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‘Paucity’ of transplant infrastructure leaves services ‘vulnerable to failure’

By Catherine Reilly - 17th Dec 2023

A “demand capacity mismatch” has left transplant services “vulnerable to service provision failure” in surge periods, a HSE review found.

The internal review, finalised in December 2022, referenced a “paucity” of dedicated infrastructure and specialist staff for provision of complex care to these patients who have unique care requirements due to immunosuppression and multiple co-morbidities. It said the capacity issues were also causing staff recruitment and retention difficulties.

The review, obtained under Freedom of Information law, was commissioned after the cancellation of an organ transplant at the Mater Misericordiae University Hospital, Dublin, in late 2021. The transplant was cancelled due to lack of critical care capacity following a surge in Covid-19 cases. This matter was examined in a separate serious incident report.

According to the wider review, the requirements for transplant services and patients had not been formally mapped-out, costed, or future-adjusted, and the governance for these services was “splintered”.

Executive powers rested entirely with Hospital Groups and transplantation had to compete with other service requirements. The clinical prioritisation of unscheduled care over all other services resulted in resources funded for transplantation being redirected.

There was also “limited information” available to manage the transplant process and drive performance improvement.

The review noted organ retrieval predominantly occurred out-of-hours because the donor hospital usually did not have emergency theatre space to accommodate retrieval during normal working hours.

“The restrictions of cold ischaemia time determines the timing of implantation, this all forces the whole process ‘out-of-hours’. When organs for donation are made available to the transplant centre the next day, [this impacts] elective surgery lists.”

Capacity shortfalls relating to protected beds, specialist staff, theatre access, and critical care were raised in the review.

In regard to renal transplant at Beaumont Hospital, Dublin, for example, it was noted deceased donor transplantation (which usually involves two transplants per donor) competed for access to the emergency theatre.

As Beaumont was the site of the national neurosurgical centre and had an expanding catchment population, the demand for access to this theatre was “overwhelming”.

“To access the theatre with two transplants, which can occupy the theatre for between six to 10 hours at any given time, [would mean] other emergency cases are deferred. Transplant surgeons have to frequently ‘negotiate’ with other colleagues as to which emergency is most pressing or can the transplant surgery be delayed to allow life or limb saving surgery to proceed instead. This has led to prolonged cold ischaemia times of over 20 hours in approximately 20 kidney transplants last year, which in turn, contributes to [the risk of] delayed graft function.”

At the Mater, general cardiac and thoracic cases competed for finite resources with the lung and heart transplant service as well as general emergency and acute cases.  This meant that cardiac and thoracic, including cancer, cases were regularly cancelled when a transplant was being carried out, either due to lack of theatre provision or ward/ICU beds.

In common with the other programmes, the liver and pancreas transplant programmes at St Vincent’s University Hospital in Dublin competed for the same resources required for other emergency and urgent care cases.

Liver transplants took place in the same theatre as scheduled hepatopancreaticobiliary (HPB) cases so transplantation between Monday and Friday typically resulted in cancellation of two major HPB cases. Pancreas transplants usually occurred in one of the other gastrointestinal surgery theatres, again displacing scheduled (usually cancer) cases.

According to the review, increasing capacity so that patients with different urgent care needs are not competing for the same resources is fundamental to providing a consistent, quality-assured service.

“Transplantation is a highly effective therapy for complex patients with very acute healthcare needs. The relative scarcity of organs and the loss of individuals whilst on transplant waiting lists confers an urgency to this therapy that needs to be taken into consideration by the Government, the Department of Health, the HSE, and the hospital system when resourcing and implementing this service.”

Among the review recommendations was a formal strategy to quantify the requirements for transplantation services and an increase in critical care capacity to meet the requirements for all patients.

A HSE spokesperson said it is developing a strategy for organ donation and transplant services to deliver required outputs for the next 10 years.

The strategy is at final draft stage and will be presented to the HSE executive management team in early 2024.

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