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ORGAN DONATION AND TRAUMA By Tristan Saggese

Organ Donation Presentation

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Organ Donation and Trauma

Organ Donation and TraumaBy Tristan Saggese

Hello. For those of you that dont know me, my name is Tristan, and today Ill be talking about the organ donation process as it related to trauma and trauma hospitals. 1

Some Important InformationDonation restrictions / contradictions 30% of organ donations are from trauma patients Before donation: Identify and evaluate donors, Obtain consent, Brain Death, Preservation etc.

Before I introduce my three studies, I wanted to take a few minutes to discuss some pertinent information.

Before organ harvesting can proceed, a lot has to take place.

In years past, criteria for organ donation used to be fairly strict, limiting harvesting to donors aged 10-50 years of age without co-occurring conditions. With the increasing demand for organs, donation from an expanded donor pool has loosened restrictions considerably.

According to the New England Organ Bank and the California Transplant Donor Network (CTDN) some current quote unquote absolute contradictions include: Age older than 80 years, HIV infection, Active metastatic cancer, Prolonged hypotension or hypothermia.

In the united states, approximately 30% of organ donations come from trauma patients; the graph on the left hand side, sourced from United Network for Organ Sharing, shows the causes of death of patients that donated organs from 1999 to 2009.

Finally, before organ donation can occur a complicated, step by step process, typically orchestrated by an organ procurement organization (or OPO), takes place. Before organ donation occurs, OPOs Identify donors, Evaluate potential donors, Confirm diagnosis of brain death, Arrange consent from family, Clinically manage the potential donor, Obtain permission for visiting transplant surgeons to remove organs, and Preserve and package organs for transplant.

Its a long process.

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Brain DeathBrain death confirmation No overwhelming consensusLess time after brain death = More successful transplantsCriteria for Brain Death?

Before harvesting organs occurs, a crucial step in in the process is, of course, confirmation that a patient is brain dead.

There is currently no defined consensus on the most appropriate manner to for brain death diagnosis.

We know that the number of successful organ transplants increases as the time between Brain death and organ harvesting lessens; so, its important in cases of critically injured trauma patients that a speedy diagnosis take place to maximize donation success.

Finally, some early giveaways for brain death include: Hemo dynamic lability, Heart rate instability, Decreased bronchial secretions; to conclude the confirmation of brain death, a physician must show a Correction of potentially reversible causes of coma, the absence of brainstem reflexes and a "Lack of respiratory effort

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Cardiac DeathWhen Brain Death hasnt been confirmedUnited States uses Cardiac Death indicator

There are instances in which the families of critically injured patients decide to discontinue care (as recovery is seemingly unachievable); although patients may not meet the guidelines required for Brain Death confirmation, donation may be possible for patients demonstrating cardiac death; note, the protocol for diagnosis of cardiac death varyies; the process usually involves quote withdrawal of mechanical support followed by rapid organ procurement after the clinical pronouncement of death end quote.

The United States has utilized the Cardiac death standard for justification of donation, but not all countries do.

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Policy

Geisinger Medical Center, PennsylvaniaPublished 1992Efficiency of donation Process

Okay, now on to the papers.

I picked this first paper because it outlined the process and protocol for assessing trauma patients eligibility for organ and tissue donations.

This article was published at the Geisinger Medical Center in Pennsylvania. Although published in 1992, I think the study highlights some important findings.

The purpose of this study was to assess the efficiency and reassess the requirements for organ donation from patients experiencing trauma-related mortality.

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MethodsObserved108 patients admitted for trauma-related injury over 36 month period. Characterized patients based on many characteristics Questionnaire

This study carried out a Randomized, retrospective analysis of 108 patients admitted to the Geisinger Medical Center for trauma-related injury

The study then characterized patients based on a wealth of characteristics, including, Pre-morbid diagnosis, method of brain dead protocol, documentation for a request for organ procurement, potentially salvageable organs, organs harvested, and factors related to the inability to procure organs. They used the data to conclude reasons for lack of organ donations, and highlight areas for improvement

The authors of the study also distributed a questionnaire to families of patients who died via traumatic injury to elucidate reasons that families might have withheld consent for organ donation.

The table details this institutions requirements at the time for organ donation and tissue procurement.

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Results

Table 2, on the left hand side categorizes the mode of death of the 108 patients involved in the study who were potential organ donation candidates. I found it interesting, that the majority of patients, 53%, died via motor vehicle crashes.

Table 3 on the right side shows that, Of the 108 patients, roughly 80% were ineligible for organ and/or tissue harvesting. The reasons for ineligibility are categorized in the figure on the right. Among other justifications for ineligibility, one major cause was age alone. Other reasons for ineligibility included sepsis, cardiopulmonary arrest and exsanguineation.

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Results Cont.

This figure shows the systematic progression from death to organ donation.

For only 22 of the patients a documented request for organ and tissue procurement was made by the attending physician, and brain death protocol was utilized for 17 patients. Among other reasons for failure of organ removal, the main reason for unsuccessful organ procuration was refusal by the family.

Ultimately, as is shown in the figure, only 12 of the 108, or roughly 11 percent, of the trauma patients became actual organ donors.

Generally, approximately 12% of trauma patients become actual donors, the study says.8

Conclusions // TakeawaysIncreasing professional education64% consent refusalPublic education! Arbitrary age boundaries

This study, siting, similar studies, posits that increasing professional education could increase the retention rate of potential organ donors eightfold.

The study garners support for the idea that failure of families to consent, and not so much failure to identify potential sources for donations, was the most significant reason for loss of donations. 64% of potential organs and tissues were lost as a result of families refusal.

Interestingly, the study suggests that age should not be a barrier to donation. Other studies have shown that organ donations of older patients can yield significant amount[s] of functioning organs and tissues In other words, potential donors should accepted over a wider age range to cope with increasing demands

Ultimately, the questionnaire for families that refused organ donations failed. 9

People

Department of Surgery at the University of MissouriPublished 2001

This next study, for the people portion of my presentation, was published in the Journal of Trauma in 2001 at the Department of Surgery at the University of Missouri, in coordination with other medical centers, and the Center for Organ Recovery and Education in Pittsburgh, and Gift of Life Donor Program in Philadelphia.

The purpose of this study was to evaluate the opinions of Pennsylvania trauma surgeons regarding their role in organ donation, and the role of Organ procurement organizations (or OPOs) in organ donation success. Further, the study hoped to highlight ways to increase the conversion of potential organ donors into actual organ donors.

Note: OPOs also known as organ procurement organizations were created to cope with the increasing demand for organ donations. These non-profit OPOs are meant to quote procure and distribute organs for transplantation endquote, and to educate both the public and medical personnel on info regarding the donation process, among other jobs. 10

Methods18 question survey96 active trauma surgeons71 trauma surgeons repliedPurpose: donation and OPOs

The study utilized an 18 question survey developed at a regional trauma center in Johnstown, Pennsylvania.

The purpose of the survey was to highlight trauma surgeons opinions on OPOs and the donation organ process as a whole. The questions asked are quite interesting, and the surgeons responses are often quite variable.

The survey was distributed to exactly 96 trauma surgeons, 71 of whom (or 76%) replied with their answers.

The table on the right hand side, details types of trauma centers the surgeons worked in, and the types of ICUs the surgeons worked in.

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ResultsBroad range of results and opinions

The study yielded some important findings and a wide range of notable opinions.

Table 3 includes some intuitive results: almost all trauma surgeons either agreed or strongly agreed, naturally, that transplantation of postmortem organs is an reasonable and effective undertaking.

Further, most of the surgeons were familiar with the organ donation criteria. Interestingly, More than 85% of the trauma surgeons surveyed in Pennsylvania disagreed with the idea that treating a critically ill patient (prior to brain death) for the purposes of organ preservation is a professional conflict.

Further, 87% of the surgeons surveyed agreed that it is their professional responsibility to maintain organ viability to preserve the patients and familys right to donate organs and tissues. But, only 74% percent agreed that is was their responsibility to maintain organ viability for the benefit of patients awaiting transplantation.

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Results Cont.

Table 4 shows that 21 percent of the trauma surgeons surveyed only employ their institutions brain death policy when the family of the deceased patient wants the patient to become a donor. Also, interestingly, 23% of the surgeons surveyed disagreed when asked if they routinely pronounce patients brain dead who meet brain death criteria

Finally, one of the most fascinating results, in my opinion, was the fact that only 42 percent of the trauma surgeons agreed that there is adequately established criteria for pronouncing pediatric patients brain dead. 35% provided no response to the question, and only 4% answered as strongly agree

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Results Cont.

Of those 71 trauma surgeons surveyed, 23% disagreed that the OPO should be involved in assessment and management of patients prior to confirmation of brain death.

The results of the study showed that, even If trauma surgeons mostly supported some involvement of OPOs, 42 percent of those surveyed thought only the attending physician should have a say whether a family get referred to an OPO. That said, a majority agreed that the decision to refer a patient to an OPO shouldn't be made by just the attending physician.

Finally, an overwhelming majority of those surveyed agreed that the decision about whether a patient is suitable for organ donation should be up to both the attending physician and the OPO. Note: these questions were not mutually exclusive.

The table on the right hand side deals with who should approach the family of deceased patients to ask for consent for organ donation; 73% of trauma surgeons thought it was solely the trauma surgeons responsibility; 60% thought the OPOs should approach the families and 80% agreed that having the attending physician and OPO cooperate and work together in approaching families for consent is a reasonable alternative to having just one take on the burden.

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Results Cont.

Finally, more than 75% of respondents agreed that they could influence the organ donation decisions made by the families of brain dead patients. 15

Conclusion Hospital-wide donation education programs How to approach?The how and when may of the approach may be importantExample: Decoupling Pediatric brain death

The study came to a variety of conclusions regarding the effectiveness of OPO programs.

First, the study supported the idea that hospital-wide organ donation education programs help procurement of viable organs; ultimately though, the study posits, its the publics lack of understanding of brain death and organ donation that cause their reluctance to consent to donating deceased loved ones organs.

The study also suggests that in-hospital organ education programs should focus on strategies for how to approach families, and not so much how to identifying potential organ donors.

80% of the surgeons surveyed indicated that it was the role of both the attending physician and the OPO representative to approach families. Whatever the case, those trauma surgeons surveyed agreed they had some influence in families decisions.

Finally, the study suggests that the how and when to approach the family of a critically injured, brain dead patient can be equally if not more important than the who;

Studies have shown that when the discussion for organ donation and brain death are decoupled, (in other words, undertaken by two different parties--the OPO and the physician, for instance), donation occurs more frequently

Lastly, the survey clearly shows that the protocol for determination of brain death in children 5 years or younger needs to be further developed.16

Practice University of Southern California Keck School of MedicinePublished 2007 In-house coordinator program (IHC)

Finally, for my paper on practice, I chose a study was carried out by the department of surgery, Division of Trauma and Critical Care, at the University of Southern California Keck School of Medicine. The study was published in 2007.

The purpose of the study was to test if implementation of in-house coordinators (or IHCs) from OPOs could effectively increase organ donation rates at level 1 trauma centers, and USCs medical center specifically.

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BackgroundOrgan Donating Breakthrough Collaborative (Collaborative) Aggressive management protocol In-house coordinator program with help of OPOs

I want to briefly go over some background details before I get to the bulk of the study.

Due to the overwhelming demand for organ transplants, the the Department of Health and Human Services implemented a new program called the Organ Donating Breakthrough Collaborative (or Collaborative) in the early 2000s. In short, the purpose of the program was to maximize potential organ donations at hospitals with the greatest potential for donation. The collaborative set its goal at a 75% organ donation rate.

Although Division of Trauma and Critical Care at the USC Medical Center implemented an aggressive management protocol for brain-dead potential organ donors in 1999 that drastically increased organ donation success, the program fell short of the 75% goal of the collaborative.

Thus, in 2001, the USC medical center adopted an in-house coordinator program orchestrated by a local OPO to improve methods of approaching and educating families to increase its organ donation rates and success.

This study assesses the success of the in-house coordinator program after implementation at a level 1 trauma medical center.

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Methods Two full time in-house coordinatorsIHCs provided extensive Family support Timely discussion of organ donation Time with familiesPre and Post IHC periods compared

In 2001, the USC medical center employed two full time in-house coordinators, both trained OPOs, to oversee the organ procurement process. The overarching purpose of their employment was, of course to increase the number of donations by potential donors. Among other things, IHCs were tasked with providing family support

Family support entailed spending extensive time with potential donors families before and after confirmation that their loved ones were brain dead, and orchestrating timely discussion of of the prospect of organ donation with the families.

The study compares the effectiveness of the organ procurement processes before and after the implementation of the IHC program; that is, from January 1998December 2001 (the pre-IHC period) and from January 2002December 2005 (the post-IHC period)

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Results

The study had some interesting and significant results; first, as shown in the top red row, the number of trauma patient donors increased (almost to a significant degree) after implementation of the IHC program, although the other donor demographics didnt really change between the two periods

Further, the number of overall donors, the organ donation consent rate, and the conversion of potential into actual donor rates significantly increased with introduction of the IHC program.

Also, although trivial, I found it interesting that the average number of organs donated per brain dead patient was about 3.5.

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Results Cont.

Table 2 shows that there was an overall 90% decrease in the missed referrals. In other words, failure to refer families of potential organ donors to one of the OPOs decreased overall by 90%! Further, there was a 39% increase in the total number of referrals

Also, the number of organs transplanted increased by 17% in the post-IHC introduction period.

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CONCLUSIONOPOs significantly effect trauma and other patient donations More time spent with families Transplant coordination programs Time of interaction? 33% of IHC hospitals achieved 75% conversion rate goal Consent is still an issue

Studies like this one have shown that increasing the involvement of OPOs in the organ procurement process positively effects consent rates (or, families decisions to donate).

Hospitals around the country have employed similarly Successful transplant coordinators (usually physicians) responsible for quote identifying potential donors, managing their hospital course, and consenting family members. endquote. As a result, the consent and conversion rates in trauma hospitals have increased drastically.

In conclusion, this study posits that the time of interaction with families of potential donors could drastically effect consent rates. Many level 1 trauma centers have changed their policies to allow OPOs to discuss the prospect of donations earlier that confirmation of brain death now.

The study notes that following introduction of the IHC programs, consent of families is still a major issue at trauma hospitals, and more effective strategies for consent must be discovered, although tremendous progress has been achieved with programs like the IHC at USCs medical center. 22

Concluding ThoughtsHigh demand for organs; we still need strategies to increase donations Age-related factors? IHC programs?

Today, there remains an ever-increasing demand for organ donations.

The supply, of course, needs to be increased in a fashion that serves that demand. Its unclear whether that means altering the restrictions for potential donors, or administering more active in-house coordination programs at trauma hospitals with a high volume of potential donors.

Huge progression has been made in recent years, and with the establishment of programs like Collaborative. And surely more progress in procuring organ donations is yet to come. 23

ReferencesFinger, Erik B. "Organ Procurement Considerations in Trauma." : Overview, Organ Distribution, Criteria for Organ Donors. N.p., 2016. Web. 18 Aug. 2016. Johnson, Colleen M., Lee S. Miller, and Stanley J. Kurek. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, Mar. 2001. Web. 19 Aug. 2016. Kennedy, Alfred P., John C. West, and Stephan E. Kelley. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, Oct. 1992. Web. 19 Aug. 2016. Salim, Ali, Carlos Brown, Kenji Inaba, Angela Mascarenhas, Pantelis Hadjizacharia, Peter Rhee, Howard Belzberg, and Demetrios Demetriades. "Improving Consent Rates for Organ Donation: The Effect of an Inhouse Coordinator Program." The Journal of Trauma: Injury, Infection, and Critical Care 62.6 (2007): 1411-415. Web.