Achieving a 75% Conversion Rate at a Non-Transplant Hospital Maureen Bishop, RN, MA, MSN, CCRN, CCNS Clinical Nurse Specialist – CCU/ICU/PCU Hospital Liaison to Gift of Life Sally Pitt-VanBuren, BS, MS Gift of Life Hospital Development Associate

Lakeland HealthCare’s Demographics Two acute care hospitals serving Southwest Lower Michigan –Niles beds: 89 licensed beds 8 bed licensed intensive care beds 24 hour emergency services –St. Joseph beds 254 licensed beds 22 licensed critical care beds (24 hour Intensivist coverage) 24 hour emergency services

Support At All Levels Board of Directors given reports of donation activity on a regular basis, which is a requirement of CMS Senior Leadership involvement: –President puts information in associate newsletter –Vice President of Patient Services/Chief Nursing Officer sits on Corporate Organ Donation Advisory Committee Physician Support Associate Support

Lakeland’s Corporate Organ Donation Advisory Committee Multi-disciplinary group –Members include: Nursing Chaplain Senior leadership Gift of Life representatives Community representative/s –Reviews policies, procedures, associate education, stats on compliance to rules/regulations, etc.

Associate Education RNs required to do a yearly CBL on donation Physician education is done via weekly CME as well one to one education –Peer Physician Education Presentation: 11/2007 –Peer Physician Education Presentation: 10/2009 Organ, tissue, eye donation protocols reviewed in New Nursing Orientation Yearly promotion of donation awareness in April One on one education when protocols not followed

Other Educational Opportunities After action review – completed after both DCDs Departmental education done by Gift of Life: –Emergency departments –Critical/Intensive Care departments –Respiratory Therapy departments –Pastoral Care Hospital liaison educates when inappropriate approaches have been identified Real time education by Gift of Life when on-site

Hospital Liaison Role Daily rounds on patients to determine any referrals Participates in monthly death record review with Gift of Life Works with Gift of Life when at hospital for referrals Support Gift of Life in getting services completed on consented patients Liaison has been in role for over 12 years Has had first hand experience working with patients who were both donors & patients waiting for transplant

2008 Performance Overview at St. Joseph Site Performance CriteriaValueGoal Conversion Rate100%> 75% Referral Rate100% Rate of Appropriate Requests100% Timely Notification Rate92%100% Organ Donors4 Tissue Donors8

2008 Performance Overview for Niles Site Performance CriteriaValueGoal Conversion RateNA> 75% Referral Rate100% Rate of Appropriate RequestsNA100% Timely Notification Rate82%100% Organ Donors0 Tissue Donors7

2009 First Quarter Performance Overview at St. Joseph Site Performance CriteriaValueGoal Conversion Rate100%>75% Referral Rate100% Rate of Appropriate Requests100% Timely Notification Rate94%100% Organ Donors1 Tissue Donors4

2009 First Quarter Performance Overview for Niles Site Performance CriteriaValueGoal Conversion RateN/A>75% Referral Rate100% Rate of Appropriate RequestsN/A100% Timely Notification Rate100% Organ Donors0 Tissue Donors1

Challenges for Lakeland Not being a transplant facility gives us some special challenges: –Keeping the “imminent death” criteria in everyone’s minds when we have a lapse in time for patients. –Getting the ED to remember they need to make the calls and not wait for the patient to be seen by an Intensivist. –Calls must be made as early as possible since it takes up to 3 hours for a Gift of Life representative to get to our facilities.

Questions Thank You!