377 Restructuring of a pancreas transplant programme following CUSUM triggers through implementation of external peer review recommendations: A service review
Monday November 16, 2015 from 17:30 to 18:30
Plenary Room 1

Zia Moinuddin, United Kingdom

Clinical Research Fellow

Department of Transplantation

Manchester Royal Infirmary


Restructuring of a pancreas transplant programme following CUSUM triggers through implementation of external peer review recommendations: A service review

Zia Moinuddin1, Aneeza Arif1, Hemant Sharma1, Omar Masood1, Afshin Tavakoli1, Ravi Pararajasingam1, Kay Poulton1, Judith Worthington1, Bence Forgacs1, Titus Augustine1, Raman Dhanda1.

1Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, United Kingdom

Background: In the UK, NHS Blood and Transplant (NHSBT), the national transplant regulatory body, monitors centre specific performance in terms of 30-day graft loss and patient mortality by CUmulative SUMmation statistical methodology (CUSUM). A CUSUM trigger is generated each time the observed rate of graft loss and/or mortality exceeds the expected rate (1.2% for patient mortality and 10% for graft loss). Between September 2010 and June 2013, 4 triggers were identified in Manchester related to 15 graft losses. This initiated a centre generated invited external review (IER) followed by a formal NHSBT review (NHSBTR). All pancreas graft losses (n=18) and the major surgical complications (portal vein thrombosis, arterial thrombosis, enteric leaks and graft pancreatitis) between 2011-2013 were peer reviewed. The underlying reasons were deemed to be technical failure and prolonged cold ischaemia time (CIT) (Range: 12-17 hrs). The recommendations of IER and NHSBTR were to develop the following:
- Uniform agreed protocols for recipient assessment, selection and information
- Standardized donor selection criteria
- Clinics for assessment and monitoring of patients on waiting list
- Pancreas transplant specific listing multi-disciplinary team (MDT) meetings
- Standardized, uniform surgical technique for pancreas transplantation
- Logistical pathway to reduce cold ischaemia time
- Consensus-based management of post-operative complications

This study explores the process of restructuring the programme in the wake of the review and its subsequent impact on outcomes after pancreas transplantation.

Methods: In line with the peer review recommendations, a new restructured uniform unit protocol was developed along with agreed guidelines. Dedicated clinics, MDT meetings and standardised patient information booklets, assessment, anaesthetic management, post-operative and follow-up care plans and documentation were developed. Education of multidisciplinary staff was undertaken to ensure strict adherence to a time-efficient logistic pathway and the use of virtual crossmatching to enable a reduction in CIT was expanded. Surgical technique across the entire team was standardised. The use of  separate teams for back-benching and implantation was made mandatory.

The key clinical outcomes were compared between 2 periods:
Period 1 (before change in practice): January 2012 – June 2013
Period 2 (after change in practice): July 2013 – February 2015

Results: 48 transplants were performed in period 1 and 52 in period 2. There was a significant increase in the number of virtual crossmatches reported in period 2 (24/48, 50% v/s 49/52, 94%; p<0.0001, Chi-square test). In period 2, there was a significant reduction in CIT (median 760 min v/s 387 min) (p<0.0001, unpaired t-test), re-exploration rate (39.5% v/s 25.0%) and major surgical complications rate (37.5 % v/s 9.6%) (p=0.0236, Chi-Square test) (period 1 v/s period 2). Pancreatic graft loss was also significantly reduced from 29% in period 1 to 6% in period 2 [p=0.0062, Chi-square test], as was the mean hospital stay (28 days in period 1 to 19 days in period 2) [p=0.028, unpaired t-test].
Conclusion: Restructuring the pancreas transplant programme following an external peer review has led to significantly reduced CIT (now the lowest in the UK) and resultant improved graft and patient outcomes. This illustrates the positive impact a peer review can have on improving the overall quality and outcomes of a national service.

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