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The waiting list for kidney transplants is a catalog of heartbreaking stories. Siblings who want to give
the gift of life but are not compatible donors. Parents who are devastated when they hear the one gift
their child needs is out of reach. Friends who build up the courage to donate, only to hear they can¶t
help after all.

But national registries and old-fashioned planning by nurses have created new hope for patients
waiting for renal transplants.

A tool called paired kidney exchange registries allows transplant centers to track pairs of
incompatible donors and recipients and facilitate matches with others in a database. The potential
donors, frustrated by their incompatibility to their loved ones, are willing to offer an organ to
someone else in exchange for an organ for their family member or friend. The registry matches
donors and recipients from one to another, forming a chain of giving.

In the spring, transplant teams at Newark (N.J.) Beth Israel Medical Center and Saint Barnabas
Medical Center in Livingston, N.J., affiliates of the Saint Barnabas Health Care System, used the
registry to partner with a team at NewYork-Presbyterian/Weill Cornell Medical Center in New York
City in a six-way chain of generosity and gratitude.

³This kind of chain is becoming more common as organ registries become larger,´ says Marie
Morgievich, RN, APN, C, CNN, CCTC, renal transplant nurse practitioner at Saint Barnabas Medical
Center. She notes transplant centers can benefit their patients by working closely together and using
a more global approach to treating patients collaboratively.

Marian Charlton, RN, CCTC, chief coordinator of the Kidney and Pancreas Transplant Program at
Weill Cornell Medical Center, has been involved in these efforts for several years and agrees. ³The
collaboration among all the centers is amazing,´ she says. ³The centers have to be altruistic, and they
put donors into the registry so that everyone can benefit from the availability. These exchanges cross
cultural, religious, and ethnic lines ² such things just never come up. The donor is happy to give, and
the recipient is even happier.´

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The foundation for these exchange programs is collaboration among transplant centers and the
cornerstone is the nurse coordinator at each facility. These nurses are in frequent contact and are
negotiating solutions as problems occur. They coordinate schedules and shipping arrangements to
get the kidneys where they are needed in the shortest possible time.

³We often ship the kidney to the recipient because it can be hard for donors to travel,´ Charlton says.
³There are times the donor is in California and the recipient is on the East Coast. The coordination
among transplant centers is a massive undertaking.´
Morgievich and Charlton agree the nurses who coordinate the exchanges are the driving force that
makes the whole complex machine run. Larger transplant centers are the major players because they
have the expertise and resources to be innovative about approaches to exchanges.

Operating room schedules have to be coordinated, and detailed logistical communication schedules
are set up across miles and time zones, so that as the living donor kidneys are removed and prepared
for transport across the hall or across the continent, the recipient is ready. Although the surgical
procedure is similar in every case, surgeons share details about the anatomy of the organ with the
receiving surgical team.

The goal is always to have the surgeries take place as close to simultaneously as possible to minimize
the risk the donor will change his or her mind. Another consideration for the quick turnaround is to
implant the organ as soon as possible to minimize the cold ischemic time the donor kidney is out of
the body and promote immediate graft function in the recipient.

Charlton is continually impressed by the collaboration and cooperation among the transplant centers
that participate in the living donor kidney exchange programs. She works regularly with nurses
around the country who she rarely sees. Timing and coordination problems that would give a NASA
launch team pause are routinely overcome by this cadre of nurses.

According to the Alliance for Paired Donation, the average living donor kidney functions for 15-1/2
years and the average deceased donor kidney functions for about half as long.

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· National Kidney Foundation,www.livingdonors.org
· Living Donor Assistance Program,www.livingdonorassistance.org
· United Network for Organ Sharing, www.UNOS.org
· Alliance for Paired Donation,www.paireddonation.org

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Morgievich notes that if anyone entered ³kidney exchange´ into an Internet search engine five years
ago, they would have had negligible results. A Google search today produced 1.2 million results in
less than a second.

³This is a whole new ball game, and we¶ve had to create new ways to look at sharing best practices.
We¶ve even had to create a language for the way it works,´ she says. ³When we have paired donor and
recipients combined with an altruistic donor, we usually have a donor at the end of the chain. We
sometimes hold that donor over or find an appropriate recipient from the wait list. That last donor in
the chain is called a µbridge donor¶ because sometimes they wait until we can organize another series
of exchanges. They are the bridge to the new chain.´

In the case of the six-way exchange that occurred this spring, the chain was closed by a transplant to
a person on the waiting list. Morgievich remembers making the call that changed his life.

³He spent years on dialysis, and he was overwhelmed by the gift,´ Morgievich says. ³For someone
who has been waiting for so long, getting that call is everything.´ There are nearly 80,000 names on
that list, waiting for the phone to ring. Using the living donor exchange registries might make those
calls more frequent, offering more people the hope for a new life.
       


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Kathleen Singleton, RN, MSN, CNS, CMSRN, a clinical nurse specialist for med/surg nursing at
Fairview Hospital in Cleveland, remembers treating a patient who had been transferred from the
ICU to the med/surg unit after suffering from a massive gastrointestinal bleed. To further complicate
the case, the man had residual effects from a stroke three years earlier. He was one of five patients
she was caring for that day.

Singleton has witnessed the trend that patients in today¶s med/surg units typically have more
complex medical issues than a decade ago. Nurses are working in a world in which patients have
more co-morbidities and chronic illnesses, use more medications and have shorter hospital stays. All
of these factors contribute to the increased demands on nurses, says Singleton, who also is president
of the Academy of Medical-Surgical Nurses.

To understand how to best support the modern med/surg nurse, the AMSN conducted a survey of its
members, for which it had 674 respondents, and conducted member interviews. The academy then
conducted an in-depth analysis of members¶ feedback.
³It came across in the data from the survey that it was important to have a healthy workplace to be
able to deliver best practices and manage patients well in today¶s complex care setting,´ Singleton
says.

Using survey results, the academy¶s leaders created a strategic plan that focuses on five goals aimed
at helping nurses survive and thrive in the ever-changing world of healthcare.


  


 
The first goal is aimed at giving nurses tools to manage rapidly escalating demands on med/surg
nurses.

Singleton says, for example, it is not uncommon for each patient to need 10 to 12 medications a day.
The number of prescriptions purchased in the U.S. jumped 71% between 1994 and 2005, compared
to a U.S. population growth of only 9% during that same time period, according to data from the
Kaiser Family Foundation. The average number of prescriptions per capita also increased from 7.9 to
12.3 during those years, according to the report.

³People who have chronic illnesses are also living longer, and this increases the complexity of caring
for these patients,´ Singleton says. ³And we are taking care of more acutely ill patients.´

Singleton predicts med/surg nurses also will feel the impact of the additional 30 million Americans
who are expected to gain health insurance because of healthcare reforms. People who did not have
resources in the past to seek regular medical care can be discovered to be more compromised in their
health when they start pursuing care, she says.

The challenges are mounting, but best practices are continuing to develop at different institutions, so
the AMSN is developing a resource toolkit that will give RNs a chance to learn from hospitals that are
maintaining healthy work environments in spite of the increasing demand by highlighting best
practices. Nurses from different institutions also will be able to use the AMSN¶s website to network
with one another.

³Sometimes we work in an unhealthy environment, but we don¶t know it is unhealthy because we are
used to it,´ Singleton says. ³This online toolkit will give nurses an outside perspective.´





The AMSN¶s second goal is designed to support nurses in a healthcare environment that is
increasingly placing value on evidence-based practice.

³It is important for nurses to be aware of research about outcomes that can be reported and
benchmarked,´ Singleton says. ³In the future, reimbursement will be based more on quality patient
outcomes. It has that element now, but it will increase in the future.´

She encourages nurses to stay current with practices by reading nursing journals and visiting the
AMSN¶s website, which offers a resource library with access to presentations, articles and convention
information. The organization also established the Cecelia G. Grindel Evidence-Based Practice
Award last year to support nurses who are doing research.

The AMSN¶s third strategic goal encourages nurses to pursue professional development as a way to
thrive in today¶s demanding workplace. As of April, more than 12,600 nurses had earned
certification through the Medical-Surgical Nursing Certification Board.




The fourth goal aims to use the AMSN¶s network to help nurses become leaders in their profession.
By collaborating with other organizations and one another, nurses will have greater influence,
Singleton says. AMSN, for example, works with other nursing organizations to solve problems and
discuss the future of nursing on a large scale.

Singleton has personally experienced the power of collaboration when she was working in a hospital
in which specimens were sometimes mislabeled. Singleton networked with nurses from AMSN about
the problem. As a result, she developed a policy for specimen labeling and incorporated the policy
into the hospital¶s systemwide nurse orientation program.

The fifth goal focuses on refining and promoting the organization¶s identity.
³There is a misconception that med/surg nursing is not a specialty,´ says Singleton. ³We take care of
diverse patient populations. Patients can be people who just had a major surgery for the first time or
others who have a chronic illness who we¶ve known for the last 10 years. Patients are stable but have
the potential for complications.´

Med/surg nurses comprise more than 50% of nurses working in hospitals, and more than 30% of
nursing in all healthcare settings, according to the AMSN.
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