CATHOLIC HEALTH PARTNERS
By JULIE MINDA
As clinicians at the Mercy Health Liver Center in Cincinnati describe it, awaiting a liver transplant can be like walking a tightrope. To be suitable for a transplant, patients must be sick enough to need a new liver but healthy enough to be able to tolerate the transplant.
The new center is helping patients prepare for liver transplant by reaching them earlier in the disease cycle, improving their ability to get an organ quickly, guiding them on a treatment plan as they await an organ and lessening the chances of hospital readmission during their wait.
"We treat a lot of liver patients here, and we had determined they were not always being treated correctly — we needed to deliver better liver care," said Dr. Ravi Ravinuthala, clinical director of the Mercy Health Liver Center that opened in January at the Jewish Hospital-Mercy Health. Ravinuthala said with the creation of the center, Mercy has developed protocols that will "save lives by increasing patients' chances of obtaining a liver transplant."
The right score
According to the American Liver Foundation, more than 16,000 people in the U.S. are on the waiting list for a liver transplant, and there are not enough donated organs to satisfy demand. To get a transplant, patients with failing livers are referred by their doctors to one of 249 transplant centers in the U.S. Transplant teams evaluate potential recipients' physical and mental health, make sure a payment source has been identified for the transplant and ensure the patients have a support network in place. These factors help the transplant teams to determine patients' readiness for transplant.
Those suitable for transplant join a national waiting list — although donors and recipients are matched within regions. Potential recipients receive a score that reflects how sick they are — patients who are sickest but who are medically ready for surgery receive priority. Patients' scores change as their health improves or deteriorates. A hospital admission, acquired infection or similar setback could mean missing out on an available organ.
To help prevent this from happening to Mercy Health patients, that system determined it could improve patients' prospects by getting them to liver experts earlier, increasing their visibility at transplant centers, helping them better manage their health while awaiting a liver and giving them coping tools. To do this, Mercy Health created the center, with its multidisciplinary team of about two dozen staff. The center serves all six of Mercy Health's Cincinnati-area hospitals.
Early intervention
Ravinuthala said a key problem is that other clinicians weren't referring patients to him at the most opportune time in the disease cycle. He said chronic liver disease frequently occurs in tandem with other conditions, so it is common for clinicians to treat and discharge patients for other illnesses without diagnosing the underlying liver failure. So Ravinuthala and his center colleagues have been educating primary care clinicians and specialists throughout Mercy Health so they will recognize when liver disease may be occurring with another condition and then refer those patients to the liver center.
As part of this education process, Ravinuthala and his colleagues have been dispelling negative connotations that even clinicians can have about liver disease. "One of the problems in thinking that we had to address is that some people think patients caused their liver problems — they did this to themselves by taking drugs and drinking alcohol," Ravinuthala said. The liver center has imparted to clinicians all patients deserve compassion.
Better prospects
Once a patient arrives at the center, Ravinuthala and his colleagues evaluate the person, checking the functional ability of the person's liver and ensuring they are well enough for transplant. The staff then connect suitable patients with a nearby transplant center. Normally, people only have access to available organs in one region. But, because Ravinuthala has built strong connections with transplant centers in an adjacent region, including serving on the faculty of one of the centers, those centers are allowing Mercy Health patients access to organs in that region. "So, this expands the number of (organ) pools that our patients can access for a transplant," Ravinuthala explained.
According to the Center for Liver Disease and Transplantation at Columbia University Department of Surgery in New York, in 2006 potential recipients waited a median 321 days for a transplant. During Mercy Health patients' wait, the liver center's team of hepatologists, gastroenterologists, infectious disease specialists, pharmacists, a psychologist, nurses, social workers, chaplains and a dietician work together to create a tailored treatment approach for each patient to keep that person in optimal health. This includes working with their referring physician on a therapy and medication plan.
Also, team members coordinate patients' follow-up, to help ensure they're following clinicians' instructions and keeping their follow-up appointments. Dieticians help them understand the diets they need to follow to maintain their health.
"We help make appointments, we track their follow-up," explained Ravinuthala. "And, now that they are all coming through one location, we can measure outcomes better." The center has seen 55 patients to date, and by January should have enough data on all patients' health to begin to evaluate their health outcomes.
The right support
Neil Hume, 64, of Hamilton, Ohio, credits Mercy Health's liver care for saving his life. Two years ago, he was barely able to eat or sleep and had severe swelling of the stomach. When he had his gallbladder removed, clinicians discovered his liver was compromised. They referred him to Ravinuthala.
Ravinuthala and his team treated Hume's cirrhosis of the liver by periodically removing built up fluids in his stomach. They helped him learn to manage his diet, for instance by drastically curbing his salt intake, and they helped coordinate his preparations for a May 2012 transplant. The approach they took is still in use but has been formalized under the direction of the liver center.
Hume said during the worst of his pre-transplant wait, he was forgetful and his thinking was compromised. He said the support of his family and his Mercy Health clinicians was essential to his successful wait for a liver and then a successful transplant. "If it wasn't for the Jewish Hospital, I wouldn't be here," Hume said. "My doctors and nurses were like my angels of mercy. You can't get through something like this without that kind of support."
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