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

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• 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

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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

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”

20Hornby 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

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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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26

27

28

29

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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

samara.zavalkoff@mcgill.ca

Sam

Shemie

Greg

Knoll