Continuously Evaluating Performance in Deceased Donation: The Spanish Quality Assurance Program

Abstract

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

How Spain Reached 40 Deceased Organ Donors per Million Population

“…External audits of procurement hospitals in Spain have revealed that 25% of persons in a brain-dead condition are not considered medically suitable organ donors, although some of these medical contraindications are inappropriately established by the donor coordinator or the treating physician (10). While safety of the process is an unquestionable professional standard, an evidence-based analysis of the risks should guide decisions on donor selection at a moment of organ shortage.…”

“…The decrease in the occurrence of events potentially leading to devastating brain injuries as a result of transport and work safety measures, along with improvements in the treatment of neurocritical patients, explain such a decrease in mortality. The extended use of decompressive craniectomies and other neurosurgical interventions has also contributed to a progressive decline in the incidence of brain death, which has evolved from 65 cases pmp in 2001 to <50 pmp during the past years (10).…”

Brain death diagnosis in adult for potential cadaveric organ donation in Bangladesh

“…One study done in Spain comparing ICU with neurosurgery services and ICU without neurosurgery service, showed rate of brain death to be 8% and 13% among all deaths respectively. 24 Another study done in Portugal, showed hospitals with neuro-critical care units having 33% brain death among total number of deaths.…”

Brain death organ donation potential and life support therapy limitation in neurocritical patients

“…15 A real donor was defined as a BD donor entering the operating room and from whom at least one organ was harvested for transplantation. 4,5,16 The BD potential in turn was defined as the proportion of cases diagnosed with BD among the total patients admitted to hospital with GCS < 8.…”

“…3 Brain death has been estimated to represent 2.3% of all in-hospital fatalities and 12.4% of all deaths in the Intensive Care Unit (ICU). 4 Although these indicators are based on retrospective analyses of deaths occurring in critical care settings, they serve as a reference for calculating donation potential in our centers. The quality assurance program of the Spanish National Transplant Organization (Organización Nacional de Trasplantes, ONT), designed to determine the donation potential of critical care units (based on internal and external audits that evaluate the ultimate circumstances in which patients die in such units), retrospectively identifies the ''losses'' of potential donors not identified by the transplant coordinators in real time, and helps to define areas for improvement in the audited hospitals.…”