for donor-derived transmission.1Kates OS Fisher CE Rakita RM Reyes JD Limaye AP. Use of SARS-CoV-2-infected deceased organ donors: should we always "just say no?".Am J Transplant. 2020; 20 (doi:10.1111/ajt.16000): 1787-1794Crossref PubMed Scopus (0) Google Scholar,2Shah MB Lynch RJ El-Haddad H Doby B Brockmeier D Goldberg DS. Utilization of deceased donors during a pandemic: argument against using SARS-CoV-2-positive donors.Am J Transplant. 2020; 20 (doi:10.1111/ajt.15969): 1795-1799Crossref PubMed Scopus (43) Google Scholar There have been no data on the long-term safety, and sensitive molecular testing for SARS-CoV-2 in donor kidney is not routinely performed. We report a successful KT from a deceased donor who died with severe COVID-19 respiratory failure with a detailed investigation of the donor kidney and aorta tissue for SARS-CoV-2. A 30-year-old female was admitted to a hospital due to severe COVID-19 pneumonia with a positive nasopharyngeal RT-PCR for SARS-CoV-2. With clinical worsening, she was placed on extracorporeal membrane oxygenation, but developed hypoxic brain injury and progressed to brain death. Renal function was stable during her hospital course with a serum creatinine concentration of 0.7 mg/dl. SARS-CoV-2 PCR for bronchoalveolar lavage and nasopharyngeal swab re-tested 3 days prior to donation was negative. A 55-year-old male recipient with an end-stage renal disease secondary to hypertension underwent a transplant with the left kidney from this donor. The donor kidney was studied using pre-implantation surgical biopsy samples to investigate the presence of SARS-CoV-2 RNA using in situ hybridization (ISH) and quantitative RT-PCR (qRT-PCR). Aorta tissue dissected with the kidney during the organ procurement was also studied given high expression of angiotensin-converting enzyme 2 receptors in vasculature. Kidney hematoxylin and eosin staining showed acute tubular injury without any glomerular damage or inflammation (Figure 1A). ISH analyses lacked a positive signal for SARS-CoV-2 RNA in the donor kidney sample (Figure 1B) compared to the SARS-CoV-2 positive lung control (Figure 1C). All samples for qRT-PCR were negative for SARS-CoV-2. We found no evidence of SARS-CoV-2 in donor tissues. The recipient has tested negative for SARS-CoV-2 by nasopharyngeal swab RT-PCR on days 20, 30, and 90 following transplantation, and there have been no signs or symptoms of COVID-19. After an initial period of delayed graft function requiring hemodialysis, the recipient now has excellent renal recovery over 9 months following the transplant, and the most recent creatinine is 1.3 mg/dl. Evidence supporting the use of deceased donors who died due to catastrophic COVID-19-related respiratory illness is limited, and these cases do not fit in any categories of the most up-to-date guideline for COVID-19 donors.3Summary of current evidence and information–donor SARS-CoV-2 testing & organ recovery from donors with a history of COVID-19. https://optn.transplant.hrsa.gov/media/kkhnlwah/sars-cov-2-summary-of-evidence.pdf. Published September 22, 2021. Accessed December 20, 2021.Google Scholar As such, the decision of whether to accept nonlung organs from those donors has been decided on a case-by-case basis. Based on recent observations of successful KT outcomes from mild or asymptomatic SARS-CoV-2 positive donors,4Koval CE Poggio ED Lin YC Kerr H Eltemamy M Wee A. Early success transplanting kidneys from donors with new SARS-CoV-2 RNA positivity: a report of 10 cases.Am J Transplant. 2021; 21 (doi:10.1111/ajt.16765): 3743-3749Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar and a short-term safety report of KT from a donor similar to this case,5Meshram HS Kute VB Patel H Desai S Chauhan S Dave RB. A case report of successful kidney transplantation from a deceased donor with terminal COVID-19-related lung damage: ongoing dilemma between discarding and accepting organs in COVID-19 era!.Transpl Infect Dis. 2021; 23 (doi:10.1111/tid.13683)Crossref Scopus (10) Google Scholar the transmission risk of SARS-CoV-2 through KT is likely very low. In conclusion, the use of deceased donors who died after severe COVID-19 can be individually considered for KT, and these organs should not be routinely discarded. We acknowledge that our case may not be representative of many possible COVID-19 donors since the donor was negative for SARS-CoV-2 PCR at the time of transplantation. Larger scale studies are warranted to confirm our findings, and long-term graft outcomes from COVID-19 donors should be studied. We thank all the JH kidney transplant and COVID-19 research team members.

Directly observed therapy to promote medication adherence in adolescent heart transplant recipients.

HT recipients experience high levels of medication non-adherence during adolescence. This pilot study examined the acceptability and feasibility of an asynchronous DOT mHealth application among adolescent HT recipients. The app facilitates tracking of patients' dose-by-dose adherence and enables transplant team members to engage patients. The DOT application allows patients to self-record videos while taking their medication and submit for review. Transplant staff review the videos and communicate with patients to engage and encourage medication adherence. Ten adolescent HT recipients with poor adherence were enrolled into a single-group, 12-week pilot study examining the impact of DOT on adherence. Secondary outcomes included self-report measures from patients and parents concerning HRQOL and adherence barriers. Long-term health outcomes assessed included AR and hospitalization 6months following DOT. Among 14 adolescent HT patients approached, 10 initiated the DOT intervention. Of these, 8 completed the 12-week intervention. Patients and caregivers reported high perceptions of acceptability and accessibility. Patients submitted 90.1% of possible videos demonstrating medication doses taken. MLVI values for the 10 patients initiating DOT decreased from 6months prior to the intervention (2.86±1.83) to 6months following their involvement (2.08±0.87) representing a 21.7% decrease in non-adherence, though not statistically significant given the small sample size. Result of this pilot study provides promising insights regarding the feasibility, acceptability, and potential impact of DOT for adolescent HT recipients. Further randomized studies are required to confirm these observations.

A Brief History of Organ and Tissue Transplantation in Azerbaijan.

The aim of this study was to provide a brief history of transplantation in Azerbaijan. Published information on transplant in Azerbaijan is limited; therefore, we contacted transplant centers and asked questions of heads or members of transplant teams. Answers to the survey provided the basis of this report. In Azerbaijan, history of transplantation started with corneal transplants in the 1920s and kidney transplant from living and deceased donors in the 1970s. Organ transplants, except corneal transplants, were stopped from 1983 to 2002. Living donor kidney transplant and bone marrow transplant were started around 2002. Living donor liver transplant and stem cell transplant have been performed since 2008 and 2015, respectively. Until 2021, 898 kidney, 252 liver, 112 bone marrow, 22 stem cell, approximately 2000 unpreserved and 72 preserved corneal transplants, and 3 left ventricular assist device implantations have been performed in our country. Currently, organ transplant is performed in 7 hospitals of Azerbaijan (the Surgical Clinic of Azerbaijan Medical University, Republican Treatment and Diagnostic Center, Central Clinic Hospital, Central Customs Hospital, Thalassemia Center, Bona Dea Hospital, and National Ophthalmology Center). We hope that the enactment of a new law on transplantation and the establishment of the Coordination Center and Ethics Committee in the near future will create great opportunities for future progress in transplantation, allowing the thousands of patients waiting for transplant to regain their health.

Psychological Adaptation to Transplanted Organ: A Hermeneutic Phenomenological Study

Background: While organ transplantation is a common surgical procedure worldwide, it is yet well-examined how the recipients of newly-transplanted organs adapt and accept a new organ from another body. Adaptation and acceptance of a vital organ from another person is a complex phenomenon, and medical staff needs to delve into this issue to provide appropriate care. Objectives: The present study aimed to explore the transplant recipients' experiences of adaptation to the transplanted organ. Method: A qualitative research design with a hermeneutic phenomenological approach was adopted in this study. In-depth unstructured interviews were conducted by one of the authors (Z. S.) in different locations across Iran. The purposive sampling method was used to select 20 transplant recipients (n = 4 kidney transplantation; n = 10 heart transplantation; n = 4 liver transplantations; and n= 2 blood transfusion). Results: The constitutive pattern emerged from the data was ‘Psychological adaptation to transplanted organ’, with three themes (namely ‘Alien organ,’ ‘Ensure of being the patch of togetherness,’ and ‘Durability of new organ in body’) and several sub-themes. Conclusions: According to the organ recipients' experiences, it takes time for the recipients to accept another person's organ as their own. The transplant team members need to openly and proactively discuss the many psychological and spiritual issues to which the newly-transplanted organ recipients are exposed to facilitate the adaptation and acceptance of the new organs.

Burnout, professional fulfillment, and post-traumatic stress among pediatric solid organ transplant teams.

Adverse effects of clinician burnout have been studied across multiple specialties; however, there have been no studies examining rates of burnout among pediatric solid organ transplant teams. This study aimed to measure burnout, work exhaustion, professional fulfillment, and post-traumatic stress symptoms among clinicians and administrators practicing in this high-stress field. This cross-sectional study utilized a 50 item web-based survey that included the Personal Fulfillment Index and the IES-R. This survey was distributed across four pediatric solid organ transplant centers in North America. Basic demographics, clinician characteristics, and information regarding wellness and self-care activities were collected. Descriptive and correlational analyses were performed. One hundred and thirty five participants completed the survey, 76% were female and 78% were Caucasian. One-third (34%) of participants endorsed burnout, while 43% reported professional fulfillment. Approximately 15% of respondents endorsed clinically significant levels of post-traumatic stress symptoms related to patient deaths, with female clinicians more likely to endorse symptoms (p=.01). Nearly 80% of participants reported engaging in self-care activities outside of work and only 10% of participants reported participation in hospital-sponsored wellness programs. Pediatric solid organ transplant team members exhibited moderate levels of burnout, professional fulfillment, and post-traumatic stress. Female clinicians were the most likely to experience both work exhaustion and post-traumatic stress symptoms. Transplant centers are encouraged to consider interventions and programming to improve clinician wellness.

Barriers to Pretransplant Immunization: A Qualitative Interview Study of Pediatric Solid Organ Transplant Stakeholders

To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pretransplant immunization rates. Semistructured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators, and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver, and kidney transplant recipients at 3 geographically diverse large pediatric transplant centers in the US. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was used to identify themes. Stakeholders participated in 30- to 60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pretransplant immunizations, (2) lack of communication, coordination, and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations, and (5) differences between organ type in prioritization and completion of pretransplant immunization. There are multiple factors that contribute to low immunization rates among pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts

Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 μg/kg per minute and a serum lactate level >9 mmol/L. Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.

Challenges for Liver Transplantation During Recovery From the COVID-19 Pandemic: Insights and Recommendations

The coronavirus disease 2019 (COVID-19) pandemic is placing an increasing burden on liver transplant (LT) services worldwide. At the peak of the pandemic, many LT services worldwide reduced or halted their activities. With the gradual easing of lockdowns, LT teams face new challenges when restarting activities. The numbers of LTs are likely to drop in the immediate post-COVID era.Prolonged and intermittent lockdowns are likely to lead to a shortage of supplies, especially in poor resource settings. Special attention is needed to avoid nosocomial COVID-19 infection among cirrhotic patients awaiting transplant, post-transplant patients, and members of transplant teams. LT programs may have to revise existing strategies in selecting donors and recipients for transplants.Redesigning service provision, restructuring outpatient care, carefully screening and selecting donors and recipients, and performing LT with limited resources will have to be initiated in the post-COVID era if long-term recovery of LT services is to be expected. Costs involved with LT are likely to increase, considering the change in protocols of testing, quarantining, and interstate traveling.This paper discusses the different elements affecting and the widespread impact of the COVID-19 pandemic on LT and strategies to minimize the impact of these factors and to adapt so LT services can meet the health care needs during this pandemic and beyond.

Coronavirus disease 2019: Utilizing an ethical framework for rationing absolutely scarce health-care resources in transplant allocation decisions.

The novel coronavirus disease 2019 (COVID‐19) is impacting transplant programs around the world, and, as the center of the pandemic shifts to the United States, we have to prepare to make decisions about which patients to transplant during times of constrained resources. In this paper, we discuss how to transition from the traditional justice versus utility consideration in organ allocation to a more nuanced allocation scheme based on ethical values that drive decisions in times of absolute scarcity. We recognize that many decisions are made based on the practical limitations that transplant programs face, especially at the extremes. As programs make the transition from a standard approach to a resource‐constrained approach to transplantation, we utilize a framework for ethical decisions in settings of absolutely scarce resources to help guide programs in deciding which patients to transplant, which donors to accept, how to minimize risk, and how to ensure the best utilization of transplant team members.

Visibilidade da equipe de transplante de medula óssea no contexto ecossistêmico

Objetivo: Analisar, no contexto ecossistêmico, a visibilidade profissional dos membros da equipe de Transplante de Medula Óssea, na visão do usuário. Métodos: Abordagem quali-quantitativa, utilizando a Análise de Conteúdo de Bardin e análise estatística descritiva dos resultados, empregando o Statistical Package for the Social Sciences. Realizou-se a análise da frequência, porcentagem das variáveis observadas e análise estatística de estimação intervalar. Na coleta de dados utilizou-se de um instrumento com 35 questões. A amostra constitui-se de 40 entrevistados em dois serviços de transplante de dois países. Resultados: Os dados demonstram que os usuários visualizaram mais de um profissional a oferecer orientações para o cuidado no domicílio. 90% (n=36) responderam que foi o(a) médico(a) que mais orientou para a alta; 72,5% (n=29) referiram o enfermeiro(a), 42,5% (n=17) o nutricionista e 27,5% (n=11) citaram o atendimento de outros profissionais. Conclusão: A visibilidade profissional dos membros da equipe de transplante, na visão do usuário, demonstrou ainda estar influenciada pelo modelo biomédico de saúde, evoluindo, gradativamente, para a identificação de representatividades profissionais, perpassando pela conquista dos espaços destinados a cada membro na equipe de saúde do transplante em relação a orientações para a alta hospitalar após transplante.

COVID-19: A global transplant perspective on successfully navigating a pandemic.

The COVID‐19 pandemic has rapidly evolved and changed our way of life in an unprecedented manner. The emergence of COVID‐19 has impacted transplantation worldwide. The impact has not been just restricted to issues pertaining to donors or recipients, but also health‐care resource utilization as the intensity of cases in certain jurisdictions exceeds available capacity. Here we provide a personal viewpoint representing different jurisdictions from around the world in order to outline the impact of the current COVID‐19 pandemic on organ transplantation. Based on our collective experience, we discuss mitigation strategies such as donor screening, resource planning, and a staged approach to transplant volume considerations as local resource issues demand. We also discuss issues related to transplant‐related research during the pandemic, the role of transplant infectious diseases, and the influence of transplant societies for education and disseminating current information.

Mobile Application for Communication Increases the Efficiency of Organ Procurement and Transplantation.

Background:Donor organ recovery is a complex process involving organ procurement organizations and multiple surgical teams from various transplant centers. Nearly 30% of discarded organs are wasted due to reasons related to improper coordination and communication.Problem Statement:Lack of real-time communication results in many hours of preventable delay between procurement and transplant teams resulting in the high volume of organ waste, clinical frustration, and critical delays.Methods:A Plan-Do-Study-Act performance improvement methodology was utilized to design and implement a dedicated mobile communication application (app). Critical time points in the organ offer, procurement, and transplant processes were analyzed from the Report of Organ Offers, and relation coordination metrics were measured.Processes Addressed:Members of procurement and transplant teams in Iowa were interviewed and a dedicated smartphone application was implemented to replace phone calls, e-mails, faxes, and text messages during upcoming kidney offers from July 31, 2017 to July 31, 2018.Outcomes:Teams reported a substantial increase in clinical productivity and case progress awareness, including a noteworthy reduction in phone calls. The relational coordination data indicated substantially higher relationship and communication quality with the app. The Report of Organ Offer data revealed a 35% increase in organs transplanted and a 50% reduction in time from initial organ offer to transplant with the use of the mobile application.Implications for Practice:The use of a dedicated communication application reduces clinical frustration and delays during the coordination of organ offer, procurement, and transplant. Technologies that improve communication have the potential to improve organ utilization.

The HPC-a Collectogram: A Useful Tool for Determining Collection Processing Volumes

Introduction Optimal mobilization is an important step in the autologous hematopoietic cell transplant procedure. Mobilization requires the administration of growth factors such as filgrastim, a granulocyte colony stimulating factor, and plerixafor, a CXCR4 antagonist, that help release hematopoietic progenitor cells (HPC) from the marrow niche. HPCs are differentiated from other cells by their expression of CD34 on the cell surface. Through monitoring of CD34+ cells, the transplant team assesses how well a donor is mobilizing and can adjust mobilization and collection plans accordingly. This enables decision-making on the use of plerixafor and the volume of whole blood to be processed (WBP). Objective We developed the HPC- A Collectogram to help determine the volume of WBP depending on the assumed collection efficiency (CE2). This tool, built in Excel utilizes embedded formulas with input variables including target CD34 dose, dosing weight, blood volume, total WBC, peripheral blood CD34%, PBCD34 count and assumed CE2 (Figure 1). The CE2 at the time of the collection is unknown however an educated guess is made based on the median CE2 for previous collections at our center. The CE2 is a measurement of the apheresis instrument's ability to separate and extract the maximum number of CD34+ cells from cells available in the peripheral blood; yet the CE2 may be heavily influenced by variables such as donor and blood characteristics, as well as apheresis machine software/program and operator adjustments. Method Utilizing the known median CE2 value as a guide, the HPC-A Collectogram can be utilized to predict collection volumes that meet exact collection goals within an acceptable range. The decision to restrict collection based on a calculated processing volume may prevent undesirable side effects of a prolonged apheresis procedure and the over-collection of HPCs. Results For example, Jane Donor, weight 69.9 Kg, height 170.2 cm, WBC 52.2 K/uL, CD34% 0.196: To use the HPC-A Collectogram to guide collection in this patient, the user should: (1) Enter values for prescribed dose and dosing weight to calculate the absolute CD34 dose. (2) Enter current height and weight into the appropriate gender column to calculate donor blood volume. (3) Enter collection day WBC and CD34% as a decimal to determine the PBCD34 and to populate WBP and the target blood volume (BV) (the number of times the donor blood volume will need to be circulated through the apheresis instrument). (4) Choose the target BV to run based on the expected efficiency. For this example, run 3.73 BVs for an expected 40% efficiency to collect 10 million CD34+ cells/kg (Figure 2). Conclusion The HPC-A Collectogram can be a useful tool to more efficiently assist transplant team members in determining the volume of WBP required to meet prescribed dosing goals for hematopoietic cell transplantation.

Implementing a Frailty and Functional Assessment for Patients Undergoing Allogeneic Hematopoietic Cell Transplant during Routine Clinic Visits

Topic Significance & Study Purpose/Background/Rationale Frailty and poor Functional Status can adversely affect the outcome of patients undergoing allogeneic hematopoietic stem cell transplantation (alloHCT). Our alloHCT team felt the need to assess Fragility and Functional Status (F&FS) of all alloHCT recipients as standard evaluation. This study summarizes the implementation of the program. Methods, Intervention, & Analysis In May 2018 the multidisciplinary transplant team members reviewed options for F&FS assessment in our clinics with the aim of adopting Geriatric Assessment tools which were prognostic, easy to administer within the existing clinic appointment and space. After reviewing literature, it was decided to adopt 8 different tests (details in Table1). A one page scoring tool was built by the clinical nurse coordinators to capture the results of each test (Fig 2). If any part of assessment was missed, it could be completed at the next visit or admission. Findings & Interpretation It took the study team 45 days to implement the program. The tests are easy to perform and can be done by any clinical team member during the patient's transplant trajectory. There is no incremental increase in waiting time. Over a 6 month period, 283 patients were assessed using the F&FS. There was incomplete information in 57 of these patients, mainly during early implementation. The correlation of these test results with transplant outcomes was selected for presentation at the 2019 ASH meeting (Abstract #380). Discussion & Implications F&FS assessment can be used as a standard of care testing for all patients being considered for alloHCT with proper planning and teamwork.