Process Improvement in Thoracic Donor Organ Procurement: Implementation of a Donor Assessment Checklist

Quality improvement tools to manage deceased organ donation processes: a scoping review

OBJECTIVE

To collate and summarise the literature on the quality improvement tools that have been developed for deceased organ donation processes after circulatory determination of death and neurological determination of death.

DESIGN

Scoping review using the Joanna Briggs Institute framework.

DATA SOURCES

We searched for published (MEDLINE, Embase, PsycINFO, CINAHL, Web of Science) and unpublished literature (organ donation organisation websites worldwide). The search was initially conducted on 17 July 2021 and updated on 1 June 2022. Included articles discussed the creation and/or use of quality improvement tools to manage deceased organ donation processes. Two independent reviewers screened the references, extracted and analysed the data.

RESULTS

40 references were included in this review, and most records were written in English (n=38), originated in Canada (n=21), published between 2016 and 2022 (n=22), and were specific for donation after neurological determination of death (n=20). The tools identified included checklists, algorithms, flow charts, charts, pathways, decision tree maps and mobile apps. These tools were applied in the following phases of the organ donation process: (1) potential donor identification, (2) donor referral, (3) donor assessment and risk, (4) donor management, (5) withdrawal of life-sustaining measures, (6) death determination, (7) organ retrieval and (8) overall organ donation process.

CONCLUSIONS

We conducted a thorough investigation of the available quality improvement tools for deceased organ donation processes. The existing evidence lacks details in the report of methods used for development, testing and impact of these tools, and we could not locate tools specific for some phases of the organ donation process. Lastly, by mapping existing tools, we aim to facilitate both clinician choices among available tools, as well as research work building on existing knowledge.

[Education of Abdominal Organ Procurement Surgeons in Germany - Challenges and Possible Solutions]

The procurement of abdominal organs is a highly specialised operation, which marks the first important step for a successful transplantation. The article gives an overview of the organisation and the current state of the education of procurement surgeons in Germany. We comment on current challenges and discuss these in an international context.

Review of donor and recipient surgical procedures in lung transplantation

Lung transplant remains the only durable treatment of end stage lung disease. Efficient surgical technique and preservation strategy are of critical importance in avoiding ischemia reperfusion injury and primary graft dysfunction (PGD), both associated with poorer outcomes. We present our surgical and preservation strategy for both donor and recipient procedures, including endobronchial and intracorporeal lung assessment, mediastinal dissection, lung preservation, donor pneumonectomy, back bench preparation, recipient approach, pneumonectomy, along with the bronchial, pulmonary artery, and pulmonary venous anastomoses.

Cardioprotective effect of remote ischemic preconditioning with postconditioning on donor hearts in patients undergoing heart transplantation: a single-center, double-blind, randomized controlled trial

Background

The cardioprotective effect of remote ischemic preconditioning (RIPC) in cardiovascular surgery is controversial. This study investigated whether RIPC combined with remote ischemic postconditioning (RIPostC) reduces myocardial injury to donor hearts in patients undergoing heart transplantation.

Methods

One hundred and twenty patients scheduled for orthotopic heart transplantation were enrolled and randomly assigned to an RIPC+RIPostC group (n = 60) or a control (n = 60) group. In the RIPC+RIPostC group, after anesthesia induction, four cycles of 5-min of ischemia and 5-min of reperfusion were applied to the right upper limb by a cuff inflated to 200 mmHg (RIPC) and 20 min after aortic declamping (RIPostC). Serum cardiac troponin I (cTnI) levels were determined preoperatively and at 3, 6, 12, and 24 h after aortic declamping. Postoperative clinical outcomes were recorded. The primary endpoint was a comparison of serum cTnI levels at 6 h after aortic declamping.

Results

Compared with the preoperative baseline, in both groups, serum cTnI levels peaked at 6 h after aortic declamping. Compared with the control group, RIPC+RIPostC significantly reduced serum cTnI levels at 6 h after aortic declamping (38.87 ± 31.81 vs 69.30 ± 34.13 ng/ml, P = 0.02). There were no significant differences in in-hospital morbidity and mortality between the two groups.

Conclusion

In patients undergoing orthotopic heart transplantation, RIPC combined with RIPostC reduced myocardial injury at 6 h after aortic declamping, while we found no evidence of this function provided by RIPC+RIPostC could improve clinical outcomes.

Trial registration

Trial Registration Number: chictr.org.cn. no. ChiCTR-INR-16010234 (prospectively registered). The initial registration date was 9/1/2017.

Effect of Desmopressin on the Amount of Bleeding and Transfusion Requirements in Patients Undergoing Heart Transplant Surgery

One of the most common risks after a heart transplant is bleeding. In this study, the effect of desmopressin administration on the amount of bleeding and transfusion requirements after heart transplant surgery was investigated. In a double-blind clinical trial, 48 patients who were candidates for heart transplant surgery were randomly assigned to two groups. In the intervention group, patients received desmopressin of 0.3 μg/kg, 30 min. before surgery. Patients in the control group received normal saline at the same amount and time. Homeostasis was evaluated using activated clotting time (ACT), PT, PTT and PLT before, 12 and 24 hr after surgery, and also, chest tube drainage, blood products transfusion requirements during the first day in both groups. No significant differences were found between the groups in terms of ACT, PT, PTT and PLT at all times. Transfusion of packed red blood cells and the mean drainages of chest tube during the first 24 hr after surgery were significantly lower in the desmopressin group compared to the saline group. Desmopressin may reduce post-operative bleeding in patients undergoing heart transplant surgery. Further studies are required to confirm the potential effect of desmopressin on establishing haemostasis after heart transplantation.

Surgical data science: The new knowledge domain

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care, with the goal of maximizing the quality and value of care. Whereas innovations in diagnostic and therapeutic technologies have driven past improvements in the quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytical techniques, and translation or integration of research findings into patient care. We foresee the emergence of surgical/interventional data science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model, and quantify the pathways or processes within the context of patient health states or outcomes and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data are pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care, including prevention, diagnosis, intervention, or postoperative recovery. The existing literature already provides preliminary results, suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from preoperative, intraoperative, and postoperative contexts, how it could support intraoperative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.