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  • A Commentary: The Evolving Role of the Advanced Practice Provider in Transplant

    Jennifer M. Sharp, MSJennifer M. Sharp, MS
    Nurse Practitioner
    University of Michigan

    When I began my advanced practice career, nurse practitioners (NPs) had been around for some time. The first nurse practitioner program was developed at the University of Colorado in 1965 by Loretta Ford and Dr. Henry Silver. The program was focused on pediatrics, and historically, most NPs were employed in primary care specialties. NPs were able to add to the provider work force in physician offices, increasing the number of patients able to be seen and followed by any given practice. Over time NPs began to develop individual niches and opened independent clinics with the supervision of a physician. The role evolved further as the industry was able to see that both physician assistants and NPs, now collectively termed Advanced Practice Providers (APPs), were able to expand care capabilities in more focused areas of medicine, such as acute care, surgery and critical care. Nurse practitioner schools began to develop acute care programs and other specialized programs for broadening the scope of APPs into hospital settings and subspecialty practices. Regulations were developed to better define the role of APPs and to take on issues of training and certification that naturally coincided with this expansion of APP practice environments.

    While the addition of APPs to the medical workforce was a positive change for health care in general, there were a lot of murky waters to tread. While many physicians were on board with this expanding venture, others were unsure and unclear as to what APPs were supposed to be doing. What can they do? What are the liabilities? What is the difference between nurse practitioners and physician assistants? What is their scope of practice? How do they fit in on our team? What is the benefit of working with an APP? The uncertainty of answers to these questions led to confusion that likely contributed to underutilized APPs, decreased job satisfaction, and confused employers and team members.

    My Center, My Story

    I started in transplant as a bedside nurse, first at the Johns Hopkins Hospital (JHH), then at University of Michigan Health System (UMHS). After completing my training as a nurse practitioner, I transitioned to transplant surgery. I emailed Dr. Jeffrey Punch, then the Chief of the Division of Transplant Surgery and the director of the UMHS Transplant Center, more than once. I even encountered his wife (also a physician leader at UMHS) in an elevator, at which time I promptly explained who I was and why her husband needed to hire me. The possibility of working as a NP in the transplant program was a very unique opportunity. It was a natural evolution for me but somewhat confusing for those around me. I was a little bit like a transplant unicorn. I had lots of bedside nursing experience with the transplant population, which was hard to find at the time, but I was now a mid-level provider (which was what we used to be called) able to use that knowledge and experience in a more in-depth manner on the transplant team. The team did not have an inpatient nurse practitioner. Dr. Punch probably thought: “This woman has emailed me repeatedly and confronted my wife in the elevator; maybe I should hire her. She seems persistent. But what do I do with her? What’s an acute care nurse practitioner? How do we train her? Do we let the existing PAs train her?” These were legitimate questions plaguing program directors who were hiring APPs at the time. In our program, I worked alongside my fellow “MLPs” and learned the job. There were 4 of us (3 PAs and me) working with the inpatient team coordinating discharges and other tasks. We also completed H&Ps for kidney patients and saw post-operative liver transplant patients in clinic two days a week. Our center volume was 250 kidneys and 90 livers a year in the abdominal transplant programs at that time.

    Fast forward to 2018: our transplant surgery team at Michigan Medicine is now 7 APPs (2 PAs and 5 NPs). We function in the outpatient and inpatient setting alike. Collectively and via self-management, we take day call for the inpatient kidney service, oversee the junior residents who take day call for the inpatient liver service, cover 3-4 clinics each day for post-operative kidney/pancreas and liver patients, and see all pre-operative living donor kidney and liver patients prior to surgery. We are making clinical judgments and providing care in the acute setting as well as directing and following through with plans of care in the outpatient arena. We run daily multidisciplinary rounds and collaborate independently with all departments. We act on behalf of our faculty in matters of patient care when they are not available. Our role in coordinating care for the post-operative liver transplant patients has been studied and shown to improve care coordination and contribute to decreased length of stay.

    In addition to patient care, we serve on transplant center and hospital committees. We have been able to grow our group and retain talented providers. We collaborate with faculty on best practices regularly. We are involved in research, attending and speaking at national conferences. Additionally, some of us have been able to independently develop significant quality improvement interventions that have been implemented for the benefit of patients. We participate fully in the education and training of surgical residents, medical students, and NP students both in inpatient and outpatient care settings. We also play a critical role in orienting the ASTS transplant surgery fellows to our program each year.

    How and Why Did This Happen?

    The answer to these questions is complex. We know our patients have become older and sicker. Their needs have grown. Their time waiting for organ transplantation has increased. The manpower needed to manage these patients is increasing. In addition, the Accreditation Council for Graduate Medical Education work hour restrictions instituted in July 2011 have limited the amount of time residents spend in the hospital caring for patients. These issues combined have created a growing need for additional providers to meet the needs of the transplant patient population. Responsibilities have grown to meet the needs of patients, including daily clinic expansion, increasingly complex outpatient management, and maintaining the necessary continuity for successful patient outcomes and patient safety. The role of the APP has evolved in that we are able to manage, and we have gained a more autonomous role in directing, the care of transplant patients in both inpatient and outpatient settings. We provide an aspect of care continuity that is unique and have grown into a large, invaluable part of the transplant team to our faculty, fellows and patients.

    Is This Model Successful?

    For our center, this model is successful. All seven of us are able to fill in at any time, in any of the areas of responsibility. This is particularly important in transplant, as the daily work volume is unpredictable and highly variable. We continue to review and revise the role as the needs of our patients demand.

    We have been successful in providing care and education by combining the following:

    • Relationships: Getting to know and trust one another; understand preferences, values, and the things that are important to each other; respect each other inside and outside of the office.
    • Time: It has taken years to cultivate these relationships. We have successes and failures, missteps and saves, and go through all of it together, growing professionally and personally, as a cohesive team.
    • Common mission/teamwork: We depend on each other to get to our common goal: excellent, timely, and safe delivery of care to our patients. We all need one another to provide the standard of care we believe in from beginning to end of the patient experience.

    These factors are not often studied or written about. But there is a common thread among transplant teams that provide exceptional care: they work well together. Each member understands that an individual cannot carry out our mission alone. The care we provide is based around the team and the systems in which we operate. APPs enhance this structure of care delivery at Michigan Medicine.

    What Is Next for the Advanced Transplant Provider (ATP)?

    I have described the role of the surgery APP group at Michigan Medicine. However, there are APPs all over the transplant center in every division. The field of transplantation is made up of several teams: medical, surgical, pre, post, and everything in between. APPs on all these teams form another layer of connection. We provide the same underlying network for all the specific organ teams, performing different responsibilities but overall ensuring that all patients have what they need, continuously.

    Nationwide, APPs can be found in different transplant programs in clinic, in the hospital, in outreach, assisting in the operating room, and on procurements—each with different responsibilities in kidney, liver, pancreas, lung, heart, and small bowel organ transplantation. APPs are known to complete morning rounds, write progress notes, perform H&Ps, perform pre-transplant evaluations, oversee waitlist management, participate in transplant protocol development and quality improvement activities, manage post-transplant clinic follow up, coordinate discharge, and take in house and at home call. Currently there are several NP/PA fellowship programs around the nation that developed to intensify and specialize training that is needed in relation to the growing industry as APPs take on more responsibilities in transplant centers around the country and in other areas of health care.

    It is my perspective that the next logical step for the transplant advanced practice provider is to be placed into a dual role, both clinical and administrative. We have proven how versatile we are in our current clinical position. Transplant centers can only benefit from positioning APPs in leadership roles that develop center policy, mission goals, center operational strategies, fiscal development, competitive practices, and center organization.

    Being an ATP has afforded me a vast array of opportunities to grow in my profession. Transplant is a complex field. It has many moving parts. There are many important aspects of care that require extra attention and time. It is clear that the ATP role in transplant centers in today’s healthcare delivery environment is now indispensable. I have heard our role described as many things through the years, some accurate and some not so accurate. The real deal is that it is hard to define this role universally. It is all relative to where you work, what the needs are, and what structural model is utilized at that particular center.

    The field of transplant is very well suited for the APP role. The patients require intuitive, highly skilled, and continuous care. The APP allows the team providing this care to be just that: continuous. When working in tandem with faculty, the role allows for minimal breaks in delivery of quality patient care. I have no doubt that this role will continue to evolve in all parts of healthcare.

    Having said that, the role of an ATP is specific to institution; efforts are still being made for standardization in skill sets, responsibilities, and scope of practice. There are advantages to creating a value-added role from the ground up in a particular patient population at a specific center. However, developing standard responsibilities that can be maintained by the ASTS could certainly be a helpful tool for employers and personnel alike in the ever-changing health care environment.

    In an effort to continue the discussion on this topic, the Communications Committee will be collaborating with the ATP Committee members in coming months to collect job descriptions from ATPs around the country. There are currently 93 ATPs within the ASTS membership. This collaboration will give more insight into the diversity in structural models and current roles throughout the field of transplant. There is every reason to expect that ATPs will continue to play a growing role in the field of transplantation, and the ASTS is poised to help lead that growth.

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  • Opioids and The Transplant Surgeon

    Vinayak S. Rohan, MDVinayak S. Rohan, MD
    Assistant Professor of Surgery
    Medical University of South Carolina

    One need only to see the statistics to realize the gravity of the current opioid epidemic; >115 people are dying of overdoses daily, equating to an economic burden of 78.5 billion dollars /year.

    With more than 42,000 annual deaths attributed to opiates, a surge in the number of organs available for transplant is inevitable. In fact, there has been a 24-fold rise in organ transplants available from overdose deaths, a national tragedy earning the morose moniker of the “Grim Silver Lining.”

    How did we get here?

    Not surprisingly, opiates have been known to humans as long as the existence of recorded history. A reference to ‘Hulgul’ or joyplant was seen as early as 3400 BCE from Mesopotamia.

    In the U.S., the 1990s saw an increase in the use of opiates for a variety of pain-control regimens, driven and pushed by pharmaceutical companies. Marketing budgets swelled to more than $200 million a year. Extended release formulations also began to appear, and doctors, nurses and pain societies advocated for these “non-addicting” opioids.

    By 1994, 4 million people (2% of the population) were using prescription medications non-medically. Additionally, after JCAHO incorporated pain as the 5th vital sign, there was a doubling of the opioid abuse/misuse in one decade.

    Opioids and transplant

    Opiate overdose contributed to 1.1% of all donors in 2000. In 2017, it was 13.4%, an increase of 17% per year. At the same time, the discard rate for these organs is much higher than for donors from trauma, due to 56% of donors from overdose being deemed as PHS high risk (especially due to Hepatitis C.)

    We in the transplant world are acutely aware of the perpetual shortage of organs with more than 100,000 people on the waiting list. Every transplant is balancing the risk with the benefit. With the advent of new Hepatitis C drugs with excellent cure rates, trials have shown the feasibility and benefit of transplanting Hepatitis C–negative patients with Hepatitis C–positive kidneys. It is time for us as a community to adopt it in wider practice and decrease the discard rates of these organs.

    The other face of the coin is more humbling. We have to contemplate how we, as surgeons, have contributed to this epidemic and how our actions affect transplant outcomes.

    Opioids are intended for short-term treatment of surgical pain. For far too long we have prescribed opioids without seriously considering the long-term consequences. The best predictor of misuse was the number of post-discharge prescriptions, with an additional refill increasing the misuse by 44%.

     Alarmingly, 80% of heroin users first used prescription opioids. The fact is that 67% to 92% of patients have unused opiates left with them after surgery, forming an important reservoir available for abuse.

    Although the transplant rates have increased with the epidemic, outcomes have been adversely affected. Recent articles looking at the single center studies and national data have shown that graft loss and mortality are both increased in liver and kidney transplant patients who are chronic opioid users.

    As we continue to focus our energies on increasing the organ utilization, the education of patients and the prescriber regarding opioid use should not be neglected. We took the easy route in treating pain; fixing the problem is not going to be pain free. A concerted effort amongst all of us is required for the development of multimodality and alternative pain control strategies in transplantation and beyond…from my perspective.
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  • HCV Positive Allografts: A Solution for… Most?

    Dr. Ryan HelmickRyan A. Helmick, MD
    University of Tennessee Health Science Center
    Methodist University Hospital

     

    As the transplant community continues to search for a solution to the available organ shortfall, xenotransplantation remains a far-off promise and tissue engineered organs are in the earliest stages of research. Despite these challenges, the number of deceased donors has been increasing in recent years, due in large part to the opioid crisis. Between the years of 2010 and 2016, the number of deceased donors has increased overall by about 26%, while the number of donors who have died of a drug overdose has increased by 277%.1 Often these donors are classified as PHS increased risk, and many have recent or long term infection from Hepatitis B virus (HBV) or Hepatitis C virus (HCV).

    Utilization of organs from donors that are seropositive for HBV core antibody has long been considered acceptable at many centers, given the available therapies including Hepatitis B immunoglobulin as well as the antiretrovirals with a long history of successful HBV prevention. The lack of effective therapies for HCV has long limited organs from these donors only to patients who already have HCV. Some have reported positive results by utilizing the narrow subset of donors that are HCV antibody positive and RNA negative.2 Yet in the current age of highly effective direct acting antiviral therapy, this way of thinking needs to be re-evaluated. The utilization of HCV positive organs for negative patients necessitates many ethical, financial, and medical questions be addressed in a thorough fashion, ideally by the entire transplant community.

    The biggest hurdle in the utilization of HCV mismatch organs may relate to the ethical questions that arise from such transplants. Our medical school oath to “do no harm,” and the thought of knowingly “giving” someone HCV causes great hesitation; however, the transmission of cytomegalovirus (CMV) or Epstein Barr virus (EBV) in a seronegative recipient is rarely given a second thought. Treatment of CMV tissue invasive disease can be a significant though manageable challenge with severe cases causing morbidity and prolonged hospitalizations. Less frequently, EBV causes lymphomas necessitating chemotherapy and reductions in immunosuppression that can place the transplanted organs at risk of rejection. With the current state of treatment for HCV, patients receive a 12- to 24-week course of oral therapy that is often well tolerated with minimal side effects. De novo HCV infection almost never causes severe liver dysfunction, and with treatment response rates reported at 99-100% depending on the chosen direct acting antiviral regimen, post-transplant HCV should be a rather benign and easily treatable issue, especially when compared to PTLD or aggressive CMV. Given the treatability of HCV in the current era, use of these organs should flow from the basic tenets of medical ethics; with adequate informed consent, autonomous patients should have the option to proceed with these transplants.

    The next tenet of medical ethics, beneficence, may be a trickier ethical question to address. The framing of the question should not merely revolve around “should this patient get an HCV+ allograft or not?” Rather, the issue is “should this recipient get an HCV+ kidney or remain on dialysis for another year or two?” or “should this low MELD recipient take an HCV+ liver or not get transplanted at all?” Bowring et al recently described the risks to kidney recipients who decline kidneys labeled as “PHS Increased Risk” in terms of delays in transplantation.3 What further gains might patients be able to realize in terms of decreases in dialysis time by opting for a HCV mismatched organ and going through treatment after transplant?

    Once a program, surgeon, and patient are comfortable with the ethical issues regarding HCV mismatch, there are financial considerations to consider. While the early direct acting antiviral (DAA) therapies were reported to cost as much as $100,000, newer regimens are coming down in cost with estimates in the $25,000-35,000 range. When we compare these costs to the yearly costs associated with dialysis, earlier transplantation of kidney recipients might result in overall cost savings compared to waiting on dialysis for an HCV negative organ. Patients who are willing to accept HCV+ kidneys may be able to avoid dialysis altogether and realize the benefits of pre-emptive kidney transplant. As newer and more effective HCV therapies come to market and innovation and competition drive drug prices down, this will continue to be a more financially competitive option compared to years on dialysis.

    Utilization of HCV mismatch organs is not likely to be a one-size-fits-all solution as it relates to medical suitability, including long wait times and donor shortages. Does it make sense to give a 30-year-old who has not yet started dialysis an HCV+ kidney? Would it make sense if the average wait time in that recipient’s region was eight years and he was not expected to do well on dialysis? What if instead he had steatosis and grade 2 fibrosis? There are certainly patients where HCV mismatch makes a great deal of sense; older diabetic patients without living donors in regions with long waiting times are prime candidates to use HCV+ kidneys. Similarly, patients with persistently low MELD scores can benefit from liver transplant with HCV mismatch livers and DAA therapy afterwards.  

    The great efficacy that new DAA therapies for HCV have demonstrated has ushered in new opportunities for organ utilization. Given the rapidly increasing numbers of donors who are dying of drug overdose and who have HCV exposures, the transplant community has the opportunity and responsibility to utilize these organs for patients in dire need of lifesaving transplantation.

    References

    1. Chute DF, Sise ME. Effect of the Opioid Crisis on the Donor Pool for Kidney Transplantation: An Analysis of National Kidney Deceased Donor Trends from 2010-2016. Am J Nephrol. 2018;47(2):84-93. doi:10.1159/000486516
    2. Nowak KM, Witzke O, Sotiropoulos GC, et al. Transplantation of Renal Allografts From Organ Donors Reactive for HCV Antibodies to HCV-Negative Recipients: Safety and Clinical Outcome. Kidney Int Rep. 2017;2(1):53-59. doi:10.1016/j.ekir.2016.09.058
    3. Bowring Mary G., Holscher Courtenay M., Zhou Sheng, et al. Turn down for what? Patient outcomes associated with declining increased infectious risk kidneys. Am J Transplant. 2017;18(3):617-624. doi:10.1111/ajt.14577

     

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