Sande Egnor, RN CCRN Neuro -Medical Critical Care Department Charleston Area Medical Center

1. Sande Egnor, RN CCRN Neuro-Medical Critical Care Department Charleston Area Medical Center Charleston, WV Holly J. Mitchell, MPH, CHES Professional Services Liaison Center Organ Recovery &Education

2. WHY? • Recognized missed opportunities at CAMC • Process Breakdowns • Changes in policies and procedures • Misinformation regarding staff role • Create a culture of… • Accountability • Knowledge • Caring

3. Defining The Problem Knowledge Deficit: Organizational Issues: Certification has long been the hallmark in recognition of knowledge and skills among nursing professionals. A nationally recognized certification does not exist for the specialized skills needed for the care and management of organ donors and their families. Nurses working in critical care lack intensive standardized education and competency validation related to the donation process. CAMC is a transplant and donor hospital. The ability to provide renal transplant services relies largely on the number of deceased vs. living related donors. West Virginia is under the ALU. CAMC is a Medicare/Medicaid participating hospital. CMS can challenge the conditions of participation for non-compliance with the Uniform Anatomical Gift Act. Failure to refer appropriate patients places the organization at risk for low conversion rates which are monitored by our credentialing and regulatory agencies for compliance.

4. Measuring The Issue Knowledge and Competency Organizational Issues Process breakdowns (PBDs) *Late referrals for OTE *Non-designated requestors approaching families *Body Releases Loss of transplant potential for members of the community Non-Compliance with First Person Authorization Potential review of Conditions of Participation by CMS Poor outcomes for donor patients and families • Multiple certifications exist that recognize specific as well as global knowledge of critical care. • Among the certifications that are sought by critical care nurses: • Advanced Cardiac Life Support (ACLS) • Pediatric Advanced Life Support (PALS) • Trauma Nurse Core Course (TNCC) • Certified Neuroscience Registered Nurse (CNRN) • Critical Care Registered Nurse (CCRN) • Critical Care Registered Nurse Pediatrics (CCRNP)

5. Analysis • Critical Care Nurses care for 99% of organ, tissue, and eye donors at Charleston Area Medical Center. • Care of the potential or actual organ donor requires advanced knowledge and skills in the following: • Care and management of critically ill patients • History of donation and transplant at CAMC • Brain death testing and guidelines • Specific care guidelines for potential and actual donors • Spiritual and religious assessment skills • Federally mandated guidelines and laws • Conditions of participation under CMS

6. Analysis Continued • The review of the literature represented certification as a means to recognize and validate knowledge and skills and improved performance in the area of certification. • Chart reviews from 2011-2013 revealed the process related breakdowns to be attributed to the following: • Delays in the appropriate clinical management of the potential donor patient • Lack of knowledge of the effect of loss of donor opportunity on the CAMC Transplant Center • Potential risk of violating conditions of participation under CMS • Lack of understanding of best practices related to proper donor management for higher organ donation yield • Late referrals of potential and actual donors

7. CAMC - Leading the Way!!!Improvement and Innovation Process Team Members/Faculty Sande Egnor-CAMC MICU-NSICU Teresa Hill-CAMC Quality Holly Mitchell-CORE Hospital Development Glen Martin Associate Administrator CAMC General Hospital Dr. Doug Haden-CAMC Critical Care Medicine Dr. Joseph Africa-CAMC Transplant Surgeon Alice Jones-CAMC Transplant Coordinator Dr. Mary Lou Lewis-CAMC Nephrologist 3 CAMC Donor Families • Team members met to review the literature and issues related to donor management at CAMC. • Curriculum was developed and organized around clinical domains and represented faculty from the following disciplines: • Nursing • Quality • Medicine • Organ Procurement • Administration • Transplant Center • Donor Families • Organ Recipients • A certification exam was developed with input from all disciplines

8. Creating the Curriculum • Team members met weekly to create the curriculum and learning objectives • Evidenced Based Care related to management and care of the potential and actual donor were incorporated into the learning and presentation materials. • Reviewed National Best Practices and incorporated strategies to improve process within the culture at CAMC. • History of donation and history of CAMC donor and transplant program were included as a means to build pride and commitment from participants.. • Historical data related to process related break downs and knowledge deficits were researched for learning opportunities.

9. Curriculum (cont.) • Guidelines from regulatory agencies including, UNOS, HRSA, and CMS, TJC and DNV were included in the educational materials and presentations • Guidelines for transplant and allocation of anatomical gifts were incorporated utilizing information from the CAMC Transplant Center. • Power point, lecture/discussion and learning activities including journal article reviews and donor family participation were included. • Educational materials were reviewed and a certification exam was created with questions submitted from each discipline by participating faculty.

10. Course Set up • The learning sessions were divided over two days. One eight hour classroom day and one four hour day. • A course notebook was distributed containing presentations, handouts, policies/procedures for CAMC along with evidenced based care research articles and problem solving tools. • Presenters dropped in during the day and provided lectures along with Question/Answer sessions. • Participants were selected by nurse managers from the eight critical care units divided among three hospital campuses. • Participants were divided for group work and discussion.

11. Course Set up (cont.) • The day was broken up by presentations, videos and guest speakers with plenty of breaks and lunch on their own. • A survey was also provided to the participants to review /rate the course. • A exam review was provided on day two. • Each participant is required to schedule the exam with a proctor.

12. Course Agenda First Day 1145-1245 LUNCH 1245-115: Clinical Triggers and Timely Referrals 115-145: Brain Death Testing 145-200: VIDEO: Dr. Haden's explains Brain Death 200-230: Medical Management of an Organ Donor 230-315: Nursing Care of Donors 315-330: BREAK 330-400: DCD Donors 400-415 First Day Wrap up, what's next for tomorrow • 8-830: Breakfast and Registration • 830-845: CDMD Outline • 845-915: History of Donation and Transplantation • 915-945: History of Donation and Transplantation at CAMC • 945-1000: CAMC Transplant Center • 1000-1030: Federal and State Law regarding donation • 1030-1045: CAMC Policies and Procedures • 1045-1100: Patient Rights • 1100-1115 VIDEO: Chris Henry • 1115-1145: Religion and Cultural views of donation

13. Course Agenda Second Day • 830-900: Tissue and Recovery • 900-930: Allocation • 930-1000: Alice and Dr. Africa from the CAMC Transplant Center • 1000-1030: "DAY O" • 1030-1045: VIDEO: • 1045-1145: Evaluation • 1145-1245: Exam Review and Questions

14. Pre-course work! • ICU Educators!!!

15. Day One---Slide One • RN’s from three campuses come together!!!

16. Support from the Transplant Team • The whole picture presented

17. CAMC’s Renal Transplant Surgeon Dr. Joseph Africa • Fields questions from the group

18. Donor Family Participation • A donor’s gift…A mother’s mission

19. Workgroups and Praise for the Program!!! • Course/Speaker Evaluation • Work groups problem solve

20. Maintaining the Certification • Score of eighty-eight percent on exam. • Identified as unit champion for donation. • Literature review and article critique posted on unit. • Performance Improvement Project. • Sharing of best practice and CAMC guidelines. • Attendance at one donation/transplant event annually. • Re-test annually to maintain competency.

21. Outcomes Measured Immeasurable-but Impactful The “in” certification to obtain. Nurses from ICU’s requesting to take the exam. We have a waiting list to take the next course Overall improved understanding of the process. Improved accountability. Cultural change –viewing donation as part of the care process in critical care. • 21 nurses representing 8 critical care units have taken the review. • 11 have successfully completed the certifying exam. • Overall increase in timely referrals over 2012 and 2013 data. • Overall decrease in number of missed opportunities/process breakdowns.

22. Impact and Influence • Overall process improvement in donation cases with the assistance of trained staff • Standardization for measurable results • Administrative acknowledgement • Participants have agreed to work on issues such as “handoff communication” and “increased timely referrals” • Improvement in collegial relationships among CAMC critical care staff and CORE staff. • Sense of pride – staff using credentials and the program to advance the nursing career ladder.

23. What nurses are saying… • “I didn’t know the process well, and now I feel like I can do more for my families and patients”. • “This has reignited my passion for nursing!” • “I feel it is an important part of nursing care to provide this opportunity.” • “It’s important to know this stuff. I had no idea of all of what donation entails.” • “I’m glad the physicians came to see us.”

24. Celebrating Change • Administrators and unit level managers acknowledge participants and course as an innovation in best practice. • CAMC Quality Award Nominee 2014 • West Virginia Nurse Executives Organization Abstract Presentation November 2014 • Certificates Provided to Successful Candidates • Recognition Activities Planned • Article to be published in hospital newsletter • Plans to submit to ANCC and AACN as a nursing best practice • Considering to offer course to outlying hospitals