midlands collaborative, november 2012 timely identification and referral of potential organ donors...

Midlands Collaborative, November 2012

Timely Identification and Referral of Potential Organ

Donors

Paul MurphyNational Clinical Lead for Organ

Donation


Objectives

• To understand the current difficulties with donor identification and referral

• To recognise the benefits of improving current elements of the identification and referral processes

– Proportion of potential donors identified and referred

– Timeliness of referral

– Responsiveness to referral

• To agree to adopt one or other of the proposed methods of identification and referral

– Collaboration between SN-OD teams and referring hospitals

• To understand implementation and monitoring programme


Outline

• Data

– Donation after Brain Death

– Donation after Circulatory Death

– Timings of donation pathway

• Existing identification and referral criteria

• New guidance

– Provenance

– Potential benefits

– Key features

– Options

• Implementation and monitoring


Referral rates for potential DBD donors, 2010/11

= one (or more) Trust/Health Board

National rate95% CL99.8% CL

99.8% CL

95% CL


Referral rates for potential DCD donors, 2010/11

National rate

95% CL99.8% CL

99.8% CL95% CL

= one (or more) Trust/Health Board


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


Progression through the donation pathway


SN-OD responsiveness


Referral to attendanceVariation across UK

Median (hrs) Q3 (hrs)

DBD

Best 0.8 2.1

Worst 3.7 10.5

DCD

Best 0.4 1.7

Worst 1.9 4.2


Overall timings


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.


ODTF Minimum notification criteria

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.


ODTF Minimum notification criteria

Donation after Circulatory 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.


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.


British Medical Association, 2012

The research data analysed by NICE 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.


NICE SCG 135


Donor Assessment


NHS BT 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


Problems

• Not all patients are referred

– DCD

• Not all patients are referred as early

as they might be

– Intention to test

– Clinical triggers

• SN-OD response times are not

always as we would like them

– Geographical deployment


Provenance


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


Planning the family approach

Planning

Confirming understanding and acceptance of loss

Discussing donation

Establish the team: Consultant, SN-OD and nurse Clarify clinical situation Seek evidence of prior consentKey family members by nameKey family issuesAgree a process of approach and who will be involvedAgree timing and setting, ensuring these are appropriate to family needsInvolve others as required, eg faith leaders


Strategy proposals

• Every hospital should have a written policy for the identification and timely referral of all potential donors

• As a minimum every donating area within a given hospital adopts a consistent approach

• In circumstances where clinicians feel conflicted, consider approaches that ‘decouple’ early referral from that clinician

Donation Committees and SN-OD teams are asked to collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion.


1. Daily visit by SN-OD


2. Early daily phone call


3. Daily ICU team safety brief


Frenchay ICU team safety brief


4. Standard Operating Procedure


Midlands Standard Operating Procedure


5. Nurse led referrals


Implementation

• All hospitals to adopt a referral strategy by 31 January 2013

• SN-ODs to be present at an appropriate time at least five days per

week on the ICUs of all level 1 hospitals

• Non referrals continue to be reported by the PDA

• Next update of PDA will examine the timeliness of referral

• SN-OD teams will be managed against their responsiveness

midlands collaborative, november 2012 timely identification and referral of potential organ donors...

Documents

midlands collaborative

organ donation slide

implementation slide

donation pathway slide

monitoring slide

brain death donation

donor assessment slide

trusthealth board slide