organ donation past, present and future donor identification and referral rachel stoddard-murden dr...
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Organ Donation Past, Present and Future
Donor Identification and Referral
Rachel Stoddard-MurdenDr Alex Manara9th July 2013
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SOUTH WEST
Session Objectives
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• Understand difficulties with donor identification and referral
• Recognise benefits of improving elements of the process
– Increased identification and referral
– Timely referral
– Responsiveness to referral
• Consider which of the proposed methods of identification and referral may work in your hospital
Organ Donation Past, Present and Future
Organ Donation Past, Present and Future
Regional Data
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Rachel Stoddard-Murden
SOUTH WEST
-------- National rate
95 97
8893
98
86 8791
95
8489 89
Ref
erra
l rat
e (%
)
0
20
40
60
80
100
Team
Easte
rn
London
Mid
lands
North
Wes
t
Norther
n
Norther
n
Irela
nd
Scotla
nd
South
Centra
lSouth
East
South
Wal
es South
Wes
t
York
shire
1 April 2012 to 31 March 2013, data as at 4 April 2013
7th
Organ Donation Past, Present and Future 4
South West DBD referral rate SOUTH WEST
1 April 2012 to 31 March 2013, data as at 4 April 2013
Organ Donation Past, Present and Future 5
South West DBD referral rate SOUTH WEST
Re
ferr
al r
ate
(%
)
0
20
40
60
80
100
Number of neurological death suspected patients
0 10 201
1011
12
13142
3
4
5
6
7 89
Trust National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL
-------- National rate
80
72
54
72
81
52
42
54 5659 60
65
Ref
erra
l ra
te (
%)
0
20
40
60
80
100
Team
Easte
rn
London
Mid
lands
North
Wes
t
Norther
n
Norther
n
Irela
nd
Scotla
nd
South
Centra
lSouth
East
South
Wal
es South
Wes
t
Yorksh
ire
1 April 2012 to 31 March 2013, data as at 4 April 2013
Organ Donation Past, Present and Future 6
6th
South West DCD referral rate SOUTH WEST
Re
ferr
al r
ate
(%
)
0
20
40
60
80
100
Number of imminent death anticipated patients
0 10 20 30 40 50 60 70 80 90 100
1
10
11
1213
14
2
3
4
5
67
8
9
Trust National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL
Organ Donation Past, Present and Future 7
South West DCD referral rate
1 April 2012 to 31 March 2013, data as at 4 April 2013
SOUTH WEST
Organ Donation Past, Present and Future
Identification and Referral
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Dr Alex ManaraSouth West Regional CLOD
Timely Identification and
Referral of Potential Organ Donors
Organ Donation Past, Present and Future
www.odt.nhs.uk
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UK rates of referral
referral of deceased donors
0
20
40
60
80
100
2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12
year
pe
rce
nta
ge
DBD DCD
Organ Donation Past, Present and Future
91%
52%
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Overall timings
Organ Donation Past, Present and Future 11
Aims of Strategy
• 100% Identification of potential Donors
• 100% Referral of Potential Donors
• 100% Timely Referral
• Implement NICE Guidance
The consideration of donation should be core ICU / ED and part of all end of life care plans.
Timely referral promotes this possibility
Organ Donation Past, Present and Future 12
NICE Guideline 135
Organ Donation Past, Present and Future 13
British Medical Association 2012
The research data -------- showed that the use of clinical triggers and a requirement to refer according to standard criteria led to an increase in both referrals and donors. It is hoped that implementation of the NICE guideline will result in early and consistent donor referral.
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General Medical Council 2010
“If a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.”
“You should follow any national procedures for identifying potential organ donors and, in appropriate cases, for notifying the local transplant coordinator.”
Decisions to limit or withdraw treatments in potential DCD donors MUST be in compliance with national End of Life Care policy.
Organ Donation Past, Present and Future 15
UK Donation Ethics Committee
“There is no ethical dilemma if the treating clinician
wishes to make contact with the SN-OD at an early
stage, while the patient is seriously ill and death is
likely, but before a formal decision has been made to
withdraw life-sustaining treatment.”
[“Benefits] include establishing whether there are
contra-indications for organ donation……
Other practical and organisational factors might be
relevant – if the SN-OD is based at a distant location
then early contact can help to minimise distressing
delays for the family.”
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Objectives, benefits and outcomesAll potential donors are identified and referred
All donors are referred in a timely fashion
SN-ODs are deployed in a way that improves responsiveness
All patients are given the option of donation
Access to clinical advicePrompt donor optimisationResolution of potential legal obstaclesEarly assessment of marginal donorsEarly tissue typing / screeningPlanning the family approach
Reduction in delays for families and units
Increased donor numbersImproved consent / authorisation ratesIncrease in donor organsBetter experience for families and staff
Organ Donation Past, Present and Future 17
NHSBT Strategy
• Implementation not publication• Key area for collaboration
between hospitals and donor care teams
• Very clear emphasis on benefits– How not who
• Suite of options• Clarity over implementation
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Strategy proposals
• Every hospital should have a written policy for the identification and timely referral of all potential donors
• Every donating area within a given hospital adopts a consistent approach
• As far as possible ‘decouple’ early referral from individual clinician
Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion.
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1. Daily visit by SN-OD
Organ Donation Past, Present and Future 20
2. Early daily phone call
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3. Daily ICU team safety brief
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Organ Donation Past, Present and Future
North Bristol Trust ICU Safety Brief
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4. Standard Operating Procedure
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Midlands Standard Operating Procedure
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5. Nurse led referrals
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Summary
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• Donation should be a element of end of life care
• Make identification and referral routine business of the unit.
• This decouples early referral from the individual clinician caring for the patient
• Implement or develop a solutions /policy for your individual hospitals adopt to timely referral
• Ensure consistency within a given hospital
Organ Donation Past, Present and Future
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April - Septem-ber 2010
October 2010 - March 2011
April - Septem-ber 2011
October 2011 - March 2012
April - Septem-ber 2012
October 2012 - March 2013
Num-ber of audited refer-rals
2184 2577 2664 3113 3389 3600
Num-ber of actual DBD and DCD donors from eligible DBD donors
302 330 332 328 329 386
Num-ber of actual DCD donors from eligible DCD donors
168 192 192 228 243 248
250
750
1250
1750
2250
2750
3250
3750
Number of audited referrals and actual donors reported through the Referral Record, data as at 9 May 2013
Nu
mb
er
of
pati
en
ts
Organ Donation Past, Present and Future
What are the barriers to implementing the NICE guidelines in your unit: any solutions?
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Whichever is the earlier, either:
Use trigger factors in patients with a catastrophic brain injury The absence of one or more cranial nerve reflexes
AND a GCS of 4 or less that is not explained by sedation
And / or a decision is made to perform brainstem death tests.
The intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death.
Organ Donation Past, Present and Future