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October 2022; 12 (5) Research Article

A Review of Practices Around Determination of Death by Neurologic Criteria by an Organ Procurement Organization in the WAMI Region

Abhijit Vijay Lele, Sarah Wahlster, Ian Bost, Dominic Adorno, Candy Wells, Kevin O'Connor, David Greer, Michael J. Souter
First published September 2, 2022, DOI: https://doi.org/10.1212/CPJ.0000000000200077
Abhijit Vijay Lele
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Sarah Wahlster
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Ian Bost
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Dominic Adorno
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Candy Wells
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Kevin O'Connor
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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David Greer
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Michael J. Souter
Department of Anesthesiology and Pain Medicine (AVL, MJS), Harborview Medical Center, University of Washington; Neurocritical Service (AVL, SW, MJS), Harborview Medical Center, University of Washington; Department of Neurological Surgery (AVL, MJS), Harborview Medical Center, University of Washington; Department of Neurology (SW), Harborview Medical Center, University of Washington, Seattle; LifeCenter Northwest (IB, DA, CW, KOC), Bellevue, WA; and Department of Neurology (DG), Boston University School of Medicine and Boston Medical Center, MA.
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Citation
A Review of Practices Around Determination of Death by Neurologic Criteria by an Organ Procurement Organization in the WAMI Region
Abhijit Vijay Lele, Sarah Wahlster, Ian Bost, Dominic Adorno, Candy Wells, Kevin O'Connor, David Greer, Michael J. Souter
Neurol Clin Pract Oct 2022, 12 (5) 336-343; DOI: 10.1212/CPJ.0000000000200077

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Abstract

Background and Objective To examine the verification of a referring hospital's practice of determining death by neurologic criteria (DNC) by an organ procurement organization (OPO) pursuant to the Center for Medicaid and Medicare Services rule §486.344(b).

Methods In this retrospective cohort study, we examined prevalence and factors associated with deviations from acceptable DNC standards, the performance of additional ancillary testing requested by the OPO, resolution of concerns about deviations between referring hospitals and the OPO, and interactions between referring hospitals and the OPO.

Results The OPO reviewed DNC processes for 645 adult potential organ donors from 64 referral hospitals. Concerns about practice deviations from acceptable standards were identified by the OPO's medical director (also a practicing neurointensivist) on call in 19% (n = 120) and were related to clinical prerequisites (27.2%, n = 49), clinical examination (23.9%, n = 67), and apnea testing (25.3%, n = 97). The top 3 concerns were apnea test results not meeting PCO2 targets (6.7%, n = 43), errors in documentation of the clinical examination (5.3%, n = 34), and potential confounding effects of CNS depressants (2.5%, n = 16). Compared with the “no medical director concerns” group which includes all patients, where the coordinator felt that DNC determination met all the conditions on the checklist, medical director concerns were less likely to occur in hospitals with a dedicated neurocritical care unit (odds ratio [OR] 0.33, 95% CI 0.17–0.66, p < 0.001), prevalent across hospitals independent of whether their policies conformed to updated DNC guidelines (OR 0.92, 95% CI 0.57–1.45, p = 0.720). The OPO requested additional ancillary testing (6%, n = 41) when clinical prerequisites were not met (OR 12.7, 95% CI 4.29–33.5), p < 0.001). Resolution of concerns and organ donation was achieved in 99.4% (n = 641). Four patients were rejected as brain-dead donors because of the presence of cerebral blood flow on the nuclear medicine perfusion test. Referring hospitals requested support from the OPO regarding the determination of DNC (10%, n = 64) and declaring physicians were reported to lack knowledge about the institutional DNC policy (4%, n = 23).

Discussion Ongoing review of institutional DNC standards and adherence to those standards is an urgent unmet need. Both referring hospitals and OPOs jointly carry responsibility for preventing errors in DNC leading up to organ recovery.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Submitted and externally peer reviewed. The handling editor was Deputy Editor Kathryn Kvam, MD.

  • Editorial, page 334

  • Received April 13, 2022.
  • Accepted August 3, 2022.
  • © 2022 American Academy of Neurology
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