Presenters Gudata Hinika MD California Hospital Medical Center Antonio Liu MD White Memorial Medical Center California Hospital Medical Center Breakout Session C Physician Champions Sharing Methods for Superior Donation Outcomes ID: 683148
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Moderator:Peter Gruen, MD, LAC + USC Medical CenterPresenters:Gudata Hinika, MD, California Hospital Medical CenterAntonio Liu, MD, White Memorial Medical Center / California Hospital Medical Center
Breakout Session
C:
Physician Champions: Sharing Methods for Superior Donation OutcomesSlide2Questions to Run On
What “best practices” presented today would improve the brain death declaration and the organ donation processes in your hospitals?What “best practices” presented today will you share with your physician colleagues?Slide3
Improving Family-Centered Care through Standardized Brain Death DiagnosisAntonio Liu, MDNeurologistSlide4Objectives
By the end of this presentation, the attendee will be able to:Identify “best practice” standards for brain death determination.Identify effective family-centered care for families facing a brain death diagnosisUnderstand cultural sensitivity surrounding brain death diagnosisSlide5What is Brain Death?
Neurologic determination of deathIrreversible loss of function of the brain and brainstemSpinal cord reflex does not countSlide6
Confounding PracticesThere is a need for standardization:Wide variance in brain death determination practicesIn large hospital, neurologists diagnosis 25 – 30 times /yearIn small hospitals, physicians diagnosis 0 – 3 times / year
Hospital Brain Death Policies may not proceduralize the clinical exam or documentation requirements
Physicians may not be confident to declare patients without detailed standards of practice
The public expects physicians to get “dead” rightSlide7Brain Death Legislation
National: Uniform Determination of Death ActApproved in 1981In cooperation with AMA, ABA, President’s Commission on Medical EthicsAdopted by most states
State:
California
Health and Safety Code, Section 7184
An
individual who has sustained either 1) irreversible cessation of
circulation
and respiration, or 2) irreversible cessation of all
functions of
the entire brain, including brainstem, is dead.
A determination
of
death
must be made in accordance with
accepted medical
standards.Slide8
American Academy of Neurology (AAN) Guidelines 2010 PrerequisitesAcute CNS catastropheExclusion of confounding factorsNo intoxication or poisoningCore Temp > 36C
Three
cardinal
findings
Coma
Lack
of brainstem
reflexes
Apnea . . . . . . .
not just another clinical testSlide9
American Academy of Neurology (AAN) Guidelines 2010 Ancillary TestingAngiographyEEGTranscranial doppler
Technetium 99 brain scan “hollow skull”
Somatosensory evoked
potentials
New AAN:
Ancillary
testing may take the place of apnea testing if it is inconclusive or it has to be aborted.Slide10Improved Brain Death Policies
Alleviate variance in brain death determination practicesImplement a Standard Brain Death NoteUpdate policies to reflect new AAN guidelinesProceduralize comprehensive clinical examSlide11
Integrate AAN Checklist to StandardizeBrain Death Diagnosis and Documentation Prerequisites (all must be checked):Coma, irreversible and cause knownNeuroimaging explains comaCNS depressant drug effect absentNo evidence of residual paralyticsAbsence of severe acid-base, electrolyte, edocrine abnormalityNormothermia
or mild hypothermia (core temp > 36 C)
Systolic blood pressure
>
100 mm Hg
No spontaneous respirationsSlide12
Integrate AAN Checklist to StandardizeBrain Death Diagnosis and Documentation Examination (all must be checked):Pupils nonreactive to bright lightCorneal reflex absentOculocephalic reflex absent (tested only if C-spine integrity ensured)Oculovestibular reflex absentNo facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint
Gag reflex absent
Cough reflex absent to tracheal suctioning
Absence of motor response to noxious stimuli in all four limbs (spinally mediated
relexes
are permissible) Slide13
Integrate AAN Checklist to StandardizeBrain Death Diagnosis and Documentation Apnea testing (all must be checked):Patient is hemodynamically stable.Ventilator adjusted to provide normocarbia (PaCO2 35 – 45 mm HG).Patient preoxygenated with a PEEP of 5 cm of water.Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with CPAP at 10cm H2O.
Disconnect ventilator.
Spontaneous respirations absent.
Arterial blood gas drawn at 8-10 minutes, patient reconnected to ventilator.
PCO2 > 60 mm Hg, or 20 mm Hg from normal baseline value.
OR:
Apnea test aborted.Slide14
Integrate AAN Checklist to StandardizeBrain Death Diagnosis and Documentation Ancillary testing (only one needs to be performed) (to be ordered only if clinical examination cannot be fully performed due to patient factors, or if apneas testing inconclusive or aborted):Cerebral angiogramHMPAO SPECTEEGTCDNormothermia or mild hypothermia (core temp > 36 C)Systolic blood pressure
>
100 mm Hg
No spontaneous respirations
Time of death (DD/MM/YY): _______ / ________ / ________
Name of physician and signature: _______________________Slide15
Sensitive family-centered careWho informs the family about grave prognosis?Who informs the family about the impending brain death examination? And the exam results? Who informs the family about the opportunity for organ and tissue donation?
When, and how, does the physician / hospital sensitively introduce OneLegacy to the family?Slide16Sensitive family-centered care
Preparing a family to meet with OneLegacy: “I am very sorry for your loss. We will give you some time alone to be together as a family, and if you have any questions, we will contact {nurse, social worker, chaplain} for you. Later, we will introduce someone specialized in End-of-Life decisions to support you and your family through the next steps.”Slide17
Sensitive family-centered care Timing is almost EVERYTHING! Family may need time between brain death discussion with physician and donation discussion with OneLegacy. Family acceptance of brain death diagnosis is necessary before introducing the discussion of organ donation.Slide18
Sensitive family-centered careAll donation discussions with family should be planned events. Who? Where? When? clearly customized for each family during hospital and OneLegacy care plan “huddle”.Avoid the perception of conflict of interest. Slide19
Cultural Diversity & Brain DeathCultural differences may influence acceptance of brain death:Western vs. Eastern philosophies of mind / body /spirit connectionComa vs. Brain Death: waiting for a miracleSocially or economically disenfranchised may not trust diagnosisResponding to cultural differences:
Show
and Tell - “seeing is believing”
Multiple family conferences to clarify
Balance sensitivity with definitivenessSlide20
SummaryUpdated AAN Guidelines can be incorporated into hospital policies to standardize brain death determination practices.Sensitive family-centered care requires coordinated efforts of the right experts to support the family at the right time.Physicians should be prepared to aid families from varied cultural backgrounds to best understand and accept the brain death diagnosis.Slide21Thank You
Contact:Antonio Liu, MD(323) 987-1362American Academy of Neurology (AAN)www.aan.comSlide22
Physician Champions: Sharing Best PracticesDr. Gudata HinikaChief of TraumaCalifornia Hospital Medical CenterSlide23
ObjectivesBy the end of this presentation, the attendee will be able to:1) Identify procedures and protocols for improving patient resuscitation in the ED.2) Understand the value of a having an active multi-disciplinary Donation Council with physician leadership.3) Identify specific strategies for improving hospital and OneLegacy partnerhip from referral to recovery.Slide24
California Hospital DemographicsTrauma Level II facility 316-bed acute care hospital Located in downtown Los AngelesServing primarily lower income and transient populationSlide25
CHMC Organ Donation Data 2008 2009 2010 CMS GoalOrgan Donors 4 10 16 Eligible Deaths 14 15 20
Total Organs Transplanted
13 27 57
OTPD
3.25 2.70
3.80
3.75
Conversion Rate
29% 67%
75%
75%
Timely Referrals
96% 96% 92%
100%
Effective Request
89% 64% 73%
100%Slide26
ED Protocol ED Level I, II, and Consultation ActivationLevel I: All key team members must respond, i.e.; (Blood Bank, Trauma Surgeon, Anesthesiologist, ED physicians, RNs, RTs, & Radiology)
Sign-in sheet upon staff arrival
Resuscitation measures
GOAL:
Patient receives multi-disciplinary resuscitationSlide27
ED Protocol Once resuscitation is achieved:Allows for immediate ED to OR timeICU maintains 1 available bed for TraumaSlide28
Donation CouncilCHMC established Donation Council 8/2010GOAL: Process ImprovementHigh Level Chair with physician influenceActive OneLegacy CoordinatorMulti-disciplinary – meets quarterlyReview all referrals/cases/timelinessChair holds Lead persons accountable for PISlide29
OneLegacy PartnershipEducation is key Nursing Competencies/AnnualsDepartment meetingsGrand Rounds Hospital knowledgeable on policies & processEarly Referral
for Imminent & Cardiac Death
Avoids missed/late referrals for organ and tissue
CMS mandate = Goal is 100% timelinessSlide30
RN ChampionsWhat is a Nurse Champion? A registered nurse (preferably not a charge nurse) formally recognized as an advisor on the donation process. Nurses, physicians, RT’s, OneLegacy coordinators, and hospital Administration consult the Nurse Champion, regarding referrals, general donation policy, protocol or practice. When does a facility need one? Anytime. Nurse Champions foster leadership and peer-to-peer interaction/education throughout the referral process. And the charge nurses and manager can rely on the Nurse Champions to help less experienced staff navigate the referral process effectively.Slide31
RN ChampionsCHMC has 4 Nurse Champions!! 3 day shift & 1 night shiftMultiple referrals in units at one time with several OL coordinators onsite, same physicians, etc. Champions help with overall organization and communication in real-time for staff, OneLegacy and families.Slide32
OneLegacy Partnership C O M M U N I C A T E! C O M M U N I C A T E! C O M
M
U N I C A T E!
Multiple huddles
(all teams w/OneLegacy involvement)
Involve your RN Champions early for assistance
Have OL Coordinator e-mail updates to all Donor Council members to keep updated on referrals/donors
Slide33
THANK YOU!Contact information
:
Dr
.
Gudata
Hinika
California
Hospital Medical Center
Gudata.Hinika@chw.edu
(323) 545-9288Slide34
QUESTIONSfor Dr. Liu & Dr. Hinika?Slide35Questions to Run On
What “best practices” presented today would improve the brain death declaration and the organ donation processes in your hospitals?What “best practices” presented today will you share with your physician colleagues?