Canadian organ donation organizations' donor audit processes: an environmental scan

PURPOSE

Deceased donor audits (DAs) allow organ donation and transplantation systems to measure and analyze missed donation opportunities (MDOs). Missed donation opportunities can harm both patients/families denied the opportunity to donate and patients on transplant waitlists denied access to lifesaving organs. In Canada, there are no national standards for DAs, data analysis, nor accountability processes surrounding MDOs. Understanding DA current practice in each jurisdicton would facilitate developing a national strategy for DAs.

METHOD

All provincial organ donation organizations (ODOs) were invited to participate in an environmental scan (ES) of current DA practices. The two ES phases were an electronic survey followed by semistructured interviews. We collected information about the objectives, frequency, scope, data collection methodology, resources required, definitions/metrics used, and process for reporting outcomes.

RESULTS

All eleven ODOs participated in both phases of the ES (July and October 2019). The primary purposes for conducting DAs were to estimate the following: 1) donor potential (5/11, 45%); 2) system performance at the provincial level (3/11, 27%); and 3) system performance at the hospital level (3/11, 27%). Frequency of DAs varied from weekly to annually, depending on the availability of death reports, urban vs rural setting, and staffing. High variability was observed in DA methodology, donor definitions, and metrics across jurisdictions.

CONCLUSION

There is significant variability across Canadian ODOs in the methodology, definitions, timeliness, data collection, and reporting of DAs. This underscores the need for a national donor audit strategy to reduce preventable harm from MDOs to patients/families at end of life and those on transplant waitlists.

A study on the performance of the Donation Improvement Program in Korea

Background

Methods

Results

Conclusions

Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review

Background

Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes.

Objective

To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes.

Design

Scoping Review using a mixed methods approach for data extraction.

Setting

Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused.

Sample

Organ donation programs or processes.

Methods

We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results.

Results

A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%).

Limitations

Consistent with scoping review methodology, the methodological quality of included studies was not assessed.

Conclusions

This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically.

Trial Registration

Not applicable.

Systematic review of hospital-level metrics and interventions to increase deceased organ donation

BACKGROUND

Efforts to ameliorate the organ shortage have predominantly focused on improving processes and interventions at multiple levels in the organ donation process, but no comprehensive review of hospital-level features contributing to organ donation exists. We undertook a systematic review of the literature to better understand current knowledge and knowledge gaps about hospital-level metrics and interventions associated with successful organ donation.

METHODS

We searched six electronic databases (PubMed, Embase, CINAHL, Web of Science, Health Business Elite, and Google scholar) and conference abstracts for articles on hospital-level features associated with the final outcome of organ donation (PROSPERO CRD42020187080). Editorials, letters to the editor, and reviews without original data were excluded. Our main outcomes were conversion rate, donation rate, number of organs recovered, number of donors, and authorization rate.

RESULTS

Our search yielded 2177 studies, and after a thorough assessment, 72 articles were included in this systematic review. Studies were thematically categorized into 1) Hospital-level interventions associated with metrics of organ donation; these included patient- and family-centric measures (i.e. standardized interviews, collaborative requesting and decoupling, and dedicated in-house coordinators), and donor management goals that significantly increased conversion rates by up to 64%; 2) Hospital-level multi-stage programs/policies; which increased authorization rates between 30 and 50%; and 3) Hospital characteristics and qualities; being an academic center, trauma center and larger hospital correlated with higher authorization and conversion rates. Most studies had considerable risk of bias and were of low quality.

CONCLUSIONS

There is a lack of well-designed studies on hospital-level metrics and interventions associated with organ donation. The use of thoughtful, patient- and family-centric approaches to authorization generally is associated with more organ donors. Future work can build on what is known about the hospital role in organ donation to improve the entire organ donation process.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

Donor Action: An International Initiative to Alleviate Organ Shortage

Context

Donor Action, an international initiative to alleviate organ shortage, provides a comprehensive state-of-the-art methodology that helps critical care units develop a tailor-made approach to optimize donation practices and performance.

Objective

To report the impact of the Donor Action methodology on organ donation rates in 8 countries (70 critical care units) in North America and Europe.

Design

Baseline data on the clinical potential for donation, staff attitudes, knowledge toward donation, self-reported confidence in performing a range of donation roles, and educational requirements were gathered. These data were analyzed using the Donor Action database and improvement measures were introduced to address identified weaknesses.

Results

Following introduction of the program's improvement measures, which addressed identified weaknesses, donations increased on average by 53% ( P=.0017) per country at 1 year. Sustained improvements settled at 70% to 160% increases at 3 years. Although Donor Action is at various stages of implementation in different countries, the number of centers and countries demonstrating an immediate awareness effect is increasing and sustained effects in centers with the longest follow-up promise a significant impact on donation rates as more countries implement this methodology.

Donor Action Program in the Emilia-Romagna Region of Italy

Context

The high demand for organs for transplantation necessitates enhancement of organ procurement activity worldwide.

Objective

To detect critical areas in the organ donation process and to assess whether careful monitoring of deaths in each intensive care unit could improve rates of identification of brain death.

Design

Records of patients who died in intensive care units in the Emilia-Romagna region between July 1, 1998 and June 30, 2000 were reviewed through the Donor Action program.

Results

Of the 2469 patients who died during the period studied, 1010 (40.9%) had severe brain damage, as indicated by a score of 3 on the Glasgow coma scale. A total of 857 patients with severe brain damage who had spent more than 6 hours in the intensive care unit (34.7% of all deaths) were considered as potential donors. Signs of brain death were observed in 383 (44.7%) of the 857 patients who died. Rates of identification of brain death increased from 36% to 55% during the study period.

Conclusion

Considering that the characteristics of the study population had not changed, we believe that the Donor Action program was an important factor leading to the observed improvement in identification of brain death.

Potential for deceased donation not optimally exploited: donor action data from six countries

BACKGROUND

Most countries today promote living donation as an alternative to challenge the organ shortage from deceased donors. This seems justifiable provided the potential for deceased donation is optimally exploited.

METHODS

We used the Donor Action (DA) Medical Record Review (MRR) methodology in six countries, to measure whether the potential for heart-beating (HB) deceased donors was adequately converted to donation. Medical record review data were collected from 52,383 patients who died in 605 critical care units in 227 hospitals between January 2007 and December 2009.

RESULTS

On a total of 17,903 ventilated patients aged younger than 76 years and without contraindications to HB donation, 4,855 cases met criteria for brain death (BD) diagnosis and were considered potential HB donors. On average, 24.8±15.9% was not identified as potential donor, 21.9% of identified cases was not referred as such to a procurement team, and in 11.3% of identified cases, no approached was offered with the option to donate. Average consent rates/family approaches or registry consultation was 69.1±14.5%, and average conversion of potential into actual donors was 42.1±7.3%.

CONCLUSIONS

Over 57% of deceased potential donors in the study cohort were missed along the donation pathway because of nonidentification, no referral, no approach of relatives, or objections to donate. In countries with lower donation rates, expectedly more potential donors are missed proportionally. Efforts to increase the organ pool should therefore focus on optimizing clinical practices in deceased organ donation in addition to promoting living organ donation.

Higher refusal rates for organ donation among older potential donors in the Netherlands: impact of the donor register and relatives

BACKGROUND

The availability of donor organs is considerably reduced by relatives refusing donation after death. There is no previous large-scale evaluation of the influence of the Donor Register (DR) consultation and the potential donor's age on this refusal in The Netherlands.

METHODS

This study examines 2101 potential organ donors identified in intensive care units between 2005 and 2008 and analyzes the association of DR consultation and subsequent refusal by relatives and the relationship with the potential donor's age.

RESULTS

Of the 1864 potential donor cases where the DR was consulted, the DR revealed no registration in 56%, 20% registration of consent, and 18% objection. In the other 6.5% of cases, where the DR indicated that relatives had to decide, the relatives' refusal rate was significantly lower than in the absence of a DR registration (46% vs. 63%). In 6% of the cases where the DR recorded donation consent, relatives still refused donation. DR registration, objection in the DR, and the relatives' refusal rate if the DR was not decisive increased with donor age.

CONCLUSIONS

Despite the introduction of a DR, relatives still play an equally important role in the final decision for organ donation. The general public should be encouraged to register their donation preferences in the DR and also to discuss their preferences with their families. The higher refusal rate of older potential donors means that this group should receive more information about organ donation, especially because the cohort of available donors is ageing.

Critical Care staffs' attitudes, confidence levels and educational needs correlate with countries' donation rates: data from the Donor Action database

To investigate on the impact of Critical Care (CC) staffs' attitudes to donation, their acceptance of the brain death (BD) concept, their confidence with donation-related tasks and educational needs on national donation rates. Donor Action (DA) Hospital Attitude Survey (HAS) data were collected from 19 537 CC staff in 11 countries, including personal attitudes to donation, self-reported knowledge, involvement and comfort levels with donation-related tasks and educational requirements. Countries' donation performance was expressed as Procurement Efficiency Index (PEI) (organs procured and transplanted/deaths from eligible causes). National PEI rates correlated well with CC staffs' average support to donation (R = 0.700, P = 0.014), acceptance of the BD concept (R = 0.742, P = 0.007), confidence levels (R = 0.796, P = 0.002) and average educational requirements with donation-related tasks (R = -0.661, P = 0.025). Nurses reported significantly lower positive attitudes (P < 0.0001), acceptance of the BD concept (P < 0.0001), comfort levels (P < 0.0001) and requested more education (P = 0.0025) than medical staff members. DA's HAS is a powerful, standardized tool to assess CC staffs' attitudes and donation-related skills in different environments. Measures to improve countries' donation performance should focus on guidance and education of CC staff so as to ensure that all practitioners have sufficient knowledge and feel comfortable with donation-related issues.

Donation patterns in four European countries: data from the donor action database

BACKGROUND

To analyze heart-beating organ donation patterns in four countries using the Donor Action (DA) Program nationally and to identify areas for improvement.

METHODS

Medical Record Review (MRR) of 18,118 critical care deaths between January 2006 and December 2007 in Belgium, Finland, France, and Switzerland. Data were entered to the DA System Database for analysis.

RESULTS

Of 6561 patients without contraindications to donation, 45.3% met preconditions for brain death (BD) diagnosis, 31.4% had signs of severe brain damage and 28.8% met criteria for formal BD diagnosis. Belgium had the highest number of patients with formal BD diagnosis (75.7%) and Switzerland (57.4%, P<0.0001) the lowest. Although donor identification rates were uppermost in France (93.6%) and lowest in Finland (47.7%, P<0.0001); Finland excelled in donor referral (93.9% of identified cases) versus only 63.8% in Switzerland (P<0.0001), and excelled in family approach rates (92.7%) versus only 70.2% in France (P<0.0001). Consent rates were superior in Belgium and Finland and lowest in France (P<0.0001). Conversion rates (percent of potential donors vs. actual donors) were higher in France and Belgium and significantly lower in Finland and Switzerland (P=0.0187). Only Belgium had a non-heart-beating donation policy during the study period, resulting in 11.2% more donors added to the country's donor pool.

CONCLUSIONS

The DA MRR proved to be an excellent tool to identify areas of improvement within certain steps of the donation process. Moreover, DA's MRR has shown to be applicable in different countries and environments and should be considered as a unique tool for comparing countries' donation performance.

An Analysis of Critical Care Staff's Attitudes to Donation in a Country with Presumed-Consent Legislation

Context

Lack of knowledge and confidence among critical care staff in identifying potential donors and communicating with donor families may explain missed organ and tissue donations.

Objectives

To elucidate attitudes of critical care staff toward donation and their knowledge, involvement, and self-reported skills and confidence levels with donation-related tasks.

Methods

Between January 2004 and May 2006, Donor Action Foundation's Hospital Attitude Survey was used to collect data from staff members in critical care units in our university hospital (study group) and 2 other Belgian university hospitals (control group). In total, 92 physicians, 433 nurses, and 26 other staff members participated.

Results

The 2 groups did not differ significantly with regard to donation-related attitudes. The study group had a significantly lower perception of the public's approval of organ donation than did the control group ( P <.001). Nurses reported significantly less involvement than did physicians ( P <.001) in caring for potential donors, communicating severe brain damage, explaining brain death, requesting donation, and contacting procurement staff. Probably because of previous training, physicians in the study group reported less need for additional training on donation-related issues than did control physicians. However, compared with physicians, nurses in the study group requested significantly more training on a number of donation tasks. Nurses with more than 5 years of critical care experience were consistently more confident with donation-related tasks.

Conclusion

Support rates for donation are high overall, and previous training is associated with improved attitudes and decreased educational needs. Educational efforts tailor-made for nurses should increase nurses' confidence levels when confronted with potential donors and their next of kin.