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Gunter Kirste  - Germany - Monday 28 - Strategies to increase the number of cadaveric donors
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Gunter Kirste - Germany - Monday 28 - Strategies to increase the number of cadaveric donors

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  • 1. Strategies to increase the number of cadaveric donors Introducing the concept of in house coordination Prof. Dr. Günter Kirste
  • 2. Critical pathways for organ donation* POSSIBLE DECEASED ORGAN DONOR A patient with a devastating brain injury or lesion OR a patient with circulatory failure AND apparently medically suitable for organ donation Donation after Circulatory Death (DCD) Treating physician to identify/refer a potential donor Donation after BrainDeath (DBD) POTENTIAL DCD DONOR POTENTIAL DBD DONOR A. A person whose circulatory and respiratory Reasons why a potential donor A person whose clinical condition is suspected to functions have ceased and resuscitative does not become a utilized donor fulfill brain death criteria. measures are not to be attempted or continued. System or • Failure to identify/refer a potential or eligible donor B. A person in whom the cessation of circulatory • Brain death diagnosis could not be confirmed and respiratory functions is anticipated to occur within a time frame that will enable organ (e.g. does not fulfill criteria) or completed recovery. (e.g. lack of technical resources or clinician to make diagnosis or perform confirmatory tests) • Circulatory death not declared within the appropriate time frame. ELIGIBLE DBD DONOR ELIGIBLE DCD DONOR • Logistical problems (e.g. no recovery team) A medically suitable person who has been A medically suitable person who has been • Lack of appropriate recipient (e.g. child, blood declared dead based on the irreversible absence declared dead based on neurologic criteria as type, serology positive) of circulatory and respiratory functions as stipulated by the law of the relevant jurisdiction. stipulated by the law of the relevant Donor/Organ jurisdiction, within a time frame that enables • Medical unsuitability (e.g. serology positive, neoplasia) organ recovery. • Haemodynamic instability / unanticipated cardiac arrest ACTUAL DBD DONOR ACTUAL DCD DONOR • Anatomical, histological and/or functional A consented eligible donor: A consented eligible donor: abnormalities of organs A. In whom an operative incision was made A. In whom an operative incision was made • Organs damaged during recovery with the intent of organ recovery for the with the intent of organ recovery for the • Inadequate perfusion of organs or thrombosis purpose of transplantation. purpose of transplantation. Permission and/or and/or B. From whom at least one organ was B. From whom at least one organ was • Expressed intent of deceased not to be donor recovered for the purpose of transplantation. recovered for the purpose of transplantation. • Relative’s refusal of permission for organ donation • Refusal by coroner or other judicial officer to allow donation for forensic reasons UTILIZED DBD DONOR UTILIZED DCD DONOR An actual donor from whom at least one organ An actual donor from whom at least one organ was transplanted. was transplanted.*The “dead donor rule” must be respected. That is, patients may only become donors after death, and the recovery of organs must not cause a donor’s death .
  • 3. In house coordinationDSO finances a pilot project for in-house-coordinationin university hospitals and hospitals with neurosurgical ICU’s Basic Principles of the Spanish Model •Adequate legal and technical background -------------------------------------------------------------- •Transplant coordination network •Special profile of the three levels of TC •Hospital coordinators inside the hospitals •Central Office: ONT - Support Agency •Continuous brain death audit •Hospital reimbursement •Great effort in medical training •Much attention to the mass media
  • 4. In house coordinationPilot project in adaption of the „Spanish Model“Target Hopitals:University HopitalsHospitals with neurosurgical ICU In-house-coordination includes:  Analysis of donor potential (quarterly evaluation)  Identification of possible donors DSO  Development and Implemantation of Standard Operating Procedures (SOP)Hospital  Training of hospital staff In-house-coordination is done by:100 %  ICU-physicians
  • 5. In house coordination in detail:Profil: Target hospitals appoint physicians on ICU in charge of in-house- coordination Appointed physicians must proof special knowledge in organ donation (e.g. Curriculum for organ donation for key donation figures ” developed by DSO in cooperation with the German Medical Association)Reporting: Hospital reports quarterly about performance of in-house-coordination.Hospital-reimbursement: 800 € for the task of in-house-coordination for the hospital that ensures that this money benefits the physicians in charge
  • 6. SOP (Standard Operation Procedure)Development and Implemantation of Standard Operating Procedures (SOP) togetherwith DSO Coordinators and inclusion of contact persons from the hospital 1 2 3 4 5
  • 7. Analyse-Tool „Transplant – Check“ Screenshot for installation Bildschirm zur Aktualisierung der Filterdateien
  • 8. „Transplant-Check“ – Filtered Data List of all cases with: 1. Reason for release = Death and 2. ICD 10-Codes that possibly lead to brain death Contradindications for donation are highlighted = relative CI = absolute CI
  • 9. Response rate KH KH n %Projektkrankenhäuser insgesamt 112 100%Rücklauf 1. Krankenhausbefragung 102 91,1%Rücklauf 2. Krankenhausbefragung 90 80,4%Rücklauf 1. Quartalsbericht 110 98,2%Rücklauf 2. Quartalsbericht 111 99,1%Rücklauf 3. Quartalsbericht 108 96,4%Rücklauf 4. Quartalsbericht 102 91,1%
  • 10. In house coordination in organ donationDevelopment of donor data 1.Quarter2010 – 2.Quarter 2011 Start of the project© Deutsches Krankenhausinstitut 10
  • 11. In house coordination in organ donationAnalysis of potential for 4 quarters Fälle absolut Fälle % 2/2010 – 1/2011 2/2010 – 1/2011 Anzahl Quartalsberichte 392 392 Todesfälle mit primärer/sekundärer Hirnschädigung (n) 11.029 11.029 - Todesfälle mit primärer/sekundärer Hirnschädigung (%) - 100% Ausgeschlossene Fälle 7.350 66,6% - Fälle mit absoluten Kontraindikationen 1.395 12,6% - Fälle mit einer Beatmungszeit von 0 h 3.406 30,9% - Fälle mit Meldung an DSO 2.549 23,1% Fälle im strukturierten Dialog 3.679 33,4% - Fälle mit eingeleiteter Hirntoddiagnostik 347 3,1% Fälle mit festgestelltem Hirntod 199 1,8% Fälle mit abgebrochener Hirntoddiagnostik 148 1,3% - Fälle ohne eingeleitete Hirntoddiagnostik 3.332 30,2% Fälle mit Klärung der Hirntoddiagnostik nicht sinnvoll 3.202 28,1% Fälle mit Klärung der Hirntoddiagnostik strittig 41 0,4% Fälle mit Klärung der Hirntoddiagnostik sinnvoll 189 1,7%© Deutsches Krankenhausinstitut 11
  • 12. In house coordination in organ donationTarget Achievment• High Target Achievement  E.g. implementaion of SOP, PDCA- Zyklus, trainings, support of executives, increas of awareness of ICU-Personell, Analysis of donor potential• Mediocre Target Achievement  E.g. nomination of physician in charge (TXB), dialog beetween hospital and DSO- Koordinator about Patients with suspicion of brain death© Deutsches Krankenhausinstitut 12
  • 13. In house coordination in organ donationProblems regarding additional donor potential • Problems in hospital (z.B. lack of ICU-beds; lack of personnel and frequent changes, high work load on ICU) • Patients provisions and refusal of intensive care treatment by relatives prior to brain death diagnosis • Limitation in therapymeasurments respectivly priority on palliativ measurements© Deutsches Krankenhausinstitut 13
  • 14. Future of the project Continuing of the project Position of the project established in the new German Transplant Act Under discussion till end of the year