Transplant Staffing Model - UNOS

Transplant Staffing Model at a Large Volume Lung Transplant Center Kate Grief, RN, MSN, CCTC Lung Transplant Program Manager August 21, 2019 St. Josephs Hospital and Medical Center St. Josephs Hospital and Medical Center Founded in 1895 by the Sisters of Mercy 600 beds Level I Trauma Center Not-for-profit $188.7 million in community benefit during FY19 Partnership with Creighton University School of Medicine Partnership with Phoenix Childrens Hospital Neuro, Thoracic, Transplant, Living Donors, Mother & Baby, Congenital Heart, VAD Norton Thoracic Institute

2 St. Josephs Hospital and Medical Center Transplant Program Volume Since Inception Center of Excellence CMS Approved Transplant Program Lung* 788 Yes Yes Kidney 71

Yes Yes Liver 62 Yes Yes VAD 11 JCHAO Yes *Top 5 Nationally since 2016 3 Norton Thoracic Institute - Lung Transplant Program

4 Lung Transplant SRTR July 2019 Median Time to Lung Transplant in Months (1/1/13 6/30/18) U.S. 3.1 Region DSA SJHMC 0.0 2.5 0.5 0.4 0.5 1.0 1.5 2.0

2.5 3.0 Source: SRTR: Program Specific Report July 2019 3.5 5 Waiting Times Median Time to Lung Transplant in Months (1/1/13 6/30/18) 3.5 3.0 3.1 2.5 2.5 2.0 1.5 1.0 0.5

0.4 0.0 SJHMC 0.5 DSA Region U.S. Source: SRTR: Program Specific Report Jul 2019 6 Performance Analysis - Transplants Lung Transplants By Calendar Year 120 114 104 100 93

89 80 80 70 73 56 60 42 40 20 0 32 11 07 20 10 08 20

15 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20

17 20 18 20 18 20 s (a o ) 19 / 0 /2 8 f0 *On track for 115+ transplants in 2019 7

Performance Analysis - Transplants Lung Transplants By Fiscal Year 120 114 105 100 94 100 90 80 69 60 53 58 37 40 25

20 0 14 08 FY 18 9 09 FY 10 FY 11 FY 12 FY 13 FY 14

FY 15 FY 16 FY 17 FY 18 FY ) 19 0 2 0/ 2 8/ f0 19 FY

20 FY s (a o 8 Dedicated Transplant Team 4 Financial Coordinators 7 Txp Surgeons 6 Txp Pulmonologists 1 Psychiatrist 10 RN Coordinators 1 Dietitian

Dedicated Pt care units 2 Pharmacists 2 Social Workers 9 Lung Transplant Program Protocols Follow patients life long Clinic visits 2 x per week for 2 weeks Then 1x per week for 2 weeks Then 1x every other week Then monthly for the whole first year Then every 3-6 months for lifetime More frequent visits as clinical condition warrants 10 Current Structure for Donor Offers/Transplant Events Transplant Pulmonologist takes primary donor call Second pulmonologist as back up Fully evaluates every donor

Communicates with OPO Determines provisional acceptance in collaboration with the transplant surgeon Counsels patient if PHS Increased Risk Participates in donor management May be managing multiple donors Hands off when we are primary or back up 11 Current Structure for Donor Offers/Transplant Events Pulmonologist Hands off to On-call Transplant Coordinator Communicates Donor ID/Match ID RN takes over communication with OPO Negotiates OR time Coordinates transplant (procuring and implanting teams) May be coordinating multiple offers/implants Simultaneous and/or back to back transplants DCD OCS ECMO Other thoracic surgeon procuring 12

Transplant Admission RN calls patient with organ offer Makes NPO Ensures ready for transplant Notifies physician if any contraindications are identified Requests bed Negotiates time of admission Physician/mid-level on call enters transplant orders Takes phone calls re. recipient status while admitted 13 Transplant Event RN coordinates Procuring team Implanting team Anesthesia Perfusion Coordinates timing for less than 6 hour ischemia time Multiple algorithms DCD OCS Retransplant ECMO

14 Other Duties for RN on-call Delisting following transplant Notifying entire team transplant occurred Triaging out-patient phone calls May be assigned to clinic First call for out patient critical lab values Additional weekend duties Follow up on pending test results Bronchoscopy culture results RN sign outs Coordination of admission/discharges 15 Pros of Employed Team Additional opportunity to earn call-pay stipend Institutionally less expensive than 3rd party service Calling the patient for Transplant Event Problem solving/Critical thinking Aware of institutional policies and protocols Aware of surgeon preferences Knowledgeable about recipients 16

Cons of an Employed Team Transplant can occur 24/7/365 (and they do!) May not be able to relieve on call RN the next day Coordinating multiple donor offers Fatigue/Burnout/Turnover 17 Thank you