Organ Donation Past, Present and Future

Donor Identification and Referral

Dr Huw Twamley

21st May 2013

1

NORTH WEST

Session Objectives

• 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

2Organ Donation Past, Present and Future

Organ Donation Past, Present and Future

Regional Data

3

NORTH 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

Yorksh

ire

DBD referral rate

1 April 2012 to 31 March 2013, data as at 4 April 2013

5th

Organ Donation Past, Present and Future 4

NORTH WEST

Ref

erra

l ra

te (

%)

0

20

40

60

80

100

Number of neurological death suspected patients

0 10 20 30

110 11 121314 15

16

17

18

19

2

2021 22

23

242526

27

28293 30 31

32

33

45

6

7

8 9

Hospital National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL

North West DBD referral rate

1 April 2012 to 31 March 2013, data as at 4 April 2013

Organ Donation Past, Present and Future 5

1 Barrow-In-Furness, Furness General Hospital2 Douglas, Nobles I-O-M Hospital3 Chester, Countess Of Chester Hospital4 Crewe, Leighton Hospital5 Macclesfield, Macclesfield District General Hospital6 Warrington, Warrington Hospital7 Liverpool, Royal Liverpool University Hospital8 Liverpool, Alder Hey Children's Hospital9 Prescot, Whiston Hospital

10 Southport, Southport District General Hospital11 Liverpool, University Hospital Aintree12 Liverpool, Walton Centre For Neurology And Neurosurgery13 Wirral, Arrowe Park Hospital14 Lancaster, Royal Lancaster Infirmary15 Blackpool, Blackpool Victoria Hospital16 Preston, Royal Preston Hospital17 Blackburn, Royal Blackburn Hospital18 Chorley, Chorley And South Ribble District General Hospital19 Bolton, Royal Bolton Hospital20 Bury, Fairfield General Hospital21 Manchester, North Manchester General Hospital22 Manchester, Manchester Royal Infirmary23 Manchester, Royal Manchester Children's Hospital24 Manchester, Wythenshawe Hospital25 Oldham, Royal Oldham Hospital(Rochdale Road)26 Salford, Salford Royal27 Stockport, Stepping Hill Hospital28 Ashton-Under-Lyne, Tameside General Hospital29 Manchester, Trafford General Hospital30 Wigan, Royal Albert Edward Infirmary31 Bodelwyddan, Glan Clwyd District General Hospital32 Wrexham, Maelor General Hospital33 Bangor, Ysbyty Gwynedd District General Hospital

-------- 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

Tied 3rd

DCD referral rate

NORTH WEST

Ref

erra

l ra

te (

%)

0

20

40

60

80

100

Number of imminent death anticipated patients

0 10 20 30 40 50 60 70 80

1

10

11

12

13

14

15

1617

18

19

2

20

21

22

23

24

25 26

27

28

29

3

30 3132

33

4

5

6

7

8

9

Hospital National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL

North West DCD referral rate

Organ Donation Past, Present and Future 7

1 Barrow-In-Furness, Furness General Hospital2 Douglas, Nobles I-O-M Hospital3 Chester, Countess Of Chester Hospital4 Crewe, Leighton Hospital5 Macclesfield, Macclesfield District General Hospital6 Warrington, Warrington Hospital7 Liverpool, Royal Liverpool University Hospital8 Liverpool, Alder Hey Children's Hospital9 Prescot, Whiston Hospital

10 Southport, Southport District General Hospital11 Liverpool, University Hospital Aintree12 Liverpool, Walton Centre For Neurology And Neurosurgery13 Wirral, Arrowe Park Hospital14 Lancaster, Royal Lancaster Infirmary15 Blackpool, Blackpool Victoria Hospital16 Preston, Royal Preston Hospital17 Blackburn, Royal Blackburn Hospital18 Chorley, Chorley And South Ribble District General Hospital19 Bolton, Royal Bolton Hospital20 Bury, Fairfield General Hospital21 Manchester, North Manchester General Hospital22 Manchester, Manchester Royal Infirmary23 Manchester, Royal Manchester Children's Hospital24 Manchester, Wythenshawe Hospital25 Oldham, Royal Oldham Hospital(Rochdale Road)26 Salford, Salford Royal27 Stockport, Stepping Hill Hospital28 Ashton-Under-Lyne, Tameside General Hospital29 Manchester, Trafford General Hospital30 Wigan, Royal Albert Edward Infirmary31 Bodelwyddan, Glan Clwyd District General Hospital32 Wrexham, Maelor General Hospital33 Bangor, Ysbyty Gwynedd District General Hospital

Timely Identification and

Referral of Potential Organ Donors

Huw TwamleyRegional CLOD

North West Region

Organ Donation Past, Present and Future

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%

Cause of death in MC III DCD donors

10.4

16.2

12.4

25.9

3.2

5.6

26.3

3.5

4.2

6.2

27.5

7.8

8.0

42.8

0 5 10 15 20 25 30 35 40 45

Other Miscellaneous

Other Medical Disease

Primary Respiratory Disease

Hypoxic Brain Injury

Trauma (including head injury)

Other CVA (thrombotic or unclassified)

Intracranial haemorrhage (non traumatic)

Dia

gn

os

tic

ca

teg

ori

es

Percentage

Actual DCDs %

Potential DCDs %

UK Potential Donor Audit (October 2009 – March 2012)7504 patients referred as potential DCD donors877 actual DCD donors

Potential Donor

• 83 year old• PEA Out of hospital cardiac arrest• “Downtime” 15-20 minutes• Hypoxic brain injury• Known Hypertensive• Urea 16.4 Creat 94• Prev Basal cell Carcinoma

Overall timings

Organ Donation Past, Present and Future

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

NICE Guideline 135

Organ Donation Past, Present and Future

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.

Organ Donation Past, Present and Future

General Medical Council 2010

I”f 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

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.”

Organ Donation Past, Present and Future

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

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

Organ Donation Past, Present and Future

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.

Organ Donation Past, Present and Future

1. Daily visit by SN-OD

Organ Donation Past, Present and Future

2. Early daily phone call

Organ Donation Past, Present and Future

3. Daily ICU team safety brief

Organ Donation Past, Present and Future

Organ Donation Past, Present and Future

North Bristol Trust ICU Safety Brief

4. Standard Operating Procedure

Organ Donation Past, Present and Future

Midlands Standard Operating Procedure

Organ Donation Past, Present and Future

5. Nurse led referrals

Organ Donation Past, Present and Future

Summary

28Organ Donation Past, Present and Future

• 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 29

What are the barriers to implementing the NICE guidelines in your unit? Any solutiions?

Organ Donation Past, Present and Future 30

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.