DCD Heart Feasibility Study
The organ gap in NYS and the nation continues to grow, as does the number of donation after circulatory death (DCD) donors. However, hearts procured from DCD donors are not used due to the ischemic injury the heart sustains during reperfusion. On the one hand, CMS has encouraged the organ donation community to pursue all DCD opportunities yet the performance measures for transplant centers make the use of innovative transplant techniques difficult to implement.
Over the past several years, the use of DCD hearts in Australia and the UK and the overall good outcomes being reported, has caught the interest of the US heart transplant community and is a way to increase the number of available hearts for transplant in NYS. NYCTC conducted a feasibility study to review best practices from international heart transplant centers where they have successfully used DCD donor hearts in transplantation. A literature review was conducted and available data indicated a sufficient number of DCD donors to significantly increase the number of transplants.
A feasibility study was conducted and approved by the NYCTC Board of Directors in December 2017 and shared with DOH in early 2018. The membership pointed out the main obstacle to the pursuit of DCD transplantation is delays in federal approval for the preservation device, although approval was anticipated to occur in 2018 it is still currently pending.
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QAPI (Quality Assurance & Performance Improvement)
Currently, there is little non-clinical data available to transplant programs for use in tracking quality assurance and performance improvement (QAPI) metrics nationally, and a regional benchmark would allow programs to pool volumes and allow for more meaningful data in analysis. In 2017 the NYCTC developed a list of five performance measures to track, with all programs to share data, and summaries to be presented quarterly. The QAPI Initiative project was approved by the NYCTC Board of Directors at the December 2017 meeting.
MASS staff collected retrospective data from the 5 pre-existing NYS heart transplant programs in early 2018. Data is collected quarterly from all seven heart transplant programs and presented in aggregate to the Heart Policy and Operations Committee on an ongoing basis. Review of this data helps centers provide the best possible care to the patients of New York:
Metric #1: Episodes of Mechanical Circulatory Support (MCS) within 48 hours of transplant
Metric #2: Rate of dialysis before index hospital discharge
Metric #3: Rate of stroke before index hospital discharge
Metric #4: Percentage of in-patient evaluations vs. outpatient
Metric #5: Time from patient referral to first appointment
OPO Education Days
Without the tireless efforts of the staff at the organ procurement organizations, patients would not receive the life-saving transplants they need. As such the NYCTC joined with the New York State (NYS) transplant programs to host events thanking them for their hard work and dedication. Each program has hosted half-day events to recognize OPO staff and their contributions to the transplant process. The events included educational opportunities and a chance to make connections with transplant center staff with whom they had frequent contact.
Heart Allocation for Sensitized Patients
Transplant programs in NY are sharing their sensitized patient protocols in an unprecedented effort to ensure some of the sickest patients in NY receive heart transplants. The NYCTC Policy and Operations Committee (POC) looked at issues relating to out-of-sequence heart allocation for sensitized patients. The Committee reviewed UNOS policy (18.104.22.168) which revealed a provision allowing the creation a region-wide policy to help formalize the process. NYCTC worked with the New England Organ Bank (NEOB) to obtain a copy of the New England Center for Heart Transplantation’s (NECHT) policy. In discussing the possibility of adapting the protocol for use in Region 9, the members shared their desensitization protocols as well as data from their centers on the number of cases, and determined that a region-wide policy was not warranted at this time.
Retrospective Data Review
This study was performed to determine if organ selection practices for heart utilization by Region 9 transplant programs were optimal, and to identify opportunities to increase local organ recovery. A retrospective review of de-identified region-wide donor data 1/1/10-12/31/13 was performed. Over the study period 537 heart donors were identified, of which 321 (60%) were transplanted. 216 consented hearts were not used; 190 of these were not recovered, and 26 were recovered but not transplanted. 245/321 (76%) hearts were transplanted at one of 5 regional programs, 15 (5%) were transplanted out of region as primary offers, and 61 (19%) were turned down in region and exported. Of the 61 exported hearts, 43 were turned down in region for donor-related “quality” codes (UNOS 830, 833-37) by at least 1 program, the remaining 18 hearts were turned down for non-“quality” reasons, primarily histocompatibility and size. Only 5/43 exported were turned down for “quality” reasons by all regional programs offered the organ. A review of consented, not recovered donor offers suggested an additional 28 organs were possibly appropriate for transplant. Our review of regional turn-downs suggests transplant centers could potentially identify additional usable organs without compromising short term outcomes.
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Quarterly Data Review
Members and OPOs share data on a quarterly basis. Data collected from the centers is listed by those patients on ventricular assist devices (VADs) and those not on VADs. Data which includes the number of deaths on the waiting list, and the numbers of adult and pediatric heart transplants performed (heart-only and heart-multi-organ) is further broken down to show status on the waiting list. Additional data points report imported organs vs. locally recovered, as well as re-transplants. The 4 NYS OPOs provide data that includes detailed information on the allocation of the local organs consented, noting turndowns, discards and organs used for research. Data collected will serve to enhance the quality of heart and lung transplant services in NYS.
Cardiologist Call Schedule
At the request of the OPOs, each heart program submitted personal cell phone and other relevant contact information to be included in a call rotation of cardiologists whom the OPOs can reach out to, prior to organ placement, for real time consults in donor cases, particularly to help with requesting tests and/or procedures when working with donor hospital intensivists. Every month, the NYCTC distributes the call schedule to the NYS OPOs.