DONATION IN TWO HOSPITALS
A review of medical records to identify potential organ donors can be done either by an organ recovery coordinator or by a hospital staff member who has been trained by the local OPO and understands its medical suitability criteria.
Medical Record Review starts by securing the assistance of the medical records department. Normally, hospitals can provide a computerized listing of deaths and principal ICD-9 codes for a given time period. Based on the OPO's medical criteria for donor suitability, the reviewer can delete cases were there are known contraindication to organ donation (such as cancer or HIV). All remaining records are pulled for review.
Reviewers examine clinical evaluations, medical and nursing notes, and lab procedures to determine if the patient could have been a donor. First, the reviewer should look for indications of brain death, and whether or not it was declared formally. In addition, the patient's medical condition is evaluated to determine if donation was a realistic option. "Borderline" cases should be referred to an OPO manager or experienced staff member.
If the patient was brain dead and a suitable candidate for donation, the reviewer should also look for evidence of interactions with the family concerning donation and their reactions.
An effective review will collect as much information as possible about the case, including demographic information, the timing of any clinical tests for brain death and donation requests, and the hospital personnel involved. To capture this information, The Partnership has developed and refined a standardized Medical Record Review form that can be used in any hospital.
An experienced reviewer can evaluate about 10 charts an hour on average. At this rate, a two-person team can review a full six months of death records for a typical hospital in one day.
For copies of this form and further information about The Partnership's medical record review process, please contact Holly Franz at (617) 330-8650.
Although many hospital staff members may believe there is little opportunity to increase donation in their institutions, The Partnership has found that potential organ donors are missed in most hospitals, and that substantial increases in donation consent rates can be achieved by enhancing the way hospitals offer donation to families.
An analysis of more than 19,000 medical records in 88 hospitals by The Partnership reveals that the number of potential organ donors is far larger than many caregivers would expect. Despite legislation requiring hospitals to offer organ donation to the families of brain dead patients, many potential donors are never identified as brain dead, and many times families are never given the option of donation.
Since each potential donor can provide up to six organs, even a slight increase in donation in one hospital can save or greatly improve the lives of several people waiting for transplants. Simply by understanding and improving its donation process, a hospital can greatly advance its life-saving mission even outside its own walls.
Conducting a review of medical records is a straightforward, fact-based way to evaluate how your hospital is doing in organ donation and to diagnose any problems it may have. Such a chart audit can not only determine the size of your potential donor population, but can also indicate where and why donors have been lost.
The medical record review process entails a systematic selection and analysis of a hospital's death records, excluding those cases where a patient's medical condition would preclude donation. Each remaining chart is then reviewed in depth, either by an organ recovery coordinator or a hospital staff member involved in donation, to determine if the patient was a medically suitable candidate for donation. (See sidebar)
Hospital staff are often unaware that donors are missed. Medical record reviews can determine objectively if there are opportunities to increase donation in the institution and build consensus among the staff on the need to improve the donation process.
To understand how a medical record review can uncover hospital-specific donation issues and help OPO and hospital staff focus their efforts in devising strategies to increase donation, the medical record reviews of two hospitals are described below.
Hospital A, a trauma center in a suburban area, had only three donors during the year. However, a chart audit showed 20 potential donors, including 13 cases where patients were never identified or declared brain dead. In the four other cases, the family said no to donation.
Hospital B, a city hospital without a trauma designation, has a different kind of donation problem. Here, 18 of the 21 donors were identified as brain dead, but the family agreed to donate just 6 times and declined 12 times. This consent rate is well below the average for other hospitals in the region.
Clearly, Hospitals A and B both have significant opportunities to increase donation. The medical record review suggests that the underlying problem in each hospital is very different. For Hospital A, the primary issue lies in identifying potential donors, while Hospital B's main problem is in the way it handles donation requests.
Often, the medical record review is only the first step in understanding a hospital's donation process and the factors that limit its effectiveness. Additional information may be obtained through interviews, surveys, or by more closely monitoring the process by which donation is offered to families.
Using actual case outcomes, OPO and hospital staff can then identify differences among units and medical services, and can jointly develop a strategy for increasing donation in the hospital. In its demonstration project, The Partnership and four OPOs used medical record review data to identify hospital educational needs and opportunities to improve the donation process in different units. In collaboration with hospital staff, The Partnership and OPO staff developed strategies that led to increases in donation rates.
In addition to helping hospitals increase donation and contribute to saving lives, the medical record review also provides a systematic approach to tracking hospital performance in donation. The Partnership believes that hospitals should be evaluated on how they handle the donation process- identifying potential donors, referring cases to the OPO, and ensuring that donation is offered to families in a sensitive manner. As a mechanism for quality assurance, medical record reviews can document the hospital's performance in donation for JCAHO and for internal hospital quality improvement efforts.
Ongoing reviews of medical records are critical in documenting changes in the underlying potential donor population and in tracking the impact of changes in policies or procedures. Up-to-date information can help identify new obstacles to donation within the hospital and continue to allow OPOs and hospital staff to focus their improvement efforts where they can have the greatest impact.
The medical record review process is part of a comprehensive methodology The Partnership has developed to understand hospital donation processes in detail. Future issues of this newsletter will describe other tools used to increase organ donation.
