Quality assessment and performance improvement in transplantation: hype or hope?

PURPOSE OF REVIEW: Healthcare reform and the national quality strategy is increasingly impacting transplant practice, as exemplified by quality assessment and performance improvement (QAPI) regulations for pretransplant and posttransplant care. Transplant providers consider not just patient comorbidities, donor quality, and business constraints, but also regulatory mandates when deciding how to care for transplant candidates and recipients. This review describes transplant quality oversight agencies and regulations, and explores recent literature on the pros and cons of transplant QAPI. RECENT FINDINGS: Transplant's heavily regulated system of care and remuneration involves extensive QAPI process and outcome requirements, and assessment of lifelong, risk-adjusted data from the national, audited, publicly reported, electronic registry. Transplant is a model-integrated delivery system, with payment bundling and accountability for equitable access to high quality, efficient, cost-sensitive, and multidisciplinary care. However, transplant QAPI requires expensive resources and, to bolster wise risk-taking, novel treatments, and access to care, more nuanced risk adjustment, public reporting, and attention to geographic competitive variability. However, transplant QAPI requires expensive resources. In order to bolster wise risk-taking, novel treatments, and access to care, QAPI also requires more nuance in the areas of risk adjustment, public reporting, and attention to geographic competitive variability. SUMMARY: With its focus on innovation and on clinical outcomes, transplantation is poised to continue providing outstanding clinical care and to pioneering systems that advance patient safety, satisfaction, and resource utilization, leading in the field of QAPI and healthcare reform.

Effect of nutritional state of brain-dead organ donor on transplantation.

OBJECTIVE: We describe the effect of the metabolic and nutritional modifications caused by severe illness or injury in brain-dead organ donors on transplant organ function. Malnutrition is frequently found in brain-dead organ donors and nutrients may interfere with different organ functions. METHODS: Literature was obtained from MEDLINE using the key words organ donation, brain death, transplantation, nutrition, fish oil, amino acids. RESULTS: In the liver, infusion of large quantities of dextrose can restore glycogen reserves but may induce hyperglycemia and a hyperosmolar hepatic state. Feeding improves protein synthesis in hepatocytes, and fat (fish oil) administration in particular increases the hepatic energy and adenosine triphosphate content. Amino acids have a significant effect on regenerating hepatic tissue when given with fat and glucose. In the heart, free fatty acids administered during reperfusion improve cardiac functional recovery, and administration of propofol, a general anesthetic agent enriched with fatty acids, have protective effects on ischemia-and-reperfusion injury. Glutamine also can induce graft protection during ischemia-and-reperfusion injury. Renal function is improved by fish oil supplementation. In addition, effective renal plasma flow, glomerular filtration rate, and renal blood flow are increased, apparently by a reduction in thromboxane B2 production. Glycine or alanine can protect renal tubules from stress injury. CONCLUSION: Nutrition plays an important role in the modulation of organ function after transplantation.

Philosophical and ethical issues in human organ transplantation.

Organ transplantation has moved over 30 years from being experimental and heroic to being the treatment of choice in many terminal diseases of vital organs, such as biliary atresis, which would require a liver transplant, or pulmonary fibrosis, which would require a heart/lung transplant. There are now many more older and chronically sick people than ever before (Hudak et al, 1998). Transplantation offers hope for an improved quality of life. All patients have a right to care, although there remains a dichotomy between the holistic model of care and the medical model. The UKCC's (1992) Code of Professional Conduct informs practice, and clauses 1 and 5 are of particular importance in relation to this client group. This article looks at some of the problems patients may develop pre- and post-transplant and the support required to overcome or minimize these problems. Implications for healthcare staff are considered.