Saturday, April 7, 2007

Beth Israel Deaconess Medical Center

Like every transplant patient, the Beth Israel Deaconess Medical Center (BIDMC) has been through a lot, but sweeping changes have made the transplant program stronger than ever. Kidney transplantation began at the Beth Israel Hospital in 1973 under the direction of Dr. Anthony Monaco, and liver transplantation began at the New England Deaconess Medical Center in 1983 under the direction of Dr. Roger Jenkins. In 1996, amid drastic changes in the US health care system, the hospitals decided to merge. The merger led to a serious culture clash, prompting the entire liver transplant program to relocate to the Lahey Clinic. Bad turned to worse, as the hospital re-established a liver transplant program with grand plans: pediatric liver transplantation, living donor liver transplantation, and a "model program" for the rest of the world. One year later, the program was suspended in the wake of five deaths, which represented 25% of the transplants performed. The drama of the merger as a whole is the subject of the book Code Green, which thoroughly documents the events of the merger, mostly from the perspective of the nursing staff and with a seeming bias towards the Beth Israel side. The book ends with the recruitment of Paul Levy as CEO of BIDMC.

Resurrection

Paul Levy saved BIDMC, using every viable tactic imaginable. He offered joltingly honest assessments of the hospital's situation to the staff. He created a partnership with the Boston Red Sox. He even started a blog. However, development of clinical programs would rely on new clinical leadership as well as strong administrative support. Dr. Josef Fischer had recently joined the institution as Chairman of Surgery, and he in turn recruited top doctors to reinvigorate major divisions. Dr. Douglas Hanto was selected as the new chief of transplantation. He proceeded to recruit additional staff members and lead the existing ones, and together they set to the task of restoring the transplant program. All of the people in the multidisciplinary team, from surgeons to coordinators to administrators, were co-located to the same office and clinic area, fostering both patient convenience and close personal interactions among the staff across traditional boundaries. To ensure safe and thorough clinical care, detailed clinical pathways were established and a transplant-specific electronic medical record (EMR) system was implemented. The services of the transplant center were also expanded to include:

  • a Dialysis Access Center to ensure essential care for patients with end-stage renal disease (often awaiting transplantation),
  • a hepatobiliary surgery program for liver diseases that may not require transplantation but still require major surgery, and
  • a strong relationship with the Joslin Diabetes Center, which includes a kidney-pancreas transplant clinic at Joslin as well as a program in the evolving procedure of islet transplantation.

These changes have been a success, and today Beth Israel Deaconess has a balanced and busy program in kidney, liver, and pancreas transplantation with solid outcomes. They have also used their clinical and research strengths to create educational programs for future transplant specialists, including a transplant nephrology fellowship that is the only one in Massachusetts accredited by the American Society of Transplantation and a transplant surgery fellowship that is the only one in all of New England accredited by the American Society of Transplant Surgeons to fully qualify surgeons to perform kidney, liver, and pancreas transplants (other fellowships in the area are limited to one or two of these organs). Dr. Hanto summarized the efforts and results of the transplant program: "What has occurred has required real team work, hard work, committment, and willingness to think outside the box."

BIDMC Transplant Center Today

With the crises of the past seemingly resolved, Beth Israel Deaconess has moved beyond fixing problems within itself to advancing the field of organ transplantation as a whole. They have sought to expand the deceased donor pool with the use of expanded criteria donors (ECD) and donation after cardiac death (DCD), and the institution received recognition from the Organ Donation Breakthrough Collaborative for recovering organs from more than 75% of eligible deceased donors. Also, to serve the overall goal of increasing the availabilty of transplantation, BIDMC is participating in a study of kidney and liver transplantation in patients with HIV, and is currently the second-most active center in this study (behind UCSF). This is one of several clinical trials taking place at BIDMC, and research efforts also include historically strong basic science research and recent funding to establish a Center for Transplant Outcomes and Quality Improvement within the Transplant Center.

Patients and Donors

In the past, the hospital has declined to perform living donor transplants facilitated through solicitations (Web sites, billboards, etc.). This view has prompted intense discussions and quite a bit of disagreement. However, BIDMC currently is willing to evaluate candidates and solicited donors as they do any other patients. The change is not due to a shift in their beliefs, but rather a recognition that the issue remains unresolved in the transplant community and is permitted under current regulations. Given this, their desire is to not force patients to go elsewhere, or have them "caught in the middle" of an ongoing global debate, if they do find a donor in these ways. Clearly, soliciting donors will continue to be controversial both at Beth Israel Deaconess and far beyond. BIDMC would prefer to increase living donation through altruistic donors and is part of the New England Program for Kidney Exchange, through which they have recently participated in a three-way kidney swap. Though their firm beliefs on solicited donors have brought criticism, BIDMC does support many efforts to meet patient needs, including educational programs, support groups, and a one-of-a-kind Behavioral Care Program for transplant donors and recipients.

The Beth Israel Deaconess transplant program has lived through a long history and is gradually pushing forward towards the future of organ transplantation. Their "style" does not seem to support radical innovation, yet their results in transplantation are solid and they devote a fair amount of energy towards collaborative programs and clinical trials on new therapies. Like every transplant patient asked "What happened? How are things?" the answer is "It's a long story..." Thankfully, in the case of Beth Israel Deaconess Medical Center, it's now a good one.

2 comments:

Paul Levy said...

Thanks, Manu!

Tom said...

hopefully BIDMC has BANNED drug reps/drug dealers from entering the academic teaching hospital. Drug reps/dealers use undue influence via food, freebies, and other nonsense biased info to influence doctors in training and others. just say no to drug reps--hopefully, this is something the BI CEO institutes effective immediately.