alex manara draft strategy for identification & referral ... · alex manara regional clod south...

Alex ManaraRegional CLODSouth WestMarch 2012

Draft Strategy for Identification & Referral of Potential Donors

Improving organ donation within your hospital

100% Identification of potential Donors

100% Referral of Potential Donors

100% Timely Referral

Implement NICE Guidance

The possibility for donation should be core ICU / ED business and considered as part of all end of life care plans.

Early referral promotes this possibility

Whichever is the earlier, either:

Use defined clinical trigger factors in patients who have had 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 sedationand/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.

TRIGGERS FOR NOTIFICATION

NICE recognised that some of the patients who are identified by these clinical triggers will survive

Recommendation 5: Minimum notification criteria for potential organ donors

Full recommendation: Minimum notification criteria for potential organ donors should be introduced on a UK-wide basis. These criteria should be reviewed after 12 months in the light of evidence of their effect, and the comparative impact of more detailed criteria should also be assessed.

Status: Business as usual

Minimal Notification Criteria in UK

Consent / authorisation is the biggest single obstacle to donation

.

There are two important elements to referral

1.That it happens

2.That it occurs soon enough to maximise the opportunity for that person to be a donor

Achieving the strategic big wins for Organ Donation requires breaking down the barriers to success to reveal the underlying issues and plan the most effective interventions

Introduction

Why are we not using Minimal Notification Criteria?

Ethical concerns

No evidence to support introduction

Distressed families kept waiting unnecessarily

Delays in co-ordination and retrieval

Resources-

Some of the root causes of failure to refer potential donors in a timely fashion

Guidance on Issues

Some Hard Data from BMA

Maximum rate of donation in the UK if all potential donors went on to donate

recognising, of course, that in practice this is unachievable

Potential DBD donors 18.4pmpPotential DCD donors 26.4 pmpTotal UK potential donors 44.8 pmpActual UK donor rate 16.3 pmp

UK maximum would be 28.2 pmp with current consent rate

All patients with severe brain injury requiring mechanical ventilation

Call if:

Brain stem death testing planned

GCS 4

Absence of 1 or more cranial nerve reflex

pupils fixed

no corneal reflex

no cough or gag reflex

unresponsive to painful stimuli

A decision to withdraw active treatment has been made in a ventilated patient of any age

or

Clinical triggers for referral in Birmingham

ICU clinicians can buy into a triggered referral system

Long Contact: Early and Extended Interaction with Families

Impact of SNOD presence during brain death discussion and time spent

with families:

SNOD present during brain death discussion consent / authorisation

rate 63% vs. 34%

< 30 mins consent / authorisation rate 46%

> 30 mins consent / authorisation rate 62%

> 3 hrs consent / authorisation rate 75 %

In USA early referral leads to increased time with potential donor s family and results in higher donation rates Shafer, T

New Potential Donor Audit Data(Oct 2009-April 2010)

Neurological death testing

rate (%)

DBD referral rate (%)

DBD approach rate (%)

DBD consent /

authorisation rate (%)

consent / authorisation rate

where a SN-OD was involved in the approach

consent / authorisation rate where no SN-OD

was involved in the approach

76.6 86.2 93 63.2 70.1 51.3

DCD referral rate (%)

DCD approach rate (%)

DCD consent /

authorisation rate (%)

consent / authorisation rate

where a SN-OD was involved in the approach

consent / authorisation rate where no SN-OD

was involved in the approach

30.8 27.6 55.6 67.8 42.6

PDA revised in line with Donation Advisory Group membership in 2009

Advantages of Triggered ReferralAll potential donors are identified and referred

All potential donors are referred in a timely fashion

Facilitates long contact model of family support for consent / authorisation

Reduces likelihood of delays in arrival of SN-OD or retrieval team(s)

Allows better planning of the approach to the family

SN-OD immediately available at the time of family approach

End of life care plans can be defined

Improves data accuracy

Advice on confirmation of brain-stem death and donor management

ODR can be checked before the family approach

Reduces conflict of interest arguments

Key message that earlier referral should improve the service that the donor family (and hospitals) subsequently receive

Make donor identification and referral routine business of the unit. Decouple early referral from the individual clinician caring for the patient Not be prescriptive on the solutions individual hospitals adopt to timely referral BUT

Every organisation should have such a policy

Ensure consistency within a given hospital

Implementing Triggered Referral

. Early referral should improve the service that the donor family (and hospitals) subsequently receive

Daily attendance of embedded SN-OD

Daily ring round the critical care units

Incorporation into the ICU daily Safety Briefing

Adoption of an SOP

Nurse led |referral


Advantages Disadvantages

No need for formal notification Not available out of hours and on weekends

Less concern of a perceived conflict of interest by ICU staff

Absences for annual leave, sick leave, professional leave

Increasing availability to all hospitals May cause unease in ICU staff

Embedded SN-OD part of that ICU team Who gives the information?

Less effective for ED

Daily attendance of embedded SNOD



Adoption of an SOP

Nurse led |referral



No need for formal notification SN-OD may be unfamiliar to ICU staff

Less concern of a perceived conflict of interest by ICU staff

May cause unease in ICU staff

Available to all Hospitals all year round Who gives the information?On call SNOD communicates with embedded SNOD when there

Less effective for ED

Intrusive for units with low donor potential



Incorporation into the ICU daily Safety BriefingAdoption of an SOP

Nurse led |referral


Advantages DisadvantagesOrgan donation becomes part of ICU daily business

Who gives the information?

Donation considered by all members of the ICU team

Can be effective in ED if repeated in every shift

Less concern about conflict of interestDonation potential considered at start of every dayInitiated by ICU team not individuals




Adoption of an SOP

Nurse led |referral



Popular management tool Needs initiation by individual of ICU team

Directs user through whole donor pathways

Paperwork kept at bedside




Adoption of an SOP

Nurse led |referral


Advantages DisadvantagesIn ED only trigger likely to be used is an intention to withdraw treatment

Needs initiation by individual of ED nursing staff

Empowers ICU/ED nursing staff Needs a rapid response from the SN-OD teamOther members of team may not be aware of referralPotential risk of confusing and inappropriate referrals

The Potential Donor AuditStandards Set by Local Donor Teams

and TrustsCQC assessment and CQUIN targets.

Never Events

Monitoring Triggered Referrals

Does it increase referrals?Does it increase donor numbers?

100% Identification of potential Donors

100% Referral of Potential Donors

100% Timely Referral

Implement NICE Guidance

The possibility for donation should be core ICU / ED business and considered as part of all end of life care plans.

Early referral promotes this possibility

alex manara draft strategy for identification & referral ... · alex manara regional clod south...

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