Moderator:• Thomas Nakagawa, MD, Wake Forest Baptist HealthPresenters:• Darren Malinoski, MD, Cedars-Sinai Medical Center
Breakout Session A:
Optimizing Donation Outcomes within the
Context of End-of-Life Care
Optimizing Donation Outcomes within the Context of
End-of-Life Care
2011 OneLegacy Organ Donation and Transplantation Symposium
Darren Malinoski, MDDirector of
Surgical Critical CareCedars-Sinai Medical Center
Questions to Run On?
“What PI initiatives can I employ at my
hospital to better support donation
best practices?”
“What clinical practices can I implement
to improve donation outcomes
at my hospital?”
Goals for this Presentation
Emphasize the importance of organ donation for both
recipients and donors
Identify the role of critical care providers in organ donation
and discuss how their involvement improves outcomes
Discuss the role of Catastrophic Brain Injury Guidelines
(CBIGs) and how to implement them
Discuss the dilemma between DNR and organ donation
Hospital Requirements Centers for Medicare/Medicaid Services
& American College of Surgeons Notification process Declaration of brain death Organ procurement organization (OPO)
relationship Performance Improvement (PI) program Patient/family opportunity to donate
Impact of Timely Referralon Conversion Rates
Timely Referral*
Eligible Deaths
Eligible Donors
Conversion Rate
YES 20,109 14,167 70.5%
NO 3,619 2,080 57.5%
TOTAL 23,728 16,247 68.5%
* Based on OPO’s definition of timely referral
OPTN data January 2008 – June 2010
Impact of Effective Requeston Conversion Rates
Effective Request*
Eligible Deaths
Eligible Donors
Conversion Rate
YES 18,947 14,332 75.7%
NO 3,998 1,870 46.8%
TOTAL 23,728 16,247 68.5%
* Based on OPO’s definition of effective request
OPTN data January 2008 – June 2010
DI DIC
Arrhythmias
Pulmonary Edema
Acidosis Hypothermia
Hypotension
p=0.45 vs.
2007
p=0.20 vs.
2007
OTPED = effectiveness of an organ donation program Considers conversion rate & donor management
Pre-ADM(1995 – 1998)
Post-ADM(1999 – 2002)
Percent Change p-value*
Referrals for donation 341 537 + 57% < 0.001
Potential donors 214 255 + 19% 0.01
Actual donors 57 104 + 82% < 0.001
Family decline (%) 109 (51%) 106 (42%) - 9% < 0.05
Donors lost to CVS collapse 39 5 - 87% < 0.001
Medically unsuitable 9 40 + 344% < 0.001
Organs recovered 217 370 + 71% < 0.001
How Can I Adopt this at My Institution?
“Aggressive Donor Management”
“Devastating Brain Injury Guidelines”
or
CBIGs: Catastrophic Brain Injury
Guidelines
GOALTo maintain hemodynamic
stability in patients with devastating brain injuries
Devastating Brain Injury Pathway
Benefit to Patients/Families Hemodynamic Stability
Apnea test/Confirmatory Test Locate family Time to grieve/decide on next steps Some patients clinically improve and survive Preserves option of donation if chosen ***
Donors and their families want to donate 75% families consent, 42% adults registered Grieving data
98% would choose donation again
92% identified positive aspects to the
donation process/experience
Majority agreed that donation was
comforting
Associated with less depression
The Impact of Compliance with the American College of Surgeons Trauma Center Verification Requirements on Organ Donation-Related Outcomes – A Survey of the Level 1 and 2 Trauma Centers in Southern California
Compliance with ACS – 67% 5.1 vs. 5.3 donors/1000 trauma admits (p=0.88)
Trauma Surgeon on Donor Council – 67% 6.0 vs. 4.2 donors/1000 trauma admits (p=0.04) 21 vs. 11 donors/1000 ICU admits (p=0.03)
Catastrophic Brain Injury Guidelines – 48% 6.3 vs. 4.2 donors/1000 trauma admits (p=0.04) 69 vs. 62% conversion rate (p=0.01)
- D Malinoski, et al. 2011 PCSA
Background
Checklists have demonstrated utility in
several arenas
Standardized critical care endpoints
Donor Management Goals (DMGs)
Critical Care Endpoint DMG1. Mean Arterial Pressure (MAP) 60 – 110 mmHg
2. Central Venous Pressure (CVP) 4 – 12 mmHg
3. Ejection Fraction (EF) > 50%
4. Vasopressor use 1 and low dose
5. Arterial Blood Gas pH 7.3 – 7.5
6. PaO2:FiO2 (P:F) > 300 on PEEP = 5
7. Serum Na <155 mEq/L
8. Blood Glucose < 150 mg/dL
9. Urine Output (averaged over 4 hours) >0.5 cc/kg/hr
Region 5 Donor Management Goals
Region 5 Donor Management Goals
Donor Management Goals met at consent
improve outcomes
90% increase in the chance of achieving 4
organs transplanted per donor
50% decrease in the chance of developing
recipient renal delayed graft function
Balancing DNR and Donation
Timing – determine prognosis
Timing – EOL care planning
Timing – referral to OneLegacy
Maintain standard critical care until the
patient’s prognosis has truly been determined
and the intent to donate has been elucidated
Summary
Making donation a priority improves
outcomes
Aggressive donor management / CBIGs
affect the number and quality of organs
available for transplantation
Donation benefits OUR patients/families
Questions to Run On?
“What PI initiatives can I employ at my
hospital to better support donation
best practices?”
“What clinical practices can I implement
to improve donation outcomes
at my hospital?”