Objectives: Organ donor shortage is a worldwide problem, resulting in 10% to 30% mortality rates for patients on wait lists for organ transplant. For brain-dead patients in Iran, it is mandatory for intensive care unit patients with Glasgow Coma Scale below 5/15 to be reported to an organ procurement unit. However, this process has not been functioning effectively. Here, we present the effects of changing the strategies on detecting brain-dead cases on the organ donor pool.
Materials and Methods: From March 2015 to March 2016, we changed our strategy in active detection of brain-dead cases. Since March 2015, our newly established protocol for active detection of brain-dead cases includes the following changes: (1) instead of calling high-volume intensive care units 3 times per week, we switched to calling every day in the morning; (2) instead of calling low-volume intensive care units 1 time per week, we switched to calling 3 times per week; (3) we included intensive care units (cardiac and general), neurosurgery, and emergency departments, as well as nursing supervisor offices, in our call and visit lists; and (4) we increased visits to wards by our trained staff as inspectors.
Results: From March 2015 to March 2016, the number of reported suspected brain-dead cases has increased from 224 to 460 per year, with proven brain death increasing from 180 to 306 cases. The actual number of donors has also increased, from 116 to 165 donations (53% increase) over 1 year.
Conclusions: More proactive strategies have had significant effects on brain-dead detection, resulting in significantly increased donor pools and organ donations. In countries with low cooperation of hospital staff, more proactive engagement in detecting brain-dead cases is a good solution to prevent loss of potential organ donors, with a final result of decreasing wait list mortality.
Key words : Brain death, Organ procurement unit, Transplantation
Organ transplant is the final therapeutic solution of end-stage organ failure.1 Currently, patients in different countries in need of transplant of organs such as liver, kidney, heart, lung, pancreas, and tissues are first placed on wait lists; however, the demand for organs is always growing higher than the number of organ donations. For this reason in different centers, 10% to 30% of patients on wait lists die due to the lack of an organ for transplant.2,3 Although for organs such as the kidney, a significant number of transplants are performed with the use of living donors, for organs such as heart, lung, and liver, transplant is mainly dependent on organ donations from brain-dead donors. Brain dead means irreversible lack of function of whole brain and brainstem.4,5 Brain death detection is the first step toward organ donation. Only 4% of hospital deaths and 12% of intensive care unit (ICU) deaths are due to brain death, and 30% to 50% of brain-dead cases become actual organ donors.6 In some countries, organ donation is also performed after cardiac death.7,8 Currently in Iran, 27 000 people are on wait lists for kidney, liver, heart, lung, and pancreas transplant, and daily 10 to 12 people on transplant wait lists die due to lack of an organ for transplant.
In Iran, except for donations of kidneys from living donors and sometimes liver donations from parent to child, organ donation is normally possible from brain-dead donors and about 2700 such transplants are performed annually. There are 5 centers for heart transplants, 1 center for lung and heart and lung transplants, 7 centers for liver transplants, 29 centers for kidney transplants, and 1 center for pancreas and intestinal transplants. In total, there are 50 organ procurement units, with per million population in Iran being 10.3 in 2015 (see www.behdasht.gov.ir).
It seems that any effort to increase organ donation could help to prevent the death of patients on transplant wait lists. This study aimed to investigate the effects of a more active identification of brain-dead cases on the rate of organ donation. This study was conducted in the organ procurement unit of Shahid Beheshti University of Medical Sciences, which covers a population of 5 million in Tehran. Medical centers affiliated with the procurement unit include 344 ICU beds. In Iran, the method for obtaining consent for organ donation is the opt-in system.
Materials and Methods
Until March 2015, the identification of brain-dead cases in hospitals affiliated to organ procurement units of Shahid Beheshti University of Medical Sciences was conducted as follows: (1) phone calls 3 times per week to ICU centers with high patient turnover rates and trauma centers, (2) phone calls 1 to 2 times per week to ICU or health centers with low patient turnover rates, (3) overnight inspections 3 times per week at ICU and trauma centers with high patient turnover rates, and (4) inspections 1 time per week at ICU and medical centers with low patient turnover rates.
We began a more active method of identifying potential brain-dead donors from March 2015 to March 2016. The more active method was as follows: (1) daily phone calls and sometimes more than 1 call per day to ICUs, emergency departments, coronary care units (CCUs), and supervisors of medical centers and trauma centers with high patient turnover rates; (2) phone calls 3 times per week to ICUs, emergency departments, CCUs, and supervisors of medical center with low patient turnover rates; (3) night inspections (each night) at ICUs, CCUs, and emergency departments of medical centers with high patient turnover rates; and (4) night inspections 3 times per week at ICUs, CCUs, and emergency departments of medical centers with low patient turnover rates. Other changes included visiting the reported brain-dead cases by inspectors assigned to the hospital at all hours of the day and night. Finally, we compared results between the 2 periods: March 2014 to March 2015 versus March 2015 to March 2016.
In the year preceding the March 2015 strategy changes, the number of reported cases of brain death was 224; from March 2015 to March 2016, this number reached 460 (105% increase). The number of confirmed cases of brain death in the year preceding the March 2015 changes was 180 (80% of proposed cases); from March 2015 to March 2016, this number reached 306 (66% of proposed cases, 70% increase).
The number of cases transferred to the organ procurement unit in the year preceding the March 2015 changes was 125; in the year after the March 2015 protocol change, this number increased to 188. There were 127 male and 61 female patients with mean age of 45 years old (range, 17 mo to 70 y). The most common cause of brain death was cerebrovascular accident (89 patients, 47%); other causes were trauma (19%), brain hypoxia (17%), poisoning (9%), and brain tumor (7.5%) (Table 1).
In the year preceding the March 2015 change, the actual number of donors was 115 (51% of proposed cases), which then reached to 165 (35% of proposed cases) after March 2015, with a 53% increase over 1 year. Also, the overall satisfaction of families of donors increased from 75% to 90%, and the number of donated organs per each brain-dead case increased from 2.67 to 2.74 (Table 2).
In total, 118 cases of brain death were not transferred to the organ procurement unit due to the following reasons: 2 due to lack of access to family for obtaining consent, 31 due to lack of family consent, 71 because of the lack of suitable organs for donation, and 14 because of no suitable recipient (Table 3).
The first step in the process of organ donation from brain-dead cases is the identification of suspected cases of brain death. According to the law of the Ministry of Health and Medical Education of Iran, medical centers are obliged to notify cases with Glasgow Coma Scale less than 5 to relevant procurement units for subsequent follow-up (see www.behdasht.gov.ir). In Iran, brain-dead cases after identification and initial approval and following obtainment of consent are transferred to corresponding procurement units for final confirmation and retrieval of appropriate organs. Due to various reasons, including lack of familiarity and understanding of the need for early warning of brain death and the shortage of personnel in different wards for detecting brain-dead cases, it is not always possible to wait for notification from medical centers. Thus, to avoid missing a brain-dead case, a phone query system by organ procurement centers and night inspections by trained personnel from procurement units have been started so that organ procurement units can be notified of any cases of brain death in the hospitals affiliated to them as soon as possible. Certainly, when cases of brain death are detected sooner, the potential losses of suitable organs due to injuries caused by brain death and lack of proper care are reduced. This approach also provides more time to obtain consent before the patient is declared dead from brain death.
In this study, by changing the detection strategies of cases of brain death to a more active one with more calls and inspections, we witnessed a 103% increase in the detection of cases of brain death and a 53% increase in actual donations. In addition, consents from families increased from 75% to 90%. Although the ability to obtain a consent form are influenced by various factors, including cultural development of society on the issue of organ donation, an earlier detection of patients with brain death provides more time before losing a potential donor. In addition, the organ procurement personnel have more opportunities to convince families for donations. Moreover, when hospitals observe efforts of procurement unit members to identify patients with brain death and observe doctors from procurement units 24 hours per day at 7 days per week, they deal with the issue with greater understanding and cooperation. Indeed, instead of having a neutral role, these hospitals play as a catalyst and incentive for convincing families.
More active detection of cases through phone calls or inspections of medical centers not only directly caused a significant increase in the number of actual donors after brain death but also indirectly caused increases in the chances of obtaining consent forms from families and increased the quality and quantity of donated organs. In addition, the higher cooperation of medical centers facilitated the initial visits of suspected cases of brain death.
Volume : 15
Issue : 1
Pages : 60 - 62
DOI : 10.6002/ect.mesot2016.O42
From the Organ Procurement Unit, Lung Transplantation Research Center, Masih
Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran,
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Organ Procurement Unit, Lung Transplantation Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Phone: +98 21 2712 2103
Table 1. Demographic Characteristics
Table 2. Results of More Proactive Detection After 1 Year, From 2015 to 2016
Table 3. Reasons for 118 Brain-Dead Cases Not Transferred to OrganProcurement Units