The recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), outlined several recommendations for OPOs and Transplant Centers to consider to eliminate variations in performance measures and reduce the nonuse of donated organs. Establishment of one or more Donor Care Units (“DCU”) within each OPO service area is one of those recommendations that could have a significant impact on caring for donor families, honoring the gift of donation and saving more lives. A hospital-based DCU is a partnership between the OPO and one of its hospital partners where the hospital acts as the receiving facility for consented organ donors and provides dedicated ICU and OR space and staff. A well-established DCU aids OPOs in improving organ viability and increasing the yielded number of organs recovered per donor. It offers a dedicated team focused on facilitating those goals while simultaneously providing care for the donor and the donor’s family. The current model where donation cases are managed at dozens of individual hospitals on an infrequent basis consists of superimposing donor management and organ recovery needs on top of a busy ICU and OR service’s clinical routine. This results in the OPO team depending on interventions and procedures performed by the ICU teams which commonly have a relatively unpredictable time of completion, inconsistent family visitation, and reduced certainty for the scheduling process when facilitating the donor’s operating room time.
Donor Management Protocols & Recipient Benefits
The efficiencies created with expertise in a DCU will reduce overall time from donor admission to recovery and reduce potential organ decline with prolonged donor management. There are opportunities to facilitate quality improvement and clinical care protocols which can be organized to specifically improve outcomes and organs procured. These protocols are not simply limited to the types of medication infusions or diagnostic tests that are required, but can additionally include therapeutic interventions and prophylactic interventions to enhance organ function. For example, early implementation
of prone positioning or more aggressive anticoagulation can improve the potential for donor lungs to be accepted and reduce the likelihood of venous thromboembolism, respectively.
Optimizing organ donation through a DCU benefits transplant recipients in a number of ways. Consistent and standardized donor care with experienced staff improves overall donor management and the quality and yield of organs recovered. With improved quality and yield of organs recovered, more candidates are able to benefit from transplantation with improved post-transplant outcomes. In addition, having a DCU centralized within a hospital with a transplant center allows for a reduction in transport time of the recovered organs to the recipient operating room thereby reducing ischemic time impacts on organ quality.
Donor Family Benefit
Providing support and care for donor families during the recovery process can be challenging in existing hospital ICU models. The focus on family support and honoring donors is another key benefit of having an established DCU where there’s a dedicated team of trained social workers, palliative care professionals, and pastoral care support who can effectively care for families during this critical period of mourning.
Financial Benefit (Cost-Savings):
Organs recovered at transplant hospitals can be counted as Medicare organs on the hospital’s Medicare Cost Report, thus increasing the Medicare transplant ratios and reimbursement from CMS. The financial benefit to a hospital hosting a DCU will vary depending on how many and which types of organs are transplanted at the hospital, the mix of Medicare patients receiving these organs and the hospital’s cost of operation. In general, increased reimbursement from CMS will range between $20,000 and $40,000 per organ recovered resulting in funding available to offset the vast majority of costs associated with the DCU. In addition, the OPO can provide resources to ensure the impact on the hospital from a financial perspective is positive.
Impact on Hospital Resources
Integrated Hospital ICU & DCU
In-Hospital Stand Alone Unit
|Integrating the donor transfer volume into existing operations, or identified beds within an existing ICU, allows the resources to flex with accompanying volume. As long as a hospital has room for increased capacity, the donor transfer volume is absorbed into resource allocation of inpatient bed allocation. Evaluation diagnostics are treated as “urgent/stat” to accommodate timing constraints and shorten the length of stay of the donor, which is absorbed in standard resource allocation for urgent/staff diagnostics. As an added benefit, when located within transplant hospitals, these services are typically available at all hours to accommodate donor cases.||Given that the physician and nursing teams are specifically available for donor care 24 hours a day/7 days a week, there is no delay in facilitating donation-specific care. While hospital resource utilization is not reduced overall, the centralized location and staffing of the unit allows for improved timing for Diagnostic Imaging and Interventional Cardiology assessments. This is in large part due to the fact that DCU staff are able to tightly coordinate procedures across all the services and have a dedicated physician team who can facilitate consultation service escalation when necessary.|
OR Scheduling and Cath lab scheduling may be a significant resource impact for hospitals due to the need for on-call/after-hours staff utilization. To reduce the impact on scheduled OR volume/cases, hospitals may want to consider designating a separate OR room and staffing with a call team to prevent displacing routine OR volume. The DCU model is flexible and can be tailored for best results. If the DCU will handle significant volumes, dedicated facilities and staff may be optimal. Utilization of existing facilities may be best for lower volumes or at the start of the program.
In designing and implementing a DCU, the most important thing to keep in mind is to focus on the donor and the donor family. This improved experience not only helps facilitate donation in a way that maximizes the gift but also helps provide support to the family throughout the grieving process in a way that truly helps us serve our communities.