Medical Director Bulletin

Organ and Tissue Donation and Transplantation Directorate

October 2024

A message from Professor Derek Manas, Medical Director OTDT:

Hello again from me and the clinical team. 

It’s suddenly November and before we know it Christmas will be upon us again. 

I’d like to start as usual by saying goodbye to some colleagues:

Our current chair of CTAG(H) Venkat Rajamiyer is making a move across the pond to Birmingham, Alabama. Venkat has been part of the fabric of cardiothoracic transplantation in Manchester for many years and has been the CTAG(H) chair for just over 4 years. He has been committed, diligent and focused on meeting the need to improving heart transplantation in the UK. He has been a pleasure to work with and will be ‘sorely’ missed. We wish him all the best in his future endeavours.

The second person we say goodbye to is Dr Diana Garcia Saez who has served as the cardiothoracic CLU lead in Chris Callaghan's team since its inception. Diana has been a committed and worthy advocate for the cardiothoracic clinical leads in organ utilisation and has been an amazing support for Chris and the utilisation team. We will miss her ‘dulcet’ tones and perspective. We also wish her well in her future career.

My AMD colleague Rommel Ravanan has completed his term as KAG Chair. Over the past 6 years his attention to detail, commitment and talent for process driven change has ensured that KAG has been one of the most functional and agile advisory groups. We thank Rommel for all he has done for kidney transplantation during some difficult times, especially during the pandemic and I am pleased to say that it's not a goodbye as Rommel remains in his AMD role within the clinical team, leading on Research & Development (R&D) and Transplant Innovation.

Finally, it's goodbye to David Briggs. David, as many of you know, is a well-respected Senior H+I Consultant in Birmingham and over his career was very engaged with the clinical community and the British Transplantation Society. David retired and returned and, as a special favour to us, stepped into Tracey Rees's role when she retired. David is now retiring completely, and I'd like to thank him for supporting us over the last year and wish him all the best for his retirement.

I’d like now to welcome two new members to the clinical team:

Aaron Ranasinghe who is a Cardiothoracic Surgeon in Birmingham. Aaron has been part of the extended clinical family – in his role as Lead Heart CLU - but has now been appointed as the Chair of CTAG(H) and will take over from Venkat on the 1 December 2024. He will relinquish his role as Lead Heart CLU and this role will be advertised in the new year – so look out for it (his appointed Deputy Chair will be Dr Steve Pettit, a Cardiologist from Papworth). So welcome both.

The second new appointment is Dr Gareth Jones who will take over as Chair of KAG on the 1 December 2024. Gareth is a Senior Nephrologist at the Royal Free Hospital and is well known in renal transplant circles. Gareth is not really new to the clinical team as he has been the National Lead for Collaboratives for some time now. He will be supported in his collaborative lead role by Mr Ben Stutchfield from Edinburgh as his Deputy Lead, welcome both.

The Headlines

SCORE

The Sustainability and Certainty in Organ Retrieval continues to progress well. All the advisory groups have now been briefed on the planned retrieval/arrival window and planned allocation/offering window and Phil Walton will be engaging with stakeholders. The workforce work-stream have produced their recommendations and many of you would have received some email correspondence about establishing retrieval collaboratives. The transport work-stream are due to start deliberations.

Histopathology

Implementation decisions on the national plan business case is still awaited from NHS England but the interim plan has progressed well with funding for the scanner update agreed and a revenue stream to pay pathologists is in its final stage. Once we have a ‘go-live’ date I will let you know.

Living Donor Liver Transplantation

I am pleased to report that Eight pairs have been referred into the scheme and the first successful proctored adult–adult living donor liver transplant went ahead on the 29 October. The website has been populated with all the information centres need to engage the proctor team and there is educational resource for clinicians and patients as well as a link to patient educational films available. I would like a add my thanks to Lisa Burnapp who leads the program and the entire proctor team for their commitment to this project.

Cardiothoracic Review

In response to Recommendation 5 of the OUG Report, a comprehensive information gathering exercise was completed by DHSC (with representation from NHSE and NHSBT) at the end of May. That report is now in the public domain, and I would recommend you have a look at it on the Government website.

The NHS England Review of Cardiothoracic Transplant Services led by Maggie Kemner and Mr Simon Kendal is now underway, and the ICE report will help to inform that. I’d like to congratulate Mr Marius Berman from Papworth and Dr Anna Reed from Harefield who have been appointed to the review team as subject matter experts.

ISOU & OUG

ISOU

A Commissioning Symposium is set for the 6 November 2024, and will focus on strengthening collaboration between NHSE and NHSBT.

The Trust Engagement Sub-Group chaired by Chris Callaghan and Mark Cubbon have met four times to date, focusing on OUG Recommendation 10 and the development of a framework for Trusts/Boards to help them develop local Organ Utilisation strategies.

The group are encouraging Trusts to have a named Executive Sponsor and for them to develop and own their own strategies. The framework is expected to be developed by early 2025, with socialisation in late 2024. Letters have been previously disseminated to clinicians and CEOs to raise the profile of this work.

The Genomics Subgroup chaired by Rommel Ravanan and Richard Battle have now produced a draft report on their recommendations and I hope to give a further update in future bulletins.

The Xenotransplantation Subgroup chaired by John Iredale and Anthony Clarkson have met on six occasions and have focused on the regulatory environment as well as patient and public attitudes to pave the way for the future. Their report is eminent.

The ARC subgroup chaired by John Cassey and Shamik Gosh have had three meetings. They have had engagement with NHSBT and have had sight proposal submitted to DHSC for a national plan for ARCs. They are due to submit recommendations early in the new year.

OUG Implementation

Recommendation 3 - CLUs

NHSBT are focused on 3.1 (establishing decline meetings in all units), 3.3 (non-clinical declines pathway) and 3.6 (CLUs in every unit).

3.6 has been completed, pending identification of sustainable funding, and with some minor changes to CLU job descriptions to be made. 3.1 has been completed also, with work ongoing to standardise the decline meetings in units. 3.3 will require re-activation with some changes to data distribution channels, both of which are relatively easy to cover. Most work on this recommendation is already completed, with just a few larger pieces of work building on the recommendations in progress.

Organ Utilisation has increased, and this will be due to a combination of the impact of CLUs on culture change and use of machine perfusion technology. Some possible metrics have still been developed.

Recommendation 4 - Transplant Collaboratives

We are in the process of establishing the Transplant Collaboratives, with Renal Collaboratives fully rolled out and Liver Collaboratives in the process of being set up. Pancreas and Cardiothoracic Collaboratives are in the next phase. There is ongoing work to firm up on the governance and outcome measures of the transplant collaboratives.

Recommendation 8 - ARCs

A proposal to develop a National ARC plan was developed, led by Laura Barton and Ben Hume and supported by Deloitte and many members of the clinical team. This has been submitted in September to DHSC for the Spending Review bid. This included an outline of the scope of work, the estimated activity and a high-level logistics pathway.

ERAS, Clinical Collaborative, Sustainability Agenda

The Early Recovery after Surgery for transplant patients (ERASTx) continues to progress well. ERAS for Kidney Transplantation is complete and there is a comprehensive portfolio of information and educational resource on the website. ERAS for Liver transplantation will be completed soon and pancreas and lung to follow. Thank you to Carrie Scuffell and Lisa Burnapp for all their hard work.

A National Kidney Collaborative Engagement meeting is planned for the 9 December 2024 in London and many of you would have been emailed. Please ensure you have adequate representation at the meeting.

The OTDT Environmental Sustainability Working Group led by Matt Wellberry-Smith continue to provide the transplant community with resources to help reduce the environmental impact of transplant activity. Matt will provide an update in the next bulletin.

BTS Monothematic Meetings

On the 7 November, British Transplantation Society held a meeting on aging in transplantation and on the 8 November they hosted members of the the international living Donor liver transplant society to discuss the current state of living liver donation.

Adult to Adult Living Donor Liver Transplant Proctor Program

This program went ‘live’ in mid-July, and we have had 8 pairs referred into the proctor team. They have successfully proctored their first transplant at the Royal Free Hospital on the 29 October. I would like to congratulate the team for their commitment to this project and thank Lisa Burnapp for her leadership. Again, I would urge you to look at the website and review the excellent information and educational recourses that are available.

iOrbit Project

The lack of corneal tissue remains a priority for NHSBT, and I am pleased to report the the first of the new eye retrieval schemes has been rolled out.

Other

Consent to Organ Donation remains lower than expected at 61% and we are continuing with several initiatives on several fronts. We are in the early stages of planning a Consent Summit in the new year.

Islet Summit

Islet Isolation Laboratories have been under immense pressure over the last year due to the temporary closure of Kings isolation facility. This has highlighted the lack of sustainability and resilience in the service. On the 10 December 2024, we will be holding an Islet Summit in London to look at future proofing the service.

Yours sincerely,

Professor Derek Manas
Medical Director – OTDT
NHS Blood Transplant

Message from Laura Barton, OTDT Programme Manager:

Assessment and Recovery Centres – Spending Review Bid

In September, NHSBT submitted a Spending Review bid to progress the delivery of the Assessment & Recovery Centres service, given the significant benefits this offers to patients, the wider NHS and UK economy.

Thank you to all of the members of the ARCs Bid Team for their intensive efforts over the summer to pull this together.

Why do we need ARCs?

Demand for organ transplants is increasing across the UK at a greater pace than transplant activity – contributing to growing transplant wait lists. With a national ARC service, we can truly honour the gift of donation through:

• Achieving the best possible outcomes for patients
• Increasing organ utilisation, maximising the number of lives that can be saved through deceased donation and reducing transplant wait times
• Addressing urgent and serious workforce sustainability and logistics challenges
• Using mature machine perfusion techniques to improve safety within organ transplantation

ARCs have the potential to deliver an additional 750 transplants per year, with significant patient, clinical, financial and environmental benefits.

What is next?

We await an update from the Department of Health and Social Care regarding funding, as well as recommendations to be made by the ISOU ARCs Subgroup. With the support of NHSBT’s Board, we are using every opportunity to promote the ARCs service and bid – including a machine perfusion demonstration to Baroness Marron during her recent visit to Filton.

Otherwise, some of the immediate priorities for an ARCs Programme would comprise:

• Service specification development
• Commissioning options appraisal
• Industry collaboration strategy
• Digital discovery & team impact assessments
• Designing operating models and defining testing approach

To hear more

For more information, please contact our Organ Utilisation Programme Manager: laura.barton@nhsbt.nhs.uk.

Message from Rachel Hogg, Senior Statistician, Statistics & Clinical Research Team:

Performance indicators for organ retrieval surgery have historically been challenging to derive. In practice, arbitrary figures are often selected, against which data of uncertain quality are compared. It is not possible to use such data to improve practice, and commissioners are unable to rely on such material to monitor performance.

As a result of developments over the last 4 years in data quality assurance and organ damage assessment in OTDT, it has been possible for the first time to derive robust performance indicators for organ retrieval surgery at a national level.

Key performance indicators are a fundamental part of quality management. The quality of organ retrieval surgery is particularly important, given the effect on multiple organ recipients that one donor operation might have. The drive towards high quality data assurance began some years ago with a re-classification of organ damage scales to make them more clinically robust and to implement clinical review for cases of organ loss, significantly improving data reliability.

Rachel Hogg (Senior Statistician), working with Emma Billingham (Head of Commissioning) and Ian Currie (Associate Medical Director, (Retrieval) OTDT), has now provided the raw data and interpretation which allows performance statistics to be derived for important steps in the organ retrieval operation, including timings for those steps which critically affect outcome.

As examples, the two graphs above show the times by which 50% and 90% of livers are placed in ice in DBD and DCD donors. These show very clearly how one might set a target such as 30 minutes in DBD and 35 minutes in DCD. Similar data are now available for a broad range of steps in organ retrieval which will provide evidence-based KPIs in organ retrieval surgery. Unfortunately, such timings are not available for kidney or pancreas, work is in progress to collect these on the registry.

SCORE (Sustainability & Certainty in Organ Retrieval) Update

The SCORE Programme has been established for over a year now and in the that time key recommendations have been developed by the workstreams:

• NORS Service Model Workstream - A move away from 24/7 arrival of retrieval teams at the donor hospital to a planned arrival window (PAW) for retrieval teams between 8pm and 3am.
• Donation Workstream - A move away from 24/7 organ offering to daytime offering.
  
  

Extensive engagement has been undertaken with colleagues across the Donation, Retrieval and Transplant Pathway to identify the impacts of these key recommendations. Further engagement is planned as we start to think about how to implement the changes required to improve certainty across the pathway and to improve future sustainability.

Thank you to all colleagues who have engaged with the SCORE programme and assisted the team to identify the impacts of the recommendations. We look forward to your continued support as we move into the planning stage to bring these key changes to implementation in the future.

More detailed information for these and the other Workstreams can be found in the SCORE autumn update.

You can also access the answers to frequently asked questions about the SCORE programme document.

If you would like to engage with the SCORE team regarding any aspect of the SCORE Programme please contact us at score@nhsbt.nhs.uk

Message from Laura Stamp, Lead Nurse recipient Coordinator:

The NHSBT/BTS Induction Course for Recipient and Living Donor Transplant Coordinators

The 8^th Recipient and Living Donor Coordinator annual induction course was held in Stoke Gifford, Bristol, on 2 and 3 October 2024. The induction course offers transplant coordinators a robust learning programme covering the organ donation, retrieval and transplantation pathways. There was representation from the Cardiothoracic, Liver, Pancreas/Islet, Renal, Paediatric and Living Donation professional communities, which made for rigorous discussion and excellent networking opportunities.

Thanks to all the expert speakers who gave their time to deliver exceptional sessions and supportive question and answer sessions. From 2025, the 2-day annual induction event will adapt to a blended learning approach, combining a digital learning component in addition to in-person delivered content. 

The development of digital learning materials was made possible by a successful bid from Higher Education England (HEE), who provided a grant which will ensure the longevity and sustainability of the course in the coming years. More details will be shared in the New Year.

Message from the OTDT Professional Development Team - Medical Education Update:

This quarter has been an opportunity for Associate Medical Director for Deceased Donation Dr Dale Gardiner, National Research Innovation CLOD Dr Dan Harvey and National Medical Education CLOD Dr Ben Ivory to focus on supporting leadership.

Diagnosis of Death using Neurological Criteria

The Academy of Medical Royal Colleges (AoMRC) are due to launch an update of A Code of Practice for the Diagnosis and Confirmation of Death on 1 January 2025 with notable changes to the diagnosis of death using neurological criteria (DNC).

Changes anticipated to DNC include:

• A change to the time of death
• Changes to the apnoea test
• Changes to age categories
• Clarifications around conditions and personnel eligible to test
• Consideration of preconditions, rather than ‘red flags’, including a change to a higher acceptable minimum sodium concentration
• Expanded ancillary investigation guidance, and
• Greater alignment to the rest of the world
  
  

This update will necessitate CLODs, as local leaders who are more likely to be familiar with the existing code, to be fully briefed and participate in the education plan of this update, engaging clinical colleagues to support the changes to come. Bringing greater confidence and safety around testing with the updated code for DNC will be important, particularly where donation features.

In response to AoMRC’s updated code, NHSBT’s education plan will include:

• Accessible video summary guides by Dr Gardiner outlining both changes to the code and the associated form, available to all NHSBT OTDT stakeholders. This should provide consistency in messaging of the changes across a range of disciplines.
• Updates to the ODT Clinical website resources on donation after brainstem death
• Engagement opportunities to explore practical implementation and challenges as the changes embed

Consultations across a variety of stakeholders of the proposed updated form continue and the monthly Regional CLOD leaders meeting enabled an opportunity for regional leaders to discuss and give thorough consideration to it and it’s implementation.

NHSBT OTDT CLOD Induction North 8 and 9 October in Newcastle

Our most recent CLOD Induction was an opportunity to pilot the DNC changes summary guides and meet a new cohort of CLODs from across the UK.

Increasingly, we find new CLODs have attended the National Deceased Donation course as a speciality trainee doctor which now enables the CLOD Induction course to focus more on the leadership of aspects of their donation practice rather than the practice itself. To our delight, on this occasion, we were able to welcome a couple of new CLODs who were graduates of the TROD (Trainee Representative in Organ Donation) scheme, keen to maintain their donation experience in a CLOD role. We look forward to this being more common in the future.

Message sent on behalf of Mr Ian Currie, Associate Medical Director (Retrieval), NHSBT Consultant Surgeon Royal Infirmary of Edinburgh & Mr Marius Berman, Chair of the Organ Retrieval Advisory Group (RAG) NHSBT, Consultant Cardiothoracic and Transplant Surgeon and Surgial Lead for Transplantation and MCS , Royal Papworth Hospital:

National Organ Retrieval Services Virtual Masterclass

The Masterclass Organising Group have been diligently behind the scenes securing our faculty and preparing the programme for the upcoming National Organ Retrieval Services (NORS) Virtual Masterclass scheduled for the 12-14 November 2024.

This Masterclass offers a comprehensive 3-day programme and is open to all UK and International delegates. Additionally, there is an option to attend only on day one, which is specifically open to all NHS Blood and Transplant staff interested in organ donation, retrieval and transplantation.

The course is designed for practitioners with an interest in abdominal and cardiothoracic organ retrieval and transplantation, as well as surgeons focused on solid organ retrieval from deceased donors. We also welcome healthcare professionals with an interest in organ donation, organ retrieval and organ preservation including perioperative practitioners, perfusion specialists, Specialist Nurses-Organ Donation, Clinical Leads in Organ Donation (CLODs) and intensivists.

This year, we will be broadcasting live from York combining virtual presentations, with in-person collaboration to reduce travel while maintaining engagement. Registrations will be closing soon to allow our admin/events management team to send out the joining instructions.

UK National Organ Retrieval Services Cadaveric Masterclass

Both the Virtual Retrieval Masterclass and the Cadaveric Retrieval Masterclass are mandatory for those seeking full registration as a NORS surgeon. The UK National Organ Retrieval Cadaveric Masterclass course is for UK surgeons seeking full registration with NHS Blood and Transplant to lead their NORS team and perioperative practitioners involved in organ retrieval and preservation.

This year’s course will be held at the Cambridge Surgical Training Centre. Flyers have been distributed to retrieval and transplant centres through centre directors and advisory groups. Registrations open mid-October.

For further details please contact: Professional.DevelopmentODT@nhsbt.nhs.uk or look online at the NHSBT Organ Retrieval Virtual and Cadaveric Masterclass 2024 webpage.

Message from the OTDT Patient Safety Team:

Dear Colleagues,

Following the recent OTDT CARE meeting I wanted to let you all know that we are changing the Clinical Governance team’s name and job titles within OTDT.

The change will be to simply change the term “Clinical Governance” for “Patient Safety” which of course continues to encompass donors, and donor families as well as recipients so:

Clinical Governance Team > Patient Safety Team - OTDT

Clinical Governance Lead > Patient Safety Lead - OTDT

Clinical Governance Manager > Patient Safety Manager OTDT

It’s a change we have wanted to make for some time to be in line with the wider NHS, I am sure those working with colleagues in NHS trusts are aware of this. However, the main reason is this better reflects what we do which is of course all about patient safety!

Could I ask if needing to email the team to use the new email address: PatientSafety.OTDT@nhsbt.nhs.uk

This will continue to include OTDT QA who we work closely with.

The old email address: clinicalgovernance.odt@nhsbt.nhs.uk will remain in use for a period whilst we update documents and other external reference points such as websites and SharePoint.

Do bear with us whilst we work through the change requests for OTDT Documents – as I am sure you appreciate the team & email is referenced in many! Please let me know if you have any questions and share with your teams.

Kirsty McNally

Patient Safety Lead OTDT

NHSBT Blood & Transplant

Learning, Sharing, Strengthening

Mobile  07764280426

Clinical Website www.odt.nhs.uk

Cautionary Tales-Sharing Learning from Events across the Organ Donation & Transplant Pathway.  ODT Clinical Governance Team Newsletter, Issue 34, September 2024

The attached newsletter has been provided by Jeanette Foley, Deputy Chief Nurse OTDT, for information:

• Cautionary Tales Issue 34, September 2024

Message from Tanya MacHale, Business Support Manager (MDGS Team):

National Organ Utilisation Conference: 16 September 2024

The 4^th National Organ Utilisation Conference took place on the 16 September 2024. This year’s conference was held at the Education Centre within the Queen Elizabeth Hospital, Birmingham. The theme of this year’s conference was ‘Striving for Synergy’. The primary aim was to explore some of the pressing issues in UK deceased donor organ utilisation, especially those arising from the recent Organ Utilisation Group report.

The conference brought together UK transplant surgeons, transplant physicians, recipient transplant co-ordinators and other colleagues in a one-day face-to-face meeting. It was well attended by more than 130 colleagues from all over the country.

Delegates highlighted the impressive talk ‘Life at the Sharp End: Adventure Medicine and Transplant Surgery’ by Chris Imray, Consultant Vascular & Renal Transplant Surgeon, UHCW, along with the update ‘NHSBT Annual Organ Utilisation Report’ by Jenny Mehew, Principal Statistician, NHSBT.

Topics suggested for future conferences included organ/machine perfusion and Sustainability and Certainty in Organ Retrieval (SCORE).

Message from Katy Latham (National Head of H&I/Consultant Clinical Scientist) & Liz Armstrong (Head of Transplant Development):

OTDT and the Solid Organ Advisory Groups (SOAG) require expert advice on matters relating to Histocompatibility & Immunogenetics (H&I) and the use of H&I information in allocation and transplantation.

A pilot commenced in 2024 whereby H&I support to OTDT from Clinical Services H&I was provided under the leadership of the Consultant Clinical Scientist & National Head of H&I. In September, the OTDT Senior Management Team (SMT) endorsed the recommendation for H&I support to be permanently provided by NHSBT H&I (OTDT H&I Lead) with flexibility to respond to incidents and projects for a minimum of 1 day per week, up to 2 days per week.

We are grateful to Professor David Briggs who has been the OTDT H&I Lead during the pilot, and we look forward to sharing with you the new OTDT H&I Lead.

Please do continue to send any enquires to OTDTHandIsupportrequests@nhsbt.nhs.uk