Empowering Nurses to Engage With Transplant Quality Data and Outcomes.

BACKGROUND: Understanding patient outcome data and quality improvement metrics can help the health-care team target interventions to improve patient care and guide practice. Challenges to understanding and use of data include finding time during clinical work, determining meaning, and understanding a connection to practice. PROBLEM STATEMENT: Acute care nurses who routinely care for organ transplant patients could not speak to transplant quality data or outcomes. This was evidenced by 81% accuracy in interpreting transplant quality data. METHODS: The setting was an inpatient/acute care organ transplant and progressive care unit. A survey was employed to staff; the lowest scoring areas were training to accurately interpret and having time to understand transplant quality data and outcomes. A multimodal intervention that included an education session at a mandatory staff education event followed by routine posting quality data on the unit was devised. Goals were to improve the accuracy of transplant quality data interpretation to an average of 90% and the average key confidence indicators to 6.0 (out of 7.0). PROCESSES ADDRESSED: Education was created to cover background and initial results, data interpretation, and clinical significance. A display board in the staff lounge was dedicated to transplant quality data. OUTCOMES: All goals were met. Accurate interpretation improved to 90% and average key confidence indicators increased to 6.54. IMPLICATIONS FOR PRACTICE: An interdisciplinary team process that involved stakeholders was essential to success. A similar method could be employed with nurses and other frontline staff.

Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews.

The best approach to adverse-event review in solid organ transplantation is unknown. We initiated a departmental case review (DCR) method based on root-cause analysis methods in a high-volume multiorgan transplant center. We aimed to describe this process and its contributions to process improvement. METHODS: Using our prospectively maintained transplant center quality portfolio, we performed a retrospective review of a 30-month period (October 26, 2015, to May 14, 2018) after DCR-process initiation at our center. We used univariate statistics to identify counts of adverse events, DCRs, death and graft-loss events, and quality improvement action-plan items identified during case review. We evaluated variation among organ groups in action-plan items, associated phase of transplant care, and quality improvement theme. RESULTS: Over 30 months, we performed 1449 transplant and living donor procedures with a total of 45 deaths and 31 graft losses; 91 DCRs were performed (kidney transplant n=43; liver transplant n=24; pancreas transplant n=10; heart transplant n=6; lung transplant n=3; living donor n=5). Seventy-nine action-plan items were identified across improvement domains, including errors in clinical decision making, communication, compliance, documentation, selection, waitlist management, and administrative processes. Median time to review was 83 days and varied significantly by program. Median time to action-plan item completion was 9 weeks. Clinical decision making in the pretransplant phase was identified as an improvement opportunity in all programs. CONCLUSIONS: DCRs provide a robust approach to transplant adverse-event review. Quality improvement targets and domains may vary based on adverse-event profiles.

St. Louis encephalitis virus possibly transmitted through blood transfusion-Arizona, 2015.

BACKGROUND: St. Louis encephalitis virus is a mosquito-borne flavivirus that infrequently causes epidemic central nervous system infections. In the United States, blood donors are not screened for St. Louis encephalitis virus infection, and transmission through blood transfusion has not been reported. During September 2015, St. Louis encephalitis virus infection was confirmed in an Arizona kidney transplant recipient. An investigation was initiated to determine the infection source. STUDY DESIGN AND METHODS: The patient was interviewed, and medical records were reviewed. To determine the likelihood of mosquito-borne infection, mosquito surveillance data collected at patient and blood donor residences in timeframes consistent with their possible exposure periods were reviewed. To investigate other routes of exposure, organ and blood donor and recipient specimens were obtained and tested for evidence of St. Louis encephalitis virus infection. RESULTS: The patient presented with symptoms of central nervous system infection. Recent St. Louis encephalitis virus infection was serologically confirmed. The organ donor and three other organ recipients showed no laboratory or clinical evidence of St. Louis encephalitis virus infection. Among four donors of blood products received by the patient via transfusion, one donor had a serologically confirmed, recent St. Louis encephalitis virus infection. Exposure to an infected mosquito was unlikely based on the patient's minimal outdoor exposure. In addition, no St. Louis encephalitis virus-infected mosquito pools were identified around the patient's residence. CONCLUSION: This investigation provides evidence of the first reported possible case of St. Louis encephalitis virus transmission through blood product transfusion. Health care providers and public health professionals should maintain heightened awareness for St. Louis encephalitis virus transmission through blood transfusion in settings where outbreaks are identified.