1. Strategies to increase the number of cadaveric donors
Introducing the concept of
in house coordination
Prof. Dr. Günter Kirste

2. Critical pathways for organ donation*
POSSIBLE DECEASED ORGAN DONOR
A patient with a devastating brain injury or lesion OR a patient with circulatory failure
AND apparently medically suitable for organ donation
Donation after Circulatory Death (DCD) Treating physician
to identify/refer a potential donor Donation after BrainDeath (DBD)
POTENTIAL DCD DONOR POTENTIAL DBD DONOR
A. A person whose circulatory and respiratory Reasons why a potential donor A person whose clinical condition is suspected to
functions have ceased and resuscitative does not become a utilized donor fulfill brain death criteria.
measures are not to be attempted or continued.
System
or
• Failure to identify/refer a potential or eligible donor
B. A person in whom the cessation of circulatory
• Brain death diagnosis could not be confirmed
and respiratory functions is anticipated to occur
within a time frame that will enable organ (e.g. does not fulfill criteria) or completed
recovery. (e.g. lack of technical resources or clinician
to make diagnosis or perform confirmatory tests)
• Circulatory death not declared within the appropriate
time frame. ELIGIBLE DBD DONOR
ELIGIBLE DCD DONOR • Logistical problems (e.g. no recovery team)
A medically suitable person who has been A medically suitable person who has been
• Lack of appropriate recipient (e.g. child, blood
declared dead based on the irreversible absence declared dead based on neurologic criteria as
type, serology positive)
of circulatory and respiratory functions as stipulated by the law of the relevant jurisdiction.
stipulated by the law of the relevant Donor/Organ
jurisdiction, within a time frame that enables • Medical unsuitability (e.g. serology positive, neoplasia)
organ recovery. • Haemodynamic instability / unanticipated cardiac
arrest ACTUAL DBD DONOR
ACTUAL DCD DONOR
• Anatomical, histological and/or functional A consented eligible donor:
A consented eligible donor: abnormalities of organs A. In whom an operative incision was made
A. In whom an operative incision was made • Organs damaged during recovery with the intent of organ recovery for the
with the intent of organ recovery for the
• Inadequate perfusion of organs or thrombosis purpose of transplantation.
purpose of transplantation.
Permission and/or
and/or
B. From whom at least one organ was
B. From whom at least one organ was • Expressed intent of deceased not to be donor
recovered for the purpose of transplantation.
recovered for the purpose of transplantation. • Relative’s refusal of permission for organ donation
• Refusal by coroner or other judicial officer to allow
donation for forensic reasons UTILIZED DBD DONOR
UTILIZED DCD DONOR
An actual donor from whom at least one organ
An actual donor from whom at least one organ
was transplanted.
was transplanted.
*The “dead donor rule” must be respected. That is, patients may only become donors after death, and the recovery of organs must not cause a donor’s death .

3. In house coordination
DSO finances a pilot project for in-house-coordination
in university hospitals and hospitals with neurosurgical ICU’s
Basic Principles of the Spanish Model
•Adequate legal and technical background
--------------------------------------------------------------
•Transplant coordination network
•Special profile of the three levels of TC
•Hospital coordinators inside the hospitals
•Central Office: ONT - Support Agency
•Continuous brain death audit
•Hospital reimbursement
•Great effort in medical training
•Much attention to the mass media

4. In house coordination
Pilot project in adaption of the „Spanish Model“
Target Hopitals:
University Hopitals
Hospitals with neurosurgical ICU
In-house-coordination includes:
 Analysis of donor potential (quarterly evaluation)
 Identification of possible donors
DSO
 Development and Implemantation of Standard
Operating Procedures (SOP)
Hospital  Training of hospital staff
In-house-coordination is done by:
100 %
 ICU-physicians

5. In house coordination in detail:
Profil:
 Target hospitals appoint physicians on ICU in charge of in-house-
coordination
 Appointed physicians must proof special knowledge in organ donation (e.g.
Curriculum for organ donation for key donation figures ” developed by DSO
in cooperation with the German Medical Association)
Reporting:
 Hospital reports quarterly about performance of in-house-coordination.
Hospital-reimbursement:
 800 € for the task of in-house-coordination for the hospital that ensures that
this money benefits the physicians in charge

6. SOP (Standard Operation Procedure)
Development and Implemantation of Standard Operating Procedures (SOP) together
with DSO Coordinators and inclusion of contact persons from the hospital
1
2
3
4
5

7. Analyse-Tool „Transplant – Check“
Screenshot for installation
Bildschirm zur Aktualisierung der Filterdateien

8. „Transplant-Check“ – Filtered Data
List of all cases with:
1. Reason for release =
Death
and
2. ICD 10-Codes that
possibly lead to brain
death
Contradindications for
donation are highlighted
= relative CI
= absolute CI

9. Response rate
KH KH
n %
Projektkrankenhäuser insgesamt 112 100%
Rücklauf 1. Krankenhausbefragung 102 91,1%
Rücklauf 2. Krankenhausbefragung 90 80,4%
Rücklauf 1. Quartalsbericht 110 98,2%
Rücklauf 2. Quartalsbericht 111 99,1%
Rücklauf 3. Quartalsbericht 108 96,4%
Rücklauf 4. Quartalsbericht 102 91,1%

10. In house coordination in organ donation
Development of donor data 1.Quarter2010 – 2.Quarter 2011
Start of
the
project
© Deutsches Krankenhausinstitut 10

11. In house coordination in organ donation
Analysis of potential for 4 quarters
Fälle absolut Fälle %
2/2010 – 1/2011 2/2010 – 1/2011
Anzahl Quartalsberichte 392 392
Todesfälle mit primärer/sekundärer Hirnschädigung (n) 11.029 11.029
- Todesfälle mit primärer/sekundärer Hirnschädigung (%) - 100%
Ausgeschlossene Fälle 7.350 66,6%
- Fälle mit absoluten Kontraindikationen 1.395 12,6%
- Fälle mit einer Beatmungszeit von 0 h 3.406 30,9%
- Fälle mit Meldung an DSO 2.549 23,1%
Fälle im strukturierten Dialog 3.679 33,4%
- Fälle mit eingeleiteter Hirntoddiagnostik 347 3,1%
Fälle mit festgestelltem Hirntod 199 1,8%
Fälle mit abgebrochener Hirntoddiagnostik 148 1,3%
- Fälle ohne eingeleitete Hirntoddiagnostik 3.332 30,2%
Fälle mit Klärung der Hirntoddiagnostik nicht sinnvoll 3.202 28,1%
Fälle mit Klärung der Hirntoddiagnostik strittig 41 0,4%
Fälle mit Klärung der Hirntoddiagnostik sinnvoll 189 1,7%
© Deutsches Krankenhausinstitut 11

12. In house coordination in organ donation
Target Achievment
• High Target Achievement
 E.g. implementaion of SOP, PDCA-
Zyklus, trainings, support of executives, increas of
awareness of ICU-Personell, Analysis of donor
potential
• Mediocre Target Achievement
 E.g. nomination of physician in charge (TXB), dialog
beetween hospital and DSO- Koordinator about
Patients with suspicion of brain death
© Deutsches Krankenhausinstitut 12

13. In house coordination in organ donation
Problems regarding additional donor potential
• Problems in hospital (z.B. lack of ICU-beds; lack of
personnel and frequent changes, high work load on ICU)
• Patients provisions and refusal of intensive care
treatment by relatives prior to brain death diagnosis
• Limitation in therapymeasurments respectivly priority
on palliativ measurements
© Deutsches Krankenhausinstitut 13

14. Future of the project
 Continuing of the project
 Position of the project established in the
new German Transplant Act
 Under discussion till end of the year