- Email: [email protected]
Partnership for Transplantation: A New Initiative to Increase Deceased Organ Donation in Poland
Partnership for Transplantation: A New Initiative to Increase Deceased Organ Donation in Poland M. Kosieradzki, J. Czerwinski, A. Jakubowska-Winecka, T. Kubik, E. Zawilinska, A. Kobryn, R. Bohatyrewicz, K. Zieniewicz, P. Nyckowski, R. Becler, J. Snarska, R. Danielewicz, and W. Rowinski ABSTRACT Despite the long-standing history of transplantation, the shortage of organs has remained its most restrictive factor. In 2010, the number of actual deceased organ donors in Poland was 13.5/million population (pmp). However, a huge difference in organ recovery rates is evident between various regions, eg, 32 pmp, in western Pomerania compared with 1–3 pmp in southern districts. A substantial number of patients who die while awaiting organ transplantations could be saved were effective programs able to overcome barriers in deceased organ donation. Such programs, eg, the European Donor Hospital Education Program, Donor Action, European Training Program on Organ Donation, United States Collaborative in Donation were introduced several years ago, but after transient improvements there has not been real progress. A new comprehensive program—Regional Partnership for Transplantation—was initiated a year ago in 4 districts of southern Poland by the Polish Union for Transplantation Medicine. The letter of intent to activate the donation program was signed by the local administration, the president of the local medical school, president of the Physician’s Chamber, transplant centers, the Polish Union for Transplantation, and the Polish Transplant Coordinating Center. The plan of action included training of in-hospital coordinators, visits to all regional hospitals in company of a representative of the hospital founding body, examination of the real donation pool and the need for participation in a donation program training and education of the hospital staff in legal and organizational aspects of donation, brain death recognition, and various aspects of donor care. In addition, the program included communication skills workshops for intensive care unit physicians (with participation of 2 actors, an experienced anesthesiologist, and a psychologist), lectures for high school and university students and for hospital chaplains as well as alumni of higher seminaries. The preliminary results (after the first year) showed 40%–70% increases in activity of the local hospitals in the organ donation process.
D
espite a long history of organ transplantation in Poland, the deceased-donor organ recovery rate has never been satisfactory. Over the years the kidney trans-
plantation rate has reached 26/million population (pmp). Owing a number of reasons, a dramatic (40%) fall in organ recovery from deceased donors (DD) was noted in 2007.
From the Department of General and Transplantation Surgery (M.K.), Department of Surgical and Transplant Nursing (J.C.), Department of Anesthesiology and Intensive Care (T.K., R.B.), and Department of General, Liver and Transplantation Surgery (K.Z., P.N.), Medical University of Warsaw; Polish Transplant Coordinating Center (J.C., R.D.), Warsaw; Department of Health Psychology (A.J.-W.); , Children’s Memorial Health Institute, Warsaw; Specialist Hospital in Jaslo (E.Z.); Department of Surgery (A.K.,
J.S., W.R.), University of Warmia and Mazury, Olsztyn; Department of Anesthesiology (R.B.), Pomeranian Medical University, Szczecin; and Polish Union for Transplantation Medicine (W.R.), Warsaw, Poland. Address reprint requests to Maciej Kosieradzki, Dept. of General & Transplantation Surgery, Medical University of Warsaw, Child Jesus Hospital & Clinics, 59 Nowogrodzka St, 02-006 Warsaw, Poland. E-mail: [email protected]
0041-1345/12/$–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.07.110
© 2012 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2176
Transplantation Proceedings, 44, 2176 –2177 (2012)
TRANSPLANTATION PARTNERSHIP
Since then, the number of kidney transplantations has never returned to its 2006 level. In 2010, the deceased-donor organ recovery rate was 13.5 pmp. However, a huge disparity has been observed among organ recovery rates from various regions of Poland, eg, 32 pmp in western Pomerania versus 1–3 pmp in southern districts. A substantial number of patients who die while a waiting transplantation could be saved if an effective program overcame barriers to deceased organ donation. A recent survey on the attitudes and knowledge about organ donation and transplantation showed positive societal perceptions. Nevertheless, a survey of physicians, nurses, and Roman Catholic priests and nuns revealed some lack of knowledge related to legal regulations and recognition of death.1 The Spanish experience documented increased awareness regarding donation and augmented organ recovery rates from deceased donors close to 35 pmp due to permanent presence of transplant coordinators in local hospitals. A number of new programs introduced in other countries over the past several years have sought to stimulate organ donation: the European Donor Hospital Education Program, Donor Action, European Training Program on Organ Donation, and United States Collaborative in Donation.2,3 Implementation of these programs increased recovery rates, but after a period of initial enthusiasm, a plateau or even slow recession in organ donation was seen in the long run. In Poland, training of transplant coordinators was started in 2008; to date more than 250 doctors and nurses have graduated from Postgraduate Organ Donation School at the Warsaw Medical University.4 To supplement this valuable initiative, a new comprehensive program titled the Regional Partnership for Transplantation was initiated in 2010 by the Polish Union for Transplantation Medicine in 4 districts of Poland with the lowest donation rates across the country. Letters of intent activating the donation programs were signed by local public and government administrations, president of the local medical school, president of the Physician’s Chamber, and regional transplant center, Polish Union for Transplantation, and Polish Transplant Coordinating Center representatives. In addition to training for in-hospital coordinators, the plan of action included visits to all regional hospitals accompanied by a representative of the hospital’s founding body. The goal of each visit was to learn about the real donation pool, the need for participation in a donation program, and the demand for hospital staff training and education on legal and organizational aspects of donation, brain death recognition, and donor care. When required, appropriate training was provided with special emphasis on communication skills for intensive care unit (ICU) physicians, including workshops with participation of 2 actors, an experienced anesthesiologist, and a psychologist. Additionally, there were series of lectures for high school and university students as well as for hospital chaplains and alumni of higher seminaries. The aim of the program was to stimulate interest and to coordinate efforts by local and hospital authorities and
2177 Table 1. Mortality and Potential Donations in Intensive Care Units (ICUs) of the 4 Districts in 2010
District
No. of Patients Treated in ICUs
No. of Patients Who Died
Estimated Donor Potential*
No. of Actual Donors
Lubelskie Malopolska Mazovia Podkarpacie
2,232 4,324 6,815 2,714
816 1599 2521 1118
51 101 159 70
10 13 49 7
*Donation potential calculated according to DOPKI index (see the text).
medical and transplant societies, seeking to improve donor identification and care as well as provide accurate information for the public. We hoped that the 3-level involvement would result in a stable increase in donation activity in this region of Poland. So far the program has been sucessfully implemented in 4 districts with lowest donation rates: Malopolska, Podkarpacie, Lubelskie, and Mazovia. The Partnership for Transplantation Program increased donation rates in all of these regions: from 1.5 pmp in 2009 to 7.2 pmp in 2010 in Malopolska; 2.5 to 5.2 pmp in Podkarpacie; 4.5 to 7.3 pmp in Lubelskie, and from 8.6 to 12.1 pmp in Mazovia. However, a secondary goal of the program was to calculate ICU hospitalizations and ICU mortality in these districts. According to DOPKI (Improving the Knowledge and Practice of Organ Donation) index,5 15.1% of patients who die in ICU are brain-dead. Among them, 42.4% can become actual donors provided that the nonreferral rate is ⬍10%. Using this calculation method, the donation potential in all of these regions was significantly higher, regardless of the program effort. The majority of potential donors are not being identified and are lost despite the program (Table 1). In conclusion, improvement in logistics and necessary educational measures are important to increase donation rates. A comprehensive Partnership for Transplantation program proved to be an effective tool to activate deceased donor identification and organ recovery. This program shall be continued and implemented in other parts of Poland. At the moment, the greatest emphasis should be placed on the diagnosis of brain death and referral of all potential donors.
REFERENCES 1. Centrum Badania Opinii Spolecznej: Postawy wobec przeszczepiania narza¸dów. Available at http://www.uniatransplantacyjna. pl/images/Badania/k_091_11.pdf 2. Wight C: Two initiatives designed to maximize the potential for organ donation from intensive care units. Ann Transpl 3:13, 1998 3. Shafer T, Wagner D, Chessare J, et al: Organ donation breakthrough collaborative: increasing organ donation through system redesign. Crit Care Nurse 26:33, 2006 4. Czerwinski J, Jakubowska-Winecka A, Becler R, et al: Educational system for transplant coordinators in Poland: postgraduate studies at Warsaw Medical University; 2 years of experience. Transplant Proc 41:2961, 2009 5. DOPKI Consortium: DOPKI newsletter 2009, p 14
D
espite a long history of organ transplantation in Poland, the deceased-donor organ recovery rate has never been satisfactory. Over the years the kidney trans-
plantation rate has reached 26/million population (pmp). Owing a number of reasons, a dramatic (40%) fall in organ recovery from deceased donors (DD) was noted in 2007.
From the Department of General and Transplantation Surgery (M.K.), Department of Surgical and Transplant Nursing (J.C.), Department of Anesthesiology and Intensive Care (T.K., R.B.), and Department of General, Liver and Transplantation Surgery (K.Z., P.N.), Medical University of Warsaw; Polish Transplant Coordinating Center (J.C., R.D.), Warsaw; Department of Health Psychology (A.J.-W.); , Children’s Memorial Health Institute, Warsaw; Specialist Hospital in Jaslo (E.Z.); Department of Surgery (A.K.,
J.S., W.R.), University of Warmia and Mazury, Olsztyn; Department of Anesthesiology (R.B.), Pomeranian Medical University, Szczecin; and Polish Union for Transplantation Medicine (W.R.), Warsaw, Poland. Address reprint requests to Maciej Kosieradzki, Dept. of General & Transplantation Surgery, Medical University of Warsaw, Child Jesus Hospital & Clinics, 59 Nowogrodzka St, 02-006 Warsaw, Poland. E-mail: [email protected]
0041-1345/12/$–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.07.110
© 2012 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
2176
Transplantation Proceedings, 44, 2176 –2177 (2012)
TRANSPLANTATION PARTNERSHIP
Since then, the number of kidney transplantations has never returned to its 2006 level. In 2010, the deceased-donor organ recovery rate was 13.5 pmp. However, a huge disparity has been observed among organ recovery rates from various regions of Poland, eg, 32 pmp in western Pomerania versus 1–3 pmp in southern districts. A substantial number of patients who die while a waiting transplantation could be saved if an effective program overcame barriers to deceased organ donation. A recent survey on the attitudes and knowledge about organ donation and transplantation showed positive societal perceptions. Nevertheless, a survey of physicians, nurses, and Roman Catholic priests and nuns revealed some lack of knowledge related to legal regulations and recognition of death.1 The Spanish experience documented increased awareness regarding donation and augmented organ recovery rates from deceased donors close to 35 pmp due to permanent presence of transplant coordinators in local hospitals. A number of new programs introduced in other countries over the past several years have sought to stimulate organ donation: the European Donor Hospital Education Program, Donor Action, European Training Program on Organ Donation, and United States Collaborative in Donation.2,3 Implementation of these programs increased recovery rates, but after a period of initial enthusiasm, a plateau or even slow recession in organ donation was seen in the long run. In Poland, training of transplant coordinators was started in 2008; to date more than 250 doctors and nurses have graduated from Postgraduate Organ Donation School at the Warsaw Medical University.4 To supplement this valuable initiative, a new comprehensive program titled the Regional Partnership for Transplantation was initiated in 2010 by the Polish Union for Transplantation Medicine in 4 districts of Poland with the lowest donation rates across the country. Letters of intent activating the donation programs were signed by local public and government administrations, president of the local medical school, president of the Physician’s Chamber, and regional transplant center, Polish Union for Transplantation, and Polish Transplant Coordinating Center representatives. In addition to training for in-hospital coordinators, the plan of action included visits to all regional hospitals accompanied by a representative of the hospital’s founding body. The goal of each visit was to learn about the real donation pool, the need for participation in a donation program, and the demand for hospital staff training and education on legal and organizational aspects of donation, brain death recognition, and donor care. When required, appropriate training was provided with special emphasis on communication skills for intensive care unit (ICU) physicians, including workshops with participation of 2 actors, an experienced anesthesiologist, and a psychologist. Additionally, there were series of lectures for high school and university students as well as for hospital chaplains and alumni of higher seminaries. The aim of the program was to stimulate interest and to coordinate efforts by local and hospital authorities and
2177 Table 1. Mortality and Potential Donations in Intensive Care Units (ICUs) of the 4 Districts in 2010
District
No. of Patients Treated in ICUs
No. of Patients Who Died
Estimated Donor Potential*
No. of Actual Donors
Lubelskie Malopolska Mazovia Podkarpacie
2,232 4,324 6,815 2,714
816 1599 2521 1118
51 101 159 70
10 13 49 7
*Donation potential calculated according to DOPKI index (see the text).
medical and transplant societies, seeking to improve donor identification and care as well as provide accurate information for the public. We hoped that the 3-level involvement would result in a stable increase in donation activity in this region of Poland. So far the program has been sucessfully implemented in 4 districts with lowest donation rates: Malopolska, Podkarpacie, Lubelskie, and Mazovia. The Partnership for Transplantation Program increased donation rates in all of these regions: from 1.5 pmp in 2009 to 7.2 pmp in 2010 in Malopolska; 2.5 to 5.2 pmp in Podkarpacie; 4.5 to 7.3 pmp in Lubelskie, and from 8.6 to 12.1 pmp in Mazovia. However, a secondary goal of the program was to calculate ICU hospitalizations and ICU mortality in these districts. According to DOPKI (Improving the Knowledge and Practice of Organ Donation) index,5 15.1% of patients who die in ICU are brain-dead. Among them, 42.4% can become actual donors provided that the nonreferral rate is ⬍10%. Using this calculation method, the donation potential in all of these regions was significantly higher, regardless of the program effort. The majority of potential donors are not being identified and are lost despite the program (Table 1). In conclusion, improvement in logistics and necessary educational measures are important to increase donation rates. A comprehensive Partnership for Transplantation program proved to be an effective tool to activate deceased donor identification and organ recovery. This program shall be continued and implemented in other parts of Poland. At the moment, the greatest emphasis should be placed on the diagnosis of brain death and referral of all potential donors.
REFERENCES 1. Centrum Badania Opinii Spolecznej: Postawy wobec przeszczepiania narza¸dów. Available at http://www.uniatransplantacyjna. pl/images/Badania/k_091_11.pdf 2. Wight C: Two initiatives designed to maximize the potential for organ donation from intensive care units. Ann Transpl 3:13, 1998 3. Shafer T, Wagner D, Chessare J, et al: Organ donation breakthrough collaborative: increasing organ donation through system redesign. Crit Care Nurse 26:33, 2006 4. Czerwinski J, Jakubowska-Winecka A, Becler R, et al: Educational system for transplant coordinators in Poland: postgraduate studies at Warsaw Medical University; 2 years of experience. Transplant Proc 41:2961, 2009 5. DOPKI Consortium: DOPKI newsletter 2009, p 14