Organ Donation Past, Present and Future Donor Identification and Referral Becky Clarke Dr Malcolm...

Organ Donation Past, Present and Future

Donor Identification and Referral

Becky ClarkeDr Malcolm Watters11th June 2013

1

SOUTH CENTRAL


Regional Data

2

Becky Clarke SN-OD SOUTH CENTRAL

-------- National rate

95 97

8893

98

86 8791

95

8489 89

Ref

erra

l rat

e (%

)

0

20

40

60

80

100

Team

Easte

rn

London

Mid

lands

North

Wes

t

Norther

n

Norther

n

Irela

nd

Scotla

nd

South

Centra

lSouth

East

South

Wal

es South

Wes

t

York

shire

1 April 2012 to 31 March 2013, data as at 4 April 2013

6th

Organ Donation Past, Present and Future 3

South Central DBD referral rate SOUTH CENTRAL

Ref

erra

l ra

te (

%)

0

20

40

60

80

100

Number of neurological death suspected patients

0 10 20 30 40

1

10

111213

1415

16

17 18

2

3 45 6

7

8

9

Hospital National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL



SOUTH CENTRAL

South Central DBD referral rate

1 Portsmouth, Queen Alexandra Hospital

2 Southampton, Southampton University Hospitals

3 Winchester, Royal Hampshire County Hospital

4 Basingstoke, North Hampshire Hospital

5 Salisbury, Salisbury District Hospital

6 Swindon, Great Western Hospital

7 Newport, St Mary's Hospital

8 Slough, Wexham Park Hospital

9 Reading, Royal Berkshire Hospital

10 Aylesbury, Stoke Mandeville Hospital

11 Wycombe, Wycombe General Hospital

12 Milton Keynes, Milton Keynes General Hospital

13 Northampton, Northampton General Hospital

14 Oxford, Churchill Hospital

15 Banbury, Horton General Hospital

16 Oxford, John Radcliffe Hospital

17 Cheltenham, Cheltenham General Hospital

18 Gloucester, Gloucestershire Royal Hospital

-------- National rate

80

72

54

72

81

52

42

54 5659 60

65

Ref

erra

l ra

te (

%)

0

20

40

60

80

100

Team

Easte

rn

London

Mid

lands

North

Wes

t

Norther

n

Norther

n

Irela

nd

Scotla

nd

South

Centra

lSouth

East

South

Wal

es South

Wes

t

Yorksh

ire



9th

South Central DCD referral rate SOUTH CENTRAL

Ref

erra

l ra

te (

%)

0

20

40

60

80

100

Number of imminent death anticipated patients

0 10 20 30 40 50 60 70 80 90 100

1

10

11

12

13

1415

16

1718 2

3

4

5

6

7

8 9

Hospital National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL


SOUTH CENTRAL

South Central DCD referral rate


Identification and Referral

7

Dr Malcolm WattersSouth Central Regional CLOD

Timely Identification and

Referral of Potential Organ Donors


www.odt.nhs.uk

Session Objectives

9Organ Donation Past, Present and Future

• Understand difficulties with donor identification and referral

• Recognise benefits of improving elements of the process

– Increased identification and referral

– Timely referral

– Responsiveness to referral

• Consider which of the proposed methods of identification and referral may work in your hospital

UK rates of referral

referral of deceased donors

0

20

40

60

80

100

2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12

year

pe

rce

nta

ge

DBD DCD


91%

52%

Overall timings


Aims of Strategy

• 100% Identification of potential Donors

• 100% Referral of Potential Donors

• 100% Timely Referral

• Implement NICE Guidance

The consideration of donation should be core ICU / ED and part of all end of life care plans.

Timely referral promotes this possibility


NICE Guideline 135


British Medical Association 2012

The research data -------- 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.


General Medical Council 2010

I”f 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.


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.”


Objectives, benefits and outcomesAll potential donors are identified and referred

All donors are referred in a timely fashion

SN-ODs are deployed in a way that improves responsiveness

All patients are given the option of donation

Access to clinical advicePrompt donor optimisationResolution of potential legal obstaclesEarly assessment of marginal donorsEarly tissue typing / screeningPlanning the family approach

Reduction in delays for families and units

Increased donor numbersImproved consent / authorisation ratesIncrease in donor organsBetter experience for families and staff


NHSBT 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


Strategy proposals

• Every hospital should have a written policy for the identification and timely referral of all potential donors

• Every donating area within a given hospital adopts a consistent approach

• As far as possible ‘decouple’ early referral from individual clinician

Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion.


1. Daily visit by SN-OD


2. Early daily phone call


3. Daily ICU team safety brief



North Bristol Trust ICU Safety Brief

4. Standard Operating Procedure


Midlands Standard Operating Procedure


5. Nurse led referrals


Summary

27Organ Donation Past, Present and Future

• Donation should be a element of end of life care

• Make identification and referral routine business of the unit.

• This decouples early referral from the individual clinician caring for the patient

• Implement or develop a solutions /policy for your individual hospitals adopt to timely referral

• Ensure consistency within a given hospital


April - Septem-ber 2010

October 2010 - March 2011





Num-ber of audited refer-rals

2184 2577 2664 3113 3389 3600

Num-ber of actual DBD and DCD donors from eligible DBD donors

302 330 332 328 329 386

Num-ber of actual DCD donors from eligible DCD donors

168 192 192 228 243 248

250

750

1250

1750

2250

2750

3250

3750

Number of audited referrals and actual donors reported through the Referral Record, data as at 9 May 2013

Nu

mb

er

of

pati

en

ts

What are the barriers to implementing the NICE guidelines in your unit: any solutions?


Whichever is the earlier, either:

Use trigger factors in patients with 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 sedation

And / 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.

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