Communication Gaps Lead to Infections in Organ Recipients

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Delays and errors in communication from donor organ centers to recipient centers frequently contribute to the transmission of infections. Rachael Miller, MD, presented the results of a study of potential donor-derived infections reported between January 2008 and June 2010 to the Ad Hoc Disease Transmission Advisory Committee (DTAC) of the Organ Procurement and Transplantation Network, administered by the United Network for Organ Sharing (UNOS). Miller is clinical professor in infectious diseases at the University of Iowa Carver College of Medicine in Iowa City.

Communication gaps occur at multiple levels and have been associated with adverse outcomes in organ recipients, but

Delays and errors in communication from donor organ centers to recipient centers frequently contribute to the transmission of infections. Rachael Miller, MD, presented the results of a study of potential donor-derived infections reported between January 2008 and June 2010 to the Ad Hoc Disease Transmission Advisory Committee (DTAC) of the Organ Procurement and Transplantation Network, administered by the United Network for Organ Sharing (UNOS). Miller is clinical professor in infectious diseases at the University of Iowa Carver College of Medicine in Iowa City.

Communication gaps occur at multiple levels and have been associated with adverse outcomes in organ recipients, but effective communication can minimize or avert the transmission of infections. “If delays and errors in communication occur, they can have a significant impact on recipient morbidity and mortality,” Miller said.

Effective detection and management of potential donor-derived infections are made all the more difficult because of the complex and multiple channels of communication, including between donor and recipient transplant centers, diagnostic laboratories, and organ procurement organizations (OPOs) involved. “Clinicians may be unaware as to how to obtain and report relevant donor information,” Miller said.

The DTAC classifies donor-derived transmission events as proven, probable, or “intervention without documented transmission,” which typically means that an infection was averted through the use of antimicrobial therapy. For the study, a delay in communication was defined as lasting more than 3 days. An adverse event was an unexpected clinical infection, a more severe infection, or death.

The investigators identified 56 infection events involving 169 transplant recipients that met the study criteria for potential communication delays or errors. Thirty-eight events in 120 recipients were ultimately determined not to involve communication problems.

“However, 18 infection events were associated with communication delays or errors among 49 recipients,” Miller reported. Eleven of these cases involved bacterial infections, three viral, and four other or parasitic. Of these 18 occurrences, 12 (67 percent) were associated with an adverse event. Of the 20 recipients affected by an infectious adverse event, 6 died.

The researchers pinpointed several gaps involving many of the steps in the communication process. Some cases of communication error involved more than one step. In five instances, the transplant center delayed contacting the OPO to relate a suspected donor-derived infections (range 22–56 days), and in three instances, the OPO delayed contacting the transplant center or the DTAC. There were also four failures of laboratories to relay donor results to the OPO and/or the transplant center, two communications of incomplete test results from the OPO to the transplant centers, and three clerical errors.

“The good news is that if prompt and effective communication was employed it allowed the opportunity for prompt intervention that either minimized or averted recipient infection,” Miller said. Of the 38 infection events without communication errors or delays, in 23 cases intervention positively influenced the outcome for 72 recipients. The remaining 15 events affecting 48 recipients required no intervention, or intervention had no effect on the outcome.

Communication can minimize or avert infections in transplant recipients, Miller said. In January the Organ Procurement and Transplantation Network implemented policy changes regarding communication, mainly concentrating on the procedures for OPOs and transplant centers to report and share donor-related information with relevant parties. Also, the involved parties should receive better education to help minimize communication problems and add to the safety of the donation process, Miller said.

Senior author of the study and DTAC chair Emily Blumberg, MD, professor of medicine and director of transplant infectious diseases at the University of Pennsylvania in Philadelphia, told ASN Kidney News that clinicians may not be aware that some infections are derived from donors and thus may not report them in a timely manner or at all.

Blumberg said one of her goals is to present her findings at meetings of transplant medical professionals and transplant administrators, and also at UNOS regional meetings, to raise awareness of the problem so people start to ask themselves, “Could this be [a] donor-derived [problem], and before letting this proceed further, can I notify people?” UNOS has implemented a contact process to encourage every transplant program to have a patient safety officer charged with promptly communicating a suspected problem to UNOS and to the OPO so that every center with an organ recipient will be notified.

Session chair David Foley, MD, associate professor of surgery at the University of Wisconsin in Madison, suggested that within each transplant center, “One safeguard measure would be a checklist for the surgeons to maybe potentially follow up with the OPO to make sure that no data have come back that have not been informed to us” concerning a donor.

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