Organ Donation Breakthrough Collaborative

Timely Referral of Potential Organ Donors

John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally. Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication. Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program. Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals. Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery. Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974.

Of 5810 acute care hospitals in the United States, only 3.9% (231) are Level 1 Trauma Centers (L1TCs). L1TCs have a significant number of potential organ donors (PODs). Placement of Organ Procurement Organization (OPO) staff, In House Coordinators (IHCs), directly within the L1TC to increase the number of families who consent to donate and to provide system management for the trauma center's donation program, was evaluated. Four OPO staff, IHCs, were placed in offices inside two L1TCs in Houston, Texas. The IHCs were responsible for development of a donation system, donor surveillance, management, and most importantly, family support. Calendar year 2000 data on conversion of PODs to actual donors were compared between the L1TCs with IHCs (IHC-L1TC) (n=2) and trauma centers without IHCs (n=4) within the OPO's service area. IHC-L1TCs converted 44% more of the PODs to actual donors. Furthermore, the IHC-L1TCs were compared with 85 L1TCs (37% of U.S. L1TCs) without IHCs. IHC-L1TCs had a 28% greater donor consent rate and a 48% greater conversion rate of PODs to actual donors than the national L1TCs. L1TC status is the America College of Surgeons' highest level of verification for trauma care. To be certified as a L1TC, hospitals must meet strict criteria in both services and patient care. The donation process is often profoundly affected by the burden of demands made on the resources of these institutions and from divergent responsibilities between specialty services within the facility. Dedicated IHCs (OPO staff) are needed to provide early family intervention and to orchestrate the donation process to maximize organ recovery.

Assessing Organ Donation from the Dead Should Not Be Done by Reporting a Census of the Living

Several machine learning classifiers were trained to predict transplantation of a liver graft. We utilized 127 variables available in the DMG dataset. We included data from potential deceased organ donors between April 2012 and January 2019. The outcome was defined as liver recovery for transplantation in the operating room. The prediction was made based on data available 12-18 h after the time of authorization for transplantation. The data were randomly separated into training (60%), validation (20%), and test sets (20%). We compared the performance of our models to the Liver Discard Risk Index. Of 13 629 donors in the dataset, 9255 (68%) livers were recovered and transplanted, 1519 recovered but used for research or discarded, 2855 were not recovered. The optimized gradient boosting machine classifier achieved an area under the curve of the receiver operator characteristic of 0.84 on the test set, outperforming all other classifiers. This model predicts successful liver recovery for transplantation in the operating room, using data available early during donor management. It performs favorably when compared to existing models. It may provide real-time decision support during organ donor management and transplant logistics.

Expedited SARS-CoV-2 screening of donors and recipients supports continued solid organ transplantation.

Background: A 27 year-old pregnant woman (17 weeks gestation) suffered an anoxic brain injury status post hanging. She was diagnosed brain dead on day 8 of hospitalization; all days listed herein are from admission (day 1) as she was on full ventilator support and under acute critical care from the date of admission. Case Progression: The family expressed a desire for the patient to be an organ donor. Hospital Staff (HS) made an early referral to the organ procurement organization (OPO) on day 4 at the family’s request after they were made aware of the grave prognosis. The OPO, patient’s physician (MD), HS, and ethics huddled to evaluate options for fulfilling the family’s wishes. During initial conversations with the family, the MD made the family aware ethics would need to be involved regarding any decisions to withdraw care or support. Family considered all options including withdrawal of support before ultimately choosing to pursue donation. A literature search revealed that while a brain dead mother had been supported for up to 110 days to achieve a live birth, the longest that such a mother had been supported with the end result of both a live birth and organ donation had been 64 days. The OPO collaborated with the family and a dedicated multidisciplinary hospital staff to develop a strategy to pursue the family’s goals. At a minimum there was daily communication between HS/MD and OPO staff; numerous OPO staff role types were involved. The donor’s water broke on day 19. On day 35 (22 weeks gestation), HS informed OPO staff that if the donor went into labor, it would not be stopped. At 30 weeks gestation, a date was set for a planned Caesarian-section. A huddle was conducted and infectious disease testing was performed. Results: On day 104, a healthy baby was delivered weighing 2212 g at 31.5 weeks gestation. OPO staff then began organ evaluation and on day 105 of maternal somatic support and 98 days after declaration of brain death, 4 organs (kidneys, liver, pancreas) were recovered and successfully transplanted into 3 recipients. All recipients are alive with normal organ function 200 days post-transplant. The newborn infant was discharged home 33 days after delivery with no disability. Conclusions: This landmark case represents the third longest reported case of life support for a brain dead mother to deliver a viable infant. It also represents the longest duration to both deliver a viable infant and provide organs for transplant, exceeding the previous record by 41 days. This case demonstrates that careful collaboration between the OPO and donor hospital can allow families to both achieve delivery of a viable infant and save lives through organ donation. The OPO’s and hospital’s lifesaving mission was met as four individuals (one newborn child and three recipients) are alive 200 days later. Further cases of this type should be carefully evaluated and pursued as an opportunity to support the grieving family and to save lives.

Approximately 6,000 patients per year, or 16 per day, with end-stage organ failure die because of the lack of available organs. Each year only 35% to 50% of potential donors consent to donation (1). During the last 20 years, vigorous educational campaigns, both voluntary and legislative, designed to increase organ donation have failed to increase donation rates significantly. The need for organs has grown nearly five times faster than the number of cadaveric donors: the annually compounded rate (1990–2000) of increase in number of patients on waiting lists has averaged 14.1% a year, whereas the rate of increase of donors has averaged 2.9% a year (2). The American Medical Association (AMA) has been concerned about this problem for many years and has developed several policies addressing it in the past decade (3). AMA policy has supported certain forms of financial incentives for cadaveric organ donation since 1993 (Policy E-2.15, AMA Policy Database), but they have never been implemented because federal law prohibits them. AMA policy specifically prohibits payment to living donors (4). Most initiatives to increase organ donation have focused on what motivates or hinders the decision to donate. Programs to improve organ donation rates have been aimed at public and professional groups. These have included widespread educational campaigns aimed at motivating individuals to become donors. They also have included mandated choice legislation, the establishment of the Organ Procurement and Transplantation Network (OPTN), donor card programs, donor registries, and the creation of specialized organ donation teams within hospitals that discuss organ donation with families and patients. Despite these efforts, cadaveric donation rates have remained nearly stable during the past decade. This report encourages the medical and scientific communities to reexamine the motivation for cadaveric organ donation. Building on the work of the Council on Ethical and Judicial Affairs (CEJA) in 1993, which led to Opinion E-2.15, “Financial Incentives for Organ Donation,” this report identifies reasons why ethical objections to financial incentives, for cadaveric organ donation only, should be reexamined. In particular, this report considers the need to study the impact of financial incentives through limited research trials. Such studies would help measure the effect of incentives not only on donation rates but also on public perception of the transplant enterprise and of the meaning of organ donation. For the purposes of this report, donation and procurement of organs are considered completely independent from the allocation of organs. The report neither suggests nor supports any change in the current system of organ distribution, as developed and administered by the United Network for Organ Sharing (UNOS). Even if financial incentives were found to have a positive impact on cadaveric organ donation rates, allocation algorithms developed by the OPTN would continue to govern organ distribution and transplant recipients would continue to be selected according to ethically appropriate criteria related to medical need rather than ability to pay. Physicians have an obligation to hold their patients’ interests paramount and to support access for all patients to medical care (Principles VIII and IX) (5). To discharge these obligations, physicians should participate in efforts to increase organ donation, including education of their patients and the general public regarding the importance of organ donation and promotion of voluntary donation of organs. Beyond educational programs, however, physicians should support innovative approaches to encourage organ donation. Such efforts include encouragement and, if appropriate, participation in the conduct of ethically designed research studies of donor motivation. A potential impetus for cadaveric organ donation that has not been adequately explored (because of federal prohibition) is financial incentives. Such incentives are not intrinsically unethical; AMA policy has supported them since 1993. Whether a particular incentive is ethical or not depends upon the balance of benefits and harms that result, and these are currently unknown because they have never been investigated.

Objectives：The purpose of this study was to evaluate whether the diagnostic validity of the Korean version of short form (15 item version) Geriatric Depression Scale (SGDS-K) was maintained well in the community dwelling elderly. Methods：In a face-to-face household survey conducted in Korea, 2,004 subjects aged more than 65 were interviewed by trained interviewers. 63 subjects diagnosed as dementia were excluded. The Mini Mental State Examination (MMSE) and SGDS-K were administered. Major depressive disorder (MDD) and minor depressive disorder (MnDD) were diagnosed with the diagnostic section of depressive disorder of the Korean version of the Composite International Diagnostic Interview (K-CIDI) according to DSM-IV diagnostic criteria. The sensitivity, the specificity and optimal cut-off point estimation and receiver operating characteristics (ROC) curve analysis were performed to investigate the diagnostic validity of the SGDS-K to screen MDD and MnDD. The diagnostic validity tests were also compared between two groups (with cognitive impairment and without cognitive impairment) divided by the MMSE scores. Results：We suggest a score of 8 (sensitivity 0.9365, specificity 0.7603) as optimal cut-off score of SGDS-K for screening MDD and a score of 6 (sensitivity 0.7898, specificity 0.6586) as optimal cut-off score for screening both MDD and MnDD. The area under ROC curve (AUC) was 0.900 for screening MDD and 0.797 for both MDD and MnDD. In the community dwelling elderly suffering from cognitive impairment, the sensitivity and specificity were 0.9500, 0.6870 with a cut off score of 8 for screening MDD and 0.8409, 0.5691 with a cut off score of 6 for screening both MDD and MnDD. The AUC was 0.893 for MDD and 0.767 for both MDD and MnDD. Conclusion：The SGDS-K was useful in screening MDD, both MDD and MnDD in the community dwelling elderly and also useful in the elderly suffering from cognitive impairment.

Report of the Crystal City Meeting to Maximize the Use of Organs Recovered from the Cadaver Donor

As the need for transplantable organs increases, waiting lists of patients become longer. We studied the size and composition of the national pool of brain-dead organ donors during a three-year period and, on the basis of these data, considered ways to increase the rate of donation. We reviewed hospital medical records of deaths occurring in the intensive care unit from 1997 through 1999 in the service areas of 36 organ-procurement organizations to identify brain-dead potential organ donors. We examined data on characteristics of the potential donors, the processes of referral to organ-procurement organizations and of requesting donations, and the hospitals. We identified a total of 18,524 brain-dead potential organ donors during the study period. The predicted annual number of brain-dead potential organ donors is between 10,500 and 13,800. The overall consent rate (the number of families agreeing to donate divided by the number of families asked to donate) for 1997 through 1999 was 54 percent, and the overall conversion rate (the number of actual donors divided by the number of potential donors) was 42 percent. Hospitals with 150 or more beds were more likely than smaller hospitals to have potential donors and actual donors (P<0.001); 19 percent of hospitals accounted for 80 percent of all potential donors. Calculations of the number of donors per million persons in the general population did not correlate well with the performance of organ-procurement organizations as measured by the conversion rate. Lack of consent to a request for donation was the primary cause of the gap between the number of potential donors and the number of actual donors. Since potential and actual donors are highly concentrated in larger hospitals, resources invested to improve the process of obtaining consent in larger hospitals should maximize the rate of organ recovery. The performance of organ-procurement organizations can be assessed objectively through the comparison of the number of actual donors with the number of potential donors in the given service area.

Introduction: It is broadly understood and supported by previous studies that disruptive inefficiencies exist in the hospital to Organ Procurement Organization (OPO) donor referral process, including failure to notify the OPO and delayed referrals. Without a reliable and timely donor referral, life-saving organs cannot be procured and transplanted. A secure direct and automatic electronic donor referral interface was collaboratively developed and implemented to confront the issue of inefficient donor referrals by 1) eliminating the need for nurses to step away from patient care and place the phone call; and 2) automating the donor referral trigger with the goals of increasing referrals and donations while also reducing critical time spent by the hospital and OPO. Materials and Methods: The multi-disciplinary team collaborated to create a secure technical interface directly connecting the OPO and Hospital systems, as well as design seamless donor referral triggers within the Hospital EMR. These triggers automatically deliver electronic donor referrals from the Hospital to the OPO upon staff entry of pre-determined clinical data into the EMR, greatly reducing the need for donation knowledge and decision making by the hospital staff. The interface includes an additional manual trigger for staff to utilize in cases such as early family mention of donation and other exceptional situations. Upon receipt of the initial electronic referral, the OPO can quickly retrieve critical details for donation screening without pulling the hospital staff away from their critical duties of care. The above described interface has been successfully implemented in all 4 facilities in the hospital system. Results and Discussion: The interface has led to a significant increase in referrals and donations. Comparing the data from previous (2018) and following years (2019), during which time the only major process change at the hospital was the implementation of the electronic interface, there was a 49% increase in donor referrals (389 to 579) and a 333% increase in organ donors (3 to 13). Over the same period, over 190 hours of staff time were saved by the hospital and the OPO, regardless of the increase in referrals. There are several case studies of the OPO receiving an automatically triggered donor referral when the nurse was unable to connect on a phone call due to duties in a busy ICU. OPO staff were then able to retrieve the appropriate data directly from the EMR, allowing them to mobilize and ultimately recover organs and tissue which likely would have otherwise timed out. Conclusion: The results demonstrate increased efficiency in the donation referral process and project goals fulfillment by significant increase in referrals and donations as well as reduced burdens on both the Hospital and OPO through time savings. The initiative has been successful due to both the electronic interface and automating the donor referral trigger, leading to more donation and transplantation.

Over the decade between 2003 and 2012, the UK has seen major changes in how organ donation and transplantation is delivered. The number of deceased organ donors has increased from 709 (12.0 per million population [pmp]) to 1,164 (18.3 pmp); this increase has been predominantly a result of an increase in donors after circulatory death (DCD) (from 1.1 pmp to 7.9 pmp) while the numbers of donors after brain death (DBD) has remained broadly stable (around 10.5 pmp). The donor population has become older (from 14% 60 years or over to 35%) and heavier (from 14% with body mass index >=30 kg/m2 to 23%). Despite these changes in demographic factors, the number of organs retrieved from DBD donors has risen from a mean of 3.6 to 4.0 per donor and for DCD donors from 2.2 to 2.6. The number of transplants in adults in 2012 was 2,709 (967 DBD, 708 DCD, and 1,034 living) for kidney alone, 246 pancreas (including 172 kidney and pancreas), 792 (611 DBD, 142 DCD, 36 living, and 3 domino) for liver, 136 for heart only, and 179 (145 DBD and 34 DCD) for lung only. Median waiting times to transplant for adult patients were 1,167, 339, 141, 293, and 311 days, respectively. The proportion of adult non-urgent registrants in 2009 (2007 for kidneys) who were removed from the waiting list or died awaiting a graft within 1 year was 3% for kidneys, 6% for pancreas, 19% for liver, 27% for heart, and 24% for lung. Outcomes after solid organ transplants are improving; for adult patients grafted between 2003 and 2005, 5-year graft survival for kidney is 84% (DBD), 87% (DCD), and 92% (living donor), for simultaneous kidney and pancreas 72%, and for pancreas alone 50% (DBD). Five-year patient survival for liver is 77% (DBD) and 68% (DCD), heart 67%, and lung 52% (DBD). Although rates of organ donation and transplantation have increased in the UK, this has been almost solely because of a rise in DCD donation. Although donor age and weight is increasing, graft survival has generally improved. Despite a recent fall in the number of patients on the transplant waiting list, there remains a significant gap between the need for transplantation and the number of organs available from deceased and living donors. The implementation of a new strategy following the recommendations of the Organ Donation Task Force in 2008 has had a major impact in bringing together clinicians involved in both organ donation and transplantation, and these changes and clinical enthusiasm have been instrumental in achieving success. With an emphasis on the need to increase the family consent rate for organ donation, which has failed to show any improvement over the last 5 years, a new UK strategy for organ donation and transplantation, introduced in 2013, will further increase organ transplantation in the UK.

New organ allocation policy in liver transplantation in the United States.

Tissues from deceased donors provide important data for genomic research and Organ Procurement Organizations (OPOs) play a significant role. To understand the decisions of families who donated for transplantation and made decisions about donation to the Genotype-Tissue Expression Project (GTEx), we examined donation decisions of family decision makers (FDMs). 413 families were interviewed by telephone. The OPO staff who made the transplant and research requests completed self-administered surveys; a total of 309 matching surveys from 99 OPO staff were obtained. 76.8% of families donated to the GTEx project. Logistic regression analysis found that FDM consent to GTEx donation was associated with endorsement of policies to promote biobanking (OR=1.35), positive attitudes about medical research (OR=1.1), lack of concern regarding a breach of confidentiality (OR=1.54), comfort with tissue donation (OR=1.24), and prior authorization to solid organ donation (OR=3.17). OPO staff characteristics associated with GTEx donation included being female (OR=3.57), White (OR=4.97), comfort with hospital staff role in donation (OR=1.61), and number of topics discussed with families (OR=57.9). Donor type, FDM attitudes, OPO staff sociodemographics, OPO comfort with the GTEx authorization process, and intensity of discussing research-specific issues were significantly associated with GTEx donation decisions.