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Breakout Session A: Optimizing Donation Outcomes within the Context of End-of-Life Care

Breakout Session A: Optimizing Donation Outcomes within the Context of End-of-Life Care. Moderator: Thomas Nakagawa, MD, Wake Forest Baptist Health Presenters : Darren Malinoski, MD, Cedars-Sinai Medical Center. Optimizing Donation Outcomes within the Context of End-of-Life Care.

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Breakout Session A: Optimizing Donation Outcomes within the Context of End-of-Life Care

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  1. Breakout Session A:Optimizing Donation Outcomes within the Context of End-of-Life Care Moderator: Thomas Nakagawa, MD, Wake Forest Baptist Health Presenters: Darren Malinoski, MD, Cedars-Sinai Medical Center

  2. Optimizing Donation Outcomes within the Context of End-of-Life Care 2011 OneLegacy Organ Donation and Transplantation Symposium Darren Malinoski, MD Director of Surgical Critical Care Cedars-Sinai Medical Center

  3. 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?”

  4. 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

  5. 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

  6. Impact of Timely Referralon Conversion Rates

  7. Impact of Effective Requeston Conversion Rates

  8. Arrhythmias Hypotension Brain Death DI DIC Acidosis Hypothermia Pulmonary Edema Cardiovascular Collapse

  9. p=0.20 vs. 2007 p=0.45 vs. 2007 • OTPED = effectiveness of an organ donation program • Considers conversion rate & donor management

  10. How Can I Adopt this at My Institution? “Aggressive Donor Management” “Devastating Brain Injury Guidelines” or CBIGs: Catastrophic Brain Injury Guidelines

  11. Devastating Brain Injury Pathway

  12. 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

  13. 98% would choose donation again • 92% identified positive aspects to the donation process/experience • Majority agreed that donation was comforting • Associated with less depression

  14. 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

  15. Background • Checklists have demonstrated utility in several arenas • Standardized critical care endpoints • Donor Management Goals (DMGs)

  16. Region 5 Donor Management Goals

  17. 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

  18. 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

  19. Summary • Making donation a priority improves outcomes • Aggressive donor management / CBIGs affect the number and quality of organs available for transplantation • Donation benefits OURpatients/families

  20. 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?”

  21. THANK YOU Darren Malinoski, MD malinoskid@cshs.org

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