donor identification and referral zavalkoff d… · •dedicated resources to match donation...
TRANSCRIPT
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Canadian Critical Care Forum
November 2019
Donor Identification and Referral:
Preventable Death and Disability
Dr. Samara Zavalkoff
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Disclosures
Funding from Canadian Blood Services and the Organ Donation and Transplant Collaborative
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• Antibiotics are delayed in a septic patient
INCIDENT REPORT QI REVIEW
DISCLOSURE PRACTICE CHANGE
DIRECT ACCOUNTABILITY
While on service…
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Duty of Care to Patient
Consequences on other patients
Disconnected Harm
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But also to potential donors and their families
Accountability
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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
0
5
10
15
20
25
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Total NDD DCD
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2,077 2,093 2,117 2,131 2,2372,423 2,429
2,5802,903 2,979
2,829
4,380
3,796
4,529 4,660 4,654 4,588 4,573 4,564 4,5414,333 4,351
0
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
223Patients died while on waitlist
Data source: CBS System Progress Report 2018
THEGAP
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Donation Pathway
Meet Clinical Triggers
Identification and Referral
Approach
Consent
EOL + Donor management
Declaration of Death (DCD)Declaration of Death (NDD)
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Compliance with required referral legislation in Manitoba
Thanks to Transplant Manitoba.
LAW
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Donor Identification in the EDKramer 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
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• 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
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• 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
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• 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
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Physician non referral
Weiss et al, CJA 2019, in press
54% ICU MDs have not referred
43% observed a colleague not refer
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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
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Peter Drucker
“You cannot manage what you cannot measure”
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20Hornby et al, CJA 2019
166, 631 Hospital Deaths
281,007 Deaths
762 Donors
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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
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Ideal Potential Donor Audit (PDA)
All hospitalsAll critical care areas (ED, ICU)
Routine Real-time
Reporting –professional and public
Direct Feedback
Consistent Accessible
Accurate
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Mixed methods
Online questionnaire
1:1 interviews
PDA methodology and deceased donation identification and referral rates: an environmental scan of Canadian ODOs
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• 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
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GOAL
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Referral vs timely referral
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CCM 2017
251 missed~150 consented~450 organs
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• 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
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Missed Donation Opportunity Steering Committee
Andreas
Kramer
Lydia
Lauder
Debbie
NevilleShauna
O’Donnell
Jehan
Lalani
Jim
Mohr
James
Lee
Meagan
Mahoney
Samara Zavalkoff
Chair
Sam
Shemie
Greg
Knoll