Yohanna Seychelle, Naylor Kyla L, Sontrop Jessica M, Ribic Christine M, Clase Catherine M, Miller Matthew C, Madan Sunchit, Hae Richard, Ho Jasper, Roushani Jian, Parfeniuk Sarah, Jansen Melodie, Shavel Sharon, Richter Michelle, Young Kimberly, Cowell Brooke, Lambe Shahid, Margetts Peter, Piercey Kevin, Tandon Vikas, Boylan Colm, Wang Carol, McKenzie Susan, Longo Barb, Garg Amit X
Department of Medicine, McMaster University, Hamilton, ON, Canada.
St. Joseph's Healthcare Hamilton, ON, Canada.
Can J Kidney Health Dis. 2024 Feb 25;11:20543581241231462. doi: 10.1177/20543581241231462. eCollection 2024.
A key barrier to becoming a living kidney donor is an inefficient evaluation process, requiring more than 30 tests (eg, laboratory and diagnostic tests), questionnaires, and specialist consultations. Donor candidates make several trips to hospitals and clinics, and often spend months waiting for appointments and test results. The median evaluation time for a donor candidate in Ontario, Canada, is nearly 1 year. Longer wait times are associated with poorer outcomes for the kidney transplant recipient and higher health care costs. A shorter, more efficient donor evaluation process may help more patients with kidney failure receive a transplant, including a pre-emptive kidney transplant (ie, avoiding the need for dialysis). In this report, we describe the development of a quality improvement intervention to improve the efficiency, effectiveness, and patient-centeredness of the donor candidate evaluation process. We developed a One-Day Living Kidney Donor Assessment Clinic, a condensed clinic where interested donor candidates complete all testing and consultations within 1 day.
The One-Day Living Kidney Donor Assessment Clinic was developed after performing a comprehensive review of the literature, receiving feedback from patients who have successfully donated, and meetings with transplant program leadership from St. Joseph's Healthcare Hamilton. A multistakeholder team was formed that included health care staff from nephrology, transplant surgery, radiology, cardiology, social work, nuclear medicine, and patients with the prior lived experience of kidney donation. In the planning stages, the team met regularly to determine the objectives of the clinic, criteria for participation, clinic schedule, patient flow, and clinic metrics.
Donor candidates entered the One-Day Clinic if they completed initial laboratory testing and agreed to an expedited process. If additional testing was required, it was completed on a different day. Donor candidates were reviewed by the nephrologist, transplant surgeon, and donor coordinator approximately 2 weeks after the clinic for final approval. The team continues to meet regularly to review donor feedback, discuss challenges, and brainstorm solutions.
The One-Day Clinic was implemented in March 2019, and has now been running for 4 years, making iterative improvements through continuous patient and provider feedback. To date, we have evaluated more than 150 donor candidates in this clinic. Feedback from donors has been uniformly positive (98% of donors stated they were very satisfied with the clinic), with most noting that the clinic was efficient and minimally impacted work and family obligations. Hospital leadership, including the health care professionals from each participating department, continue to show support and collaborate to create a seamless experience for donor candidates attending the One-Day Clinic.
Clinic spots are limited, meaning some interested donor candidates may not be able to enter a One-Day Clinic the same month they come forward.
This patient-centered quality improvement intervention is designed to improve the efficiency and experience of the living kidney donor evaluation, result in better outcomes for kidney transplant recipients, and potentially increase living donation. Our next step is to conduct a formal evaluation of the clinic, measuring qualitative feedback from health care professionals working in the clinic and donor candidates attending the clinic, and measuring key process and outcome measures in donor candidates who completed the one-day assessment compared with those who underwent the usual care assessment. This program evaluation will provide reliable, regionally relevant evidence that will inform transplant centers across the country as they consider incorporating a similar one-day assessment model.
成为活体肾供体的一个关键障碍是评估流程效率低下，需要进行30多项检查（如实验室检查和诊断检查）、问卷调查以及专家会诊。供体候选人要多次前往医院和诊所，并且常常要花费数月等待预约和检查结果。在加拿大安大略省，供体候选人的评估时间中位数接近1年。等待时间越长，肾移植受者的预后越差，医疗费用也越高。更短、更高效的供体评估流程可能有助于更多肾衰竭患者接受移植，包括接受 preemptive 肾移植（即避免透析的需要）。在本报告中，我们描述了一项质量改进干预措施的开展情况，以提高供体候选人评估流程的效率、有效性和以患者为中心的程度。我们设立了一日活体肾供体评估诊所，这是一个精简的诊所，有意向的供体候选人可在1天内完成所有检查和会诊。
一日活体肾供体评估诊所是在对文献进行全面综述、收集成功捐献者的反馈意见以及与汉密尔顿圣约瑟夫医疗中心的移植项目负责人会面后设立的。成立了一个多利益相关方团队，成员包括来自肾脏病学、移植外科、放射学、心脏病学、社会工作、核医学的医护人员以及有过活体肾捐献经历的患者。在规划阶段，该团队定期开会，以确定诊所的目标、参与标准、诊所日程安排、患者流程以及诊所指标。
如果供体候选人完成了初步实验室检查并同意采用加速流程，他们就可以进入一日诊所。如果需要进行额外检查，则在另一天完成。诊所结束约2周后，肾脏病医生、移植外科医生和供体协调员会对供体候选人进行复查，以做出最终批准。该团队继续定期开会，审查供体的反馈意见，讨论挑战，并集思广益寻求解决方案。
一日诊所于2019年3月实施，现已运行4年，通过持续收集患者和医护人员的反馈意见进行迭代改进。迄今为止，我们已在该诊所评估了150多名供体候选人。供体的反馈一直是积极的（98%的供体表示他们对诊所非常满意），大多数人指出诊所效率高，对工作和家庭义务的影响最小。医院管理层，包括各参与科室的医护人员，继续表示支持并合作，为参加一日诊所的供体候选人创造无缝体验。
诊所名额有限，这意味着一些有意向的供体候选人在提出申请的当月可能无法进入一日诊所。
这种以患者为中心的质量改进干预措施旨在提高活体肾供体评估的效率和体验，为肾移植受者带来更好的预后，并有可能增加活体肾捐献。我们的下一步是对诊所进行正式评估，收集在诊所工作的医护人员和参加诊所的供体候选人的定性反馈意见，并衡量完成一日评估的供体候选人与接受常规护理评估的供体候选人的关键流程和结果指标。这项项目评估将提供可靠的、与当地相关的证据，为全国的移植中心在考虑采用类似的一日评估模式时提供参考。
