LUHS Tissue Program by yurtgc548

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									Tissue Transplantation Services:
    Coming into Compliance
    Phillip J. DeChristopher, MD, PhD, Chair
    Anne Link, MT(ASCP), Tissue Coordinator
    Meg Kim, RN, OR Manager

    Committee Representatives from:
       • Russo Operating Room
       • Ambulatory Surgery Center
       • Oral Health
       • Center for Clinical Effectiveness
       • Clinical Laboratories
       • Hospital Administration
       • Materials Management
       • Patient Safety and Risk Management
       • Purchasing
                                          Confidential: For Quality Improvement Purposes Only
               Aim Statement
•   Tissue Transplantation is a common practice in Loyola’s OR,
    ASC, and Oral Health Center.

•   In July 2005, the FDA and The Joint Commission (TJC)
    introduced new regulations and standards to ensure safe
    practices for tissue management.

•   New systems were required to:
      Acquire, receive, store, and issue tissue
      Trace the use of tissue bi-directionally
      Investigate and follow-up on adverse events related to tissue
       use and donor infections

•   The goal of this project was to standardize processes for tissue
    management at Loyola to ensure compliance with federal
    regulations and TJC standards.
                                                 Confidential: For Quality Improvement Purposes Only
    Project Measures of Success
To achieve a minimum of 90% compliance with the following measures:

Tissue Receipt
•   Package integrity and transport temperature are documented for incoming
    tissue

Tissue Tracking
•   Tissues received are documented on the incoming tissue log

Tissue Storage
•   Daily temperatures for equipment and storage spaces are documented and
    corrective action is taken when temperatures are out of range

Tissue Preparation
•   Materials used to prepare and/or process tissue are documented

                                                    Confidential: For Quality Improvement Purposes Only
 The program manages over 70 different
types of tissue products from 40 vendors.

 Services that regularly use tissue include:

            • Cardiovascular
            • Neurology
            • Ortho
            • Burns / Plastics
            • General Surgery
            • Ophthalmology
            • Oral Surgery
                                 Confidential: For Quality Improvement Purposes Only
    Solutions Implemented

•   Formed a multi-disciplinary Tissue Services Committee
•   Created/hired a new position - Tissue Coordinator
•   Consolidated tissue storage in the main OR, ASC and Oral
    Health
•   Replaced an OR freezer
•   Installed and validated an electronic, continuous-temperature
    monitoring and alarm system
•   Developed and implemented a Tissue Services Policy Manual
•   Implemented standardized processes permitting traceability
    and auditing of tissue transplanted, including ongoing
    reporting of incidents or non-conformances

                                              Confidential: For Quality Improvement Purposes Only
                                           Documentation of Package Integrity and T ransport T emperature
                            UCL = 134.10




                                                   Jan 07: All tissue is checked
                     120




                     100

                            Mean = 91.55



                      80
Percent Compliance




                      60                                                                                                               July 07: Packing slips for 26 items
                            LCL = 49.00
                                                                                                                                            were not scanned/saved

                      40




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                                                                                     Confidential: For Quality Improvement Purposes Only
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  Prior to 2007: Data applies only to certain frozen bone
  Jan 07- Present: Data applies to all tissue
                                                                                 Log- In of Incoming T issue
                            UCL = 110.48
                     110
                                                                            Jan 07: All tissue is logged

                     100




                      90    Mean = 88.50




                      80
Percent Compliance




                      70
                            LCL = 66.52


                                                       Confidential: For Quality Improvement Purposes Only
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  Prior to 2007: Data applies only to certain tissue
  Jan 07-Present: Data applies to all tissue
                                                          Documentation of Storage Device T emperature
                     100               June 07: Implementation of the Rees
                            UCL = 98.99    Temperature Monitoring System




                      95
                            Mean = 93.95
Percent Compliance




                      90
                            LCL = 88.91




                      85

                                                                       Jan 07: Began temperature monitoring
                                                                               for all tissue storage devices


                                                                            Confidential: For Quality Improvement Purposes Only
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  Prior to 2007: Data applies only to refrigerated and frozen tissue
                                                                   Documentation of T issue Preparation
                            UCL = 105.67

                     105




                     100




                      95

                            Mean = 92.65
Percent Compliance




                      90




                      85




                      80    LCL = 79.63




                      75


                                Jan 07: Began
                      70                monitoring
                                        for all tissue
                                                                                     Confidential: For Quality Improvement Purposes Only
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  Prior to 2007: Data applies only to autologous bone
  Jan 07 – Present: Data applies to all tissue
Analysis & Outcomes

• The program has achieved a ≥ 90%
 target for all measures of success

• LUHS Tissue Services had a
 successful 2007 Joint Commission
 survey with no recommendations!


                            Confidential: For Quality Improvement Purposes Only
             What’s Next?
•   Acquire a tissue tracking software system
    which will enable us to effectively and
    efficiently document, manage, track and
    trace our tissue inventory usage
•   Continued oversight of tissue management
    by the Tissue Services Committee.

Thanks to all those involved in making our tissue
  program a success and in full compliance with
          Joint Commission Standards!


                                  Confidential: For Quality Improvement Purposes Only
                   Femoral
                    Head



Cervical Spacers



                    Tibia

 Achilles Tendon
   Injectable Bone Putty




Cancellous
Bone Chips
                              Crushed
                           Cancellous Bone
     Pulmonary
   Valve Allograft




                         Aortic and Mitral Valves –
                           bovine or porcine source

Aortic Valve Allograft
                           Cornea



  Regenerative
 Tissue Matrix –
derived from human skin   Tympanic
                          Membrane

								
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