Organ Donation Update: Success Brings New Challenges

In the world of organ transplants, timing is everything. So when members of an Arkansas heart transplant team recently faced an unexpected delay due to a rather important individual, they took decisive action to overcome it.
 
The team was retrieving a donor heart from a Des Moines, Iowa, hospital. But they weren’t the only important visitors in the area on that October 2006 day. “President Bush had been visiting Des Moines,” recalls Paul Sodders, MHA, Public Affairs Manager of the Iowa Donor Network. “And just as the heart team was getting ready to leave the hospital with the donor heart to fly back to Arkansas, we learned that there would be no flights leaving the Des Moines airport until after President Bush left on Air Force One.”
 
With no time to waste, a transplant coordinator made a bold move. “He called the airport and asked to speak with the Secret Service,” says Sodders. “He explained that the heart team really needed to leave on schedule. He asked them to do anything in their power to help.”
 
The Secret Service rose to the challenge. They told the heart team to head for the airport immediately, and relayed a message to the Presidential motorcade, already on its way, to slow down. “The heart team beat the motorcade to the airport, and with the quick action of their pilot, who was also coordinating with the Secret Service, they were airborne just before the President arrived,” says Sodders.
 
A Shifting Challenge
This story is just one example of the focused determination that characterizes the nation’s transplant community, says Dennis Wagner, MPA, director of the Organ Donation Breakthrough Collaborative at the Health Resources and Services Administration (HRSA) Division of Transplantation, part of the US Department of Health and Human Services in Rockville, Maryland. Wagner recently reflected on this and other highlights of his three and a half years leading the Collaborative, as he accepted a new post as Deputy Director of HRSA’s Center for Quality. Virginia McBride, RN, MPH, who has served as a public health analyst in the Division of Transplantation since 1999 and has worked closely with Wagner, has assumed the Collaborative’s leadership role.
 
Wagner says dogged pursuit of the ultimate goal — to use every available organ — will be important as the transplant community begins to shift its focus from an age-old problem — not enough organs — to an emerging one — not enough capacity to use the greater number of organs that are now available.
 
This new challenge is a direct result of the success Wagner and his team have had at increasing organ donations, which rose by an unprecedented 10.8 percent in 2004, an additional 8.3 percent in 2005, and yet another 5.6 percent in 2006. “We were excited to learn that December 2006 was another record month for organ donation in the US,” says Wagner. “We closed the year with 8,015 deceased organ donors, up from 6,190 in 2002. That is a key bottom line and shows just how far we’ve come.”

 

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How far, that is, since Wagner and his colleagues launched the first Organ Donation Collaborative in 2003. Modeled after the Institute for Healthcare Improvement’s Breakthrough Series Collaborative, the Organ Donation Collaborative was designed to identify and spread best practices in order to increase the number of transplantable organs available to the 94,000 patients on the national candidate list.

 

Now in its fourth cycle, the Collaborative has not only succeeded in increasing the number of donors, but has also helped to improve the donor conversion rate, which is the percentage of eligible donors who actually donate. In October 2006, HRSA honored 371 hospitals (from an eligible pool of 787) for achieving and sustaining for at least a year conversion rates of 75 percent or more among eligible donors — up from 185 such hospitals in 2005.

 

Now the Collaborative has broadened its aims to include increasing the number of organs transplanted per donor from the current three to 3.75, out of the maximum potential of eight. However, getting more organ donations is only part of the story and the challenge. 

 

“We noticed that as the number of donors increased, the number of organs that were used from each donor dipped,” says Ginny McBride. Although that dip has now begun to reverse itself, McBride and Wagner believe it revealed an important problem.

 

“We believe that the growing number of available organs began to stress the system, because the organ procurement organizations (OPOs) didn’t have the capacity to process a higher volume of organs over a long time and the transplant programs may not have had the capacity to receive them,” says Wagner. OPOs are liaison organizations designated by the US federal government to coordinate every aspect of the organ donation process for a given region of the country.

 

The reasons for the bottleneck are purely practical. “If you have two surgeons doing 75 kidney transplants a year, and you need them to accommodate 250, that program has to grow in terms of staffing, nursing, space, etc.,” says Wagner. When there is not adequate capacity, says Wagner, hospitals may not be ready to accept as many organs as they would like.

 

McBride says just in case there’s any doubt about this growing reality, Collaborative teams have studied how often transplant centers have to turn down donated organs. The data clearly suggest the need for a new paradigm. 

 

“This community of practice has to adjust to a new reality,” say Wagner. “The old reality was that the benefit of transplants is limited by the availability of donor organs. The new reality is that the problem isn’t necessarily a shortage of organs; it’s putting more of the organs we already have available to us to good use.”  

 

Reducing Variation in Practice

The wide variation in organ utilization among the nation’s transplant centers convinces Wagner and McBride that dramatic improvement is possible. “If we look at who’s best in the nation at making large percentages of hearts, livers, and kidneys available for transplant and ask what if all centers performed at that level, we’d have 10,000 additional transplants every year,” says Wagner.

 

Efforts are already underway to study best practices and learn how to safely increase the number of organs transplanted at each program, says McBride. “In Minnesota and San Francisco, for example, the transplant centers and the OPOs are running kidney mini-Collaboratives, and they will share what they’re learning at the next Learning Session of our national Collaborative in April.”

 

As he moves into a new role at HRSA, Dennis Wagner says he leaves the organ program in McBride’s steady hands. “Ginny has been integral to our success from the beginning,” he says. And that success can transfer to other areas of improvement.  

 

“My hope is that the learning we’ve experienced with organ donation can be applied to other spheres,” says Wagner, “particularly what we’ve learned about scope and scale. We work at a very large scale, but we’ve shown that there is tremendous opportunity to take the Collaborative methodology, the Model for Improvement, bold aims, the use of effective questions, transparent data and reporting, and implement them successfully on a bold national level.”

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