Role of the accident and emergency department in the non-heart-beating donor programme in Leicester.

Abstract

To describe the development of a non-heart-beating donor (NHBD) programme in an accident and emergency (A&E) department over a three year period.
The A&E department at the Leicester Royal Infirmary at present deals with approximately 200 prehospital cardiopulmonary arrests per year. A programme of kidney retrieval from non-heart-beating donors was started in April 1992. Strict criteria for admission to the programme, appropriate consent procedures, facilities, lines of communication, and feedback were developed to enhance its success.
Of 66 patients referred to the NHBD programme over a three year period from 1 April 1992, 51 sets of relatives were available to be asked for possible organ donation, and 34 sets (66%) gave their consent. Twenty five patients had successful in situ perfusion of the kidneys. Forty seven organs were retrieved and 34 went on to be transplanted. To date, 27 kidneys are still working. As a result, 23.8% of kidneys transplanted in Leicester over this time period have been from the NHBD programme.
The NHBD programme in Leicester has proved very successful, requiring organisation of resources and personnel both from the transplant service and the A&E department. The programme has provided such a significant boost to the renal transplant rate in Leicester that other hospitals with large A&E departments should consider setting up similar programmes.

Full text

Page 1

ItAccidEmergMed 1996;13:321-324
Role of the accident and emergency department
in the non-heart-beating donor programme in
Leicester
T B Hassan, M Joshi, D N Quinton, R Elwell, J Baines, P R F Bell
Abstract
Objective-To describe the development
of a non-heart-beating donor (NHBD)
programme in an accident and emergency
(A&E) department over a three year
period.
Background and methods - The A&E
department at the Leicester Royal Infir-
mary at present deals with approximately
200 prehospital cardiopulmonary arrests
per year. A programme ofkidney retrieval
fromnon-heart-beating
started in April 1992. Strict criteria for
admission to the programme, appropriate
consent procedures,
communication, and feedback were devel-
oped to enhance its success.
Results - Of 66 patients referred to the
NHBD programme over a three year
period from
relatives were available to be asked for
possible organ donation, and 34 sets (66%)
gave their consent. Twenty five patients
had successful in situ perfusion ofthe kid-
neys. Forty seven organs were retrieved
and 34 went on to be transplanted. To date,
27 kidneys are still working. As a result,
23.8% ofkidneys transplanted in Leicester
over this time period have been from the
NHBD programme.
Conclusions-The NHBD programme in
Leicester has proved very
requiring organisation of resources and
personnel both from the transplant serv-
ice and the A&E department. The pro-
gramme has provided such a significant
boost to the renal transplant rate in
Leicester that other hospitals with large
A&E departments should consider setting
up similar programmes.
(7AccidEmergMed 1996;13:321-324)
donors
was
facilities, lines of
1 April 1992,
51
sets of
successful,
Key terms: non-heart-beating donor; renal transplanta-
tion; resources; personnel
The continuing shortfall in the number of kid-
neys available for transplantation in the United
Kingdom l has led to the successful develop-
ment of alternative sources from non-heart-
beating
donors
(NHBD).2
described the initial experience in Leicester,
showing that 19 of 27 referrals were from
patients who had undergone
resuscitation in the accident and emergency
(A&E) department following cardiopulmonary
arrest in the community. The procedure they
Varty
et
al
2
unsuccessful
described allows emergency in situ perfusion
by cannulation ofthe femoral vessels and isola-
tion ofthe kidneys. Hence, this limits the warm
ischaemia time before transplantation. Similar
success
has been
reported
programmes elsewhere in Europe.3"
The high proportion of such referrals from
the A&E department reflected its important
role in the success of the programme.
After three years, most referrals continue to
be from the A&E department. No previous
reports have discussed this essential role in
such programmes. We describe the develop-
ment ofthis retrieval system within our depart-
ment and its logistic impact, both on the
department and the transplant
Leicester.
from NHBD
service
in
Methods
ORGANISATION
The A&E department at the Leicester Royal
Infirmary, serving a population of 900 000,
sees approximately 100 000 new patients per
year. Of these, some 200 have suffered a
prehospital cardiopulmonary arrest. Most pre-
hospital cardiopulmonary arrest are known to
carry a poor prognosis, often as a result oflim-
ited access to immediate advanced life support
(ALS) measures, particularly defibrillation.5 6
They are therefore potentially a useful source
for
a NHBD programme.
programme in Leicester was launched by the
University Department of Surgery in conjunc-
tion with the A&E department. After discus-
sions
withthe
coroner,
committee, and senior medical and nursing
staffwithin the hospital, a proposal for institut-
ing a hospital-wide non-heart-beating donor
programme was developed. Proposals were
also
discussed with various
including the press, to gauge public opinion.
Within the A&E department, proposals for
instituting the programme were presented to
the staff and active multidisciplinary medical
and nursing discussion took place. This was
supplemented by further meetings during the
first year in order to identify and correct teeth-
ing problems and further educate staff on the
success of the programme.
In
1992,
the
thelocal
ethics
local
groups,
CRITERIA FOR ADMISSION TO THE PROGRAMME
Patients under the age of 65 years who had
undergone unsuccessful resuscitation follow-
ing prehospital or intradepartmental cardiop-
ulmonary arrest were eligible to be included in
the programme. Exclusion factors included an
Leicester Royal
Infirmary, Leicester,
United Kingdom:
Department of
Accident and
Emergency Medicine
T B Hassan
M Joshi
D N Quinton
Department of
Surgery
P R F Bell
Department of
Surgery, Leicester
General Hospital,
Leicester
R Elwell
J Baines
Correspondence to:
Dr T B Hassan, senior
registrar in accident and
emergency medicine,
Leicester Royal Infirmary,
Infirmary Square, Leicester
LE1 5WW.
Accepted for publication
13 March 1996
321

Page 2

Hassan,Joshi, Quinton, Elwell, Baines, Bell
Table 1
Details ofthe donors
Total number ofcardiopulmonary arrests 1992-1995
Total number of referrals to the transplant team
Male/female ratio
Mean age (whole group)
Mean age (successful retrieval group)
Mean resuscitation time in successful donors
Mean resuscitation time in unsuccessful donors
582
66
57:11
43.9 years (19-64)
44.8 years (22-63)
65 min (30-92)
58 min (26-96)
unwitnessed cardiac arrest where no basic life
support (BLS) measures had been instituted
for a period of 30 minutes or more, known
malignancy, known renal disease or diabetes
mellitus, and infection as a likely cause for the
cardiopulmonary arrest. After the second year,
the criteria for age was changed to exclude
those over the age of 60 years since several
retrievals in the 60-65 year age group had
failed as a result of poor perfusion.
CONSENT AND PROCEDURE
Once a resuscitation attempt had been offi-
cially
terminated by
transplant team were contacted. Relatives of
the deceased were informed of the death of
their loved ones immediately ifthey were avail-
able. The difficult issue of organ transplanta-
tion was broached only by a senior member of
the transplant team or A&E staff. In those cir-
cumstances where relatives were not immedi-
ately available, the procedure to perfuse the
kidneys was instituted temporarily and subse-
quently withdrawn if permission was refused.
Perfusion in such cases was continued up to a
maximum of 90 minutes. This particular
aspect ofthe programme met with the approval
of both the coroner and the ethics committee.
The procedure of in situ perfusion adopted
by Booster et al 7 was used to achieve renal
cooling. This employed a triple lumen kidney
transplant catheter with a rapid 8 litre infusion
of chilled (4°C) kidney perfusion solution and
subsequent slower infusion.
the A&E
staff,
the
PERSONNEL
The A&E department cardiac resuscitation
team consists of two to three doctors, three
trained nurses, and an operating department
assistant (ODA). Once resuscitation has been
terminated and the patient declared dead, they
are moved to another area of the department
(the A&E operating theatre), where ventilation
and cardiac massage is continued to ensure
some renal perfusion while the renal catheter is
being positioned by
During the first year, this occupied the services
of at least two nurses and the ODA. Subse-
quently,
a
mechanical
massage and ventilation was used (Thumper
CPR System-Michigan Instruments), releas-
ing these personnel. A senior member of the
A&E staff or transplant team is also constantly
involved with the bereaved relatives during this
time.
the
transplant
team.
devicefor cardiac
COMMUNICATIONS AND FACILITIES
Rapid access to the transplant team is essential
in order
to achieve
grammes. During weekday working hours, this
success in such
pro-
is more easily achieved as the transplant regis-
trar (responsible for placement ofthe catheter)
and the transplant coordinator are available on
site
at
thehospital.
weekends, a delay of 15-20 minutes ensues
while the relevant personnel arrive from home.
Within the A&E department, facilities for
storing large quantities of the cold perfusate
and appropriate surgical equipment are re-
quired, as well as an area where the procedure
for placement of the catheter can take place.
After hours and
at
FEEDBACK
Following the successful launch of the pro-
gramme, several informal meetings between
the transplant team, the nursing team, and the
medical teams have continued in order to
identify areas for improvement within the pro-
gramme. Feedback on successful donations
and the ultimate success of the transplanted
kidneys is provided by the transplant coordina-
tor.
Results
During the three year period, 1 April 1992 to
31 March 1995, 582 prehospital or intrade-
partmental
cardiopulmonary
identified by either the dedicated cardiac arrest
database or the departmental patient regis-
tration computer system. The NHBD trans-
plant programme began at the same time and,
during this same period, 66 referrals to the
transplant service were
referred were predominantly male (approxi-
mate male to female ratio 5: 1), with a mean age
of43.9 years. This was very similar to the mean
age of the patients who subsequently had a
successful retrieval performed. All referrals
made to the transplant service were in patients
who had initially been identified as having suf-
fered a witnessed cardiopulmonary arrest, and
most cases had had prolonged resuscitatory
efforts by the Leicestershire Ambulance and
Paramedic Service. On arrival in the A&E
department, all patients underwent a further
shorter period of resuscitation along standard
European Resuscitation Council guidelines
before efforts were terminated. The mean
resuscitation time in the two groups from onset
of collapse to termination of the resuscitation
attempt was 58 and 65 minutes. These data are
summarised in table 1.
Four of the 66 patients suffered a cardiopul-
monary arrest in the resuscitation room and
had significantly reduced resuscitation times
(mean 28 minutes, range 26 to 35 minutes).
Unfortunately, none of these patients went on
to have a successful retrieval. In two, relatives
refused permission; in another, relatives were
not contactable; in one retrieval was unsuc-
cessful due to technical difficulties.
Of the 66 patients referred to the transplant
service, 25 had successful in situ perfusion of
their kidneys performed followed by an organ
retrieval procedure. In
kidneys were retrieved and 34 went on to be
successfully transplanted. To date 27 kidneys
are still working. Ofthe 51 sets ofrelatives who
were asked, 34 (66%) gave their consent and
17 refused.
arrestswere
identified. Patients
'
thesepatients,
47
322

Page 3

Role ofA&E in the non-heart-beating donorprogramme
Table 2
the NHBD programme
Outcome ofreferrals to the transplant servicefor
Successful retrievals
Failed retrievals
Technical errors
Relatives refused
Relatives unavailable
Donor unsuitable
Prolonged resuscitation period
Transplant staff unavailable
Coroner unavailable
25
41
7
17
8
4
3
1
1
Eight sets of relatives were uncontactable
within the 90 minute limit time for perfusion.
In seven patients, a variety of technical errors
mainly related to catheter placement resulted
in unsuccessful retrieval and in two cases the
transplant team or coroner were unavailable. In
seven others the procedure was subsequently
aborted either because further inquiry sug-
gested prolonged cardiopulmonary arrest with
no BLS being carried out, or because of the
identification of exclusion factors. Data on
failed retrievals are summarised in table 2.
The figure shows the times of referral of
patients to the transplant service over a 24 hour
period. Almost a half of referrals were made
between 9.00 am and 5.00 pm. It is notable,
however, that seven of the 25
retrievals occurred outside these hours. The
aetiology ofthe cardiopulmonary arrests for 46
patients who were initially admitted to the pro-
gramme
in table
causative factor was coronary artery disease.
successful
is shown
3. The main
Discussion
The NHBD programme, the first of its kind in
the United Kingdom,
successful in significantly increasing the trans-
plant rate of kidneys in Leicester. During the
three year period, the programme has provided
23.8% of the total number of kidneys trans-
planted in Leicester. Interestingly, although
ours has been a hospital-wide programme,
there have been many fewer referrals from the
rest of the hospital. This relates to a variety of
factors. Essential among these is a greater
enthusiasm for the programme from within the
A&E department, allied to a significant com-
mitment, good communication, and flexibility
among the staff. The NHBD programme has
also fitted in well with the existing bone,
cornea, and heart valve retrieval programmes
already present within the department.
The A&E department is one ofthe busiest in
the country. As a result, it is responsible for
dealing with a large number of cardiopulmo-
nary arrests, a significant proportion of which
are unfortunately unsuccessful. Success rates
for treating prehospital
Leicestershire are, however, equivalent to other
reported data in the United Kingdom.9 In the
last three to four years, the number of prehos-
pital cardiopulmonary arrests being brought to
the A&E department has steadily increased
and this
awareness and usage ofbasic and advanced life
support
community. Similar increases in the number of
cardiopulmonary arrests being treated in the
A&E department since the inception of pre-
has proved
to be
cardiac
arrests
in
is undoubtedly related to greater
skills by paramedic
staff
in
the
18
16
14
co
CL
9~
0.
0
4-21
0
9.00-13.00
17.01-21.00
01.00-05.00
13.01-17.00
21.01-01.00
05.01-09.0
Times of referral to the transplant service
over a 24 h period (unavailable in six patient
Times ofreferralfor individualpatients to the programme.
Table 3
submitted to the NHBDprogramme
Aetiology ofcardiopulmonary arrest in patients
oo
ts)
Coronary artery disease
Valvar disease
Dissection of the thoracic aorta
Idiopathic cardiomyopathy
Pulmonary hypertension secondary to an atrio-septal
defect
Myocarditis
Asthma
Meningitis
Drowning
Alcoholic poisoning
Small bowel infarction secondary to volvulus
Status epilepticus
Necropsy not performed
31
2
2
1
1
1
2
1
1
1
1
1
21
hospital
elsewhere.'0 It is also notable that almost all
referrals
to
the NHBD programme were
related to a medical cause for collapse, chief
among these being coronary artery disease.
There was, however, one trauma case, a 19
year old who suffered a fatal cervical spine
injury while playing football. Fatal trauma
cases may, in the future, be an additional
source for the programme.
Undoubtedly, one of the main difficulties in
having an NHBD programme based mainly in
the A&E department is the initial unavailability
of relatives in the acute resuscitation situation.
The advantage of immediate in situ perfusion
is that the procedure allows the warm ischae-
mia time to be prolonged by one to two hours
until relatives can be located. However, be-
cause ofthe acuteness ofthe event, the relatives
are often poorly prepared to accept bad news.
As a result, the task of discussing possible
organ donation is made all the more difficult.
The experience of the transplant team and
senior staff in A&E in Leicester is that this does
not seem to increase the likelihood of refusal.
In our series, 17 out of 51 sets of relatives
(33%) who were available to be asked refused
permission for donation of organs. Gore et al"
quoted a figure of 30% of relatives refusing
permission for organ donation in patients who
were brainstem dead on an intensive care unit.
Our success rate for consent therefore com-
pares favourably with that of Gore and his col-
leagues, who often had more time to build up a
programmes
havebeen
reported
323

Page 4

324
Hassan,_oshi,Quinton, Elwell, Baines, Bell
rapport with relatives. The importance of hav-
ing senior personnel experienced and trained
in broaching such difficult issues cannot be
overstated. This has been found to be an
important
factor
in poor
donation.12 13
In several patients retrieval failed because of
a variety of mechanical errors. These were
often related to the difficulty in passing the
catheter through atherosclerotic large vessels.
Inadequate positioning of the catheter and a
number ofother anecdotal causes have steadily
been eliminated as reasons for the procedure
failing. Similar difficulties have been encoun-
tered in other programmes. Booster et al7 iden-
tified 61 potential NHBD patients over a 10
year period. Relatives of the patients were not
present in eight cases or refused permission for
donation of organs in four. Successful retrieval
occurred
in 49
patients,
kidneys,
28
of which
discarded for a variety of reasons. However,
their procurement rate for kidney transplants
increased by 20% as a result. They, too, are
strong advocates of an NHBD programme.
Although call out for the transplant team
occurs on a relatively infrequent basis, it is
important to continue communication links in
order to foster good relationships and maintain
impetus for the programme. The first year
undoubtedly provided a significant burden of
work for the A&E staff during a retrieval, in
addition to the normal work load of the
department. Once working well, it has now fit-
ted in to the work patterns of the department.
A busy unit is unfortunately the location of a
high proportion of irredeemable deaths in a
relatively young age group. This system allows
for benefits not only for relatives who see some
good coming from a tragic situation, for the
patients who will receive the transplanted
kidneys, but also for staff morale in the A&E
department.
In summary, the NHBD programme in
Leicester has proved to be very successful,
requiring
reorganisation
rates of organ
resulting
were
in
98
subsequently
of resources
and
personnel from the transplant service and A&E
department. In addition, the utilisation of
existing facilities and personnel within the
department has greatly helped to complement
the programme. Much more important has
been the positive psychological support pro-
vided for grieving relatives and boost in morale
for A&E staff which comes with a successful
retrieval. The programme has provided
significant increase to the renal transplant rate
in Leicestershire and we would strongly urge
other hospitals with large A&E departments to
pursue setting up similar programmes.
a
Our thanks to all medical and nursing staff at the Leicester
Royal Infirmary and Leicester General Hospital who are
involved in or have supported the NHBD programme in the
past three years.
1 United Kingdom Transplant Support Service Authority
Report. Bristol: UKTSSA, 1991,1992,1993.
2 Varty K, Veitch PS, Morgan JDT, Kehinde GO, Donnelly
PK, Bell PRF. Response to organ shortage: kidney retrieval
programme using non-heart beating donors. BMJ 1994;
308:575.
3 Ruers TJM, VroemanJPAM, Koostra G. Non-heart beating
donors: a successful contribution to organ procurement.
Transplant Proc 1985;18:408-10.
4 Costelao AM, Grino JM, Gonzalez C. Long term renal
function of kidneys transplanted from non-heart beating
cadaver donors. Transplant Proc 1991;23:2584-6.
5 Kellerman AL, Hackman BB, Somes G. Predicting the out-
come of unsuccessful prehospital advanced cardiac life
support. JAMA 1993;270: 1433-6.
6 Gray WA, Capone RJ, Most AS. Unsuccessful emergency
medical resuscitation-are continued efforts in the Emer-
gency department justified. N EnglJ Med 1991;325:1393-
8.
7 Booster MH, Wignen RMH, Ming Y, Vroemen JPAM,
Koostra G. In situ perfusion of kidneys from non-heart
beating donors: the Maastricht protocol. Transplant Proc
1993;25: 1503-4.
8 Advanced Life Support Working Party of the European
Resuscitation Council, 1992. Guidelines for advanced life
support. Resuscitation, 1992;24:111- 21.
9 Hassan TB, Hickey FG, Goodacre S, Bodiwala GG.
Pre-hospital cardiac arrest in Leicestershire-targetting
areas for improvement._AccidEmergMed (in press).
10 Hamer DW, Gordon MWG, Cusack S, Robertson CE. Sur-
vival from cardiac arrest in an A&E department: the impact
of out of hospital advisory defibrillation. Resuscitation
1993;26:31-6.
11 Gore SM. Ross RM, Wallwork J. Availability of transplant-
able organs from brain stem dead donors in intensive care
units. BMY 1991;302:149-53.
12 Conference ofMedical Royal Colleges and their Faculties in
the UK. Report of the Working Party on the supply of donor
organsfor transplantation. London: HMSO, 1987.
13 Stein A, Hope T, Baum JD, Organ
approaching the donor's family. BMJ 1995;310:1149-50.
transplantation: