230.2: An audit cycle optimising the documentation of brain death in a hospital in the United Arab Emirates.

Abstract

Background: The legal framework allowing clinicians to declare mechanically ventilated patients in the United Arab Emirates (UAE) dead by neurological criteria (‘brain dead’) was finalised in 2017 [1,2]. The correct diagnosis of brain death is important in allowing for meaningful end of life discussions which may include options for deceased organ donation. Correct certification of death is critical to this process [3]. The aim of this audit cycle was to ensure robust processes and procedures that will yield the correct diagnosis and documentation of brain death in every patient, every time. Methods: For the initial audit, the Saudi Arabian death certification protocol was implemented as a standard of best practice and used in every suspected case of brain death (adult and paediatric) in our institution. After its use in eleven cases, data was examined by an expert committee consisting of neurologists and intensive care doctors convened specifically to refine the process. Case notes and documentation were reviewed and deficits were identified. A more detailed policy and procedure was implemented with changes reflected in the protocol paperwork. Use of the new protocol and paperwork was then audited after 12 cases. Results: After introduction of the new form a repeat audit was performed. All forms were completed correctly (n=12), satisfying UAE criteria for diagnosis of brain death in 100% of cases. Conclusions: The new procedure and paperwork eliminated the errors demonstrated in the first audit. Discussion: Changes implemented included: 1. Explicit delineation of all preconditions required for clinical testing 2. Removal of free text ‘yes’ and ‘no’ answers which were easily subject to human error 3. An outline of the order in which all components of testing should be carried out 4. Providing guidance as to the required background of the clinicians performing testing Saudi Arabia has a well established national system of organ donation [3]. Our finding was that the UAE, which is implementing the program for the first time requires a more bespoke solution. The UAE has a uniquely diverse medical workforce with many clinicians having worked with different medical and legal definitions of brain death. Standardising the procedure in a robust form that outlines the process in greater detail was found to be necessary to ensure a unified approach that satisfies the legal requirements to determine brain death. Re-audit and re-assessment of the new form will follow.