UPMC to develop organ donation program for ED

Program to complement rapid response system

The University of Pittsburgh Medical Center (UPMC) Presbyterian is laying the foundation for a program designed to facilitate organ donations in its emergency department. Not only does this represent an innovative approach to the organ donation process, which has traditionally been restricted to the ICU, but it also underscores UPMC's unique approach to rapid response.

While many facilities now have a rapid response team in place, UPMC has several; in fact, it views those teams as part of a rapid response system — of which the organ donation program, or Condition T (for "transplant"), will be a logical extension.

"The rapid response system includes equipment, administrative supervision, and QI to make sure you have the right people, that they show up on time, and that you are adequately funded," explains Michael Devita, MD, professor of critical care medicine and internal medicine at UPMC School of Medicine, the driving force behind Condition T and developer of several protocols for rapid response teams. UPMC Presbyterian, he adds, has a total of 12 rapid response teams.

"This is simply a new application," echoes Charissa Pacella, MD, director of emergency medical services for UPMC Presbyterian. "The basic tenet underlying rapid response teams is to mobilize all the right equipment, personnel, and actions to get things done."

"You have to think of this as a system," Devita emphasizes. "The whole goal [of rapid response] is that when a situation requires a lot of things to happen in a certain order in a certain way in a very short time, you need to plan it ahead and rehearse it ahead." So, for example, when a patient is about to "code" and you need to send the rapid response team, "you have to make sure the critical care doctor and nurse, the medicine, and equipment all show up in a couple of minutes," says Devita. "We want the same type of response in the ED."

System creates an advantage

Because the ED already is part of the existing system, Devita continues, this extension will be much smoother. "They do not use all the teams, but they have a sepsis team for patients admitted in shock, and an ACS [acute cardiac system] team to get patients into the cath lab as quickly as possible," he notes.

When a patient passes away in the hospital, it is routine for CORE (the local Center for Organ Recovery and Education) to be contacted to determine if the deceased is an organ donor, he continues. The challenge is that while ICUs are equipped to respond rapidly enough for a transplant to be possible, EDs are not. UPMC says many organs from patients who die in the ED are never used.

"If we have the same rapid assembly deployment of personnel, equipment, and services in the ED [as they have in the ICU] we could do what would not be possible otherwise," Devita asserts.

One of the obvious concerns, he says, is that the public may be wary of staff being too aggressive about procuring organ donations. "We want people to feel safe coming here and knowing they will get the best care possible," Devita emphasizes. "We are building the protocol so that 'Condition T' does not get triggered until after the patient dies, after CORE notification and learning that the patient was a donor — that's when we activate the system. This way it also frees the ED of any burden of worrying if a patient is a donor."

Earlier attempts at other institutions to develop such a program have failed, says Devita, "either because of inadequate community education and support, or because the hospital did not continue to provide the administrative support they needed. It's a fairly sizable package you need to put together from an educational and administrative standpoint."

A three-year program

The UPMC initiative — which is being funded by a grant from the Healthcare Resources Services Administration as part of its collaborative aimed at increasing the number of organs transplanted in the United States by more than 40% — will take three years to complete, says Devita. "That's our timeline; we already have a lot of the pieces, but it's just not all together yet."

Devita and his team will use the first six months to create a web site, make slide shows, and get the educational and equipment infrastructure in place. Next, staff will be trained at UPMC Presbyterian — hopefully, early this summer. "Then, probably in late fall, there will be additional training at the University of Michigan," Devita adds.

The project, he continues, will be characterized by a process approach and by transparency. "We will try to create all the process steps and allow everyone in the world to use it," he says. "We will make available the policies, the content of the equipment cart, educational pieces, slide sets for the community, hospital staff, ED staff, and members of the team."

The web site, he adds, will be an "open source," and will include surveys to evaluate community attitude and knowledge exams for health care professionals.

As for the team members, says Devita, "we have identified the skills that need to be available; individual hospitals may chooses to staff theirs differently, but at ours we have a group of emergency medicine physicians who are not on duty in the ED but who participate in several research projects, and who are available when emergencies happen."

The key, he adds, is staff availability and staff with the knowledge and skills to set up the equipment and perform the initial procedures. As for the equipment itself, "we need to have a mechanism to get everything together at the same time."

The project, he re-emphasizes, "is all about process. The biggest thing is the notion of a pre-planned team. You need pagers, a mechanism for triggering a bunch of pagers at the same time, and equipment that is in a [convenient] locale and ready to use at all times. And your hospital has to have policies to permit this to occur — such as death determination."

[For more information, contact:

Michael Devita, MD, Professor of Critical Care Medicine and Internal Medicine, UPMC School of Medicine, Pittsburgh, PA. Phone: (412) 848-7442.]