An Automated Electronic Screening Tool (DETECT) for the Detection of Potentially Irreversible Loss of Brain Function

Abstract

Background: A major reason for the low number of organ donors in Germany is a deficit in the recognition of patients who may have impending irreversible loss of brain function (ILBF) in hospitals capable of organ retrieval.

Methods: We used anonymized data from the German Organ Procurement Organization (Deutsche Stiftung Organtransplantation, DSO) to compare two 12-month periods (a reference period and an evaluation period) before and after the implementation of an electronic screening tool (DETECT) at the University Hospital Dresden (UKD) with four other university hospitals without tool implementation (comparative cohort). DETECT is intended to aid in the recognition of potentially impending ILBF. The study endpoints encompassed patients with potentially unrecognized ILBF, patients with recognized ILBF, organ donations performed, and reports to the DSO. Changes in absolute risk were compared with Breslow-Day tests.

Results: 309 patients who died with primary or secondary brain lesions were identified in the UKD in the reference and evaluation periods (164 and 145 patients, respectively), and 1060 (529, 531) in the comparative cohort. In the UKD, the number of unrecognized cases of possibly impending ILBF was 14/164 (8.54%) in the reference period and 1/145 (0.69%) in the evaluation period, yielding an absolute reduction of 7.85% (95% confidence interval [--3.36; --12.33]); by contrast, in the comparative cohort, there was a 0.55% absolute increase between the two periods ([--2.21; 3.30]; p = 0.002 for the comparison between the two cohorts). Only minor differences in absolute risk change were seen with regard to the probability of recognized ILBF (7.09% [0.29; 13.88] vs. 2.42% [1.18; 6.01]; p = 0.234), organ donation (4.70% [--0.89; 10.28] vs. 0.55% [--2.17; 3.26]; p = 0.214), or reporting to the DSO (4.17% [--1.77; 10.11] vs. 2.22% [--1.44; 5.89; p = 0.447); these changes may have arisen by chance.

Conclusion: These findings suggest that the use of DETECT can help to reduce the deficit in the recognition of patients with impending or manifest ILBF.

Figures

Figure 1

DETECT is a tool for the time-controlled evaluation of data imported from the patient data management system (PDMS) and applies certain defined criteria to identify patients with potentially impending irreversible loss of brain function (ILBF), then correspondingly sends targeted messages to a transplantation representative (TXR) in the hospital where the patient is being treated. Notification of the TXR by DETECT initiates structured further procedures in the hospital. *1 Neuro-intensive care specialist, neurologist, neurosurgeon, ward attending; *2 patient data management systems in the intensive care unit. DSO, German Organ Procurement Organization (Deutsche Stiftung Organtransplantation); ICM, integrated care manager; TXR, transplantation representative.

Figure 2

Frequency (in percent) of the study endpoints, with 95% confidence intervals DSO, German Organ Procurement Organization (Deutsche Stiftung Organtransplantation); ILBF, irreversible loss of brain function; UKD, Universitätsklinikum Dresden

eFigure

Evaluation of Transplantcheck data from the other university hospitals in the eastern region of the German Organ Procurement Organization (DSO) not including UKD (above) and from UKD (below), for the reference period (left) and the evaluation period (right). The overlapping circles in the lower diagram (right) depict the complete prospective detection by the DETECT tool, during the evaluation period at UKD, of all cases retrospectively characterized as relevant by the Transplantcheck analysis. The detection of patients with impending ILBF by the DETECT screening tool is linked to the Transplantcheck data (circles), with demonstration of the donor detection gap on the basis of the relevant cases (vertical bars). In the Transplantcheck analysis, all cases treated in a hospital were screened and the question was retrospectively asked, for all patients who died of primary or secondary brain damage, why no diagnostic evaluation for ILBF had been performed; such patients were assigned to defined categories by individual case analysis. After the exclusion of patients with medical contraindications to organ donation, status post cardiopulmonary arrest, and absence of brainstem areflexia, the remaining cases (blue segment) were relevant to the question of identifiability by DETECT. These cases were individually analyzed and assigned to various categories: “effectuated organ donations (light blue),” “reports to the DSO without any effectuated organ donation (medium blue),” and “no consent for organ donation (light blue)” are the categories corresponding to presumably undetected cases (red region), subcategorized into “patient advance directive allowed stopping treatment without discussion of the option of organ transplantation (bright red),” “treatment reduction was agreed upon without discussion of the option of organ transplantation (medium red),” and “an ILBF diagnostic evaluation would have been indicated (dark red).” The number of cases in the last-named category was essentially the same in the two observation periods in the university hospitals of the DSO eastern region not including UKD; in contrast, the corresponding numbers in UKD were 14 in the comparison period and only 1 in the reference period.