Our commitment to quality is reflected in the comprehensive programs and continuity of services OSU Medical Center offers its transplant patients including pre-transplant evaluation, communication throughout the waiting process, acute medical care during and following surgery, intensive outpatient treatment, post-transplant outpatient visits and on-going telephone follow-up.

Patient Satisfaction

OSU Medical Center routinely asks its patients to judge its quality of care based upon the most important criteria - patients' own experiences. According to our surveys, over 93% of our patients hospital-wide gave us high marks for being responsive to their needs.

Transplant-specific Patient Satisfaction (on a scale of 1-10, 10 being best, first quarter 1997)

• Quality of Care received from physicians 9.34
• Quality of Care received from nurses 9.33
• Quality of Satisfaction with hospital stay 9.34

Referring physicians, dialysis centers, insurance case managers, and other transplant centers can make a referral for a patient to be evaluated for transplantation appropriateness at OSU Medical Center.

Patients are instructed, when calling to inquire about evaluation, that their insurance company needs notification before making the initial evaluation appointment. The pre-transplant office staff and hospital business office work with the patient to determine insurance availability and pre-certification requirements. Pre-transplant coordinators and business office staff then work together to meet insurance company requirements for evaluation and transplant procedure approval.

Screening/Testing

Each patient referred to OSU Medical Center as a candidate for kidney, pancreas, kidney-pancreas or liver transplant is contacted by a pre-transplant coordinator. The referring party is responsible for providing the coordinator with all applicable medical information according to the transplant referral protocol provided at time of referral. The coordinator collects this information, assembles a chart, screens the information, and if appropriate, makes an appointment for the patient to meet with a transplant surgeon and other members of the transplant team during a pre-transplant clinic visit.

Every attempt is made to have all the pre-transplant initial testing, lab work (including tissue typing), education, surgeon interview, and social work consultation completed in one day on an outpatient basis during this clinic visit.

Education

During the pre-transplant clinic, patients take part in a comprehensive education program that details the surgical procedure, medications, recovery, and rehabilitation associated with the transplant process. During the pre-transplant period, the main focus is on educating patients and their families about the following:

• patients' responsibilities, role in the process
• what happens clinically during surgery and recovery
• potential complications
• lifestyle modifications
• drug therapy
• cost factors
• support groups

Further Evaluation

Following initial testing, the transplant team evaluates the information gathered on the candidate and determines whether transplantation is appropriate. They also determine what additional information is needed prior to listing the patient. These tests are customized based on the candidate's history and conditions, thus avoiding unnecessary testing and costs. It is preferred that these tests be completed at OSU Medical Center, but depending on the patient's geographic location or payer preference, they may be completed local to the patient. Coordinators send follow up letters to the referring physician and/or dialysis center, summarizing the pre-transplant clinic visit and any additional information required. At this time, a letter is also sent to the patient's insurance company, with a copy of the pre-transplant patient chart, requesting pre-certification of the transplant procedure.

Program Acceptance/Listing

Once all medical information is received/completed, the transplant team evaluates the information and determines if the patient should be listed. Following approval by the OSUMC Patient Selection Committee, candidates for kidney-pancreas, pancreas only, or liver transplant are submitted to the Ohio Solid Organ Transplant Consortium (OSOTC) Patient Selection Committee for approval. After insurance and OSOTC approval is received, the patient is contacted. A confirmation of listing letter is sent to the patient outlining reasons to call the pre-transplant coordinators and informing him/her of monthly blood work requirements. A copy of this letter is forwarded to the referring physician/dialysis center and insurance case manager. After listing, the coordinators continue to follow transplant candidates, monitoring them for listing status and information changes.

Tissue Typing

The Tissue Typing Laboratory lists patients with LOOP and UNOS for cadaveric organ donations. If testing has determined that a patient awaiting kidney transplantation has a suitable living related or unrelated donor, surgery is scheduled.

The Tissue Typing Laboratory assures that a graft is immunologically compatible with its recipient. The lab uses histocompatibility testing, cross-match testing, and transplant support testing to serve transplant patients. Histocompatibility testing is the primary way a patient's tissue is "matched" with potential donor tissue. The process involves matching a person's unique configuration of six human leukocyte antigen (HLA) molecules with a potential pool of approximately 100 different varieties.

Cross-match testing helps prevent hyperacute rejection. The testing involves mixing cells from the donor's and recipient's serum to determine whether rejection promoting antibodies will occur. If they do, the patient will not receive an organ from that particular donor.

Transplant support testing includes monitoring new drugs that patients use, testing to determine a patient's overall ability to maintain a graft, and developing new tests to support many of the clinical aspects of transplantation.

Surgery

When an organ becomes available, the patient with the best match according to UNOS criteria is admitted and prepared for the transplant procedure. If the final organ match is acceptable, the patient is transplanted. Ideally, surgery is performed as soon as the organ is available. However, using the latest perfusion techniques, OSU Medical Center is able to transplant liver and pancreas organs within 12 to 24 hours and kidneys within 72 hours of recovery. The surgery may last as little as three hours or for more than twelve hours. Following the patient's admission, calls are made to the transplanted patient's dialysis center, referring physician, and insurance company to notify them of the transplant.

Inpatient Stay

Most kidney and kidney-pancreas patients do not require a stay in the Surgical Intensive Care Unit (SICU) after surgery. They are monitored in a Special Care Room right on the Transplant Unit. Liver transplant patients are transferred to the Transplant Unit as soon as possible, following a brief stay in the SICU. During the inpatient stay, the transplant surgeons and Patient Care Resource Managers (PCRMs) make daily rounds and review posted lab results. The patient receives individualized education from floor nurses and attends two education classes on medication and general discharge instructions. The PCRMs coordinate the patient's care process, communicate with insurance case managers, and plan for discharge. A social worker visits the patient to address any psychosocial issues associated with the transplant. A post transplant coordinator also calls the patient shortly after discharge to answer any remaining questions and to discuss long-term follow-up with the transplant program.

Outpatient Care and Monitoring

The Day Care Room located on the Transplant Unit allows patients to be discharged earlier with daily follow up care on an outpatient basis.

Patient management processes are directed by the transplant team at OSU Medical Center for the first three months post transplant with active communication with the patient's family physician. A case management system is utilized in which each patient has an assigned coordinator, surgeon, and transplant nephrologist. This collaborative team ensures personalized and coordinated follow-up care for each patient. At three months, the patient's primary care is transitioned to the family physician. However, the transplant team maintains an active role in the patient's care indefinitely.

Patients are followed on an outpatient basis with vital signs and laboratory profiles three times per week for the first six weeks post transplant. This data is obtained by the patient and the results faxed or telephoned into the post transplant office, where they are immediately evaluated by a transplant coordinator and as appropriate, by a transplant surgeon. Further information is obtained from the patient if necessary, and patients are instructed regarding treatment changes by telephone. A routine follow-up clinic visit occurs at six weeks post-transplant, at which time lab frequency is reduced to twice a week until 3 months post transplant.

All admissions in the first ninety days post transplant for transplant-related reasons must be to OSU Medical Center. The ninety day period begins again at day one with each transplant-related readmission. It is preferred that all transplant-related admissions also be to OSUMC for the first year post transplant. However, other arrangements can be made depending on the patient's circumstances and geographic location.

Patients are seen again in the outpatient clinic at three months post transplant, at one year post transplant, and annually thereafter, unless more frequent visits are required. Patients experiencing medical problems may be asked to see a transplant nephrologist. Lab work and vital sign frequency is reduced to once per week at three months post transplant, to every other week at six months post transplant, and to once per month at one year post transplant. Urine cultures, CSA levels, and any other additional information is obtained on an as-needed basis.

Communication with the referring physician occurs at the beginning and end of each hospitalization, as well as with each outpatient clinic visit. Follow up between the community physician and the transplant surgeon overseeing post transplant care is encouraged at all times. Because of the many interactions of other medications with immunosuppressives, patients are instructed to check with the post transplant office prior to filling any prescription.

Extensive patient records are maintained by the post transplant office in hard copy as well as in electronic format indefinitely. All clinical information and follow up is maintained in a transplant database. These electronically stored records are accessible by all members of the transplant team in multiple locations. The immediate availability of patient information in electronic format enhances the ability of the transplant team to optimally manage the patient's care.

Patients and health care providers have access to a toll-free number which is staffed 24 hours a day by a transplant coordinator with immediate access to a transplant surgeon. The transplant team currently monitors the condition of more than 1,500 transplant recipients around the country. This unique service benefits the patient by providing access to the transplant team for all questions regarding their transplant. This ease of access aids in resolving compliance issues and in early identification of potential problems. Coupled with the electronic database, this service also benefits the physicians, and ultimately the payer, by providing a mechanism to maintain constant contact with transplant recipients and to monitor their progress with outcome related measures.

Transplant Patient Services

Financial Counseling: Although patients are ultimately responsible for the costs associated with a transplant, financial resources are not the determining factor in selection for the transplant program. A full-time transplant financial counselor, business office staff, and transplant social workers will assist patients and their families with questions about insurance coverage for their transplant and post-transplant medications.

Patient Education: Throughout the transplant process, a team of health care specialists work with patients and their families to help them be as knowledgeable as possible about the transplant process, the actual surgery, and follow-up care, including medications. All patients are provided with a comprehensive transplant notebook containing written patient education materials for reference at home. Around the clock access to the transplant team is provided to all patients so that questions may be addressed in a timely manner.

Social Services: Licensed Independent Social Workers (LISW), specially trained in transplant, assist patients in adjusting to lifestyle changes brought on by their disease and its treatment. They also provide information about financial assistance resources, area hotels and other housing options, transportation, and assist in ensuring continuity of care.

Pastoral Care: The staff of the Pastoral Care department can help patients address the spiritual questions and concerns sometimes raised by facing a transplant. Pastoral Care staff visit with patients and their families to listen, talk, reflect, pray and offer spiritual support in times of need. A sanctuary is also available in Rhodes Hall, the acute-care hospital, as a quiet place for prayer or reflection.

Nutrition Counseling: Nutritional needs vary based on a patient's medical history and the type of organ received. Throughout the transplant process, a registered dietician specializing in the care of transplant patients will assist patients to individualize their nutritional care and educate patients on their dietary needs.