regional variation of organ donors in swedish icus may indicate missed opportunities for donation...
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Regional variation of organ
donors
in Swedish ICUs may indicate
missed opportunities for donationThomas Nolin*, Sten Walther*, Caroline Mårdh*, Göran Karlström* & Charlotte
Möller**
* The Swedish Intensive care Registry, SIR **The Swedish Council for Organ and Tissue Donation
http://www.icuregswe.org
The Swedish Intensive care Registry - SIR
SSAI Congress, Bergen 15-17 June, 2011Poster presentation
16 June 2011 Swedish Intensive care Registry, SIR 2
Background
The Swedish Council for Organ and Tissue Donation (Donationsrådet):– Objective: 22 donors per million people (DPMP) by 2014– Focus on withholding/withdrawing medical treatment in ICU
The National Board of Health and Welfare (Socialstyrelsen):– Proposal for new regulations on life-sustaining treatment
Potential conflict of interest in end-of-life decisions and organ procurement?
16 June 2011 Swedish Intensive care Registry, SIR 3
Starting point - Definition
Potential deceased organ donor– Intensive care patient with
– Mechanical ventilation and
– Brain death diagnosis (completed) and
– Identified as medically suitable for organ donation (no absolute contraindications to organ donation)
http://www.dopki.eu
Eligible donation after brain death: A medically suitable person who has been declared dead based on neurologic criteria as stipulated by the law of the relevant jurisdiction. Domínguez-Gil B et al. Review. The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transplant International 2011.
Diff
ere
nt
wo
rdin
g –
th
e s
am
e d
efin
itio
n
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Objectives
To examine the incidence of patients with – New severe brain damage, – who received mechanical ventilation and – were diagnosed with brain death, and – the number of actual organ donors in
the 21 Swedish county councils
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Dataset – Who?
All deceased intensive care patients in
All Swedish ICU’s
A structured protocol for follow up of
deceased intensive care patients– SIR and
– Swedish Council for Organ & Tissue Donation
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21 County councils in Sweden
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
New severe braindamage
and mechanicalventilation
and brain death and medically suitable and positive orpresumed consent
Actual organ donation
Per
cen
t o
f d
ecea
sed
wit
h .
..
Norrbotten (143) Västerbotten (285) Västernorrland (271) Jämtland (99)Gävleborg (257) Dalarna (153) Värmland (277) Uppsala (304)Västmanland (135) Örebro (254) Södermanland (187) Stockholm (1 191)Östergötland (271) Jönköping (190) Kalmar (185) Västra Götaland (1 136)Halland (191) Kronoberg (133) Blekinge (112) Region Skåne (846)Sweden (6 620)
2009-2010:83 ICU's> 81 583 admissions6 620 deaths244 actual organ donors
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6 620 deaths in 83 ICU’s during 2009-2010
New, severe brain damage New, severe brain damage- and mechanical ventilation- and brain death- and medically suitable
New, severe brain damage- and mechanical ventilation- and brain death- and medically suitable- and positive or presumed consent- and actual organ donation
County council variations
0
.1
.2
.3
.4
.5
Eve
nt r
ate
0 200 400 600 800 1000 1200
Number deceased (2009-2010)
0
.02
.04
.06
.08
.1
.12
.14
Eve
nt r
ate
0 200 400 600 800 1000 1200
Number deceased (2009-2010)
0
.03
.06
.09
.12
.15
Eve
nt r
ate
0 200 400 600 800 1000 1200
Number deceased (2009-2010)
Potential deceased organ donors Actual organ donors
Alert limit -2SD
Alarm limit -3SD
New, severe brain damage
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Conclusions
The number of actual organ donors varied from 0.5 % to 10.1 % of all ICU deaths
There was no obvious relationship between the proportion of patients with new severe brain damage (17.9 – 43.4 %) and the proportion of actual organ donors
May indicate that organ donors were missed in regions with a low rate of actual organ donors
Thank you!
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Actual organ donors per million people per year2009 - 2010
0
5
10
15
20
25
Norra Uppsala-Örebro Stockholm-Gotland Sydöstra Västra Södra
Region
DP
MP
DPMP (Donors per miljon people)
Swedish Council for Organ & Tissue Donation's objective for 2014: 22 DPMP
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Actual organ donors per million people per year2009 - 2010
0
5
10
15
20
25
30
35
40
Norrb
otte
n
Väste
rbot
ten
Jäm
tland
Väste
rnor
rland
Dalarn
a
Gävleb
org
Värm
land
Örebr
o
Västm
anlan
d
Uppsa
la
Stock
holm
V. Göt
aland
Jönk
öping
Österg
ötlan
d
Sörm
land
Hallan
d
Krono
berg
Bleking
e
Kalmar
Skåne
Sweden
County Council
Act
ual
org
an d
on
ors
per
mill
ion
peo
ple
per
yea
r Swedish Council for Organ & Tissue Donation's objective for 2014: 22 DPMP
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New severe brain damage?
No: 4 634Yes: 1 986
Mechanical ventilation?Mechanical ventilation?
Yes: 1 795 Yes: 3 326No: 191 No: 1 308
Braindeath451
Circulatorydeath1 308
Group 120%
CirculatoryDeath3 326
Group 250%
Circulatorydeath191
Group 33%
Circulatorydeath1 344
Group 420%
Group 57%
Number of deceased patients: 6 62083 ICU’s in Sweden 2009-2010
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Why couldn’t death be diagnosed by direct criteria (brain death?
1. Withdrawal of medical treatment
2. Withholding medical treatment
3. Medically unsuitable as organ donor
4. Cardiac activity could not be restored
5. No attention was paid to the patient as a possible donor
6. The deceased was negative to organ donation
7. No access to diagnostic radiology
8. No access to competent clinical neurological examination
9. No clinical suspicion of total cerebral infarction
New, severe brain damage and mechanical ventilation and circulatory death. N 1 344.
713
236
355
235
9
31
2
0
596
Multiple choices
16 June 2011 Swedish Intensive care Registry, SIR 14
Who defines medically suitable?
Transplant surgeon and coordinator!
But…
There was no contact with transplant coordinator in potential deceased organ donor cases (N 375) in:– 2009: 28/209 (13.4 %)
– 2010: 13/166 (7.8 %)All cases should be contacted!
A quality indicator in SIR
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Dataset
The data are sent electronically to SIR– validated and displayed on the SIR open website
within 6 hours from completed validation– http://avlidna.icuregswe.org
As yet only in Swedish!
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Actual (=effective) donor
Individual from whom at least one organ was recovered for the purpose of transplantation
Utilized donor– A deceased person from whom at least one organ
has been retrieved and transplanted
http://www.dopki.eu