Donor Identification and Referral: Preventable Death and Disability Dr. Samara Zavalkoff Canadian Critical Care Forum November 2019
Disclosures Funding from Canadian Blood Services and the Organ Donation and Transplant Collaborative
While on service… • Antibiotics are delayed in a septic patient INCIDENT REPORT QI REVIEW DISCLOSURE PRACTICE CHANGE DIRECT ACCOUNTABILITY 3
Consequences on other patients Duty of Care to Patient Disconnected Harm
Accountability But also to potential donors and their families 5
Deceased donor rate in Canada, 2008-2018 (donors per million population = dpmp) 25 20.6 20 +42% 15 14.4 Since 2008 10 6.2 5 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Total NDD DCD Data source: CBS System Progress Report 2018 6
Transplants vs. people waiting for transplants in Canada, 2006-2018 6,000 4,660 4,654 4,588 4,573 4,564 4,541 4,529 4,380 4,351 4,333 3,796 4,000 THE GAP 2,979 2,903 2,829 2,580 2,000 2,423 2,429 2,237 2,117 2,131 2,093 2,077 223 Patients died while on waitlist 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Transplants Persons on waitlist Data source: CBS System Progress Report 2018 7
Donation Pathway Meet Clinical Identification EOL + Donor Triggers and Referral management Approach Consent Declaration of Death (NDD) Declaration of Death (DCD) 8
Compliance with required referral legislation in Manitoba LAW Thanks to Transplant Manitoba. 9
Kramer et al, CJA 2019 Donor Identification in the ED McCallum et al, CJEM 2019 Empson et al, EMJ 2017 18% brain death not 84% NDD, 64% DCD not identified identified UK: up to 16% missed UK: only 47% potential referral were on the donor were referred registry 10
Expert guidance: System Level • 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 13
Expert guidance: Professional Level • 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 14
Knowledge Gaps • 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) 16
Physician non referral 54% ICU MDs have not referred 43% observed a colleague not refer Weiss et al, CJA 2019, in press 17
Reason Selected % Responses (n=104) Organ dysfunction would preclude donation 59 Too emotionally distressed 42 Ethical or medicolegal conflicts with families 39 Reasons for physician non referral 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 Weiss et al, CJA 2019, in press
“You cannot manage what you cannot measure” Peter Drucker
281,007 Deaths 166, 631 Hospital Deaths 762 Donors Hornby et al, CJA 2019 20
Key numbers and rates, April 2018 – March 2019 Table 1 Key numbers and rates DBD DCD All Patients meeting organ donation referral criteria 1 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
Ideal Potential Donor Audit (PDA) All critical care All hospitals Routine Real-time areas (ED, ICU) Reporting – Direct professional Consistent Accessible Feedback and public Accurate 22
PDA methodology and deceased donation identification and referral rates: an environmental scan of Canadian ODOs Online questionnaire Mixed methods 1:1 interviews 23
Environmental Scan- areas explored • 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 24
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GOAL 30
Referral vs timely referral 31
251 missed ~150 consented ~450 organs CCM 2017 32
Organ Donation and Transplant Collaborative funding • 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 33
Missed Donation Opportunity Steering Committee Sam Lydia Debbie Jehan Shauna O’Donnell Neville Lalani Lauder Shemie Samara Zavalkoff Chair samara.zavalkoff@mcgill.ca Greg Jim Andreas Meagan James Kramer Knoll Mahoney Mohr Lee 34
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