1. Organ Donation Past, Present and Future Donor Identification and Referral Dr Huw Twamley 21 st May 2013 1 NORTH WEST

2. Session Objectives Understand difficulties with donor identification and referral Recognise benefits of improving elements of the process – Increased identification and referral – Timely referral – Responsiveness to referral Consider which of the proposed methods of identification and referral may work in your hospital 2 Organ Donation Past, Present and Future

3. Regional Data 3 NORTH WEST

4. -------- National rate 95 97 88 93 98 86 87 91 95 84 89 Referral rate (%) 0 20 40 60 80 100 Team EasternLondon Midlands North West Northern Ireland Scotland South Central South East South Wales South West Yorkshire DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 5 th Organ Donation Past, Present and Future 4 NORTH WEST

5. North West DBD referral rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 Organ Donation Past, Present and Future 5 1Barrow-In-Furness, Furness General Hospital 2Douglas, Nobles I-O-M Hospital 3Chester, Countess Of Chester Hospital 4Crewe, Leighton Hospital 5Macclesfield, Macclesfield District General Hospital 6Warrington, Warrington Hospital 7Liverpool, Royal Liverpool University Hospital 8Liverpool, Alder Hey Children's Hospital 9Prescot, Whiston Hospital 10Southport, Southport District General Hospital 11Liverpool, University Hospital Aintree 12Liverpool, Walton Centre For Neurology And Neurosurgery 13Wirral, Arrowe Park Hospital 14Lancaster, Royal Lancaster Infirmary 15Blackpool, Blackpool Victoria Hospital 16Preston, Royal Preston Hospital 17Blackburn, Royal Blackburn Hospital 18Chorley, Chorley And South Ribble District General Hospital 19Bolton, Royal Bolton Hospital 20Bury, Fairfield General Hospital 21Manchester, North Manchester General Hospital 22Manchester, Manchester Royal Infirmary 23Manchester, Royal Manchester Children's Hospital 24Manchester, Wythenshawe Hospital 25Oldham, Royal Oldham Hospital(Rochdale Road) 26Salford, Salford Royal 27Stockport, Stepping Hill Hospital 28Ashton-Under-Lyne, Tameside General Hospital 29Manchester, Trafford General Hospital 30Wigan, Royal Albert Edward Infirmary 31Bodelwyddan, Glan Clwyd District General Hospital 32Wrexham, Maelor General Hospital 33Bangor, Ysbyty Gwynedd District General Hospital

6. -------- National rate 80 72 54 72 81 52 42 54 56 59 60 65 Referral rate (%) 0 20 40 60 80 100 Team EasternLondon Midlands North West Northern Ireland Scotland South Central South East South Wales South West Yorkshire 1 April 2012 to 31 March 2013, data as at 4 April 2013 Organ Donation Past, Present and Future 6 Tied 3 rd DCD referral rate NORTH WEST

7. Referral rate (%) 0 20 40 60 80 100 Number of imminent death anticipated patients 01020304050607080 1 10 11 12 13 14 15 16 17 18 19 2 20 21 22 23 24 25 26 27 28 29 3 30 31 32 33 4 5 6 7 8 9 HospitalNational rate95% Lower CL 95% Upper CL99.8% Lower CL99.8% Upper CL North West DCD referral rate Organ Donation Past, Present and Future 7 1Barrow-In-Furness, Furness General Hospital 2Douglas, Nobles I-O-M Hospital 3Chester, Countess Of Chester Hospital 4Crewe, Leighton Hospital 5Macclesfield, Macclesfield District General Hospital 6Warrington, Warrington Hospital 7Liverpool, Royal Liverpool University Hospital 8Liverpool, Alder Hey Children's Hospital 9Prescot, Whiston Hospital 10Southport, Southport District General Hospital 11Liverpool, University Hospital Aintree 12Liverpool, Walton Centre For Neurology And Neurosurgery 13Wirral, Arrowe Park Hospital 14Lancaster, Royal Lancaster Infirmary 15Blackpool, Blackpool Victoria Hospital 16Preston, Royal Preston Hospital 17Blackburn, Royal Blackburn Hospital 18Chorley, Chorley And South Ribble District General Hospital 19Bolton, Royal Bolton Hospital 20Bury, Fairfield General Hospital 21Manchester, North Manchester General Hospital 22Manchester, Manchester Royal Infirmary 23Manchester, Royal Manchester Children's Hospital 24Manchester, Wythenshawe Hospital 25Oldham, Royal Oldham Hospital(Rochdale Road) 26Salford, Salford Royal 27Stockport, Stepping Hill Hospital 28Ashton-Under-Lyne, Tameside General Hospital 29Manchester, Trafford General Hospital 30Wigan, Royal Albert Edward Infirmary 31Bodelwyddan, Glan Clwyd District General Hospital 32Wrexham, Maelor General Hospital 33Bangor, Ysbyty Gwynedd District General Hospital

8. Timely Identification and Referral of Potential Organ Donors Huw Twamley Regional CLOD North West Region Organ Donation Past, Present and Future

9. UK rates of referral Organ Donation Past, Present and Future 91% 52%

10. Cause of death in MC III DCD donors UK Potential Donor Audit (October 2009 – March 2012) 7504 patients referred as potential DCD donors 877 actual DCD donors

11. Potential Donor 83 year old PEA Out of hospital cardiac arrest “Downtime” 15-20 minutes Hypoxic brain injury Known Hypertensive Urea 16.4 Creat 94 Prev Basal cell Carcinoma

12. Overall timings Organ Donation Past, Present and Future

13. Aims of Strategy 100% Identification of potential Donors 100% Referral of Potential Donors 100% Timely Referral Implement NICE Guidance The consideration of donation should be core ICU / ED and part of all end of life care plans. Timely referral promotes this possibility Organ Donation Past, Present and Future

14. NICE Guideline 135 Organ Donation Past, Present and Future

15. British Medical Association 2012 The research data -------- showed that the use of clinical triggers and a requirement to refer according to standard criteria led to an increase in both referrals and donors. It is hoped that implementation of the NICE guideline will result in early and consistent donor referral. Organ Donation Past, Present and Future

16. General Medical Council 2010 I”f a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.” “You should follow any national procedures for identifying potential organ donors and, in appropriate cases, for notifying the local transplant coordinator.” Decisions to limit or withdraw treatments in potential DCD donors MUST be in compliance with national End of Life Care policy. Organ Donation Past, Present and Future

17. UK Donation Ethics Committee “There is no ethical dilemma if the treating clinician wishes to make contact with the SN-OD at an early stage, while the patient is seriously ill and death is likely, but before a formal decision has been made to withdraw life-sustaining treatment.” [“Benefits] include establishing whether there are contra-indications for organ donation…… Other practical and organisational factors might be relevant – if the SN-OD is based at a distant location then early contact can help to minimise distressing delays for the family.” Organ Donation Past, Present and Future

18. Objectives, benefits and outcomes All potential donors are identified and referred All donors are referred in a timely fashion SN-ODs are deployed in a way that improves responsiveness All patients are given the option of donation Access to clinical advice Prompt donor optimisation Resolution of potential legal obstacles Early assessment of marginal donors Early tissue typing / screening Planning the family approach Reduction in delays for families and units Increased donor numbers Improved consent / authorisation rates Increase in donor organs Better experience for families and staff Organ Donation Past, Present and Future

19. NHSBT Strategy Implementation not publication Key area for collaboration between hospitals and donor care teams Very clear emphasis on benefits – How not who Suite of options Clarity over implementation Organ Donation Past, Present and Future

20. Strategy proposals Every hospital should have a written policy for the identification and timely referral of all potential donors Every donating area within a given hospital adopts a consistent approach As far as possible ‘decouple’ early referral from individual clinician Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion. Organ Donation Past, Present and Future

21. 1. Daily visit by SN-OD Organ Donation Past, Present and Future

22. 2. Early daily phone call Organ Donation Past, Present and Future

23. 3. Daily ICU team safety brief Organ Donation Past, Present and Future

24. North Bristol Trust ICU Safety Brief

25. 4. Standard Operating Procedure Organ Donation Past, Present and Future

26. Midlands Standard Operating Procedure Organ Donation Past, Present and Future

27. 5. Nurse led referrals Organ Donation Past, Present and Future

28. Summary 28 Organ Donation Past, Present and Future Donation should be a element of end of life care Make identification and referral routine business of the unit. This decouples early referral from the individual clinician caring for the patient Implement or develop a solutions /policy for your individual hospitals adopt to timely referral Ensure consistency within a given hospital

29. Organ Donation Past, Present and Future 29

30. What are the barriers to implementing the NICE guidelines in your unit? Any solutiions? Organ Donation Past, Present and Future 30  Whichever is the earlier, either: Use trigger factors in patients with a catastrophic brain injury The absence of one or more cranial nerve reflexes AND a GCS of 4 or less that is not explained by sedation  And / or a decision is made to perform brainstem death tests. The intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death.