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SCIENTIFIC ABSTRACTS 1997
American Academy of Neurological Surgeons (AANS)
UNDERSTANDING OF BRAIN DEATH AND ORGAN RETRIEVAL
Holly Franz, BSN, Carol Beasley, M.P.P.M., Andrea Poretsky, B.A., Susan Wolfe, B.A., William DeJong, Ph.D., and Patrick McNamara, Ph.D. The Partnership for Organ Donation, Two Oliver Street, Boston, MA 02109. 617-482-5746
PURPOSE: To test the hypothesis that understanding of brain death was significantly related to a family's decision to donate the organs of their brain-dead relative.
METHODS: Telephone interviews were conducted with the legal next of kin of 164 medically suitable organ donor candidates. 102 donor and 62 non-donor families were interviewed 4-6 months after their relative's death concerning specific aspects of the donation request process and understanding of brain death. A brain death understanding index was created that summed (range 0, 3) correct responses to brain death questions (coefficient alpha=.54). Chi square analysis was used to test the hypothesis that donor and non-donor respondents differed in their understanding of brain death.
RESULTS: 80% (81/102) of donor and 52% (32/62) of non-donor families achieved a score of 2 or 3 on the knowledge index (chi square=21.8, p<.00008). Only 61% (62/102) of the donor and 53% (33/62) of non-donor families reported receiving an explanation of brain death. 83% (84/102) of donor respondents and only 56% (34/62) of non-donor respondents reported they were given enough time to understand brain death before the physician brought up donation (chi square=12.8, p< .0004).
CONCLUSIONS: 1) Donation is significantly associated with understanding of brain death. 2) Non-donor families were less likely to a) receive an explanation of brain death and b) less likely to be given time to understand brain death when an explanation was given.
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EXPLANATION OF BRAIN DEATH TO FAMILIES OF POTENTIAL ORGAN DONORS
Holly Franz, BSN, Carol Beasley, M.P.P.M., Andrea Poretsky, B.A., Susan Wolfe, B.A., William DeJong, Ph.D., and Patrick McNamara, Ph.D. The Partnership for Organ Donation, Two Oliver Street, Boston, MA 02109. 617-482-5746
PURPOSE: To assess the impact on organ procurement of physician explanations of brain death to the families of brain dead patients.
METHODS: Telephone interviews were conducted with the legal next of kin of 164 medically suitable organ donor candidates. 102 donor and 62 non-donor families were interviewed 4-6 months after their relative's death concerning specific aspects of the donation request process and understanding of brain death. A brain death understanding index was created that summed (range 0, 3) correct responses to brain death items (coefficient alpha=.54). Chi square analysis was used to test the hypothesis that donor and non-donor respondents differed in their understanding of brain death.
RESULTS: Understanding of brain death was associated with donation: 80% (81/102) of donor families and 52% (32/62) of non-donor families achieved a score of 2 or 3 on the knowledge index (chi square=21.8, p<.00008). While 94% (96/102) of the non-donor and 82% (51/62; chi square < 1) of the donor families indicated that a physician had given them the explanation of brain death, scores on the understanding index did not significantly differ between respondents who had, and respondents who had not received an explanation of brain death.
CONCLUSIONS: 1) Understanding of brain death is associated with donation, 2) yet there is no clear relationship between receiving an explanation of brain death from a physician and understanding of brain death.
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Canadian Association of Transplantation/Canadian Transplantation Society (CAT/CTS)
READINESS OF HOSPITAL STAFF TO HANDLE ORGAN DONATION
C. Beasley, P. McNamara, E. Guadagnoli, A. Poretsky, The Partnership for Organ Donation, Boston, MA; P. Taylor, HOPE Program, Edmonton, Alberta, Canada; E. Ferre, British Columbia Transplant Society, Vancouver, BC, Canada.
PURPOSE: We used Prochaska and DiClemente's (1992) "transtheoretical model of behavioral change" to classify critical care staff into 1 of 4 readiness stages: those who intend no involvement in donation requests ("pre-contemplative"), those who intend greater involvement ("contemplative"), those who are becoming more involved ("preparatory") and those who are active in requests and intend to remain active ("active/maintenance"). We hypothesized that active staff would be a) more knowledgeable about- and comfortable with donation requests, but would b) constitute a minority of critical care staff.
METHODS: 787 critical care staff at 4 Canadian hospitals (in Vancouver, and Edmonton ) completed a questionnaire which assessed a) support for- b) factual knowledge of- c) "comfort levels" with- organ donation request procedures.
RESULTS: 55.9% of staff were classified as "pre-contemplative", 20.8% as "contemplative", 9.3% as "preparatory" and 14% as "active" (p<.0001). As compared to active staff, pre-contemplative staff were less likely to say they would donate a relative's organs (71.8% vs 59.1%; p<.01); less likely to believe that brain death was a valid determination of death (96% vs 90%, p<.09); and less likely to report that they were comfortable explaining brain death (86.4% vs 27.7%), introducing donation (92.7% vs 23%) or asking families to donate (77.3% vs 15.4%; all differences <.0001). Contemplative (87%) and preparatory (84%) staff were more likely to report that they would like to receive further training in donation than were pre-contemplative (54%) or active (56%) staff (p<.0001).
CONCLUSION Over 75% of this sample of critical care staff were classified as non-"active" or not ready to handle donation cases. Approximately 30% were classified into the intermediate readiness stages. These are the staff who, with appropriate training, would most quickly progress to the active stage.
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Society of Critical Care Medicine (SCCM)
READINESS OF CRITICAL CARE STAFF TO HANDLE POTENTIAL ORGAN DONATION CASES
Michael Evanisko, M. Phil., Carol Beasley, M.P.P.M., Andrea Poretsky, B.S., Patrick McNamara, Ph.D. The Partnership for Organ Donation, 2 Oliver St., Boston, Ma, 02109.
INTRODUCTION: Critical care nurses and physicians normally care for those patients who progress to brain death. They are also often responsible for requesting organ donation from the family of a brain dead patient. We hypothesized that staff skills in requesting donation are critical to hospital donation performance but currently inadequate.
METHODS:1061 critical care staff from 28 hospitals in 4 separate regions of the United States who had been involved in a potential organ donation event in the 6 months prior to survey administration completed a questionnaire which assessed a) factual knowledge concerning organ donation, b) understanding of brain death and c) previous training in effective donation request procedures (e.g. "decoupling" the request for donation from the explanation that the patient is brain dead). Tests for association of staff responses to donation rate were run.
RESULTS: Staff training in effective request procedures was significantly correlated with donation rates (r=.40, p=.032). Less than a third of respondents, however, received training. 52.9% of staff in hospitals where donation rates were high (1 SD above the aggregate mean) and 23.5% of staff in hospitals where donation rates were low had received training (chi square=35.5, p=.0001). Levels of factual knowledge concerning donation and brain death were unexpectedly low but were not significantly related to hospital donation performance.
CONCLUSIONS: Hospital staff training in effective donation request procedures rather than generalized knowledge concerning organ donation and brain death is significantly associated with donation performance yet two-thirds of critical care staff report no specialized training.
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AFRICAN AMERICAN DONATION RATES CAN BE INCREASED
Michael Evanisko, M. Phil., Carol Beasley, M.P.P.M., Andrea Poretsky, B.S., Patrick McNamara, Ph.D. The Partnership for Organ Donation, 2 Oliver St., Boston, MA, 02109.
INTRODUCTION: More than one-third of all the patients on the kidney transplant waiting-list are African American yet organ donation rates among African American families are significantly below that of whites. We hypothesized that donation rates among black families could be significantly enhanced by improving the donation request process at the hospital.
METHODS: We reviewed medical records and collected prospective data on 1647 black, and 4438 white brain dead patients over a 5 year period who met medical criteria for donation. Cases were drawn from 129 hospitals in 9 different regions of the United States. We focused on characteristics of the donation request including who made the request to the family, whether the request was made in a quiet, private setting and whether the request for donation was ÒdecoupledÓ in time from the explanation of brain death given to the family. If the request process included these three process factors it was considered ÒoptimalÓ.
RESULTS: 11.8% of black and 23.6% of white families consented to donation (chi square=1.1, p=.29) when no recommended request factors were present. Consent rates for both black and white families were significantly increased over baseline when decoupling alone occurred but not when the other two recommended factors occurred alone. When all three factors were present (an optimal process) consent rates increased to 52.2% for black families (chi square=25.07, p<.00001) and 75.4% for white families (chi square=88.5, p<.00001). Approximately 50% of both white and black families received the optimal request process. Consent rate was 70.5% for white families when the requester was also white and fell to 57.0% for white families when the requester was not white (chi square=20.0, p=.0001). Consent rates did not significantly vary as a function of race of requester for black families.
CONCLUSIONS: Black donation rates can be significantly enhanced when recommended request procedures are followed. Decoupling the request for donation from the explanation of brain death is particularly important. Racial or ethnic identity of the requester had no effect on consent rates for black families.
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Society for Organ Sharing (SOS)
ESTIMATING THE ECONOMIC IMPACT OF AN INITIATIVE TO INCREASE ORGAN DONATION IN A TRANSPLANT CENTER
Richard A. Fowler CPTC, Brian Letourneau MSPH, Lila Nichols
PURPOSE: To estimate the economic impact of improving organ donation practices in a transplant center to assist in determining the cost/benefit of devoting hospital resources to establishing "best practices" in organ donation.
METHODS: Medical records review (MRR) was conducted for January-October of 1996 at Medical College of Virginia Hospitals to assess the number of medically suitable potential donors and the outcome of each. Reasons for non-donation were categorized as "controllable" and "non-controllable." Controllable causes were those subject to influence by hospital practices, including failure of staff to identify suitable cases or request donation, and denial of consent. Using comparative data collected at 124 hospitals, we projected the number of donors that would occur if currently-established best practices were adopted. Using historical data on average number of organs recovered from each donor, as well as the fraction of organs procured within the hospital that were also transplanted there, we estimated the increase in transplant volumes. Information on average charges for transplant procedures was applied to the expected incremental increase in organ transplants to determine an upper bound on hospital income that could be generated through improved donation practices.
RESULTS: MRR showed donor potential of 42 with 15 actual donors (donation rate=36%). Projecting on the basis of 10 months of data, we estimated annual donor potential of 50. Controllable causes of non-donation included: 2 cases not asked, and 19 cases where consent was denied (consent rate=44%). Based on comparative data from other hospitals, we estimated that an overall consent rate of 56% was attainable (adjusted for the racial/ethnic composition of the donor pool). If all controllable reasons for non-donation were corrected, we estimated a total of 28 donors per year would occur. Applying the current average of 3.7 organs recovered per donor, and a rate of 44% of organs procured in the hospital also being transplanted there, we estimated that 20 additional transplant procedures could result in this center from adoption of best practices. With average hospital charges of $156.6K per procedure, the upper bound of the projected economic impact is $3.1 million.
CONCLUSIONS: Transplant centers can estimate the economic impact of improvements in organ donation in their institution. By factoring in allocation patterns in their region and average charges for transplant procedures, administrators can make more informed decisions about what level of resources to devote to initiatives to establish best practices in organ donation. These estimates should be interpreted conservatively, recognizing that donor potential varies from year to year, allocation patterns can change, and charges for procedures typically exceed actual revenues.
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THE ROLE OF HOSPITAL-BASED FAMILY SUPPORT TEAMS IN IMPROVING THE QUALITY OF THE ORGAN DONATION PROCESS
Carolyn Thall, Greg V. Jensen ACSW LIC, Cindy Wright MA CPTC, Renee Meade RN BSN, Sara Baker RN BSN
PURPOSE: To design an in-hospital team to provide family support in cases of brain death and potential organ donation, and to ensure consistent and early identification of potential organ donors, optimal family communication, and a request for organ donation which respects family needs and conforms to best-demonstrated practices.
METHODS: A multidisciplinary Donation Committee at University of Iowa Hospitals and Clinics, lead by the Head of the Department of Surgery, and representing all critical care disciplines and units, as well as administration and the local organ procurement organization, developed a protocol for organ donation drawing upon best-demonstrated practices, and the specific needs and characteristics of the hospital. To ensure consistent application of the protocol, and to ensure that a trained staff person was always available to support the family and the health care professionals involved, a Family Support Person (FSP) role was defined. The Donation Committee also defined specific FSP team responsibilities, the criteria for team membership, and team structure. They identified and recruited team members.
RESULTS: Specific responsibilities of the FSP include: responding to notification from the critical care units of any patient with a Glasgow coma scale score of <4 with no pupillary response to light; staying apprised of whether the patient meets organ donor criteria; collaborating with the health care team to develop a communication plan with the family ensuring that they receive clear and consistent information; providing explanations of the grave prognosis, and brain death testing and results; assessing the family's understanding of brain death; and providing ongoing support to the family, the care team, and the OPO. The FSP also guarantees timely notification of the OPO (in accordance with protocol) and ensures smooth coordination with the OPO coordinator. The FSP ensures that the issue of organ donation is not raised too early, or inappropriately, and that the OPO coordinator is not introduced until the family has accepted that their relative is brain dead. In addition to the support role, FSPs are responsible for educating general hospital staff about their role and how to access FSP services. They also collect data on each potential donor case which is reviewed monthly as part of normal quality assurance to ensure that the hospital's donation protocol is being followed, and to address any problems that may occur. A team of FSPs was created, lead by a master's-prepared Social Worker who is accountable to the Social Service department and to the Head of the Department of Surgery.
CONCLUSIONS: Family Support Person teams are an option for hospitals aiming to improve family support, and bring greater consistency and quality to their handling of organ donation. Such teams can play an active role in the implementation of quality improvement efforts in organ donation.
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COMPARISON OF HOSPITAL STAFF ATTITUDES AND CONFORT WITH DONATION-RELATED TASKS IN FOUR COUNTRIES
Carol Beasley MPPM, Celia Wight SRN HV, Bernard Cohen PhD, Blanca Miranda MD, Milagros Fernandez MD, Holly Franz RN
PURPOSE: As part of the Donor Action collaboration, a hospital survey was administered in nine hospitals in four countries to gather baseline data on staff attitudes about organ donation and their level of self-reported confidence in performing a range of organ donation roles.
METHODS: A standard survey instrument was administered in 4 hospitals in Canada, 2 in Spain, 2 in The Netherlands, and 1 in the UK. In eight hospitals the survey was administered to all ICU staff; in one hospital (in The Netherlands) it was administered to a random sample of all hospital staff. The instrument was created in English, and translated into Spanish and Dutch.
RESULTS: Data were analyzed by country and showed consistently strong perception that organ donation saves lives (97%). Support for organ donation (93%) and willingness to donate one's own organs (79%) were high in all four country samples. The Canadian respondents were most likely to agree that donation helps families with grief (75%, with lower agreement in the UK (57%), Spain (47%) and The Netherlands (14%) (p<0.0001). Average ratings of comfort were highest for comforting the family (66%), and notifying the transplant coordinator (61%), with lower comfort reported regarding explaining brain death (43%), introducing organ donation (38%) and requesting organ donation (31%). Significant differences across countries were observed in all categories related to comfort with tasks. For example, 77% of UK respondents reported themselves comfortable explaining brain death, versus 52% of Canadian respondents, 47% of Dutch respondents and 11% of Spanish respondents (p<0.0001). Similar results were seen regarding requesting organ donation: UK 53%, Canada 36%, The Netherlands 30%, Spain 13% (p<0.0001).
CONCLUSIONS: There has been a lack of data about hospital staff attitudes and skills that would allow for comparison across national systems, and would support the targeting of specific educational strategies to the needs within different countries. These results show the feasibility of collecting and comparing data across national systems. These pilot findings indicate that attitudes are highly positive, but show wide variations in self-perceived comfort with organ donation related activities. Work remains to correlate attitudes and comfort levels to donation performance. It is noteworthy that the sense of staff comfort is lowest in Spain which has the highest donation rates. This may reflect the degree to which role specialization with respect to donation has been successfully integrated into hospital practice. Expansion of the survey to additional hospitals will help to answer such questions.
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American Association of Critical Care Nurses/National Teaching Institute (AACN)
SOLVING THE ORGAN DONOR SHORTAGE
Carol L. Beasley, MPPM; Tana Sherman; Cynthia Steger, MDiv
As an independent, non-profit organization, The Partnership for Organ Donation is actively involved in research and implementation projects to increase organ donation. A successful strategy includes not only positive public attitudes, but also supportive hospital practices. Although The Partnership's 1993 Gallup survey showed that public attitudes toward organ donation are highly favorable, only about one third of potential donors actually donate. Hospital staff often fail to recognize potential donors or to request donation in a way that meets the emotional and information needs of grieving families. For donation rates to increase, hospital practices must support organ donation. The Partnership currently is collaborating with the University HealthSystem Consortium to increase organ donation in 24 hospitals across the U.S. A similar project is underway in two Canadian hospitals. Our model fosters the development of professional standards for organ donation ,ensuring that the health care team is working collaboratively to meet the needs of the family. Our work confirms that donation can increase substantially--from an average of 33% to 60% or more.
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SCIENTIFIC ABSTRACTS 1996
American Society of Transplant Physicians (ASTP)
RELATIONSHIP OF FAMILY SATISFACTION IN HOSPITAL WITH ORGAN DONATION RATE
Holly G. Franz, RN, BSN; Andrea Poretsky, BS; Susan Wolfe, BA; Carol Beasley, MPPM, The Partnership for Organ Donation; William DeJong, PhD, Harvard School of Public Health
PURPOSE: As part of a larger study designed to identify donation process features that predict whether a potential donor's family will grant consent for donation, this research focuses on identifying the degree to which a familyÕs perception of the overall quality of care in the hospital is associated with higher rates of consent for organ donation.
METHODS: Telephone interviews were conducted with the legal next of kin of 164 potential organ donors, 102 who gave consent for donation and 62 who did not. Family members were interviewed during June 1994-February 1995, four to six months after their relativeÕs death. Respondents were read a series of statements describing desirable features of the overall hospital process and asked to what extent they agreed or disagreed that the statements were consistent with their experience. The statements covered issues such as hospital communication of the patientÕs prognosis, degree to which staff answered the familyÕs questions, whether the family thought they were given adequate time with the patient before and after death, and whether the family felt the patient received the best possible care. Excluded from this analysis were family-initiated donation cases, and those with missing data (n=49).
RESULTS: A satisfaction index was created that summed the responses for 8 items relating to familiesÕ satisfaction. The higher the sum, the more positive their experience. This index showed a reasonable level of internal consistency (ChronbachÕs alpha=.66). Consent to donation increased with higher index scores. Families that scored a 7 or 8 on the satisfaction index had a donation rate of 64%, whereas families with lower index scores had a donation rate of 31% (p<.01).
CONCLUSIONS: The familyÕs perception of the overall quality of care delivered in the hospital is associated with their decision to donate. Families who have higher satisfaction scores are more likely to donate their relatives' organs. These findings underscore the importance of developing a communication strategy that consistently addresses the family's need for information and contact with the healthcare team.
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National Association of Transplant Coordinators (NATCO)
THE DONATION PROCESS IN PEDIATRIC CASES
PURPOSE: Staff in pediatric units go to great lengths to treat families as the "patient" to ensure optimal communication about the condition of their child. Staff also report a need to protect families, specifically from the request for organ donation and the OPO coordinator, an outsider. Given the higher involvement of hospital staff with families of pediatric patients compared to families of adult patients, a reserach initiative was undertaken to compare the differences and/or similarities between the pediatric unit and adult units and to understand what effects donation rates among families of pediatric patients.
METHOD: Detailed data were collected on x medically suitable pediatric potential donors referred to 7 organ procurement organizations from x/xx to x/xx. In addition, a retrospective medical record review was conducted for this same time period. The study includes a total of x cases.
RESULTS: The families of pediatric patients consent to donation at the same rate as other types of patients. 35% of pediatric patients became donors compared to 37% of all other types of patients. Higher consent rates among pediatric families were observed when a "collaborative" request approach was used, meaning a healthcare professional from the hospital introduced the topic of donation and the organ procurement coordinator made the formal request for donation. Analysis indicate that with this type of approach consent rates are 64% compared to other combinations which result in a consent rate of 40% (p².02). Unfortunately the ideal approach occured in only 45% of the cases. Similar results are found in families of adult patients.
The families of pediatric patients are no more likely to have understood and accepted brain death before the discussion of organ donation. Among pediatric families, 55% are offered a decoupled approach versus 53% among the families of adults. When the request is decoupled, consent rates increase to x% among pediatric families, and x% among adult families.
CONCLUSION: Pediatric intensive care units need to make a greater effort to work with the organ procurement coordinators to offer the ideal request process.
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SCIENTIFIC ABSTRACTS 1995:
American Academy of Neurological Surgeons (AANS)
Identifying Untapped Organ Donor Potential
Jean Williams, M.M., Carol Beasley, M.P.P.M., Jessica Drachman, B.A., Steven Gortmaker, Ph.D., Michael J. Evanisko, M.A., M.Phil. The Partnership for Organ Donation, Two Oliver Street, Boston, MA 02109.
PURPOSE: To understand the composition of the potential organ donor pool, and to identify those cases most likely to be missed
METHODS: Retrospective medical record reviews were conducted on all deaths at 63 study hospitals during 1/1/90 - 12/31/92, in the service area of four organ procurement organizations (OPOs). Study hospitals were primarily major trauma, teaching or large community hospitals, and collectively accounted for 73% of the total donation of the four OPOs. Subjects included all brain dead patients who were medically suitable for organ donation.
RESULTS: Of the 2742 potential donor cases identified, 37% (1006) resulted in donation. The leading cause of non-donation was the family denying consent (1060 cases, 39%). In 524 cases (19%), the next-of-kin were never offered the option to donate, either because brain death was not identified or because hospital staff did not ask the family, and the remaining 152 cases (5%) resulted in non-donation for a variety of other reason. The average age of potential donors was 33 years. The two leading causes of deaths were traumatic injury (48%, 1306 cases) and cerebrovascular accidents (CVA) (36%, 989 cases).
The data were then broken down into two groups: cases where a donation request was made (2066 cases, 80%) and cases where a donation request was not made (524 cases, 19%) and analyzed by age and cause of death. The average age of patients where a request was made was x, compared to an average age of 45 for patients where a request was not made. In nine percent of trauma cases, families were not asked, compared to 24% of CVA cases. In summary, those potential donors who are older and have died of a CVA, are more likely to be offered the option of donation than families of younger patients who suffered a traumatic injury.
CONCLUSIONS: The implications for increasing donation, from the current donor pool are significant. If all potential donors had been identified and a request made, and assuming a consent rate similar to those cases where a request was made (49%), there would have been an additional 250 donors. At current rates of organ utilization (3.3 organs /donor) more than 800 lives could have been saved or improved. The data indicate that older patients and patients dying from CVA's are most likely to be missed. Being more aware of these patients as potential organ donors will help reduce the current organ shortage. It is imperative that critical care physicians and neuroscientists recognize these patients and refer them for evaluation as organ donors.
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Society of Critical Care Medicine (SCCM)
Standards of Practice Needed to Ensure Effective Donation Process
Kara Helander, M.B.A., Carol Beasley, M.P.P.M., Steven Gortmaker, Ph.D., Jessica Drachman, B.A. The Partnership for Organ Donation, 2 Oliver Street, Boston, MA 02109.
INTRODUCTION: The shortage of donated organs is a crisis for the 35,000 Americans currently awaiting transplants. Research shows that a "decoupled" request process results in higher donation rates, but there is little consistency in health care professionals' beliefs or practices regarding the donation process.
METHODS: Detailed donation process information was collected prospectively for 528 medically suitable potential donor cases in 31 hospitals in four regions of the U.S. from 7/91 through 6/92. A survey on attitudes and knowledge regarding organ donation was also administered between 3/91 and 2/92 at these hospitals with 329 MDs and 726 ICU nurses responding.
RESULTS: A donation request is decoupled when a family is given time to understand and acknowledge the death of their loved one before donation is introduced, and occurred in only 50% (152/306) of the cases in the study hospitals. Results showed 61% (93/152) consent rates when the request was decoupled vs. 41% (63/152) when the request is not decoupled. Consistent with the actual behavior around decoupling, the survey reflected widely varying beliefs about the best time to raise donation. Forty-eight percent believed the appropriate time to raise donation is prior to final determination of brain death, 22% said at the time of brain death, and 29% believed after brain death had been determined. This lack of consensus may be related to a lack of training, as only 31% had received training in explaining brain death, and 40% in how to make a donation request.
CONCLUSION: Donation can increase significantly if 1) decoupling is accepted as a standard of practice for organ donation and 2) relevant hospital professionals receive appropriate training.
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American Society of Transplant Physicians (ASTP)
Survey to Understand the Potential for Living Related Kidney Donation in the United States
Ellen Sheehy, MPPM, Kenneth J. Lifton, MA, Kara Helander, MBA, Thomas Rosenthal, MD, Alan Hull, MD, Carol Beasley, MPPM, The Partnership for Organ Donation, Boston, MA., 02109
PURPOSE: To estimate the potential for living donation to alleviate the shortage of donor organs.
METHODS: A survey was conducted at the 1994 Annual Meeting of the American Society of Nephrology. The survey was completed by 206 US respondents including 173 nephrologists (84%).
RESULTS: Ninety percent of respondents are supportive or very supportive of living-related donation, and 79% of respondents feel comfortable or very comfortable discussing living-related donation with potential donors. Of the 81% of respondents who report discussing living donation with patients, 54% have a formal policy for offering the option of living donation to the potential recipient and 48% have one for the potential donor. Sixty one percent have written materials to explain the living donation option, but 32% have no materials. Respondents estimate that 45% (2721/5988) of their patients on the national kidney transplant waiting list have at least one family member who could be considered for evaluation as a living donor. The two major reasons identified for those cases where a family member could be, but is not considered for living donation, are the potential recipient opposes having the option raised (53%) and the potential recipient is at high risk for poor outcome (50%). Of those patients with at least one family member who could be considered for evaluation as a living donor, the offer of evaluation was made an estimated 91% (2474/2721) of the time. Respondents estimate that 67% (1663/2474) of family members offered the option of being evaluated consented to the evaluation. An estimated seventy-two percent (1202/1663) of the potential donors actually evaluated are identified as suitable living donors. These estimates suggest that 20% (1202/5998) of the respondents' patients have a family member who is willing and suitable to be a living donor. If these results were applied to the national kidney waiting list (27,498, UNOS 12/31/94, 5,500 of the patients listed could receive a living-related transplant. By contrast, in 1993, there were 2,698 transplants from living donors which represented only 11% (2,698/24,973) of the waiting patients.
CONCLUSIONS: There was strong support for living-related donation, but a lack of consistent policies on handling living donation with potential patients and donors. With the development and use of more consistent living donation policies, protocols, and educational materials it would be possible for more family members to be identified as possible donors. This could potentially effect a significant increase in the number of living-related transplants.
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American Society of Transplant Surgeons (ASTS)
The Effects of Hospital Characteristics on Donation Performance
Ellen Sheehy, M.P.P.M., Andrea Poretsky, B.S., Carol Beasley, M.P.P.M., Steven Gortmaker, Ph.D., Michael J. Evanisko, M.A., M. Phil. The Partnership for Organ Donation
PURPOSE: Given frustration over the shortage of donor organs, much attention is focused on understanding and improving hospitals' donation performance. Research was conducted to explore whether trauma designation or existence of a transplant program was associated with superior donation performance.
METHODS: Medical records reviews (MRR) were conducted for 1990 at 69 hospitals to determine baseline rates of donation as well as rates of referral, family approach, and consent. The sample included 13 hospitals that were trauma centers and had transplant programs, 23 trauma centers without transplant programs, 2 transplant hospitals not designated as trauma centers and 31 hospitals that were neither trauma centers nor transplant centers. All of these hospitals were in the service area of four regionally diverse organ procurement organizations (OPOs). These data are being collected on an ongoing basis with the goal of designing interventions based on the results.
RESULTS: No statistically significant differences existed in donation performance between transplant and non-transplant centers. The transplant center donation rate (donors/medically suitable potential) was 32.5% (90/277) vs. 32.7% (209/639) for non-transplant centers. The rate of referral of medically suitable organ donors to the OPO was 61.7% (171/277) for transplant hospitals and 57.6% (368/639) for non-transplant centers. 71.8% of families were approached in transplant centers and 70.4% at non-transplant centers. Of those families approached, consent was given in 50.7% of the cases in transplant hospitals and in 49.0% of the cases in non-transplant hospitals.
Trauma centers typically recover a higher percent of potential donors than hospitals which are not trauma centers. The 1990 donation rate was significantly higher at trauma centers than non-trauma centers, 35.4% (235/664) vs. 25.4% (64/252) (p<.05). The referral rate for trauma centers was 59.0% (392/664) vs. 58.3% (147/252) for non-trauma centers. The percent of families approached was also higher at trauma centers, 72.9% vs. 65.5%, and of those families approached, 52.0% consented to donation at trauma centers vs. only 42.4% at non-trauma centers.
CONCLUSIONS: Despite clear incentives and institutional interest in maximizing donation, transplant centers in this study were no more effective in donation than centers without a transplant program. Trauma centers, however, did outperform non-trauma centers on donation measures. Some bias may exist due to non-random sampling. It is imperative that hospitals focus attention on improving their performance by striving to refer 100% of potential donors to the OPO and by ensuring that all families of potential organ donors are offered the option of donation. By implementing donation process improvements, transplant centers will serve as role models for all hospitals and will contribute directly to alleviating the organ donor shortage.
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Society for Organ Sharing (SOS)
The Changing Potential Organ Donor Pool
Carol Beasley, Ellen Sheehy, Kenneth J. Lifton, Michael J. Evanisko, The Partnership for Organ Donation.
PURPOSE: Increasing donation requires understanding the changing size and composition of the donor pool as well as characteristics of patients most likely to be missed as potential donors.
METHODS: Retrospective medical records reviews were conducted at 63 hospitals from 1/1/1990 to 12/31/1992. Data were collected on 2,742 brain dead patients who were medically suitable potential donors and analyzed according to cause of death, age, and donation outcome.
RESULTS: The study showed a 5.8% average annual decrease in the size of the potential donor pool over the 2 year study period (977 in 1990 to 867 in 1992). Traumatic deaths decreased at an average annual rate of 7.2% (468 to 403), while cerebral vascular accident (CVA) deaths increased at an average annual rate of 10.3% (304 to 370). Potential donors under age 50 decreased by an average annual rate of 6.5% (707 to 618), while potential donors age 50 or older decreased at an annual rate of 0.6% (248 to 245). The donation rate for the overall study was 37% (1006/2742). The donation rate for trauma deaths was 45% (588/1306), and for CVA, 32% (321/989). The donation rate for patients under age 50 was 42% (829/1976), and for patients age 50 or older, 24% (173/721). Families of patients age 50 or older and patients dying of CVAs were less likely to be approached for organ donation. The rate of non-request was significantly higher (p<.001) for CVAs (24%) than for trauma deaths (9%). The rate of non-request was significantly higher (p<.001) for patients age 50 or older (37%) than for patients under age 50 (12%).
CONCLUSION: Over the time period studied, there were shifts in the potential donor pool toward segments with lower donation rates and higher non-request rates. In 1992, the segments with higher donation rates (trauma deaths and patients under age 50) made up a smaller percentage of the total potential pool, while potential donors exhibiting higher non-request rates (CVA) made up a much greater percentage of the pool. To increase donation, given the changing donor pool, there needs to be a strong focus on education to increase the percentage of cases in which a request for donation is made, particularly in cases with high non-request rates, like CVA and age 50 or older.
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Society for Organ Sharing (SOS)
A Comparison of Staff Knowledge and Donation Performance in Transplant and Non-transplant Hospitals
Carol Beasley, Ellen Sheehy, The Partnership for Organ Donation, Steven Gortmaker, Harvard School of Public Health
PURPOSE: To explore whether transplant hospitals differ from non-transplant hospitals in donation performance and staff knowledge of transplant facts.
METHODS: Medical records reviews were conducted for 1990 at 15 transplant and 54 non-transplant hospitals to determine donation performance. In addition, 1,061 physicians, nurses and others with recent experience in caring for potential organ donors from 7 of the 15 transplant hospitals and 21 of the 54 non-transplant hospitals were surveyed in 1991.
RESULTS: There were no statistically significant differences between transplant centers and non-transplant centers in staff knowledge of basic transplant facts. 41% of the staff in transplant centers and 54% of the staff in non-transplant centers knew that one-year kidney graft survival exceeded 75%. 57% of the staff in transplant centers and 57% of the staff in non-transplant centers responded correctly that more than 20,000 patients were on the transplant waiting list. Transplant centers' donation process measures were not superior to those of non-transplant centers. The rate of referral of medically suitable organ donors to the organ procurement organization (OPO) was 62% (171/277) for transplant hospitals and 58% (368/639) for non-transplant centers. 72% of the families were offered donation in transplant centers and 70% at non-transplant centers. Of those families approached, consent was given in 51% of the cases in transplant hospitals and in 49% of the cases in non-transplant hospitals. Finally, there was no statistically significant difference between the transplant center donation rate (donors/medically suitable potential) 32% (90/277), and the non-transplant rate, 33% (209/639).
CONCLUSIONS: Despite institutional incentives, transplant centers in this study were no more effective at increasing organ supply or educating critical care staff than hospitals without transplant programs. Some bias may exist due to non-random sampling, however the geographic distribution of the study hospitals suggests that they are reasonably representative of hospitals of similar type and size. Since many transplant centers are also Level I trauma centers with significant potential for donation, it is imperative that transplant centers focus attention on improving their performance by striving to refer 100% of potential donors to the OPO and by offering donation to all families of potential organ donors.
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North American Transplant Coordinators Organization (NATCO)
A Hospital Intervention Project to Increase Organ Donation
Carie L. Capossela, BA; Rebecca L. Foster, BA; Holly G. Franz, BSN, CPTC; Ellen Sheehy, MPPM; Carol Beasley, MPPM
PURPOSE: To measure the impact of a comprehensive hospital intervention project on rates of organ donation; to assess the impact of the intervention on intermediate outcome measures, specifically identification, referral and approach rates, and rates of consent to donation.
METHODS: Data were collected from fifty large hospitals within the service area of three organ procurement organizations (OPOs) from 1/1/90 - 12/31/92. Direct hospital intervention began in January, 1991, with the objective of improving the organ donation process.
The intervention included three key steps. First, data were collected from medical records reviews, hospital staff surveys, and interviews to assess donation performance and professional attitudes. Next, a strategy was developed to introduce a recommended set of practices in the hospital. Finally, the strategy was implemented through systematic educational inservices, revised protocols for donation, and the formation of an in-hospital team to serve as a focal point for education and monitoring performance.
RESULTS: The 1992 data show an increase in identification, referral and approach rates. In 1990 88% (714/810) of the potential donors were identified by hospital staff, 53% (431/810) were referred to the local OPO and 66% (534/810) of families were given the option of organ donation. In 1992 the identification rate increased to 96% (714/741), the referral rate increased to 79% (587/741) and the approach rate to 85% (629/741). During the same time period consent rates remained relatively flat at 52% (276/531) in 1990 and 53% (330/627) in 1992. Donation rate (donors/medically suitable potential) increased from 32% (258/810) to 41% (306/741).
CONCLUSION: A positive change in donation occurred in the study, attributable to the increases in identification, referral and approach rates. Consent rates remained stable. While the intervention produced positive results, future efforts should retain focus on increasing identification, referral and approach rates and strengthen focus on consent. Next steps should focus on identifying those factors that correlate with higher consent rates and incorporating them into a standardized practice for requesting organ donation.
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North American Transplant Coordinators Organization (NATCO)
Explaining Brain Death: A Critical Feature of the Donation Process
Holly Franz, BSN, CPTC; William DeJong, PhD; Susan Wolfe, BA.
PURPOSE: This study was designed to identify features of the donation request process that predict whether a potential donor's family will grant consent to donation. A 1993 Gallup poll showed that 33% of donation opponents believe there is some hope of recovery for a brain dead person, compared to 20% of supporters. Thus, if the explanation of brain death provided to a potential donor family fails to clear up their misunderstandings, a decision against donation may be more likely.
METHODOLOGY: Telephone interviews were conducted with the legal next of kin of 167 potential organ donors, 107 of whom consented to donation and 60 of whom did not. All interviews occurred four to six months after their decision. Respondents were asked if anyone at the hospital had explained brain death, when this had been done, and who gave them the explanation. Other questions assessed their present understanding of what brain death means.
RESULTS: While nearly all respondents said that their loved one was brain dead, a large number of respondents reported that the meaning of brain death was never explained. Of those who did receive an explanation, nondonor respondents were less likely to say that it was understandable, and more likely to believe that brain death is like a coma, rather than true death with no hope of recovery. Additionally, nondonor respondents were less likely to say that brain death was explained before the issue of organ donation was raised.
CONCLUSION: Confusion about brain death may have a negative effect on a family's decision to donate. To ensure clearer understanding, improved methods of presenting brain death are necessary. Communication methods should be refined and supporting materials developed and used in conjunction with face-to-face discussion.
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