Transplant Staffing Model at a Large Volume Lung Transplant Center Kate Grief, RN, MSN, CCTC Lung Transplant Program Manager August 21, 2019

St. Joseph’s Hospital and Medical Center Founded in 1895 by the Sisters of Mercy 600 beds Level I Trauma Center Not-for-profit $188.7 million in community benefit during FY19 Partnership with Creighton University School of Medicine Partnership with Phoenix Children’s Hospital Neuro, Thoracic, Transplant, Living Donors, Mother & Baby, Congenital Heart, VAD Norton Thoracic Institute

St. Joseph’s Hospital and Medical Center Transplant Program Volume Since Inception Center of Excellence CMS Approved Transplant Program Lung* 788 Yes Kidney 71 Liver 62 VAD 11 JCHAO *Top 5 Nationally since 2016

Norton Thoracic Institute - Lung Transplant Program 738 patients total – as of April 4, 2019

Lung Transplant SRTR July 2019 Source: SRTR: Program Specific Report July 2019

Source: SRTR: Program Specific Report Jul 2019 Waiting Times Source: SRTR: Program Specific Report Jul 2019

Performance Analysis - Transplants *On track for 115+ transplants in 2019

Performance Analysis - Transplants

Dedicated Transplant Team 4 Financial Coordinators 7 Txp Surgeons 6 Txp Pulmonologists 10 RN Coordinators Dedicated Pt care units 2 Social Workers 2 Pharmacists 1 Dietitian 1 Psychiatrist

Lung Transplant Program Protocols Follow patients life long Clinic visits 2 x per week for 2 weeks Then 1x per week for 2 weeks Then 1x every other week Then monthly for the whole first year Then every 3-6 months for lifetime More frequent visits as clinical condition warrants --5 year survival ~55% --over 3000 clinic visits in last FY

Current Structure for Donor Offers/Transplant Events Transplant Pulmonologist takes primary donor call Second pulmonologist as “back up” Fully evaluates every donor Communicates with OPO Determines provisional acceptance in collaboration with the transplant surgeon Counsels patient if PHS Increased Risk Participates in donor management May be managing multiple donors Hands off when we are primary or back up -Rotated between the pulmonologists 1 week at a time -Typically donor call while on service --very rarely, RN may cover donor call Not uncommon to be coordinating multiple transplants Records is 3 in <24

Current Structure for Donor Offers/Transplant Events Pulmonologist Hands off to On-call Transplant Coordinator Communicates Donor ID/Match ID RN takes over communication with OPO Negotiates OR time Coordinates transplant (procuring and implanting teams) May be coordinating multiple offers/implants Simultaneous and/or back to back transplants DCD OCS ECMO Other thoracic surgeon procuring --Rotated between 10 transplant coordinators --AOC on call at all times --Algorithymic approach in place

Transplant Admission RN calls patient with organ offer Makes NPO Ensures ready for transplant Notifies physician if any contraindications are identified Requests bed Negotiates time of admission Physician/mid-level on call enters transplant orders Takes phone calls re. recipient status while admitted

Transplant Event RN coordinates Procuring team Implanting team Anesthesia Perfusion Coordinates timing for less than 6 hour ischemia time Multiple algorithms DCD OCS Retransplant ECMO

Other Duties for RN on-call Delisting following transplant Notifying entire team transplant occurred Triaging out-patient phone calls May be assigned to clinic First call for out patient critical lab values Additional weekend duties Follow up on pending test results Bronchoscopy culture results RN sign outs Coordination of admission/discharges ---Goes through physician on call

Pro’s of Employed Team Additional opportunity to earn call-pay stipend Institutionally less expensive than 3rd party service Calling the patient for Transplant Event  Problem solving/Critical thinking Aware of institutional policies and protocols Aware of surgeon preferences Knowledgeable about recipients --evaluated services, but will not use for thoracic at this time due to cost, ischemia time of t-organs and “well oiled machine” --re-evaluating flat rate model for different call structures

Con’s of an Employed Team Transplant can occur 24/7/365 (and they do!) May not be able to relieve on call RN the next day Coordinating multiple donor offers Fatigue/Burnout/Turnover --turnover with cost to institution

Thank you