1. Moderator: Peter Gruen, MD, LAC + USC Medical Center Presenters: Gudata Hinika, MD, California Hospital Medical Center Antonio Liu, MD, White Memorial Medical Center / California Hospital Medical Center Breakout Session C: Physician Champions: Sharing Methods for Superior Donation Outcomes

2. Questions to Run On What “best practices” presented today would improve the brain death declaration and the organ donation processes in your hospitals? What “best practices” presented today will you share with your physician colleagues?

3. Antonio Liu, MD Neurologist

4. Objectives By the end of this presentation, the attendee will be able to: Identify “best practice” standards for brain death determination. Identify effective family-centered care for families facing a brain death diagnosis Understand cultural sensitivity surrounding brain death diagnosis

5. What is Brain Death? Neurologic determination of death Irreversible loss of function of the brain and brainstem Spinal cord reflex does not count

6. Confounding Practices There is a need for standardization: Wide variance in brain death determination practices In large hospital, neurologists diagnosis 25 – 30 times /year In small hospitals, physicians diagnosis 0 – 3 times / year Hospital Brain Death Policies may not proceduralize the clinical exam or documentation requirements Physicians may not be confident to declare patients without detailed standards of practice The public expects physicians to get “dead” right

7. Brain Death Legislation National: Uniform Determination of Death Act Approved in 1981 In cooperation with AMA, ABA, President’s Commission on Medical Ethics Adopted by most states State: California Health and Safety Code, Section 7184 An individual who has sustained either 1) irreversible cessation of circulation and respiration, or 2) irreversible cessation of all functions of the entire brain, including brainstem, is dead. A determination of death must be made in accordance with accepted medical standards.

8. American Academy of Neurology (AAN) Guidelines 2010 Prerequisites Acute CNS catastrophe Exclusion of confounding factors No intoxication or poisoning Core Temp > 36C Three cardinal findings Coma Lack of brainstem reflexes Apnea....... not just another clinical test

9. American Academy of Neurology (AAN) Guidelines 2010 Ancillary Testing Angiography EEG Transcranial doppler Technetium 99 brain scan “hollow skull” Somatosensory evoked potentials New AAN: Ancillary testing may take the place of apnea testing if it is inconclusive or it has to be aborted.

10. Improved Brain Death Policies Alleviate variance in brain death determination practices Implement a Standard Brain Death Note Update policies to reflect new AAN guidelines Proceduralize comprehensive clinical exam

11. Integrate AAN Checklist to Standardize Brain Death Diagnosis and Documentation Prerequisites (all must be checked):  Coma, irreversible and cause known  Neuroimaging explains coma  CNS depressant drug effect absent  No evidence of residual paralytics  Absence of severe acid-base, electrolyte, edocrine abnormality  Normothermia or mild hypothermia (core temp > 36 C)  Systolic blood pressure > 100 mm Hg  No spontaneous respirations

12. Integrate AAN Checklist to Standardize Brain Death Diagnosis and Documentation Examination (all must be checked):  Pupils nonreactive to bright light  Corneal reflex absent  Oculocephalic reflex absent (tested only if C-spine integrity ensured)  Oculovestibular reflex absent  No facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint  Gag reflex absent  Cough reflex absent to tracheal suctioning  Absence of motor response to noxious stimuli in all four limbs (spinally mediated relexes are permissible)

13. Integrate AAN Checklist to Standardize Brain Death Diagnosis and Documentation Apnea testing (all must be checked):  Patient is hemodynamically stable.  Ventilator adjusted to provide normocarbia (PaCO2 35 – 45 mm HG).  Patient preoxygenated with a PEEP of 5 cm of water.  Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with CPAP at 10cm H2O.  Disconnect ventilator.  Spontaneous respirations absent.  Arterial blood gas drawn at 8-10 minutes, patient reconnected to ventilator.  PCO2 > 60 mm Hg, or 20 mm Hg from normal baseline value. OR:  Apnea test aborted.

14. Integrate AAN Checklist to Standardize Brain Death Diagnosis and Documentation Ancillary testing (only one needs to be performed) (to be ordered only if clinical examination cannot be fully performed due to patient factors, or if apneas testing inconclusive or aborted):  Cerebral angiogram  HMPAO SPECT  EEG  TCD  Normothermia or mild hypothermia (core temp > 36 C)  Systolic blood pressure > 100 mm Hg  No spontaneous respirations Time of death (DD/MM/YY): _______ / ________ / ________ Name of physician and signature: _______________________

15. Sensitive family-centered care Who informs the family about grave prognosis? Who informs the family about the impending brain death examination? And the exam results? Who informs the family about the opportunity for organ and tissue donation? When, and how, does the physician / hospital sensitively introduce OneLegacy to the family?

16. Sensitive family-centered care Preparing a family to meet with OneLegacy: “I am very sorry for your loss. We will give you some time alone to be together as a family, and if you have any questions, we will contact {nurse, social worker, chaplain} for you. Later, we will introduce someone specialized in End-of-Life decisions to support you and your family through the next steps.”

17. Sensitive family-centered care Timing is almost EVERYTHING! Family may need time between brain death discussion with physician and donation discussion with OneLegacy. Family acceptance of brain death diagnosis is necessary before introducing the discussion of organ donation.

18. Sensitive family-centered care All donation discussions with family should be planned events. Who? Where? When? clearly customized for each family during hospital and OneLegacy care plan “huddle”. Avoid the perception of conflict of interest.

19. Cultural Diversity & Brain Death Cultural differences may influence acceptance of brain death: Western vs. Eastern philosophies of mind / body /spirit connection Coma vs. Brain Death: waiting for a miracle Socially or economically disenfranchised may not trust diagnosis Responding to cultural differences: Show and Tell - “seeing is believing” Multiple family conferences to clarify Balance sensitivity with definitiveness

20. Summary Updated AAN Guidelines can be incorporated into hospital policies to standardize brain death determination practices. Sensitive family-centered care requires coordinated efforts of the right experts to support the family at the right time. Physicians should be prepared to aid families from varied cultural backgrounds to best understand and accept the brain death diagnosis.

21. Thank You Contact: Antonio Liu, MD (323) 987-1362 American Academy of Neurology (AAN) www.aan.com

22. Physician Champions: Sharing Best Practices Dr. Gudata Hinika Chief of Trauma California Hospital Medical Center

23. Objectives By the end of this presentation, the attendee will be able to: 1) Identify procedures and protocols for improving patient resuscitation in the ED. 2)Understand the value of a having an active multi- disciplinary Donation Council with physician leadership. 3)Identify specific strategies for improving hospital and OneLegacy partnerhip from referral to recovery.

24. California Hospital Demographics Trauma Level II facilityTrauma Level II facility 316-bed acute care hospital316-bed acute care hospital Located in downtown Los AngelesLocated in downtown Los Angeles Serving primarily lower income and transient populationServing primarily lower income and transient population

25. CHMC Organ Donation Data 2008 20092010 CMS Goal Organ Donors 410 16 Eligible Deaths 1415 20 Total Organs Transplanted 1327 57 OTPD 3.25 2.703.80 3.75 Conversion Rate 29%67%75% 75% Timely Referrals 96%96%92% 100% Effective Request 89%64%73% 100%

26. ED Protocol ED Level I, II, and Consultation ActivationED Level I, II, and Consultation Activation Level I:Level I: All key team members must respond, i.e.; (Blood Bank, Trauma Surgeon, Anesthesiologist, ED physicians, RNs, RTs, & Radiology) Sign-in sheet upon staff arrivalSign-in sheet upon staff arrival Resuscitation measuresResuscitation measures GOAL: Patient receives multi-disciplinary resuscitationGOAL: Patient receives multi-disciplinary resuscitation

27. ED Protocol Once resuscitation is achieved: Allows for immediate ED to OR timeAllows for immediate ED to OR time ICU maintains 1 available bed for TraumaICU maintains 1 available bed for Trauma

28. Donation Council CHMC established Donation Council 8/2010CHMC established Donation Council 8/2010 GOAL: Process ImprovementGOAL: Process Improvement High Level Chair with physician influenceHigh Level Chair with physician influence Active OneLegacy CoordinatorActive OneLegacy Coordinator Multi-disciplinary – meets quarterlyMulti-disciplinary – meets quarterly Review all referrals/cases/timelinessReview all referrals/cases/timeliness Chair holds Lead persons accountable for PIChair holds Lead persons accountable for PI

29. OneLegacy Partnership Education is key Nursing Competencies/AnnualsNursing Competencies/Annuals Department meetingsDepartment meetings Grand RoundsGrand Rounds Hospital knowledgeable on policies & processHospital knowledgeable on policies & process Early Referral for Imminent & Cardiac Death Avoids missed/late referrals for organ and tissueAvoids missed/late referrals for organ and tissue CMS mandate = Goal is 100% timelinessCMS mandate = Goal is 100% timeliness

30. RN Champions What is a Nurse Champion?What is a Nurse Champion? A registered nurse (preferably not a charge nurse) formally recognized as an advisor on the donation process. Nurses, physicians, RT’s, OneLegacy coordinators, and hospital Administration consult the Nurse Champion, regarding referrals, general donation policy, protocol or practice. A registered nurse (preferably not a charge nurse) formally recognized as an advisor on the donation process. Nurses, physicians, RT’s, OneLegacy coordinators, and hospital Administration consult the Nurse Champion, regarding referrals, general donation policy, protocol or practice. When does a facility need one?When does a facility need one? Anytime. Nurse Champions foster leadership and peer-to-peer interaction/education throughout the referral process. And the charge nurses and manager can rely on the Nurse Champions to help less experienced staff navigate the referral process effectively.

31. RN Champions CHMC has 4 Nurse Champions!!CHMC has 4 Nurse Champions!! 3 day shift & 1 night shift 3 day shift & 1 night shift Multiple referrals in units at one time with several OL coordinators onsite, same physicians, etc.Multiple referrals in units at one time with several OL coordinators onsite, same physicians, etc. Champions help with overall organization and communication in real-time for staff, OneLegacy and families.Champions help with overall organization and communication in real-time for staff, OneLegacy and families.

32. OneLegacy Partnership C O M M U N I C A T E! C O M M U N I C A T E! Multiple huddles (all teams w/OneLegacy involvement)Multiple huddles (all teams w/OneLegacy involvement) Involve your RN Champions early for assistanceInvolve your RN Champions early for assistance Have OL Coordinator e-mail updates to all Donor Council members to keep updated on referrals/donorsHave OL Coordinator e-mail updates to all Donor Council members to keep updated on referrals/donors

33. THANK YOU! THANK YOU! Contact information: Dr. Gudata Hinika California Hospital Medical Center Gudata.Hinika@chw.edu (323) 545-9288

34. QUESTIONSfor Dr. Liu & Dr. Hinika?

35. Questions to Run On What “best practices” presented today would improve the brain death declaration and the organ donation processes in your hospitals? What “best practices” presented today will you share with your physician colleagues?