Organ and Tissue Donation and Recovery

Keystosuccessfulorganprocurement:Anexperience-basedreviewofclinicalpracticesatahigh-performinghealth-careorganization

Organprocurement(OP)fromdonorsafterbraindeathandcirculatorydeathrepresentstheprimarysource oftransplantedorgans.Despitefavorablelawsandregulations,OPcontinuestofacechallengesfora numberofreasons,includinginstitutional,personal,andsocietalbarriers.Thisfocusedreviewpresents someofthekeycomponentsofasuccessfulOPprogramatalarge,high-performingregionalhealth network.Thisreviewfocusesoneffectiveteamapproaches,aggressiveresuscitativestrategies,optimal communication,familysupport,andcommunityoutreachefforts.

KeyWords:Organdonoroptimization,organprocurement,teamapproaches,teameffectiveness, transplantation

INTRODUCTIONOrganprocurementcontinuestobetheonlyhopeforthousandsofpatientsawaitinglife-savingtransplantationprocedures.Thereareapproximately120,000individualsawaitingorgantransplantationintheUnitedStatesalone[Figure1].[1]Inadditiontosignificantimprovementsinrecipientqualityoflife,organtransplantationalsoofferssubstantialhealth-caresavingsatthesocietallevel.

FromJanuarytoDecember2016,outof36,474totaltransplantsperformedintheUnitedStates,27,630(82.2%)originatedfromdeceaseddonors,and5,982(17.8%)originatedfromlivingdonors.[1]Deceasedorgandonationsoriginateprimarilyfromtraumapatientswhohavesuccumbedtotheirinjuriesandthosewhoexperienceddevastatingcerebrovascularaccidents(CVAs).Ofimportance,inthemorerecentpast,asignificantshifttowardorganrecoveryfromdonorswhosufferedanoxicbraininjuryhasbeennoted,asexemplifiedbydatafromtheOrganProcurementandTransplantationNetworkandourlocalorganprocurementorganization(OPO),GiftofLife(GoL)DonorProgram,Philadelphia,Pennsylvania[Table1a

Abstract

andb].[1]Theongoingneedfortransplantableorgansandtheevolvingdemographicsofpotentialorgan donorsmandateproactiveapproachestobothhospital-wideeducationandprocessimprovement surroundingtheorgandonationprocess.

InGoLDonorProgram'sdonorserviceareaofeasternPennsylvania,southernNewJerseyandthestateof Delaware,timelyreferralsofpotentialorgandonorsandplannedfamilyapproacheswithorgandonation opportunities,combinedwithhemodynamicoptimizationandmaintenanceofeffectiveend-organ perfusionhaveresultedin48.6organdonorspermillionpopulation(PMP)and127.2transplantsPMP[ Table2a].[2]Ourinstitution'spartnershipwithGoLfacilitatesongoingeffortstocriticallyanalyzethe organdonationprocess,focusonmeaningfulclinicaleducation,andimplementeffectiveprocess improvementinitiatives.

Thegoalofthismanuscriptistofocusspecificallyondonationpracticesimplementedatahigh-performing,universityhospitalwithasustainedtrackrecordofregionalleadershipinorganprocurement[ Table2bandc].Afteraninitialefforttohardwirehighlyeffectiveprocessesintoourinstitutionalculture, wewereabletoincreasetheauthorizationratefrom64%in2012to81%in2016.Ourconversionrate increasedfrom46%in2012to75%in2016remainingconsistentlyhighsince2013[Table2d].

ORGANPROCUREMENTORGANIZATIONS

Giventhegreatimportanceoftheorganrecoveryprocesstothemaintenanceofthecriticallifelineof organs,keycomponentsoftheoverallorgandonationparadigmmustbeoptimizedandstreamlined.[3,4,5] AsshownschematicallyinFigure2,theoverallprocessoforganprocurementisbothhighlystructured, quitecomplex,andmustincludepublicandhealth-careteameducation,sensitivitytothefamily'sneeds, clinicalexpertise,andlogisticalfactorssurroundingorganrecovery,distribution,andtransplantation.[3] RegionalOPOscoordinatetheprocurementprocesswithinandbetweenparticipatinginstitutions.[4]In additiontoOPOs,bedsidecareteamsplayacrucialroleinfacilitatingtheoverallprocessandmaintaining thecultureofacceptancefororganprocurement.[5]Suchteamsareinterdisciplinary,consistingofnurses, physicians,advancedpractitioners,respiratorytherapists,pastoralcare,OPOpersonnelandotherhealth-careprofessionals–allworkingtowardthecommongoalofprovidingcomforttothegrievingrelativesof thepotentialorgandonorwhilemaintaininghopethatanotherlifecanbesavedintheprocess.[5]In additiontotheirconsultativeroleintheoverallguidanceofthecareofpotentialorgandonors,OPOsalso ensurethatappropriateethicalandclinicalstandardsarefollowedduringtheprocurementprocessandthat keyqualityindicatorsarebeingcontinuouslymonitoredandreported,withappropriatefollow-upactions promptlyinstituted.[6]

THEHEALTH-CARETEAM'SFOCUSONFAMILYCAREANDSUPPORT

Forfamiliesofthepotentialorgandonor,theIntensiveCareUnit(ICU)periodisoftentoobrief,makingit difficulttofullyandcompletelycomprehendthemagnitudeofeventstakingplace.Regardlessofthe durationofthepatient'sadmission,theclinicalstaff'saptitudetofosterasafehavenforrelativesis criticallyimportant.[7]Atourinstitution,thissupportstartsfromthemomentthefamilyarrivesinthe emergencydepartmentorICU.Familiesareespeciallysusceptiblewhenanonsurvivableneurological injuryorillnessoccurssuddenlyintheirlovedone.[8]Thisisoftenassociatedwithemotionalexhaustion, whichcanbefurthercompoundedwhenthequestionoforgandonationcomesup.[9]Throughoutthe patient'sstay,pastoralcareispresenttoprovidesupportivecaretofamiliesofcriticallyillpatients, addressingtheirphysical,emotionalandspiritualneeds,andpreparingthemfornextstepsshouldorgan donationbecomeapossibility.

OPTIMALWORKINGRELATIONSHIPWITHOURREGIONALORGAN PROCUREMENTORGANIZATION

WehavelearnedthatitiscriticalforourteamtoreferpotentialorgandonorstotheOPOinatimelyfashionwhilethebedsideteamcontinuestosupportthepatientandthefamily.Inpracticalterms,potentialdonorsareidentifiedbycertain“triggerevents,”orclinicaloccurrencesthataremorelikelytoresultinbraindeath;mostfrequentlysignificanttraumaticbraininjury,CVAs,andconditionsresultinginanoxia[Figure3].TheseeventspromptbedsidestafftonotifytheOPOinanticipationofeitherimminentbraindeathorpotentialdonationaftercirculatorydeath(DCD).[10]Earlyinteractionswiththefamilyandagraduallyescalating,stepwiseapproachbystaffmembersadequatelytrainedinstandardsandpracticesoforgandonationareofgreatimportance.ItisstandardprocedureforourclinicalteamtoinformGoLofpotentialorgandonorsinastimelyamanneraspossible.Duringthisprocess,ourteamcontinuestobediscrete,sympathetic,andrespectfuloffamilymoralvaluesandviews.Ourinstitutionutilizesafamilycommunicationprotocolthathelpsfacilitatethedifficultstep-wiseprocessofnotifyingfamiliesofthegravityoftheirlovedone'scondition[Figure4].Theprotocolisdesignedtoaddressanypotentialconcernsoffamilymembersandhealth-careprovidersandisnowapartofthestandardizedprocedurethatisusedthroughoutourOPO'sentirecoveragearea.Inaddition,ourhospitalstaffiswellawareofstateandfederallegislation,includingPennsylvaniaAct102of1994andtheCentersforMedicareandMedicaidServicesConditionsofParticipationforOrgan,TissueandEyeProcurement(aswellastheunderlyingUSDepartmentofHealthandHumanServicesstatute,theSocialSecurityAct,Section1138)whichrequireshospitalstoreferalldeathsandimminentdeathstoOPOsandlimitsrequestsfordonationtotrainedOPOpersonnelordesignatedrequestors.WeabidebytheselawsandutilizeGoLtoproceedwithalldonorrequestsonbehalfofourinstitution.

OurOPOacquiresbasicinformationonthepotentialorgandonorthroughthephone,andthen,dispatchesacoordinatortothehospital.Ourstaffhasauniversalunderstandingthattimelyreferralsprovideboththeorganprocurementandthebedsideteamswiththetimetheyneedtooptimallysupportthefamilywhilepreservingtheiropportunitytodonate.Throughfrequentteamhuddles,thebedsideteamandtheOPOcoordinatordiscusstheuniqueneedsofthefamilyandclinicalmanagementstrategies.Theyincorporatethesefindingsintofamilyanddonorcareplans.

Theprocessofofferingtheopportunityfororgandonationtofamilieshasmaturedovertheyears.Well-trained,specializedOPOcoordinatorsnowperformthisrolewiththesupportofourcareteam.OPOcoordinatorsscreenformedicalsuitability,acquireauthorizationfromnextofkin,coordinateallocationandrecoveryoforganswhileprovidingemotionalsupporttofamilies,andattendingtothephysiologicalneedsofpotentialdonors.[11]Asateam,weworktogethercloselyandsupporteachotherintheseefforts.

Regardingpracticalaspectsoftheimplementationofprocurementprocedures,effectiveeducationofthepotentialdonor'sfamilyandthesubsequentconversationsarekeystepstowardsuccessfuldonation.Authorizationismorelikelytobeobtainedwhenthefamilyapproachisdoneinasensitive,appropriatelytimedmanner,[12]specificallybyatrainedemployeeoftheOPOaccompaniedbyamemberofthepatient'scareteam.[13]Allthosewhospeakwiththefamilyaretrainedtorespondtoquestionsorconcernsinacalmandreassuringfashion.Discretionandsympathywithrespecttofamilycultural,religious,andmoralvaluesandviewsarestrictlyobservedduringeachconversation.[9]

TheOPOcoordinatorandclinicalstaffmustbewellawareandrespectfulofthechallengesthatfamiliesofpotentialorgandonorsface,includingtherealitiesoffuneralarrangements,limitedfinancialresources,andthefearofphysicalbodyalterationsfollowingthedonationprocess.[13]WerelyonourOPOcoordinatortotaketheleadinaddressingtheseconcernswithfamilies,providingthemsupportduringtheseimportantconversations.

AlthoughtheOPOcoordinatortakestheleadinexplainingthedonationpathwaystopotentialdonorfamilies,itiscriticalforclinicalstafftobeknowledgeableofbothdonationafterbraindeathandDCD.AreferenceguidetobothpathwaysisalsoprovidedforICUresidents[Figure5].Professionalism,experience,andfamiliaritywiththeprocessleadtoincreasedorgandonationauthorizationandconversion

rates.[14]Betterknowledgeandunderstandingoftheoverallprocess,includingcommonthemes experiencedthroughbothmedicalandsocialinteractions,allhelpfacilitateclinicalcareofthepotential donor,professionalandteamdevelopment,aswellasgreaterinvolvementinorganprocurementand relatedadvocacy.[15]Conversationswithinandbetweenallinvolvedteamshelpfacilitateawareness, attentivenessandpromotetheoverallsupportfordonorfamiliesandorgandonation.Thecultivationofa constructivedialogregardingthedonationprocessandmaintenanceofproficiencyamonghealth-care providerscreatesanatmosphereofsupportforthedonationprocess.Teamcommunicationsshouldclearly emphasizethattheworkanddedicationofbothICUandOPOstaffarefullyrecognizedandgreatly appreciated.[16]OurexperienceworkingwiththelocalOPOhasallowedustocultivateacultureoftrust andcollaboration.This,inturn,providesafoundationwhichdrivesorgandonationoutcomes,achieving someofthebestdonationauthorizationandconversionoutcomesinourregion[Table2bandc].

UNDERSTANDINGKEYPRINCIPLESOFBRAINDEATH

Ithasbeenpostulatedthatasignificantsourceofconfusionassociatedwiththeprocessoforgandonationisthemisinformationand/orlackofunderstandingregardingtheconceptofbraindeath.[17]Itisessentialthatthoseinvolvedindirectpatientcarehaveafullconceptualgraspofbraindeath,skillandexperienceinpronouncementprocedures,andfamiliaritywiththeprinciplesoforganoptimizationandmaintenance.

PhysiciansandICUnurseshaveafundamentalresponsibilitytoestablishcareandsupportforthepatient'srelativesandtoeducatefamilymembersonthegravityoftheirlovedone'scondition,includingstepsthatwillbetakentodeterminebraindeath[Figure4].Authenticandcomprehensiveeducation,includingclarificationsandexplanationsofwhatbraindeathentails,willassistrelativesinrecognizingthefinalityofthiscondition.[18]Whenpossible,addressingthefamilyinaprivatesetting,andatatimedeemedsuitablebythefamily,iscriticallyimportant.

Whentheattendingphysicianprovidesthefamilywithatransparentexplanationofprognosis,testing,andpronouncementofdeath,itmustbeemphasizedthatstrictpoliciesandnumeroussafetyproceduresareinplacetoascertainanaccuratediagnosis.[19]Theconceptofbraindeathmustbeclearlydifferentiatedfrom“vegetativestate”orcoma.[12]Oncebraindeathhasbeendetermined,providingthefamilywiththedateandtimeofdeathiscriticaltotheirunderstanding.Ofimportance,communicationwiththefamilymustbeconsistentacrossallmembersoftheclinicalcareteam.

ItiscriticalforbothhealthcareandOPOteamstoestablishtrustwithapotentialdonor'sfamily,especiallyforthepurposeofeducatingontheconceptofbraindeath.[17]ICUteamsconsistingofphysicians,nurses,andpastoralcare,buildandsustainarespectful,supportive,andreverentatmosphereforthepatientandfamily,providingspaceandtimeforadequatereflectionandgrieving.TheICUnursemaintainsapresenceduringmeetingswithfamilymembersandisalwaysavailabletoanswerquestionsandaddressconcerns.Pastoralcarelendsacalmingpresenceandlisteningear.TheOPOcoordinatorisoftenpresentduringfamilymeetings.Ofimportance,afterteammemberscommunicatethepresenceofbraindeath,athoroughassessmentofthefamilyunderstandingofthisconcepthelpsinestablishingfamilyreadinessforaconversationaboutdonationopportunities.

Delaysinthedeterminationofbraindeathcanbestressfultothefamilyandmayimpedesuccessfulorganprocurement.Tostandardizethisprocedureandencourageitstimelyconduct,ourinstitutionhasinstitutedamultipoint,well-organizedchecklistthatoutlinesestablishedstepsrequiredforthediagnosisofbraindeath[Figure6].Wealsohaveacomprehensivebraindeathpolicythatensuresclinicaluniformityandprocessstandardizationwithinourinstitution.

Determinationofapatient'seligibilityforeitherdonationafterbraindeathorDCDshouldbecarefullyevaluatedby“rulingdonorsin”ratherthan“rulingthemout”.Whenthehealth-careteambelievesbraindeathisimminent,waitinguntilthepatientbecomesbraindeadeliminatesthefamily'sburdenofhavingto

makeawithdrawaldecisionandoftenextendsthenumberoforganstheirlovedoneisabletodonate.At ourinstitution,weofferthisoptiontothefamilyinacollaborativeconversationwiththeOPOcoordinator.

STANDARDSOFPRACTICEFORMANAGEMENTOFTHEORGANDONORTodeterminemedicalsuitability,weworkwithourOPOcoordinatortosecurebloodforimmunologicand otherpertinenttesting,aswellasdonor-to-potentialrecipientmatchcharacteristics.Allvitalorgansare physiologically“protected”duringtheentireprocessbyspecificallydirected,protocol-driventherapeutic maneuvers,guidedbyestablisheddonormanagementcriteriaandperformedunderthesupervisionof trainedintensivistsandOPOpersonnel.[4,20,21,22]

Eachhospitalequippedwithcriticalcarefacilitiesshouldhaveestablishedguidelinestoidentifypotential organdonors,notifyOPOstaff,andprovidecriticalcareservicesneededtomaintainphysiologicstability ofthebraindeadorpotentialDCDdonors.[22]Greatattentionmustbepaidtoensurethatpotentialdonors continuetobeeffectivelyresuscitatedandappropriatelymanaged.Anyuntowardclinicalevents,suchas hypoxiaorhypotension,shouldbeprimarilypreventedorpromptlyaddressedbeforeend-organdamage occurs.Invasivecentralvenouscatheters,sonography-basedhemodynamicassessments[23,24,25,26]as wellasothermethodsofnoninvasivehemodynamicmonitoring[27,28,29]shouldbeemployedliberally whenappropriateclinicalindicationsarepresentfortheirdeployment.

Althoughmanycasesoforgandonoroptimizationwillnotinvolveintensivehemodynamicsupport,some organdonorsmayrequirethehighlevelsoftreatmentintensityandinvestmentofbothtimeandresources toprovideanadequate“bridge”betweenthedeterminationoforgandonorstatusandthesubsequent surgicalorganrecovery.Hypothermiaiscommonlyencounteredinthebrain-deadpatient.Consequently, maintenanceofbodytemperaturegreaterthan35°Cisimportant,[30]especiallywhenattemptingto optimizeprocurementofmorephysiologicallysensitiveorgans(e.g.,heartandlung).Althoughourcurrent abilitytosustainorganviabilityvariesgreatlyaccordingtoorgantype,itisimportanttorememberthat bothorganviabilityandthenumberoforgansprocuredperdonorcorrelatewiththequalityoforgandonor optimizationbytheICUteam.[31,32,33,34]

STANDARDIZEDDONORMANAGEMENTPROTOCOLS

Theimportanceofstandardizedclinicalmanagementprotocolscannotbeoveremphasizedinthecontextof maximizingorganyieldperdonor.[34]Notonlydosuchprotocolsimprovetheoutcomeandqualityof organrecoverybuttheyalsoprovideabenchmarkbasedonwhichorganizationscanlearn,self-improve, andultimatelybecompared.Tothatend,organprocurementmanagementgoalshavebeenincorporated intoourinstitutionalprotocolstoensurethatuniformproceduresareappliedforeachpotentialand confirmedorgandonor.Thisparadigmconsistsofamultipointorgandonationchecklistandasetof standardizedordersthathavebeensuccessfullyimplementedandarefollowedwithahighdegreeof compliance.Bothorgandonormanagementgoals[Figure7]andprotocol-basedordersets[Figure8]help facilitateasmoothclinicaltransitionfromourinstitution'sICUstafftotheregionalOPO'sstaff.Itisvery likelythatourperformanceasanorganprocurementinstitutionis,atleastinpart,duetothestrict adherencetoestablishedprotocolsandguidelines.

AROUND-THE-CLOCKINTENSIVISTSUPPORT

Thecontinuousavailabilityofanintensivecarespecialistisespeciallyimportanttoallmetricsofsuccessfulorganprocurementprocessdiscussedabove.Wealsobelievethishelpsmaximizethenumberofviableorgansrecoveredfromeachdonor.[35]Intensivistpresencefacilitatestheperformanceofadvancedbedsideprocedurestoassistinorganoptimizationandallocationsuchasechocardiography,bronchoscopy,

centralvenoushemodynamicmonitoring,ortransesophagealechocardiography.[26,28,36,37,38,39]Not onlyareourintensivistsavailable24hadaytoassistinproceduresandcriticaldecision-makingbutalso theirpresenceisvitalastheyprovidesupportforthefamiliesandhospitalstaff.

TRANSITIONFROMINTENSIVECAREUNITTOTHEOPERATINGROOMClosecooperationbetweenICUstaff,membersoftheOPO,andtheoperatingroom(OR)personnelis paramounttooptimizeprocurement.Thedurationbetweenfamilyauthorizationandthedonor'stransport totheORcanbeupto24–36h.Atourinstitution,westrivetoprovidethefamilywithasmuchtimeas possibleattheirlovedone'sbedsidepriortotheorganprocurement.Fordonationafterbraindeath,we supportthefamilywhenevertheywanttoaccompanythedonortotheORdoor,andforDCD,wesupport thefamily'spresenceintheORsuitefromthetimeofwithdrawalofsupportuntilcardiacdeathis declared,allbasedonthefamily'swishesandinaccordancewithourspecificinstitutionalpolicies.

WhilepreparingforDCDintheORthepatientissterilelydrapedwithfaceandhandsuncoveredtoallow contactwithfamilyshouldtheydecidetobepresentafterthewithdrawaloflifesupport.Everyeffortis madetopreparetheORenvironmentinawaythatfacilitatesthefamily'scomfortandend-of-life observances.Thebedsidecareteamextubatestheprospectivedonorandadministerscareandcomfort medicationsastheywouldintheICU.Thedonoriscloselymonitoredbythestaff.Oncedeathis determinedanddeclared,thefamilyistakentoadesignatedprivateareawherecontinuedsupportservices areoffered.Forbraindeaddonors,thepatientistakentotheOR,androutineprocessesarefollowedbythe combinedsurgical,anesthesiology,andorganrecoveryteams.

CARETEAMEXPECTATIONFORDONATIONEDUCATIONANDCASEFOLLOW-UP

Theclinicalknowledgeandexpertiseofallcriticalcarestaffplayanimportantroleintheidentification andsubsequentcareforpotentialdonorsaswellasprovidingmuch-neededsupportfortheaffected families.[40,41]OurinstitutionprovidestrainingforallnewnursesduringboththeTraumaNurseCourse andCriticalCareNurseCourse.WealsocollaboratewithGoLDonorProgramtoprovideregularin-servicingfornursingstaff.Thisapproachallowsustoensurethatnewnurseshaveadequatefoundational knowledgeoftheorgandonationprocess,withamplecontinuingeducationopportunitiesthroughouttheir employment.Ourresidentsreceiveeducationaltrainingthatincludesallaspectsofthedonationprocess, includingtimelinessofreferrals,explainingbraindeath,collaborationwiththeOPO,familysupportand approachfordonation,anddonormanagement.Educationalmeetingswithrespiratorycarestaffkeepthem abreastofnewclinicaldevelopmentsandthushelpfavorablyaffectdonormanagementandtransplant outcomes.Aspartofroutineclinicalpastoraleducation(CPE),pastoralcareresidentsarepresentedwitha broadrangeofscenariospertinenttotheorgandonationprocessaswellastheirspecificrolesinfamily support.

Follow-upcommunicationwithGoLDonorProgramisessentialincontinuingtoengagestaffinthe donationprocess.Thisfollow-upincludescasereviewswithphysicianleadersandclinicalstaffinaddition tosharingdonationoutcomesandup-to-dateprocessqualitydataatdonationcouncilmeetings,aswellas otherstandingclinicalforums.Amongkeyfactorsintheoverallprocess,thecareteam'sabilitytoevaluate theirfamilycommunicationandclinicalmanagementstrategieshelpsdetermineanyopportunitiesfor improvementandguidesfutureapproachestofurtherimprovedonationoutcomes.

IMPACTOFORGANDONATIONONCARETEAM

ItiscriticaltorememberthatICUnursesaretaskedwithmultiple,oftencompetingprioritiesandresponsibilitieswhileprovidingcaretotheirpatients,predisposingbedsidepersonneltosignificantamountsofemotionalstress.[15]Aboveandbeyondtheirregularbedsideduties,theorgandonationprocessoftencallsonnursestocontributeinnumerousotherways,includingtheprovisionofcarefornext

ofkin,coordinatingmultiplebedsideteams,andensuringthatorganoptimizationstrategiesareactively utilized.Notinfrequently,bedsidenursesfocussignificantenergiesonaddressingtheneedsofthe potentialdonor'srelatives.[14]

Manyphysicians,advancedpractitioners,nurses,respiratorytherapists,andpastoralcarestafffindthe abilitytoprovidecomfortandmodifyrelevantprocessesinaccordancetoafamily'swishesbothgratifying andempowering.Theabilitytofocusonthepromiseofabetterlifeforthepotentialorganrecipients allowsthecareteamcopewiththehighcomplexity,increasedworkload,andstressoftheoverallsituation. Criticalcarenurseshavedescribedtheorgandonationprocessasonewithaprofoundeffectonthe patient'scaregivers,anundertakingwhichteststheirpersonalskillsandprofessionalcapabilitiesalike.[14] Apositiveattitudeofhealth-careworkerstowardorgandonationshapestheircompassionandcaretoward adonorandthefamily.Insummary,thephysician,nurse,andsupportstaffwhoarethoughtful,receptive, sensitive,andsympatheticarepivotalinaidingfamiliesduringthedifficultandemotionallytaxing transition,fromacceptingtheirlovedone'sdeathtoembracingtheconceptoforgandonation.

COMMUNITYAWARENESSOFORGANDONATIONANDDONORDESIGNATION

Educationthatcontributestoraisingtheawarenessoforganandtissuedonationandtransplantationin general,andmorespecificallytoencouragethepublictodesignatethemselvesasorgandonorsisvery importanttothecontinuedviabilityoforganprocurementefforts.[42,43,44]Appropriateresourcesshould beutilizedtoeducatethepublic,especiallymiddle-andolder-agedpersons,toensuretheyunderstandthat theirorgansmaybeequallyvaluableinthesettingoflife-savingtransplantation.Finally,itisarelatively commonmisconceptionthatthehealth-careteamwillnotprovideoptimalcareforsomeonewhoisdonor designated.[45]

InPennsylvania,donordesignationonadriver'slicense,state-issuedidentificationcard,orlivingwill constitutelegalfirstpersonconsent.Evidenceofpreviouslyexpresseddispositionfromthepotentialdonor notonlyhelpshealth-careprofessionalsunderstandthedonor'swishesbutalsohelpsguidefamily membersandremovestheburdenofnotknowingtheirlovedone'spredeterminedwishes.[9] Consequently,ourOPOprovidesthisinformationtousatthetimeofareferralforapotentialorgandonor sinceinmostcases,theycanretrieveitfromthestate'sdepartmentofmotorvehicles(DMV)database. Whenthetimeisappropriateforafamilytobeapproachedaboutdonation,theOPOcoordinatorinforms themoftheirlovedone'sdecisiontobecomeanorgandonor.Thefamilyissupportedbyourteamandthe OPOastheycompleteadisclosureform.Itisessentialthatourteamscarefullycollaborateduringthistime sothatthisinformationcanbesharedwiththefamilyinawaythatissupportivetothemwhilerespectfully fulfillingthewishesofthedonor.

Ourhospitalnetwork,spearheadedbyclinicalstaff,participatesinlocalcommunityeventstodisseminate accurateinformationaboutdonationandtransplantationandtoencouragedonordesignation.During NationalDonateLifemonth,weholdanannualflagraisingeventwhichiswell-attendedbythepublicand hospitalstaffalike.Weinspireandeducateattendeesthroughvariousfocusgroups,sessions,andon-field presentationsatlocalsportingevents,includingminorleaguebaseballgamesandprofessionalindoor footballgames.

Twoareasofopportunityforoutreachexpansionincludeyoungpeopleandminorities.Inthiscontext, focusedprogramsintheLehighValleyregion(Pennsylvania,USA)beganincludingor gandonation presentationsfordriver'seducationandbiologystudentsandatseverallocalhighschools.Minority outreachmustbeenhancedaswell,especiallybecauseanunderlyingsentimentmaystillbepresentthat discriminationpreventsminoritypatientsfromreceivingtheorgantransplantstheyneed.[45]

ONGOINGCOMMITMENTTOORGANDONORANDDONORFAMILIES

Organdonorsareheroesandtheirgiftstoothersaretrulyunique.GoLDonorProgrampaystributeto donorsandtheirfamiliesindonorremembranceceremonies,withourhealth-careteamjoiningasinvitees. Duringsuchevents,familiesareprovidedwithmaterialstodisplayattheirlovedone'sfuneralormemorial servicetorecognizethemfortheirlife-savinggifts.Specificexamplesincludeacertificateofrecognition, adonormedal,lapelpins,andDonateLifebracelets.

GoLDonorProgramthroughitsHeartsofGoldvolunteerinitiativehelpsmakememorialquiltstopay tributetothememoryoftheorgandonors.Donorfamiliesareencouragedtohonorandremembertheir lovedonebyconstructingaquiltsquareforthe“ThreadsofLove”memorialquilt.GoLallowsthequiltto bedisplayedatvariouslocationsthroughouttheregiontohelpadvanceorgandonorawareness.[46]Our hospitaldisplaysthesectionsofthequiltthatcontainpatchescommemoratingdonorsfromwithinour network'scampuses.Thisisextremelymeaningfultoourhospitalstaffandvisitors.

BycollaboratingwithGoLDonorProgramonhospital-widedonationawarenessevents,weareableto betterunderstandtheselflessnessofdonorsandfamiliesinvolvedintheorgandonationprocess.Along withcontinuedcommunicationandinteractionswithfamilies,GoLalsooffersgriefcounselingaswellas opportunitiesforfamiliestobecomeinvolvedinvariousorgandonationeducationalandadvocacy programsbysharingtheirlovedone'sstorywithothers.[45]

OurhospitalnetworkcollaboratescloselywithGoLDonorProgramtoprovideanannualcelebrationof lifeduringwhichdonorfamilies,transplantrecipients,andhospitalstaffgathertosharetheirstoriesand experiencesrelatedtodonationandtransplantation.Beingabletocelebratethelivesofourdonorsand recipientsprovidesinspirationtoourcareteam,supportstaff,andadministration.

CONCLUSIONS

Well-managedandmaintainedorgandonationprogramsinacutecarehospitalsareessentialtothesuccess oforgantransplantationefforts.Despitefavorablelaws,regulations,andtheuniversalinvestmentinorgan procurementnetworks,significantchallengesandopportunitiesforimprovementexist.Thismanuscript presentedkeycomponentsofasuccessfulorgandonationprogram,asexemplifiedbyourhospital network.Thecornerstonesofoursuccessincludecontinuedinstitutionalcommitmenttoahighquality organdonationprogramandastrong,collaborativerelationshipwithourOPOthatencouragestimely referralsandworkingtowardcommongoals.

Theseeffortsincludeongoingclinicalstaffeducationthatincorporatesallaspectsofthedonationprocess. Wealsoorganizeinspirationaleventswherethehealth-careteamhastheopportunitytohearstoriesfrom donorfamiliesandtransplantrecipientswhoselivestheyhavedirectlyorindirectlytouched.Ourclinical staffisfurtherinvolvedbyspearheadingcommunityoutreacheffortstodispeldifferentorgandonation mythsandencouragedonordesignation.Thus,ourprovidersareabletocontributewellbeyondtheir primaryclinicaldutiesandresponsibilities,andtoimprovetheunderstandingoforgandonationamong variouslocalaudiences.

Intheclinicalsetting,ourstrengthsincludefocusedpatientandfamilycare,consistentfamily communicationwithproactivesupportsystems,andadherencetoguideline-driven,standardized resuscitativeanddonormanagementstrategies.Well-attendedandengageddonationcouncilmeetings, physicianleadershipforumsandafteractionreviews,supportedbyGoLDonorProgramstaff,allowour health-careteamtohavefrankconversationsthathighlighttheimportanceofmaintainingoptimal practicesandfosteringthecultureofcontinuousprocessimprovement.

Conflictsofinterest

Therearenoconflictsofinterest.

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Figures and Tables

Figure1

TheUnitedStatestransplantwaitinglistcandidatesbyorgantype,basedonOrganProcurement,andTransplantationNetwork(OPTN)dataasofMarch29,2017

Table1

Nationalandlocalorganprocurementstatisticsbycauseofdeathforyears2011-2016

Table2

Organprocurementstatisticsreflectingdonationoutcomesofourlocalorganprocurement organization,GiftofLifeDonorProgram,andSt.Luke'sUniversityHealthNetwork-Bethlehem

Figure2

Schematicrepresentationoftheorganprocurementandtransplantationprocess.OPO:Organprocurementorganization

Figure3

Laminateddonationprocessinformationcardprovidedtoallhealth-careproviderswhohavethepotentialtointeractwithpotentialorgandonorsduringtheirdailywork.ShownarereferraltriggersforidentifyingandreferringpotentialorgandonorstoourOrganProcurementOrganization

Figure4

Familycommunicationprotocolincorporatedasapartofourglobalinstitutionalapproachtosupportfamiliesofpotentialorgandonors

Figure5

Standardizedprotocolforfacilitatingorgandonationbasedonthetwoprocurementapproaches–donationafterbraindeathanddonationaftercardiacdeath

Figure6

Braindeathdeterminationguidelinesincludedinourinstitution'sorgandonationprocessinformationcard

Figure7

Organdonormanagementgoals.Onceapotentialorgandonorisidentified,allclinicalpersonnelinvolvedindirectbedsidecareworkwiththeorganprocurementorganizationcoordinatortofollowtheseguidelines

Figure8

Organdonormanagementstandingorders.Thislistofstandingordersmirrortheordersetavailableinourelectronicmedicalrecord

“This course was developed and edited from the open access article: Keys to successful organ procurement:

An experience-based review of clinical practices at a high-performing health-care organization - Int J Crit Illn Inj Sci.

2017 Apr-Jun; 7(2): 91–100. (doi: 10.4103/IJCIIS.IJCIIS_30_17: 10.4103/IJCIIS.IJCIIS_30_17), used under the Creative

Commons Attribution License.”