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Dissemination and implementation (D&I) science is the practice of taking evidence-based interventions and sustainably incorporating them into routine clinical practice. As a relatively young field, D&I techniques are underutilized in cardiothoracic surgery. This review offers an overview of D&I science from the context of the cardiothoracic surgeon. First, we provide a general introduction to D&I science and basic terminology that is used in the field. Second, to illustrate D&I techniques in a real-world example, we discuss a case study for implementing lung protective management strategies for lung donor optimization nationally. Finally, we discuss challenges to successful implementation that are unique to cardiothoracic surgery and give several examples of evidence-based interventions that have been poorly implemented into surgical practice. We also provide examples of successful D&I interventions—including deimplementation strategies—from other surgical subspecialties. We hope that this review offers additional tools for cardiothoracic surgeons to explore when introducing evidence-based interventions into routine practice. [Display omitted] [ABSTRACT FROM AUTHOR]

Hypoxemia is the most common barrier to lungs being transplanted from eligible organ donors who are brain dead (BD). Atelectasis is the principal reversible contributing factor to hypoxemia after brain death. We evaluated prospectively whether ventilation in the prone position in donors who are BD would reverse atelectasis, improve oxygenation, and result in more lungs being transplanted. Organ donors managed at the recovery center of 1 organ procurement organization over a 2-year period who exhibited hypoxemia (partial pressure of arterial oxygen [PaO 2 /fraction of inspired oxygen of <300 mm Hg) and had evidence of atelectasis were ventilated in the prone position for 12 hours or longer during donor management. A subset underwent computed tomography (CT) imaging to quantify the degree of atelectasis before and after prone positioning. Outcomes were compared with those of a control group with hypoxemia and atelectasis managed similarly but in the supine position in the previous 2 years. A total of 40 lung-eligible donors who were BD with hypoxemia and atelectasis were managed in a prone position and compared with 79 donors in supine position. Baseline PaO 2 was similar between the prone and the supine groups (194 ± 78 vs 177 ± 77 mm Hg, p = 0.26) but increased more in the prone group at 4 hours (by 113 vs 54 mm Hg, p = 0.001) and remained 74-mm Hg higher at 12 hours (340 vs 266 mm Hg, p = 0.0006). CT-graded atelectasis was significantly reduced after ventilation in the prone position but persisted in the supine group (p = 0.001). Final PaO 2 was not significantly higher (344 vs 306, p = 0.12), but lungs were more often transplanted in the prone group (45% vs 24%, p = 0.03). Ventilation in the prone position reverses atelectasis and rapidly and sustainably improves oxygenation in organ donors who are BD with hypoxemia. This effect appears to translate into more lungs being transplanted. [ABSTRACT FROM AUTHOR]

On November 24, 2017, a change in lung allocation policy was initiated to replace the donor service area with a 250-nautical-mile radius circle around the donor hospital. We aim to analyze the consequences of this change, including organ acquisition cost and transplant outcomes, at the national level. Data on adult patients undergoing lung transplantation between April 27, 2017, and June 22, 2018 (30 weeks before to 30 weeks after allocation policy change) were extracted from the Scientific Registry of Transplant Recipients database. Patients were classified into pre-change and post-change subgroups. Six-month overall survival was evaluated by Kaplan-Meier analysis. Organ acquisition costs were compared between the pre-change and post-change groups. Of the 3317 adult patients removed from the waiting list during the study period (pre-change 1637 vs post-change 1680), 2734 underwent transplantation (pre-change 1371 of 1637 [83.8%] vs post-change 1363 of 1680 [81.1%]), and 382 died or became too sick to be transplanted (pre-change 168 of 1637 [10.3%] vs post-change 214 of 1680 [12.7%], P =.077). Six-month survival rates of transplanted patients were similar between the two groups. However, average organ acquisition costs increased after policy change (pre-change $50,735 ± $10,858 vs post-change $53,440 ± $10,247, P <.001) with an increase in nonlocal donors (pre-change 44.3% vs post-change 68.9%, P <.001). Organ acquisition costs and resource utilization increased with the new lung allocation policy, whereas deaths on the waiting list or after transplantation did not decrease. Further optimization of the allocation policy is necessary to balance access to transplant and proper stewardship of human and financial resources. [ABSTRACT FROM AUTHOR]

National and institutional data suggest an increase in organ discard rate (donor lungs procured but not implanted) after a new lung allocation policy was introduced in 2017. However, this measure does not include on-site decline rate (donor lungs declined intraoperatively). The objective of this study is to examine the impact of the allocation policy change on on-site decline. We used a Washington University (WU) and our local organ procurement organization (Mid-America Transplant [MTS]) database to abstract data on all accepted lung offers from 2014 to 2021. An on-site decline was defined as an event in which the procuring team declined the organs intraoperatively, and the lungs were not procured. Logistic regression models were used to investigate potentially modifiable reasons for decline. The overall study cohort comprised 876 accepted lung offers, of which 471 donors were at MTS with WU or others as the accepting center and 405 at other organ procurement organizations with WU as the accepting center. At MTS, the on-site decline rate increased from 4.6% to 10.8% (P =.01) after the policy change. Given the greater likelihood of non-local organ placement and longer travel distance after policy change, the estimated cost of each on-site decline increased from $5727 to $9700. In the overall group, latest partial pressure of oxygen (odds ratio [OR], 0.993; 95% confidence interval [CI], 0.989-0.997), chest trauma (OR, 2.474; CI, 1.018-6.010), chest radiograph abnormality (OR, 2.902; CI, 1.289-6.532), and bronchoscopy abnormality (OR, 3.654; CI, 1.813-7.365) were associated with on-site decline, although lung allocation policy era was unassociated (P =.22). We found that nearly 8% of accepted lungs are declined on site. Several donor factors were associated with on-site decline, although lung allocation policy change did not have a consistent impact on on-site decline. [Display omitted] [ABSTRACT FROM AUTHOR]

Background Lung procurement for transplantation occurs in approximately 20% of brain dead donors and is a major impediment to wider application of lung transplantation. We investigated the effect of lung protective management at a specialized donor care facility on lung procurement rates from brain dead donors. Methods Our local organ procurement organization instituted a protocol of lung protective management at a freestanding specialized donor care facility in 2008. Brain dead donors from 2001 to 2007 (early period) were compared with those from 2009 to 2016 (current period) for lung procurement rates and other solid-organ procurement rates using a prospectively maintained database. Results An overall increase occurred in the number of brain dead donors during the study period (early group, 791; late group, 1,333; p < 0.0001). The lung procurement rate (lung donors/all brain dead donors) improved markedly after the introduction of lung protective management (early group, 157 of 791 [19.8%]; current group, 452 of 1,333 [33.9%]; p < 0.0001). The overall organ procurement rate (total number of organs procured/donor) also increased during the study period (early group, 3.5 organs/donor; current group, 3.8 organs/donor; p = 0.006). Conclusions Lung protective management in brain dead donors at a specialized donor care facility is associated with higher lung utilization rates compared with conventional management. This strategy does not adversely affect the utilization of other organs in a multiorgan donor. [ABSTRACT FROM AUTHOR]