CONTINUOUS IMPROVEMENT IN ORGAN DONATION

Abstract

Nowadays, transplanting organs is a normal and regular activity in our hospitals. The number of possible transplants rises steadily, increasing the already strong pressures facing staff. The organ procurement system developed in Spain over the last few years and described previously (1, 2) is based on a decentralized network of specifically trained transplant coordinators (most of them physicians and belonging to the intensive care units) comprising three levels: national, regional, and local (i.e., hospital), with organ procurement as the main goal. Thus, a transplant coordinator is present in each hospital with an intensive care unit and is responsible for the whole process, from donor detection to organ and tissue retrieval. This approach has proved to be successful in overcoming obstacles, such as untrained or inadequately trained staff dedicated to organ procurement, failure to identify donors, or reluctance to approach grieving families, and has led to an important increase in organ donation. Since 1990, the cadaveric donor rate has increased by 75% and the number of available organs has doubled. Greater experience and improved results have lead to a substantial change in the characteristics of both donors and donating hospitals. We have tried to analyze all these changes and their possible social, medical, and economical implications. Since 1990, when the basic human infrastructure was developed to identify potential donors and obtain organs, the number of donors has risen progressively (Fig. 1), and an additional 10% increase was observed during the first 6 months of 1995. Not only did the number of donors increase considerably, but the number of organs retrieved increased as well (Fig. 2). The percentage of multiorgan retrieval soared from 30% in 1989 to 77% in 1994, enabling a 2-fold rise of possible solid organ transplants. We have observed some variations in the characteristics of these organ donors. The average age has been increasing each year, making a difference of more than 5 years between 1992 and 1994 (34.5±17 to 39.6±18 years). More than 20% of our current donors are over 60 years old. Although classically the most frequent source of potential donors was the cranial trauma patients, Spain has recently seen a reversal in the percentages of death caused by trauma and by cerebrovascular accidents among organ donors. In 1992, 52% of deaths were caused by cranial trauma (43% road traffic trauma and 9% other traumas) and 39% were caused by an acute cerebrovascular accident. In 1994, those figures were 37% and 53%, respectively; moreover, only 27% of all donors died due to road traffic accidents. These changes are directly related to the 40% decrease in fatal road traffic accidents since the enactment of a new road security law in July 1992. In spite of this drop, no parallel decrease in donation rates was noticed. On the contrary, donor rates continue to rise. Family refusal rates decreased slightly from 27.6% of all interviews in 1992 to 23.6% in 1994, with a wide range between regions (10-40%). There are 112 hospitals in which organ procurement is allowed and from which at least one effective donor has been reported to the donor registry since 1990. Among these hospitals, 32 have transplant and neurosurgery units (type I hospitals), 30 have a neurosurgery unit but no transplant unit (type II), and 50 have neither a neurosurgery nor a transplant unit (type III). Table 1 shows the annual average of donors in each type of hospitals. The average index (donors × 100 hospital beds in each type of hospital) is summarized in Table 2. Type I hospitals account for the largest number of donors, but the percentage increase observed was higher in the other types of hospitals: 100% and 300% vs. 50%. In 1989, 24.7% of all donors were provided by hospitals without a transplant unit. This percentage increased to 31.6% in 1994 (P<0.05) (136 vs. 303 donors). The overall budget for the network dedicated to organ procurement each year is $6,400,000. This figure includes salaries, the administrative budget, and training courses. Following a dialysis and renal transplant cost study performed in the Basque country (3), we can estimate that the 10,000 renal transplant recipients now living in Spain with a functioning kidney graft represent an approximate savings of $207,000,000 each year. If the annual number of kidney transplants performed in Spain had continued as in 1989 around 1000, the estimated savings would be considerably less. The transplants, surpassing 1000 grafts per year (average number of kidney grafts during 1987, 1988, and 1989) since 1990, have saved during those years approximately $50,000,000 of the overall renal replacement therapy budget. The estimation of other benefits following other types of solid organ or tissue transplants still remains much more difficult to evaluate. Organ donation rates have increased substantially since the development of a network of trained health professionals. This 75% increase from 14 to 25 donors pmp has been followed by the consequent rise in transplantation activity-from 27 cadaveric kidney grafts in 1989 to 42 cadaveric kidney grafts pmp in 1994, and from 4.4 liver transplants pmp in 1989 to 16 liver transplants pmp in 1994. The evolution has differed among the Spanish regions but the general trend has been an improvement in all regions. In some Spanish regions, such as the Canary Islands, the donor rate (42.4 donors pmp) is probably the highest rate ever achieved in the world and could be considered as a standard potential donor rate and not a real donor rate (4). The change observed in the donor characteristics is the consequence of the fortunate decrease observed in the number of fatal road accidents (5) coupled with an increase in the identification of potential donors. Nevertheless, we are still far from the theoretical maximum donor capacity that was estimated in a study performed in Basque country. The study showed a potential of 53 donors pmp, assuming that all donors are identified and no cardiac arrest or family refusals occur (6). Analysis of the donor's characteristics is of basic importance because we have to be very careful about possible influences of these changing factors on the graft's function. At the same time, efforts should be made to ensure that no potentially usable organs are unnecessarily discarded (7). We will certainly have to pay great attention to donor and organ management, ischemic times, effects of drugs, etc., and it is obvious that extra care must be taken when using organs from so-called “marginal” donors (8). All types of hospitals have contributed to the improvement in organ donation rates. Obviously the largest hospitals with transplant units account for the greatest number of donors, but it is important to note how small hospitals with or without neurosurgery units have improved their performance with a 2-fold increase in the number of non-transplant-hospital donors. It is also important to note that the index of donation/100 hospital beds is within the range of the estimated theoretical capacity of donation in type II and III hospitals (1.3-2.2 and 0.3-0.7, respectively) but not in type I hospitals, which are below this theoretical capacity (3-4 donors/100 hospital beds) (9). The amount of money saved during this 5-year period with only an extra 1000 renal transplants each year could cover eight organ procurement organizations like the Organización Nacional de Trasplantes. However, we also must take into account that this network is maintaining the basic 1000 annual kidney grafts. Other economical benefits, such as those derived from tissue procurement, have not been included in the estimated costs, and social and professional benefits cannot easily be estimated. Spain has made a lot of progress in organ donation during the last few years, but more must be achieved. The organ coordinating network has been able to identify more and more donors in all types of hospitals, demonstrating the network's efficiency on the basis of a favorable cost effectiveness analysis. It has also been essential to the provision of data for the overall analysis of the organ donation process in the state or the circumstantial evaluation of problems in each region or hospital. Continual evaluation of such data provides us with the means to find appropriate solutions. Keeping records of all potential donors and cerebral deaths should enable us to find out when and how donors are lost, and to define when and where efforts are needed. If we succeed in this, Spanish people will continue to benefit from a secure and confident transplantation service. Integrated ways to improve organ donation developed in Spain since 1990 have been successfully and significantly increasing the cadaveric donor rate (from 14.3 donors pmp in 1989 to 25 donors pmp in 1994) and the number of available organs (from 1440 in 1989 to 3025 in 1994). This obviously has led to an important increase in the number of transplants with the consequent social, medical, and economical benefits. Characteristics of both donors and donating hospitals have changed substantially. Average donor age rose more than 5 years and the percentage of traffic road accidents as a cause of brain death fell from 43% to 27%. Organ donation has improved in all kinds of hospitals, being proportionally more important in the small hospitals with no transplant unit, demonstrating the efficacy of the national network of transplant coordinators as a whole, which is based on a favorable cost effectiveness analysis. Note added in proof. A final 8% increase in the organ donor rate has been observed during 1995, resulting in 1038 donors: 27 donors pmp.Figure 1: Organ donor evolution in Spain from 1989 to 1994.Figure 2: Organs retrieved for transplantation in Spain from 1989 to 1994.