The ICU Death Audit 25 November 2014 James Judson Medical Specialist Organ Donation New Zealand The ODNZ ICU Death Audit • Established end of 2007 • Approved by Ministry of Health • Approved by National Ethics Committee • Stringent requirements for confidentiality of data • To study the relationship between ICU death & organ donation in the whole country How the ODNZ ICU Death Audit works • Data are collected on all ICU deaths in NZ • Entered securely online by Link nurse(s) of each ICU • Stored securely in a server, hosted by Enigma • Data good but not perfect – some missing, incomplete, incorrect • Indicative rather than absolute • 2008–2012 is our baseline period Data overview 2008–2012 ICU deaths 5,662 Ventilated in ICU and died with severe brain damage 1,745 (SBD+IPPV) (31% of ICU deaths) 5,662 deaths in 24 New Zealand ICUs 2008–2012 ICU Deaths Donors ICU Deaths Donors Waikato 23 Nelson 5 WLG 22 Tauranga 0 CHC 23 Taranaki 1 DCCM 41 Timaru 5 MMH 11 Rotorua 4 CVICU 0 Wanganui 0 Hawkes 10 Southland 3 DUD 21 Hutt 2 NSH 3 Whakatane 0 SSH 3 Wairau 1 WAH 5 Gisborne 2 PNH 4 Grey 2 1,745 with severe brain damage and IPPV Larger ICUs (n=11) ICU SBD+IPPV Donors DCCM 41 WLG 22 Smaller 28 CHC 23 Waikat 23 MMH 11 DUD 21 SSH 3 WAH 5 PNH 4 CVICU 0 Hawkes 10 Smaller ICUs (n=13) ICU Tauranga NSH Southland Rotorua Nelson Hutt Timaru Wanganui Taranaki Whakatan Gisborne Wairau Grey SBD+IPPV Donors 0 3 3 4 5 2 5 0 1 0 2 1 2 SBD+IPPV as % of Total Deaths 2008–2012 All Small Large 31% 18% 35% SBD+IPPV overview 2008–2012 Ventilated in ICU and died with severe brain damage 1,745 (SBD+IPPV) (31% of ICU deaths) Of these 1,745 Discussed with ODNZ Organ donation mentioned Organ donation formally discussed 20% (350/1745) 29% (512/1745) 22% (381/1745) Of the 381 where organ donation was formally discussed 184 brain dead donors 7 DCD donors Families agreed to donate 191/381 = 50% of the time D/w ODNZ as % of SBD+IPPV 2008–2012 All Small Large 20% 22% 20% OD mention as % of SBD+IPPV 2008–2012 All Small Large 29% 31% 29% Formal Discussion as % of SBD+IPPV 2008–2012 All Small Large 22% 21% 22% Possibly brain dead “PossBD” = (1,745 SBD+IPPV) + FDP – BSA = 622/1,745 (36%) BD Testing as % of PossBD 2008–2012 All Small Large 61% 62% 61% What do these 5 years data tell us? • • • There is unexplained practice variation amongst ICUs in: – mention of donation – discussion of donation – discussion with ODNZ – brain death testing There must be missed opportunities for organ donation – within the “Possibly BD” population – within the “Potential DCD” population How can we reduce unexplained practice variation? ODNZ services 1. Link nurse & Link doctor in all ICUs 2. Continue the ICU death audit changed data entry & accommodates DCD 3. Maintain 24h 7d availability on 09 630 0935 for donor co-ordinator & medical specialist 4. Provide set of ICU Guidelines in every ICU ODNZ initiatives to reduce missed opportunities 1. Site visits: raise awareness, discuss & educate 2. Audit meetings @AKL airport twice a year 3. On-line audit filters 4. Local screening system to ID all opportunities 5. Expanded Link nurse role 6. Regular feedback reports for ICUs (soon) 7. Developing a smart phone App Site visits ICU AKL CVICU AKL DCCM AKL SSH PICU Christchurch Dunedin Gisborne Grey Hawkes Bay Hutt Middlemore Nelson North Shore Palmerston North Rotorua Southland Taranaki Tauranga Timaru Waikato Wairau Wanganui Wellington Whakatane Whangarei 2011 2012 2013 Apr Apr Apr Sep 14-Nov 13-Nov 28-Aug 28-May 2014 14-Apr 18-Nov 26-Feb 29-Aug Aug May Oct May (May) Jun Sep 03-Aug 18-Jul 05-Nov 03-Oct 09-Jul Mar 27-Nov 28-Aug 27-May Jun 16-Oct Feb May 03-Aug Sep 23-Aug 02-Sep x 16-Oct 22-Aug 10-Jul 14-Feb System of audit filters set up in 2012 Targeting 5 groups of ICU patients 1. Possibly missed brain dead donors (possibly brain dead & OD not discussed) 2. Possibly missed DCD donors (potential DCD & OD not discussed) 3. Possibly brain dead but not tested for brain death 4. Tested for brain death but not brain dead 5. Neither brain dead nor extubated before death How does it work? • If certain pre-set criteria are met • Pop-up message triggered at data entry • Correct the data if it is wrong • Link nurse d/w link doctor • Supply an explanation on-line • ?d/w whole medical team • ?d/w ICU management team • ICU team look at own practices Deceased organ donors in NZ so far 2008 – 2014 ytd (currently 44) 50 45 40 35 2008 2009 2010 2011 2012 2013 2014 Target 50 30 25 20 15 10 5 Dec Nov Oct Sept Aug July June May April Mar Feb Jan 0 The End
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