Moderator: Thomas Nakagawa, MD, Wake Forest Baptist Health Presenters: Darren Malinoski, MD, Cedars-Sinai Medical Center Breakout Session A: Optimizing.

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?”

THANK YOU

Darren Malinoski, MD [email protected]