The Logistics of Saving Lives as a Mass Exporter Two OPOs and Their Experience with the Timing of Donor Cases

Who Are We? Amanda “Mandi” Richard, RN, MSN, CCRN, CPTC Clinical Manager, New Mexico Donor Services Lisa Magaro, RN, BSN, CPTC Organ Team Lead and Procurement Transplant Coordinator, Nevada Donor Network Heather Osipowicz, BS, MSBS, CTBS Hospital Services Educator, Nevada Donor Network

Knowing More About Our OPOs Nevada Donor Network Demographics Population – 2,198,000 DSA – 13 of 16 Counties in Nevada 12th largest by land, 52nd largest by population Transplant Center 1 kidney center, located in Las Vegas Recovery Surgeon Local transplant surgeon is also the only local recovery surgeon currently

Knowing More About Our OPOs Nevada Donor Network

Knowing More About Our OPOs Nevada Donor Network Nearly 2 million of our 2.198 million population reside in one county Led the country in 2016 in transplants (164 TPMP) and donors per million population (49 DPMP) *Per OPTN and US Census Data All A-C level hospitals within 30 miles of each other Transplant Center is also the Nevada’s only Level One Trauma Center, and produces our highest yield of organ donors Transient Community Las Vegas visitors Temporary community presence

Authorization to Recovery Timeframes Nevada Donor Network

Knowing More About Our OPOs New Mexico Donor Services Demographics Population – 2,085,000 DSA – State of New Mexico 5th largest by land, 54th largest by population Minority-Majority DSA Transplant Centers 2 Kidney Centers in Albuquerque 1 Kidney Center just approved for pancreas Recovery Surgeons: 1 kidney [and now pancreas] surgeon who is also a local transplant surgeon Mandi to discuss geographical area logistics

Knowing More About Our OPOs New Mexico Donor Services

Knowing More About Our OPOs New Mexico Donor Services

Knowing More About Our OPOs New Mexico Donor Services 2012-2014 period of time with no recovery surgeon August 2014 Dr. Hanna Choate came to our team!

Donor Management to Recovery Timeframes New Mexico Donor Services

Shared Allocation and Logistical Challenges of Region 5 Mass Exporters No local liver or thoracic programs Limited flight options Accepting centers have ability to accept multiple organ offers for same recipient Late decline by transplant centers OR timing delays due to backup center needs when primary Identifying recovery team if local recovery surgeon is unavailable Serology testing Difficulty offering rapid recovery or uncontrolled DCD to donor families

Case Studies

Case Study #1 New Mexico Donor Services 7 year old who collapsed at home related to a recent asthma exacerbation. Received CPR with 3 rounds of medications, estimated downtime 26 minutes. PMH: asthma Timeline 11/2: Admitted to hospital 11/5 1200: Physician discussed donation with family 11/5 1630: Sent ID testing 11/6 2236: Declared Brain Dead

Case Study #1 New Mexico Donor Services Timeline Continued… Following Brain Death Determination: T4 Protocol Initiated 11/7 0800: Levophed and Epinephrine drips weaned off completely 11/7 1200: ECHO Completed 11/7 1600: Heart, Liver, and Kidneys placed Time to set the OR!

Case Study #1 New Mexico Donor Services Time to set the OR… 2 teams coming Liver team requests ASAP OR Recipient in ICU, very ill, and “is going to die tonight if she doesn’t get transplanted”. Heart team requests no sooner than 0800 the next morning ICU patient, very unstable, may need ECMO overnight. Surgeon cannot fly out as he would be the one to place the patient on ECMO Could not agree on the OR time

Case Study #1 New Mexico Donor Services Where do we go from here? Think outside the box! OPO directly connected the heart and liver surgeons Liver center identified a heart surgeon at their hospital that would come and recover Heart center discussed, and agreed Liver center hospital’s heart surgeon recovered the heart Heart center sent perfusion staff and charter plane to return with heart

Case Study #1 New Mexico Donor Services A Successful Outcome! A 1 year old little girl and a 12 year old little girl were both successfully transplanted!

Case Study #2 New Mexico Donor Services 57 year old female found down at home. Bystander CPR initiated, and patient was asystolic when EMS arrived. Estimated downtime 45 minutes. PMH: COPD, asthma, chronic pain, HTN, depression, insomnia Timeline Heart, Liver, and Kidney allocation started simultaneously Exhausted Heart List to Zone C Liver and Kidneys placed

Case Study #2 New Mexico Donor Services Time to set the OR… At 1400, OR set for 0200 Liver was backed up Center was verified to be interested as a backup At 2000, OPO Coordinator was notified primary team was coding out for a “closer offer” Backup center also coded out – due to “closer offer” 0200 OR was cancelled, and Coordinator was back to liver allocation At 0500, new OR set for 0900

Case Study #2 New Mexico Donor Services Case Outcome Timeframe of case totaled 70 hours Liver successfully transplanted Allocated as SLK Kidney placed in local back up due to recipient stability Right kidney placed with a high CPRA recipient Declined one hour post-recovery, due to flight schedules 3 other mandatory shares with provisional code out Ultimately placed at local transplant center

Case Study #3 Nevada Donor Network 28 year old male, who had been complaining of a headache and went to bed early. Wife found him snoring loudly, and later he was in cardiac arrest, with unknown total downtime. Cardiac arrest was secondary to suspected drug overdose. PMH: HTN and previous suicide attempt with drug overdose (2 months prior) Toxicology: Positive for opiates and THC Timeline 10/22 1700: Initial Referral called, patient is areflexic 10/22 1800: Family wanting to WDLS, Family Services and Transplant Coordinator onsite.

Case Study #3 Nevada Donor Network Timeline Continued… 10/22 1840: Neurology examined patient, and first exam consistent with brain death (this hospital requires 2 exams to pronounce). 10/22 2200: Authorization and DRAI obtained. Family places time constraints on case, want case completed no later than 10/25, but prefer by evening of 10/24. 10/22 2330: Serologies drawn and sent, ETA for results 11:15 next day. 10/23 1440: Brain death declaration completed with second exam and CBF. 10/24 0630: Echo completed and results pending; allocation not yet started. 10/24 1020: Family onsite; allowing more time for case to be allocated and completed. 10/24 2145: Heart, Liver, Kidneys, and Pancreas placed. Lung allocation continues.

Case Study #3 Nevada Donor Network Time to Set the OR… 10/24 2240: OR scheduled for 10/25 0300 10/24 2320: Accepting liver center calls to say their liver team and surgeon are delayed on another case… for the same recipient! Currently getting biopsy, and if good, accepting that liver, and declining ours. Urgent calls made to backup liver centers. One center unable to accept due to timing of OR and could not get a team mobilized in time. 10/25 0005: Liver accepted by regional center, and okay with local recovery. OR proceeded as scheduled.

Case Study #3 Nevada Donor Network Final Outcome Donor Family allowed us additional time outside of the original time constraints. Backup Liver Center that ultimately accepted the liver was okay with local surgeon recovering, so OR time was not rescheduled. 4 lives were saved! Heart transplanted into a 64 year old male Liver transplanted into a 53 year old male Right kidney transplanted into a 48 year old male Left kidney transplanted into a 46 year old female

Table Discussion Questions How can we, as OPOs and transplant centers, work collaboratively to decrease timeframes from the start of a case to organ recovery? During cases in which a donor family has placed time constraints, what policies or procedures do you have in place to be able to maximize the donation potential?

Thank you!