Emergency department referral for organ donation: more organ donors and more organs per donor

Barriers and Facilitators Towards Deceased Organ Donation: A Qualitative Study Among Three Major Religious Groups in Chandigarh, and Chennai, India

This study aimed to examine the barriers and facilitators of the public toward deceased organ donation in Chandigarh, and Chennai, India, from three major religious groups, Hinduism, Islamism, and Christianity. Twenty-five focus groups were conducted (n = 87) stratified by study region, religion, sex, and age. Data were analysed using framework analysis. The results revealed that individuals were primarily willing to donate their organs. However, their religious views regarding death, after-life beliefs, funeral ritual practices, and lack of knowledge regarding their religion's position toward deceased organ donation created tension and ambiguity in the decision-making. However, younger age groups (18-30 years) appeared more open and positive toward deceased organ donation. The conclusion demands a clear need for religious leaders and stakeholders to address their religion's stance, which creates tension and ambiguity in any uncertainties surrounding cultural and religious-based views among the Indian population.

The Impact of Early Brain-Dead Donor Detection in the Emergency Department on the Organ Donation Process in Iran

We aimed to assess the impact of hospital characteristics on the outcomes of detected possible brain-dead donors, in our organ procurement network in Iran. Data was collected through twice-daily calls with 57 hospitals' intensive care units and emergency departments over 1 year. The donation team got involved when there was suspicion of brain death before the hospital officially declared it. The data was categorized by hospital size, presence of neurosurgery/trauma departments, ownership, and referral site. Out of 813 possible donors, 315 were declared brain dead, and 203 were eligible for donation. After conducting family interviews (consent rate: 62.2%), 102 eligible donors became actual donors (conversion rate: 50.2%). While hospital ownership and the presence of trauma/neurosurgery care did not affect donation, early referral from the emergency department had a positive effect. Therefore, we strongly recommend prioritizing possible donor identification in emergency rooms and involving the organ donation team as early as possible. The use of twice-daily calls for donor identification likely contributed to the consistency in donation rates across hospitals, as this approach involves the donation team earlier and mitigates the impact of hospital characteristics. Early detection of possible donors from the emergency department is crucial in improving donation rates.

Increasing Solid Organ Donation: A Role for Emergency Physicians

BACKGROUND

More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors.

DISCUSSION

Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies.

CONCLUSION

With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.

Solid organ donation from the emergency department - missed donor opportunities

OBJECTIVE

A significant gap exists between people awaiting solid organ transplantation and solid organ donors. The purpose of this study was to determine whether there were missed donors in the emergency department (ED).

METHODS

We performed a health records and organ donation database review of all patients dying in a large tertiary ED from November 1, 2014 to October 31, 2017 at two campuses with 160,000 visits per year. Demographic and donor suitability data were collected. The primary outcome was missed potential solid organ donors. Missed potential donors were intubated, had a pulse, and had no donation contraindications. The secondary outcome was cases where no notification was made to the organ donation organization at all.

RESULTS

There were 605 deaths in the ED. Patients had a mean age of 71.1 years, 58.3% were male, and 12.4% died of a traumatic cause. There were 10 missed potential donors. Missed potential donors had a mean age of 67.4 years, 70.0% were male, and 20.0% died from trauma. In all 10 cases, patients had withdrawal of life-sustaining therapy for medical futility, and referral for donation occurred after death. Missed ED donors could have increased hospital-wide donation up to 10.6%. No notification was made in 12 (2.0%) cases; however, none of these would have been successful solid organ donors.

CONCLUSION

The ED is a source of missed organ donors. All potential donors were missed due to referral after withdrawal of life-sustaining therapy. ED physicians should consider the possibility of solid organ donation prior to the withdrawal of life-sustaining therapy.

Solid organ donation from the emergency department - A systematic review

OBJECTIVES

A significant gap exists between people awaiting an organ transplant and organ donors. The purpose of this study was to determine what percent of successful donors come from the emergency department (ED), whether there are any missed donors, and to identify factors associated with successful and missed donation.

METHODS

This systematic review used electronic searches of EMBASE, MEDLINE, and CINAHL according to PRISMA guidelines on July 7, 2017. We included primary literature in adults describing successful and missed organ donation. Two authors independently screened articles, and discrepancies were resolved through consensus. Quality was assessed using the STROBE checklist.

RESULTS

This systematic review identified 1,058 articles, and 25 articles were included. For neurologic determination of death, ED patients comprised 4%-50% of successful donors and 3.6%-8.9% of successful donors for donation after circulatory determination of death. ED death reviews revealed up to 84% of missed neurologic determination of death, and 46.2% of missed circulatory determination of death donors who died in the ED are missed due to a failure to refer for consideration of organ donation. Clinical heterogeneity precluded pooling of the data to conduct a meta-analysis.

CONCLUSIONS

The ED is a source of actual and missed donors. Potential donors are often missed due to incorrect assumptions regarding eligibility criteria and failure of the healthcare team to refer for consideration of donation. ED healthcare professionals should be aware of organ donation referral protocols at their institution to ensure that no organ donors are missed.

The Implementation of a Multidisciplinary Approach for Potential Organ Donors in the Emergency Department

BACKGROUND

The aim of this study was to evaluate the implementation process of a multidisciplinary approach for potential organ donors in the emergency department (ED) in order to incorporate organ donation into their end-of-life care plans.

METHODS

A new multidisciplinary approach was implemented in 6 hospitals in The Netherlands between January 2016 and January 2018. The approach was introduced during staff meetings in the ED, intensive care unit (ICU), and neurology department. When patients with a devastating brain injury had a futile prognosis in the ED, without contraindications for organ donation, an ICU admission was considered. Every ICU admission to incorporate organ donation into end-of-life care was systematically evaluated with the involved physicians using a standardized questionnaire.

RESULTS

In total, 55 potential organ donors were admitted to the ICU to incorporate organ donation into end-of-life care. Twenty-seven families consented to donation and 20 successful organ donations were performed. Twenty-nine percent of the total pool of organ donors in these hospitals were admitted to the ICU for organ donation.

CONCLUSIONS

Patients with a devastating brain injury and futile medical prognosis in the ED are an important proportion of the total number of donors. The implementation of a multidisciplinary approach is feasible and could lead to better identification of potential donors in the ED.

Grief, Stress, Trauma, and Support During the Organ Donation Process

The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family's experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other's positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members' efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other's roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff.

Missed opportunities for organ donation in patients with intracranial haemorrhage at the emergency department: A single-centre study

Background:

The demand for transplantable organs has increased in Singapore. However, organ donation has been consistently lower than international standards. Donation after brain death (DBD) most commonly follows intracranial haemorrhage (ICH).

Objective:

Our aim was to identify missed opportunities for organ donation among those who presented to the Emergency Department (ED) and died following ICH.

Methods:

A retrospective study was carried out for all cases of ICH presenting to the ED from 1 January 2013 to 31 December 2017. The patients’ medical records were reviewed for identification of potential donors and actualisation of organ donation.

Results:

There were 615 cases of ICH, with a mortality rate of 6.0%. Among those who died, 28 (75.7%) died in the Intensive Care Unit (ICU) and nine (24.3%) patients had withdrawal of care in the ED. Thirty patients (81.1%) were potential donors but organ donation was actualised in only three (8.1%) patients. Thirteen organs, as well as heart valves and iliac vessels were retrieved from the organ donors for transplantation.

Conclusion:

There were missed opportunities for organ donation. EDs have an important role to play in the national organ donation programme by identifying potential donors for organ donation and considering admitting these patients to ICU to facilitate organ donation.

Barriers to Brain Death Notifications From Emergency Departments

PURPOSE

Emergency departments (EDs) are a new focus of interest in recent years as a possible solution for increasing organ donations, as, EDs are full of missed opportunities. In this study, we aimed to determine the barriers to the identification and referral by emergency medicine physicians (EMPs) of potential brain death (BD) cases.

MATERIALS AND METHODS

The participants of the study consist of 252 EMPs who had answered the questionnaire sent via e-mail.

FINDINGS

The following causes were found in the questionnaire: (1) negative attitudes and lack of knowledge about organ donation in society (63.1%); (2) religious beliefs (57.5%); (3) family refusal (57.1%); (4) disruption of bodily integrity (45.6%); (5) inadequate knowledge of doctors (50.4%); (6) difficulties in predicting the prognosis of the patient and diagnosing BD in EDs (40.1%); (7) fear of negative reactions from relatives of patients (37.7%); (8) the absence of an organ procurement unit (OPU) (36.5%); (9) lack of ideal candidates (27%); (10) increased workload in EDs (23.8%); and (11) fear of legal problems arising (23.8%). Of the participants, 42.9% stated that there was an OPU in their hospital. Of the participants, 15.8% reported that they have good communication with the OPU.

CONCLUSIONS

Negative attitudes and lack of knowledge about organ donation in society, religious beliefs, inadequate knowledge of EMPs, and the absence of an OPU in hospitals are important barriers to organ donor notification from EDs. Increasing social awareness and increasing of the level of knowledge of EMPs and close cooperation between OPU and EDs will significantly contribute to the increase of organ donor notifications from EDs.

Results After Implementing a Program of Intensive Care to Facilitate Organ Donation

A program of intensive care to facilitate organ donation (ICOD) represents one of the ways to increase donation rate following brain death (BD).

OBJECTIVES

To analyze the impact and cost-effectiveness of setting up an ICOD strategy.

METHOD

Retrospective cases of BD donors from the Spanish region La Rioja were included, after implementation of an ICOD program (2011-2016). This was activated in cases of devastating neurologic injury where treatment had been rejected following therapeutic futility criteria. Follow-up of kidney and liver transplant patients with the obtained grafts was carried out.

RESULTS

A total of 134 potential donors were admitted to intensive care unit (ICU), of whom 106 were selected under the ICOD strategy. BD was diagnosed in 108 cases (25 conventional donors, 83 ICOD donors). A total of 21.6% of potential ICOD donors did not evolve to BD, subsequently dying in the ICU. ICOD cases accounted for more than 50% of donors each year. This cohort had an average stay of 2.4 days in the ICU and accounted for a small proportion of total ICU admissions. A total of 68 (81.9%) ICOD donors were finally effective and 146 grafts were extracted, the majority being abdominal organs (liver and kidney). Probability of survival 1 year after liver transplant (ICOD donor) was 90.9%, with 1 case of primary graft failure. Survival 1 year after kidney transplant (ICOD donor) was 92.7%. No differences were detected in survival rates of kidney and liver transplant patients regarding donor type (ICOD vs conventional).

CONCLUSIONS

Implementation of an ICOD program allows an increase in the pool of valid and quality grafts for transplant as well as implying a minimum consumption of intensive medicine resources. The results in transplant patients support this strategy.

Organ and tissue donation from poisoned patients in the emergency department: A Canadian emergency physician survey

OBJECTIVES

Screening for organ and tissue donation is an essential skill for emergency physicians. In 2015, 4,631 Canadians were on a waiting list for a transplant, and 262 died while waiting. Canada’s donation rates are less than half of comparable countries, so it is essential to explore strategies to improve the referral of donors. Poisoned patients may be one such underutilized source for donation. This study explores physician practices and perceptions regarding the referral of poisoned patients as donors.

METHODS

In this cross-sectional unidirectional survey, 1,471 physician members of the Canadian Association of Emergency Physicians were invited to participate. Physicians were presented with 20 scenarios and asked whether they would refer the patient as a potential organ or tissue donor. Results were reported descriptively, and associations between demographics and referral patterns were assessed.

RESULTS

Physicians totalling 208 participated in the organ or tissue donation scenarios (14.1%); 75% of scenarios involving poisoning were referred for organ or tissue donation, compared with 92% in a non-poisoning scenario. Poisons associated with lower referrals included sedatives, acetaminophen, chemical exposure, and organophosphates. A total of 175 physicians completed the demographic survey (11.9%). Characteristics associated with increased referrals included previous referral experience, donation training, donation support, >10 years of service, urban practice, emergency medicine certification, and male gender.

CONCLUSIONS

Scenarios involving poisoning were referred less often when compared with an ideal scenario. Because poisoning is not a contraindication for referral, this represents a potential source of donors. Targeted training and referral support may help improve donation rates in this demographic.

The First 2 Years of Activity of a Specialized Organ Procurement Center: Report of an Innovative Approach to Improve Organ Donation

The number of patients requiring organ transplants continues to outgrow the number of organs donated each year. In an attempt to improve the organ donation process and increase the number of organs available, we created a specialized multidisciplinary team within a specialized organ procurement center (OPC) with dedicated intensive care unit (ICU) beds and operating rooms. The OPC was staffed with ICU nurses, operating room nurses, organ donor management ICU physicians, and multidisciplinary staff. All organ donors within a designated geographic area were transferred to and managed within the OPC. During the first 2 years of operation, 126 patients were referred to the OPC. The OPC was in use for a total of 3527 h and involved 253 health workers. We retrieved 173 kidneys, 95 lungs, 68 livers, 37 hearts, and 13 pancreases for a total of 386 organs offered for transplantation. This translates to a total of 124.6 persons transplanted per million population, which compares most favorably to recently published numbers in developed countries. The OPC clearly demonstrates potential to increase the number of deceased donor organs available for transplant. Further studies are warranted to better understand the exact influence of the different components of the OPC on organ procurement.

Hospital characteristics associated with increased conversion rates among organ donors in New England

BACKGROUND

It is unknown whether hospital characteristics affect institutional performance with regard to organ donation. We sought to determine which hospital- and patient-level characteristics are associated with high organ donor conversion rates after brain death (DBD).

METHODS

Data were extracted from the regional Organ Procurement Organization (2011-2014) and other sources. Hospitals were stratified into high-conversion hospitals (HCH; upper-tertile) and low-conversion hospitals (LCH; lower-tertile) according to conversion rates. Hospital- and patient-characteristics were compared between groups.

RESULTS

There were 564 potential DBD donors in 27 hospitals. Conversion rates differed between hospitals in different states (p < 0.001). HCH were more likely to be small (median bed size 194 vs. 337; p = 0.024), non-teaching hospitals (40% vs. 88%; p = 0.025), non-trauma center (30% vs. 77%; p = 0.040). Potential donors differed between HCH and LCH in race (p < 0.01) and mechanism of injury/disease process (p < 0.01).

CONCLUSION

There is significant variation between hospitals in terms of organ donor conversion rates. This suggests that there is a pool of potential donors in large specialized hospitals that are not successfully converted to DBD.

Recommendations for further improvement of the deceased organ donation process in Belgium

Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.