Achieving a 75% Conversion Rate at a Non-Transplant Hospital

Maureen Bishop, RN, MA, MSN, CCRN, CCNSClinical Nurse Specialist – CCU/ICU/PCU

Hospital Liaison to Gift of LifeSally Pitt-VanBuren, BS, MS

Gift of Life Hospital Development Associate

Lakeland HealthCare’s Demographics

• Two acute care hospitals serving Southwest Lower

Michigan– Niles beds:

• 89 licensed beds • 8 bed licensed intensive care beds• 24 hour emergency services

– St. Joseph beds• 254 licensed beds• 22 licensed critical care beds (24 hour Intensivist

coverage)• 24 hour emergency services

Support At All Levels

• Board of Directors given reports of donation activity

on a regular basis, which is a requirement of CMS• Senior Leadership involvement:

– President puts information in associate newsletter– Vice President of Patient Services/Chief Nursing

Officer sits on Corporate Organ Donation Advisory

Committee• Physician Support• Associate Support

Lakeland’s Corporate Organ DonationAdvisory Committee

• Multi-disciplinary group– Members include:

• Nursing• Chaplain• Senior leadership• Gift of Life representatives• Community representative/s

– Reviews policies, procedures, associate education,

stats on compliance to rules/regulations, etc.

Associate Education

• RNs required to do a yearly CBL on donation • Physician education is done via weekly CME as well

one to one education– Peer Physician Education Presentation: 11/2007– Peer Physician Education Presentation: 10/2009

• Organ, tissue, eye donation protocols reviewed in

New Nursing Orientation• Yearly promotion of donation awareness in April• One on one education when protocols not followed

Other Educational Opportunities

• After action review – completed after both DCDs• Departmental education done by Gift of Life:

– Emergency departments– Critical/Intensive Care departments– Respiratory Therapy departments– Pastoral Care

• Hospital liaison educates when inappropriate

approaches have been identified

Real time education by Gift of Life when on-site

Hospital Liaison Role

• Daily rounds on patients to determine any referrals• Participates in monthly death record review with

Gift of Life• Works with Gift of Life when at hospital for referrals• Support Gift of Life in getting services completed on

consented patients• Liaison has been in role for over 12 years• Has had first hand experience working with patients

who were both donors & patients waiting for transplant

2008 Performance Overview atSt. Joseph Site

Performance Criteria Value Goal

Conversion Rate 100% > 75%

Referral Rate 100% 100%

Rate of Appropriate Requests 100% 100%

Timely Notification Rate 92% 100%

Organ Donors 4

Tissue Donors 8

2008 Performance Overview forNiles Site

Performance Criteria Value Goal

Conversion Rate NA > 75%

Referral Rate 100% 100%

Rate of Appropriate Requests NA 100%

Timely Notification Rate 82% 100%

Organ Donors 0

Tissue Donors 7

2009 First Quarter Performance Overview

at St. Joseph SitePerformance Criteria Value Goal

Conversion Rate 100% >75%

Referral Rate 100% 100%

Rate of Appropriate Requests 100% 100%

Timely Notification Rate 94% 100%

Organ Donors 1

Tissue Donors 4

2009 First Quarter Performance Overviewfor Niles Site

Performance Criteria Value Goal

Conversion Rate N/A >75%

Referral Rate 100% 100%

Rate of Appropriate Requests N/A 100%

Timely Notification Rate 100% 100%

Organ Donors 0

Tissue Donors 1

Challenges for Lakeland

• Not being a transplant facility gives us some special challenges:

– Keeping the “imminent death” criteria in everyone’s minds when we have a lapse in time for patients.– Getting the ED to remember they need to make the calls and not wait for the patient to be seen by an Intensivist.– Calls must be made as early as possible since it takes up to 3 hours for a Gift of Life representative to get to our facilities.

Questions

Thank You!

1-800-482-4881