Organ Donation: A Collaborative Effort Mount Sinai Health System Region 9 Donation and Transplantation Collaborative March 20, 2018

The Mount Sinai Health System (MSHS) Combines the Icahn School of Medicine at Mount Sinai and 7 hospital campuses, Mount Sinai Brooklyn, Mount Sinai Downtown, Mount Sinai Hospital, Mount Sinai Saint Luke’s, Mount Sinai Queens, Mount Sinai West, New York Eye and Ear Infirmary of Mount Sinai Mount Sinai Transplant offers transplantation services, including heart, intestinal, liver, kidney, pancreas, corneas and bone marrow The Recanati/Miller Transplantation Institute Mount Sinai Heart 250 ICU beds (Adult, PICU and NICU) 481,000+ ED visits 145,000+ Inpatient admissions Internationally recognized leader in Palliative Care

MSHS Program Background University of Pittsburgh Medical Center reviewed 4 system hospitals: Mount Sinai Downtown, Mount Sinai Hospital, Mount Sinai Saint Luke’s and Mount Sinai West Deficiencies in donors due to undefined referral process; resulting in low conversion rates and few organs transplanted per donor Adopted recommendations: Implement a nurse referral process that is timely; without MD permission Establish a multidisciplinary Organ Donor Council at each hospital Standardize policies and procedures regarding donation across MSHS Promote donation as a system-wide initiative directly related to the Mount Sinai Transplant program Approached by LiveOnNY to partner on a 3-year CMS Demonstration Project: implement a dedicated team of in-house OPO coordinators (IHC) to serve 6 of MSHS acute care hospitals

Background: Historical Approach Process LiveOn Coordinator Approach Advance Care Planning Catastrophic Event / Grave Prognosis Breaking Bad News Family Decisions End of Life Process issues: Referrals not being made within 1 hour of clinical triggers being met Late in the process of decision making End of life decisions may have already been made Family may be unaware of patient wishes related to donation LiveOnNY Coordinator not part of previous discussions and/or decisions LiveOnNY Coordinator seen as “vulturistic” by care team and/or families

MSHS Organ Donation Program Goals Increase the number of organ donors and organs transplanted across MSHS Improve patient satisfaction, donors and families are offered compassionate end-of-life support Build partnership and trust between MSHS clinical teams and LiveOnNY Culture shift such that MSHS staff recognize and promote donation in eligible patients Move initial discussions of organ donation upstream as part of goals of care discussions

LiveOnNY Partnership Future State Organ donation Cadaveric/scientific donation Interviews/writing/life review / videography Legacy art projects Development (MSHS) / philanthropy (outside) Care Team Approach that includes IHC IHC integrated into the clinical team for “legacy building” Advance Care Planning Catastrophic Event / Grave Prognosis Breaking Bad News Family Decisions End of Life

MSHS Organ Donation Initiative Mount Sinai Health System Organ Donor Council Nurse Driven Protocol In-house Donor Coordinators CNO & CMO Site Led Donor Councils Policy & Practice Standardization Palliative Care Partnership Centralized Daily Operations & Oversite

MSHS Organ Donation Council Launched January 2018, meets bimonthly Multidisciplinary Team: Chaired by MSHS CMO Site CNOs Site CMOs Chaplaincy Legal LiveOnNY Senior Leadership MSHS Operational Lead Guiding Principles: Create positive experiences built on compassion to enable conversion of referrals to consenting donors and families Partner with LiveOnNY to build a robust organ donation program Foster a multidisciplinary approach in patient and family engagement Standardize policies and procedure related to organ donation across MSHS Integrate organ donation into life planning and legacy building for all patients Process Improvement Coordinator Palliative Care Regulatory Social Work Transplant Leadership

Implementation of Nurse-Driven Referral Protocol ? Nursing staff will call in all organ and tissue referrals to LiveOnNY Timely referral within 1 hour of clinical trigger or cardiac death Quick triage to In-house LON coordinators (Clinical Program Coordinators) for potential organ donation Documentation of all referral information in the EMR Ongoing monitoring to ensure all referrals are made and are timely

MSHS In-House LiveOnNY Coordinators (IHC) Launched February 7, 2018 Team of 5 rotate across the 6 different sites 24/7 availability to respond to all organ referral across MSHS Following cases from referral through to organ procurement Operational integration into care teams: Internal title Clinical Program Coordinator MSHS badges, lab coats and scrubs; co- branded business cards Dedicated workspace IT setup: internal email addresses, remote access to email and EMR EMR documentation: discussions, interventions, status of donor process Participate in ICU and Pal Care rounds and goals of care discussions Educating staff, patients, families, and visitors about organ donation Participation in Organ Councils and process improvement activities

Hospital Specific Organ Donation Councils Multidisciplinary Team: Chaired by site CNO and CMO Chaplaincy ED leadership ICU leadership In-house Coordinator LiveOnNY Leadership Operationally focused councils meet monthly or bimonthly Review site specific data Review recent cases: identification of best practices and improvement opportunities Discuss local operational issues/barriers related to donation Identify education and outreach opportunities MSHS Operational Lead Process Improvement Coordinator Palliative Care Regulatory Social Work

Policy and Practice Standardization Policies Anatomical Gift Donations Brain Death Death after Circulatory Death (DCD) Practice EMR documentation RN referrals In-house Coordinators Organ donor management DCD OR support and preparation DCD – MD pronouncement of death in the OR

Palliative Care Partnership Short term goal: seamless integration of IHC into care team Script development for family introductions for early engagement Rounding with Palliative Care Teams In-house Coordinator coaching/mentoring by Palliative Care MD leadership Evaluating palliative care best-practices to leverage for IHC program Developing tools and framework to integrate organ donation discussions upstream as part of Advance Care Planning Long term goal: transform the IHC into a legacy building team

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