Transcript Timely Identification and Referral of Potential Organ Donors

Timely Identification
and Referral of
Potential Organ
Donors
Paul Murphy
National Clinical Lead for Organ
Donation
Midlands Collaborative, November 2012
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
Midlands Collaborative, November 2012
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
Midlands Collaborative, November 2012
Referral rates for potential DBD donors,
2010/11
99.8% CL
95% CL
National rate
95% CL
99.8% CL
= one (or more) Trust/Health Board
Midlands Collaborative, November 2012
Referral rates for potential DCD donors,
2010/11
99.8% CL
95% CL
National rate
95% CL
99.8% CL
= one (or more) Trust/Health Board
Midlands Collaborative, November 2012
UK rates of referral
referral of deceased donors
DBD
DCD
100
percentage
80
60
40
20
0
2005-6
2006-7
2007-8
2008-9
2009-10
2010-11
2011-12
year
Midlands Collaborative, November 2012
Progression through the donation pathway
Midlands Collaborative, November 2012
SN-OD responsiveness
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Referral to attendance
Variation across UK
Median (hrs)
Q3 (hrs)
DBD
Best
Worst
0.8
3.7
2.1
10.5
DCD
Best
Worst
0.4
1.9
1.7
4.2
Midlands Collaborative, November 2012
Overall timings
Midlands Collaborative, November 2012
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.
Midlands Collaborative, November 2012
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.
Midlands Collaborative, November 2012
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.
Midlands Collaborative, November 2012
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.
Midlands Collaborative, November 2012
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.
Midlands Collaborative, November 2012
NICE SCG 135
Midlands Collaborative, November 2012
Donor Assessment
Midlands Collaborative, November 2012
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
Midlands Collaborative, November 2012
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
Midlands Collaborative, November 2012
Provenance
Midlands Collaborative, November 2012
Objectives, benefits and outcomes
All potential donors
are identified and
referred
All patients are given the option of donation
All donors are
referred in a timely
fashion
Access to clinical advice
Prompt donor optimisation
Resolution of potential legal obstacles
Early assessment of marginal donors
Early tissue typing / screening
Planning the family approach
SN-ODs are
deployed in a way
that improves
responsiveness
Reduction in delays for families and units
Increased donor numbers
Improved consent / authorisation rates
Increase in donor organs
Better experience
Midlands Collaborative, November 2012
Planning the family approach
Planning
Confirming
understanding and
acceptance of loss
Establish the team: Consultant, SN-OD
and nurse
Clarify clinical situation
Seek evidence of prior consent
Key family members by name
Key family issues
Agree a process of approach and who will
be involved
Agree timing and setting, ensuring these
are appropriate to family needs
Involve others as required, eg faith leaders
Discussing
donation
Midlands Collaborative, November 2012
Strategy proposals
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.
• 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
Midlands Collaborative, November 2012
1. Daily visit by SN-OD
Midlands Collaborative, November 2012
2. Early daily phone call
Midlands Collaborative, November 2012
3. Daily ICU team safety brief
Midlands Collaborative, November 2012
Frenchay ICU team safety brief
Midlands Collaborative, November 2012
Frenchay ICU team safety brief
Midlands Collaborative, November 2012
4. Standard Operating Procedure
Midlands Collaborative, November 2012
Midlands Standard Operating Procedure
Midlands Collaborative, November 2012
Midlands Standard Operating Procedure
Midlands Collaborative, November 2012
5. Nurse led referrals
Midlands Collaborative, November 2012
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