Professional Development Programme for Organ Donation 1 Paul Murphy Gurch Randhawa Ella Poppitt September 2010 Identification and Referral “Improving organ

Professional Development Programme for Organ Donation1

Paul MurphyGurch RandhawaElla Poppitt

September 2010

Identification and Referral

“Improving organ donation within your hospital”


The progression of your learning journey

On

line T

oo

l: Self-A

ssessment T

ool, Docum

ent Sharing, P

odcasts, Discussion

Forum

, PD

P A

tlas, Program

me P

rogress Tracker

National Kick-Off Event(inc Law & Donation after Cardiac Death Master Class)

Change Management & Leadership Fundamentals

Master Class 1 (Diagnosis of Brain Stem Death and Regional Peer Consulting

Group Launch)

Master Class 2(Donor Management & Physiology and Emergency Medicine)

Making Change Happen(Development of action plan to implement changes in Trust)

Master Class 3(Referral / consent / authorisation / Media

Paediatrics(

Regional Collaboratives

National Review Event(Review of Programme and Ethics and Media Skills Master

Class)

National Kick-Off Event(inc Law & Donation after Cardiac Death Master Class)

Change Management & Leadership Fundamentals

Regional Peer Consulting Group(Introduction and coaching in action learning sets)

Making Change Happen(Development of action plan to implement changes in Trust)

Regional Collaboratives

National Review Event(Review of Programme and Ethics and Media Skills Master

Class)

Podcasts: Eye & Tissue D

onation, Epidemiology of D

onation & Transplantation, Audit &

Statistics and PD

A: interpretation & Action

Online Tool Self Assessm

ent Tool, Docum

ent Sharing, Podcasts, Discussion Forum

, Programm

e Atlas, Program

me Progress Tracker

All Clinical Leads Chairs of Donation Committees


Agenda

1Identification, referral and consent / authorisation: an overview

40mins

2 Approaches to consent / authorisation 40mins

Break 15 mins

3 Cultural and religious influences 45mins

Break 15 mins

6 Close 5mins

Identification, referral and consent/ authorisation

An overview

Dr Paul Murphy

4

Professional Development Programme for Organ Donation

Introduction

Achieving the strategic big wins for Organ Donation requires breaking down the barriers to success to reveal the underlying issues and plan the most effective interventions

5

There are two important elements to referral

1.That it happens

2.That it occurs soon enough to maximise the opportunity for that person to be a donor

Consent / authorisation is the biggest single obstacle to donation

Considerable evidence for modifiable factors within the family approach.


Introduction

Achieving the strategic big wins for Organ Donation requires breaking down the barriers to success to reveal the underlying issues and plan the most effective interventions

6

International evidence suggests that timely identification and

referral may improve all facets of the donation pathway, and

thereby increases the possibility of an individual’s desire to

donate being identified and fulfilled.


Pathway for a potential DBD donor

Audited Patients Was patient ever ventilated?

Was BSD a likely diagnosis?

Were BSD tests performed?

Was BSD diagnosed?

Were there any absolute contraindications?

Was subject of solid organ donation considered?

Were Next of Kin offered donation?

Was consent/authorisation obtained?

Did organ donation occur?

Referral to Co-ordinator staff


Understanding the bigger picture

8

• NICE short clinical guideline

– Donor identification and referral

– Family consent

– Consultation begins in spring 2011

• Never events consultation

– Inadvertent ABO mismatch

– Failure to refer patient on Organ Donor Register

• Quality Outcome Framework for Primary Care

– % patients registered on ODR

– www.nice.org.uk/aboutnice/gof/suggestions.jsp

Identification and referral of potential donors

9



Donation not considered

Brainstem dead, donation not considered (approx 140 cases / year)

1.4

37.2

13.3

1.4

5.3

41.4

0.0 10.0 20.0 30.0 40.0 50.0

cardiac instability

not known

family

no NOK

coroner

contra-indication to donation (incl. age)

% total


Donation considered, family not approached

Brainstem dead, family not approached (approx. 70 cases / year)

1.1

9.5

24.3

4.2

24.3

36.6

0 10 20 30 40 50

cardiac instability

not known

family

no NOK

coroner

contra-indication to donation (incl. age)

% total


Why do we not consider / refer everyone?

• delays in co-ordination and retrieval – arrival of SN-OD

– very limited absolute contra-indications

– protracted decision-making and offering algorithm

– inconsistency between theory and practice

• lack of confidence with process

• family – cultural and language barriers

– fear of violence

– tragic circumstances

• difficulties with Coroner / Procurator Fiscal / police

• resources

Drilling down to the root causes of failure to refer

potential donors in a timely fashion


Age distribution of deceased donors since January 1st 2000

0

500

1000

1500

2000

2500

0-10 11-20 21-30 31-40 51-60 61-70 71-80 81-90

Age group

Nu

mb

er

DBD DCD

Ages of deceased donors in the UK


Contra-indications to Donation

• absolute

– variant CJD

– HIV disease (not HIV infection)

• near absolute

– disseminated malignancy

– melanoma (except local melanoma treated > 5 years before donation)

– treated malignancy within 3 years (except non-melanoma skin cancer)

– age > 90 years

– known active tuberculosis untreated bacterial sepsis

Near absolute contra-indications may be overridden when the recipient’s condition is grave (e.g. fulminant hepatic encephalopathy)

Oldest deceased donors in UK (yrs)

DCD DBD

Kidney 80 85

Liver 70 85

Heart - 62

Lung 56 65

Pancreas 59 63


Minimum Notification Criteria from Organ Donation Taskforce

Donation after Brain-stem Death

When no further treatment options are available or appropriate, and

there is a plan to confirm death by neurological criteria, the DTC should

be notified as soon as sedation/analgesia is discontinued, or immediately

if the patient has never received sedation/analgesia. This notification

should take place even if the attending clinical staff believe that donation

(after death has been confirmed by neurological criteria) might be

contra-indicated or inappropriate.

All patients should be have the possibility for donation considered as part of their end of life care, and early referral

promotes this possibility


Minimum Notification Criteria from Organ Donation Taskforce

Donation after Cardiac Death

In the context of a catastrophic neurological injury, when no further

treatment options are available or appropriate and there is no intention to

confirm death by neurological criteria, the DTC should be notified when a

decision has been made by a consultant to withdraw active treatment and

this has been recorded in a dated, timed and signed entry in the case

notes. This notification should take place even if the attending clinical staff

believe that death cannot be diagnosed by neurological criteria, or that

donation after cardiac death might be contra-indicated or inappropriate.

These proposals are an acceptable but minimum description of what is necessary. They should be implemented in all acute Trusts.

ODTF Report


Expanded Notification Criteria from Organ Donation Taskforce

Clinical Triggers

The Taskforce considers that there is an urgent need for a pilot study

looking at the impact of introducing clinical indicators as a trigger for

notification. The Taskforce believes that it should assess not only the role

of triggers in increasing donation, but also the impact upon staff and

patients and their families of introducing what the Taskforce accepts is a

radical change of practice. The Taskforce believes that having the

evidence from such a study would be critical in gaining the necessary

support to be able to move the agenda forward on this important issue.

These clinical notification proposals should be seen not in isolation, but as part of the overall strategy

ODTF Report


US Breakthrough Collaborative

Clinical Triggers

• Likelihood of death

– GCS < 5

– Absence of one of more brain stem reflexes

• Declared intention to perform brain death tests

• Declared intention to withdraw cardiorespiratory support

Overarching strategies

• focus on change, improvement

and results

• rapid and early referral and

linkage

• integrated donation process

• ‘aggressive pursuit of every

donation

‘In short, early referral leads to increased time with potential donor’s family and results in higher donation rates’

Shafer, T (2006)



400

450

500

550

600

650

700

750

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Org

an D

onors

1999 2000 2001 2002 2003 2004 2005 2006

Collaborative Starts Here


400

450

500

550

600

650

700

750

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Org

an D

onors

1999 2000 2001 2002 2003 2004 2005 2006 2007

Collaborative Starts Here



All patients with severe brain injury requiring mechanical ventilation

Call if:

• brain stem death testing planned

• GCS ≤ 4

• absence of 1 or more cranial nerve reflex

– pupils fixed

– no corneal reflex

– no cough or gag reflex

– unresponsive to painful stimuli

A decision to withdraw active treatment has been made in a ventilated patient of any age

or

Clinical triggers for referral………in Birmingham


Advantages of Clinical Triggered Referral


Advantages of Clinical Triggered Referral

All patients should be have the possibility for donation considered as part of their end of life care, and early referral promotes this possibility

• all potential donors are referred

• early access to coordination and retrieval advice

– advice on confirmation of brain-stem death

– allows donation potential to be identified and end of life care plans to be defined

– reduces likelihood of delays in arrival of SN-OD or retrieval team(s)

– facilitates ‘long contact’ model of family support for consent / authorisation

• improves accuracy of PDA data


‘Never Events’

‘Never events’ are defined as serious, largely preventable patient safety incidents that should not occur if the available preventable measures have been implemented by healthcare providers.

Criteria:

• clear potential for or has caused severe harm / death

• evidence of occurrence in the past (i.e. it is a known risk)

• existing national guidance on prevention

• event is largely preventable if guidance is implemented

• occurrence can be easily defined, identified and continuously measured

The occurrence of a never event is a clear indicator of an organisation that which has not put in place the right system and processes to

prevent the incidents from happening.


Current ‘Never Events’

• wrong site surgery

• retained surgical instrumentation

• wrong route administration of chemotherapy

• failure to detect misplacement of orogastric or nasogastric tubes prior to use

• in-hospital maternal death from post-partum haemorrhage following elective Caesarean section

• iv administration of mis-selected concentrated potassium chloride

In July 2010 the Government committed to proceed with work to impose fines for an extended list of never events.


Proposed ‘Never Events’

• inadvertent transplant of an ABO / HLA incompatible organ

• A person who is on the Organ Donor Register and who does not have an absolute contra-indication for organ donation and who dies without having been referred for consideration of organ donation.

• consultation in October

‘..serious failure will not be tolerated, especially where there are clear guidelines and procedures in place to prevent serious incidents. Where serious failings still occur, organisations will be subject to serious sanctions…’

Documents

Professional Development Programme for Organ Donation 1 Paul Murphy Gurch Randhawa Ella Poppitt September 2010 Identification and Referral “Improving organ