Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Over-Utilization of Current Neuro Status Leads to Missed Donation Potential
Nicole
Mullins
, RN, BSN
, RN, BSN
, Mid America Transplant
The Challenge
In July 2024, Mid-America Transplant (MT) transitioned to a new Administrator on Call (AOC) model, onboarding three experienced professionals from another OPO. Previously, this role was covered by three internal leaders with a combined 23 years of experience. In the latter half of 2024, MT observed a decline in donation rates, driven by a reduced approach rate. Data revealed a sharp increase in Medical Rule Outs (MRO) due to “Not expected to expire”—a judgment that a patient would not die within 120 minutes post-extubation, disqualifying them from DCD recovery. However, 25% of these patients did expire within that timeframe, indicating missed donation opportunities.
DCD eligibility assessments vary, particularly in evaluating neurological and respiratory status. These complex decisions rely on detailed clinical information from hospital partners. The data prompted a reevaluation of training and processes in order to standardize DCD screening.
The Approach
We first interviewed the new AOCs to understand their approach to DCD evaluations. We discovered gaps in their understanding of ventilator parameters and MT’s historical emphasis on organ viability over neuro status—except in clear-cut cases. Additionally, there was limited recognition of the inherent difficulty in predicting death. This highlighted the need for standardized, collaborative decision-making.
In January, we conducted targeted training, including ventilator management led by our Chief Medical Officer and case reviews. We then launched a Lean project to implement two key accountability processes:
Dual AOC Screening: Any MRO due to “Not expected to expire” must be reviewed with a backup AOC (one of the original internal AOCs).
Daily Second Review: A daily report flags all prior-day MROs for review by a different AOC. Disagreements are escalated to monthly AOC meetings.
The Results
The interventions were well received. MROs due to “Not expected to expire” dropped from an average of 32 per month (Oct 2024–Jan 2025) to 5 per month (Feb–May 2025)—an 80%
reduction.
In the pre-implementation period, 22% of patients ruled out for this reason died within 120 minutes; post-implementation, this dropped to 14%. This change enabled approximately 25 additional organ approaches (about 6 per month).
This correlated with increases in:
Approaches: 232 → 285 (+23%)
Authorizations: 158 → 187 (+18%)
Organ Donors: 95 → 115 (+21%)
Organs Transplanted: 240 → 289 (+20%)
Insights & Lessons Learned
While other factors may have contributed to the 20% increase in organ donors and transplants, the evidence strongly suggests that changes to the DCD eligibility review process were a major driver. The initial decline in donation potential highlights the challenges of effectively transferring institutional knowledge. Moving forward, a more robust and standardized training and review process for new AOCs will be essential to maximizing donation opportunities and saving more lives.