POTENTIAL DONOR AUDIT

Thomas Gaskell Allen

Description

POTENTIAL DONOR AUDIT 36-MONTH SUMMARY REPORT 1 APRIL 2003 – 31 MARCH 2006 1 INTRODUCTION 1.1 Fully validated data from the Potential Donor Audit (PDA) covering the 36-month period from 1 April 2003 to 31 March 2006 are now available. The dataset used to obtain the results for this report comprises data for all audited patient deaths in UK Intensive Care Units (ICUs) over the period 1 April 2003 to 31 March 2006, as recorded on the National Transplant Database (NTxD). It is based on PDA forms received and validated by UK Transplant on or before 20 July 2006. This report summarises the main findings of the PDA over the 36-month period. 1.2 UK Transplant were still receiving completed PDA forms for the period from January to March 2006 at the time of analysis and so the results summarised in this report are subject to change. 2 DEFINITIONS 2.1 The majority of this report refers to potential heartbeating (HB) donors, defined as patients for whom death was diagnosed following brain stem tests and who had no absolute medical contraindications to HB solid organ donation. 2.2 Section 9 refers to potential non-heartbeating (NHB) donors, defined as patients for whom NHB donation was possible and active treatment was withdrawn. 3 BREAKDOWN OF AUDITED DEATHS IN ICUs 3.1 In the 36-month period from 1 April 2003 to 31 March 2006 there were a total of 69,826 audited patient deaths in UK ICUs. A detailed breakdown from the number of ...

Informations

• Publié par: Inyo
• Nombre de lectures: 49
• Langue: English

Extrait

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POTENTIAL DONOR AUDIT 36-MONTH SUMMARY REPORT 1 APRIL 2003 – 31 MARCH 2006

INTRODUCTION

Fully validated data from the Potential Donor Audit (PDA) covering the 36-month period from 1 April 2003 to 31 March 2006 are now available. The dataset used to obtain the results for this report comprises data for all audited patient deaths in UK Intensive Care Units (ICUs) over the period 1 April 2003 to 31 March 2006, as recorded on the National Transplant Database (NTxD). It is based on PDA forms received and validated by UK Transplant on or before 20 July 2006. This report summarises the main findings of the PDA over the 36-month period.

UK Transplant were still receiving completed PDA forms for the period from January to March 2006 at the time of analysis and so the results summarised in this report are subject to change.

DEFINITIONS

The majority of this report refers to potential heartbeating (HB) donors, defined as patients for whom death was diagnosed following brain stem tests and who had no absolute medical contraindications to HB solid organ donation.

Section 9 refers to potential non-heartbeating (NHB) donors, defined as patients for whom NHB donation was possible and active treatment was withdrawn.

BREAKDOWN OF AUDITED DEATHS IN ICUs

In the 36-month period from 1 April 2003 to 31 March 2006 there were a total of 69,826 audited patient deaths in UK ICUs. A detailed breakdown from the number of audited patient deaths to the number of HB solid organ donors is given in Figure 1 and Table 1 summarises the key percentages by financial year.

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Figure 1

A breakdown from audited patient deaths to HB donors

Audited patient deaths (n=69,826)

Was the patient ever on mechanical ventilation?

Yes (n=63,554)

No (n=6,272)

Was brain stem death a likely diagnosis?

Yes (n=5,933)

No (n=57,621)

Were brain stem tests performed?

Yes (n=4,156)

No (n=1,777)

Was death diagnosed after brain stem tests?

Yes (n=4,016)

No (n=140)

Were there any absolute medical contraindications to HB solid 1 organ donation?

Yes (n=26)

No (n=3,990)

Was the subject of HB donation considered?

Yes (n=3,607)

No (n=383)

2 Were the next of kin approached for permission?

Yes (n=3,397)

No (n=210)

Was consent for HB donation given?

Yes (n=2,030)

No (n=1,367)

Did HB solid organ donation occur?

Yes (n=1,827)

1 Either known or suspected CJD or known HIV 2 Includes cases where the next of kin made the approach

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No (n=203)

Table 1 Summary of key percentages from ventilated patients to HB donors 2003/2004 2004/2005 2005/2006 TOTAL  N N N N Patients on mechanical ventilation at some 20,888 21,989 20,677 63,554 point during their stay in ICU Brain stem death possible 2,166 2,016 1,751 5,933 Brain stem death tested (percentage of brain 1,447 (67%) 1,418 (70%) 1,291 (74%) 4,156 (70%) stem death possible patients) Potential HB donors 1,392 1,356 1,242 3,990 No record of discussion/approach regarding 201 (14%) 223 (16%) 169 (14%) 593 (15%) HB solid organ donation (percentage of potential donor families) Consent given for HB solid organ donation 695 (58%) 685 (60%) 650 (61%) 2,030 (60%) (percentage of families who were approached) Consent not given for HB solid organ 496 (42%) 448 (40%) 423 (39%) 1,367 (40%) donation (percentage of families who were approached) Actual HB solid organ donors, based on data 625 (90%) 620 (91%) 582 (90%) 1,827 (90%) provided through the PDA (percentage of patients with family consent) 4 OVERALL HB REFUSAL RATE 4.1 Refusal rate is based on potential donors, for whom HB solid organ donation was considered and the next of kin were approached for permission (or made the approach). The refusal rate is the proportion of these families who did not consent to HB solid organ donation. 4.2 During the 36-month period, the overall refusal rate was 40% and the 95% confidence limits for this percentage range from 38% to 42%. 4.3 The number of refusals (n=1,367, 40% of 3,397) includes families who did not give their consent to solid organ donation because their loved one had stated in the past that he/she did not wish to be a donor. By excluding the 206 patients who had told their families in the past that they did not wish to be a donor, and this was given as a reason for non-consent, the overallrelativerefusal rate was 36%. The remainder of this report includes these 206 patients in the calculation of the refusal rate.

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5 MONTHLY VARIATION IN THE HB REFUSAL RATE 5.1 Monthly refusal rates are shown in Figure 2. From this figure it is apparent that over the 36-month period there is no clear monthly pattern. This figure also shows that the refusal rate was highest in April 2003 (56%) and lowest in April 2005 (25%). The differences in the monthly refusal rates from 1 April 2003 to 31 March 2006 are statistically significant (p=0.03) and remain so (p=0.02) after taking account of differences in the refusal rate due to monthly variation in all the considered demographic variables (ie age, sex and ethnicity of potential donors). Figure 2 Month-to-month variation in HB refusal rate 60 56 Refusal rate Overall refusal rate

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EFFECT OF DEMOGRAPHIC VARIABLES ON THE HB REFUSAL RATE

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The refusal rates for males and females (for the 3,392 potential donors out of 3,397 for whom sex was recorded) were both 40%.

Age is represented by a categorical variable with intervals 0 – 17, 18 – 24, 25 – 34, 35 – 49, 50 – 59 and 60+ years. The refusal rates for the six age groups (for the 3,395 potential donors out of 3,397 for whom age was recorded) are illustrated in Figure 3. The highest refusal rate occurred in the 0 – 17 and 25 – 34 year-old age groups (44%). The lowest refusal rate occurred for potential donors between 18 and 24 years of age and for potential donors aged 60 plus years (39%). The differences between the six refusal rates are not statistically significant (p=0.5).

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Figure 3 50

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Age variation in HB refusal rate

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Overall refusal rate

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0 0 - 17 18 - 24 25 - 34 35 - 49 50 - 59 60+ Age group (years) To conduct a meaningful analysis, ethnicity has been split into white and known non- white groups. The refusal rates (for the 3,201 potential donors out of 3,397 for whom ethnicity was recorded) were 35% for white potential donors and 70% for known non- white potential donors. The 95% confidence limits for these two refusal rates range from 33% to 37% for white potential donors and 64% to 76% for known non-white potential donors.

There is very strong statistical evidence (p<0.001) of a difference between the refusal rates for white and known non-white potential donors and the ethnicity effect remains highly significant after allowing for age, sex and temporal effects.

OVERALL HB RELATIVE APPROACH RATE

Relative approach rate is based on potential donors for whom HB solid organ donation was considered. The approach rate is the proportion of this group of potential donors whose relatives were approached for permission for donation, or whose relatives made the approach.

During the 36-month period from 1 April 2003 to 31 March 2006, the overall approach rate was 94% and the 95% confidence limits for this percentage range from 93% to 95%.

DONOR TRANSPLANT COORDINATOR TEAM

Table 2 shows the number of potential HB donors, the referral and the conversion rate by donor transplant coordinator (DTxC) team. The referral rate is the percentage of potential donors referred to a coordinator, and the conversion rate is the percentage of potential donors who became actual HB donors. The referral rates range from 44% in Liverpool to 72% in East of Scotland and the conversion rates range from 37% in North Thames to 63% in Portsmouth. There is a significant difference in both the referral and conversion rates between the DTxC teams, p<0.001 and p<0.001, respectively. After risk adjusting the referral and conversion rates for patient age, sex and ethnicity and temporal effects there are no significant differences between the teams.

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Table 2

Table 3

Number of potential HB donors and the referral and conversion rates

Donor transplant coordinator team Belfast Bristol Cambridge Cardiff East of Scotland Leeds Leicester Liverpool Manchester Newcastle North of Scotland North Thames Nottingham Oxford Plymouth Portsmouth Sheffield South Thames est Midlands est of Scotland

176 99 128 198 87 214 75 278 327 266 43 575 96 171 90 102 122 456 351 136

92 62 75 99 63 143 48 122 174 151 24 330 55 104 47 61 78 273 221 65

(52%) (63%) (59%) (50%) (72%) (67%) (64%) (44%) (53%) (57%) (56%) (57%) (57%) (61%) (52%) (60%) (64%) (60%) (63%) (48%)

76 56 65 102 49 102 34 118 143 115 21 214 45 89 47 64 56 196 165 70

Number of families approached and the refusal rate

Donor transplant coordinator team Belfast Bristol Cambridge Cardiff East of Scotland Leeds Leicester Liverpool Manchester Newcastle North of Scotland North Thames Nottingham Oxford Plymouth Portsmouth Sheffield South Thames est Midlands est of Scotland

176 99 128 198 87 214 75 278 327 266 43 575 96 171 90 102 122 456 351 136

149 88 117 169 76 185 60 227 277 225 39 480 81 151 83 86 109 369 317 109

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67 28 46 56 24 76 23 90 104 97 14 243 33 57 27 16 48 145 138 35

(45%) (32%) (39%) (33%) (32%) (41%) (38%) (40%) (38%) (43%) (36%) (51%) (41%) (38%) (33%) (19%) (44%) (39%) (44%) (32%)

(43%) (57%) (51%) (52%) (56%) (48%) (45%) (42%) (44%) (43%) (49%) (37%) (47%) (52%) (52%) (63%) (46%) (43%) (47%) (51%)

42% 39% 37% 29% 40% 41% 37% 41% 40% 41% 41% 41% 41% 39% 40% 29% 43% 40% 41% 40%

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The number of potential donors whose family were approached for consent to donation and the number who refused consent are shown in Table 3, by DTxC team. The unadjusted refusal rates range from 19% in Portsmouth to 51% in North Thames and there is a significant difference across the teams, p<0.001. Risk adjusting the refusal rate for patient age, sex and ethnicity and temporal effects takes account of most of the variation, but there are still some differences between the teams, mainly due to two teams having a lower refusal rate than nationally.

POTENTIAL FOR NON-HEARTBEATING DONATION

The potential for non-heartbeating donation could be obtained from the PDA forms from January 2004 onwards. The following results comprise data for all audited patient deaths in UK ICUs over the period 1 January 2004 to 31 March 2006. Some of the subgroup analyses are based on relatively small numbers of individuals and as a consequence some of the percentages quoted suffer from a lack of precision and should be regarded with some caution.

In this 27-month period there were a total of 52,978 audited patient deaths in UK ICUs. A detailed breakdown of the 52,978 audited patient deaths is given in Figure 4, and Table ummarises the key percentages by financial year.

4 s Figure 4

A breakdown from audited patient deaths to NHB donors

Audited patient deaths (n=52,978)

Was the patient ever on mechanical ventilation?

Yes (n=48,160)

No (n=4,818)

Was nonheartbeating donation possible?

Yes (n=4,139)

No (n=44,021)

Was active treatment withdrawn?

Yes (n=2,409)

No (n=1,730)

Was the subject of NHB donation considered?

Yes (n=586)

No (n=1,823)

1 Were the next of kin approached for permission?

Yes (n=518)

No (n=68)

Was consent for NHB donation given?

Yes (n=283)

No (n=235)

Did NHB solid organ donation occur?

Yes (n=167)

1 Includes cases where the next of kin made the approach

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No (n=116)

Table 4 Summary of key percentages from ventilated patients to NHB donors 2005/2006 TOTALJan-Mar 2004/2005 2004  N N N N Patients on mechanical ventilation at some 5,494 21,989 20,677 48,160 point during their stay in ICU NHB donation possible 455 2,076 1,608 4,139 Potential NHB donors - active treatment 307 (67%) 1,251 (70%) 851 (53%) 2,409 (58%) withdrawn (percentage of NHB donation possible) No record of discussion/approach regarding 264 (86%) 1,030 (82%) 597 (70%) 1,891 (78%) NHB solid organ donation (percentage of potential donor families) Consent given for NHB solid organ donation 27 (63%) 105 (48%) 151 (59%) 283 (55%) (percentage of families who were approached) Consent not given for NHB solid organ 16 (37%) 116 (52%) 103 (41%) 235 (45%) donation (percentage of families who were approached) Actual NHB solid organ donors, based on 19 (70%) 60 (57%) 88 (58%) 167 (59%) data provided through the PDA (percentage of patients with family consent) 9.3 The overall refusal rate for 518 potential NHB donors whose families were approached or made the approach during the 27-month period was 45% and the 95% confidence limits for this percentage range from 41% to 49%. Note that these limits are wider than those for the refusal rate for HB donors. 9.4 When looking at the month-to-month variation, the refusal rate was highest in October 2004 (67%) and lowest in July 2005 (25%). This can be seen in Figure 5. The differences in the monthly NHB refusal rates over the 27-month period were not statistically significant (p=0.4).

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0 - 17 18 - 24 25 - 34 35 - 49 50 - 59 60+ Age group (years) Ethnicity information was available for 456 (88%) of the 518 potential NHB donors whose families were approached for consent. Of these potential donors, with known ethnicity, 24 were non-white and in 19 (79%) of these cases consent for donation was not given. The refusal rate for white patients was 39%, with a 95% confidence interval of 34% to 44%. There is evidence to suggest differences in the refusal rate between white and non-white patients, but the number of non-white patients analysed is very small.

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Refusal rate

0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2004 2005 2006 Month 9.5 The refusal rates for males and females were 43% and 49%, respectively, with no statistically significant difference between them (p=0.2). There was also no significant difference in the refusal rate between the six age groups 0 - 17, 18 - 24, 25 - 34, 35 - 49, 50 - 59 and 60+ (p=0.3). The refusal rates for these age groups are shown in Figure 6. Figure 6 Age variation in NHB refusal rate

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Overall refusal rate

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Month-to-month variation in NHB refusal rate

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10 SUMMARY 10.1 In the 36-month period, 1 April 2003 to 31 March 2006, there were 3,990 potential HB donors. The overall HB refusal rate, for the 3,397 patients whose relatives were approached or made the approach for consent to donation, was 40%, although there is evidence of variation in this rate over the time period analysed. There is also a clear difference in the refusal rates for white and non-white potential HB donors, but no differences related to sex or age group. The overall HB approach rate was 94%. 10.2 There are significant differences in the referral, conversion and refusal rates for HB donation across the donor transplant coordinator teams. Risk adjusting the refusal rate for patient age, sex and ethnicity and temporal effects takes account of most of the variation, but there are still some differences across the teams, mainly due to two teams having a lower refusal rate than nationally. 10.3 In the 27-month period, 1 January 2004 to 31 March 2006, there were 2,409 potential NHB donors. The overall NHB refusal rate, for the 518 patients whose relatives were approached or made the approach for consent to donation, was 45%. There was no statistical evidence of variation in this rate over the time period analysed. There was also no significant difference in the refusal rate between males and females or across the age groups. There was evidence of differences in the refusal rate between white and non- white patients, although the numbers used in the analysis were small. Miss Claire Hamilton, Mrs Joanne Blackwell and Dr Dave Collett UK Transplant  September 2006

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