Preventable Death and Disability Dr. Samara Zavalkoff Canadian - - PowerPoint PPT Presentation

Canadian Critical Care Forum November 2019

Donor Identification and Referral: Preventable Death and Disability

• Dr. Samara Zavalkoff

Disclosures

Funding from Canadian Blood Services and the Organ Donation and Transplant Collaborative

3

• Antibiotics are delayed in a septic patient

INCIDENT REPORT QI REVIEW DISCLOSURE PRACTICE CHANGE

DIRECT ACCOUNTABILITY

While on service…

Duty of Care to Patient

Consequences on other patients

Disconnected Harm

5

But also to potential donors and their families

Accountability

6

Deceased donor rate in Canada, 2008-2018

(donors per million population = dpmp)

+42%

Since 2008

Data source: CBS System Progress Report 2018 20.6 14.4 6.2 5 10 15 20 25 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Total NDD DCD

7

2,077 2,093 2,117 2,131 2,237 2,423 2,429 2,580 2,903 2,979 2,829 4,380 3,796 4,529 4,660 4,654 4,588 4,573 4,564 4,541 4,333 4,351 2,000 4,000 6,000 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Transplants Persons on waitlist

Transplants vs. people waiting for transplants in Canada, 2006-2018

223

Patients died while on waitlist

Data source: CBS System Progress Report 2018

THE GAP

8

Donation Pathway

Meet Clinical Triggers Identification and Referral Approach Consent EOL + Donor management

Declaration of Death (DCD) Declaration of Death (NDD)

9

Compliance with required referral legislation in Manitoba

Thanks to Transplant Manitoba.

LAW

10

Donor Identification in the ED

Kramer et al, CJA 2019 McCallum et al, CJEM 2019 Empson et al, EMJ 2017

18% brain death not identified 84% NDD, 64% DCD not identified UK: only 47% potential donor were referred UK: up to 16% missed referral were on the registry

13

• National adoption of clinical triggers
• Dedicated resources to match donation activates
• Performance measurement through potential donor audits
• Reporting and investigation of missed donation opportunities
• Missed donor identification and referral be considered a preventable and

critical patient safety event

Expert guidance: System Level

14

• Donation be consistently addressed as part of end-of-life care,

but only after a decision to withdraw life-sustaining treatment

• Healthcare professionals know how and when to identify and refer

potential donors

• Families be informed why they were not approached
• All professionals involved in EOL care can identify potential

donors

Expert guidance: Professional Level

16

• Low comfort in identifying potential donors (DCD >

NDD)

(Hancock et al, 2017)

• Challenges to DCD identification: 1)DCD education

2)standardized and systematic screening process

(Squire, et al, 2018)

Knowledge Gaps

17

Physician non referral

Weiss et al, CJA 2019, in press

54% ICU MDs have not

referred

43% observed a colleague

not refer

Reasons for physician non referral

Weiss et al, CJA 2019, in press

Reason Selected % Responses (n=104)

Organ dysfunction would preclude donation

59

Too emotionally distressed

42

Ethical or medicolegal conflicts with families

39

Patient background did not support donation

34

Expressed desire to leave the ICU as quickly as possible

29

Not competent to provide valid consent

14

Lack of donation resources

9

Peter Drucker

“You cannot manage what you cannot measure”

20

Hornby et al, CJA 2019 166, 631 Hospital Deaths 281,007 Deaths 762 Donors

Key numbers and rates, April 2018 – March 2019

Table 1 Key numbers and rates DBD DCD All Patients meeting organ donation referral criteria1 2004 5974 7728 Referred to NHS Blood and Transplant 1982 5539 7287 Referral rate % 98.9% 92.7% 94.3% Neurological death tested 1715 1715 Testing rate % 85.6% 85.6% Family approached 1493 1752 3245 Family approached and SN-OD present 1423 1527 2950 % of approaches where SN-OD present 95.3% 87.2% 90.9% Consent/authorisation given 1082 1099 2181 Consent/authorisation rate % 72.5% 62.7% 67.2% Actual donors from each pathway 970 612 1582 % of consented/authorised donors that became actual donors 89.6% 55.7% 72.5%

1 DBD - A patient with suspected neurological death excluding those that were not tested due to reasons: cardiac arrest occurred despite

resuscitation, brainstem reflexes returned

1 DCD - A patient in whom imminent death is anticipated, ie a patient receiving assisted ventilation, a clinical decision to withdraw

treatment has been made and death is anticipated within 4 hours

Source: Annual PDA Report 2018/19, NHS Blood and Transplant

22

Ideal Potential Donor Audit (PDA)

All hospitals All critical care areas (ED, ICU) Routine Real-time Reporting – professional and public Direct Feedback Consistent Accessible Accurate

23

Mixed methods Online questionnaire 1:1 interviews

PDA methodology and deceased donation identification and referral rates: an environmental scan of Canadian ODOs

24

• ODO demographics
• Potential Donor Audit practices
• Inclusion Exclusion criteria for PDA chart review
• Definitions (eg potential donor)
• Data
• Costs and Resources
• Reporting and feedback
• Training
• Privacy issues

Environmental Scan- areas explored

25

26

27

28

29

30

GOAL

31

Referral vs timely referral

32

CCM 2017

251 missed ~150 consented ~450 organs

33

• Root cause analysis of missed donor ID&R and KT plan
• Economic evaluation of national PDA implementation
• Evaluate audit and feedback strategies
• Integrate donor IDR into hospital accreditation

Organ Donation and Transplant Collaborative funding

34

Missed Donation Opportunity Steering Committee

Andreas Kramer Lydia Lauder Debbie Neville Shauna O’Donnell Jehan Lalani Jim Mohr James Lee Meagan Mahoney Samara Zavalkoff Chair samara.zavalkoff@mcgill.ca Sam Shemie Greg Knoll