Canadian organ donation organizations’ donor audit processes: an environmental scan

The Research Institute of the McGill University Health Centre (Montreal, QC, Canada), in collaboration with Canadian Blood Services, invited all eleven Canadian ODOs to complete the ES. The ES was designed to understand the current state of DA practices in each ODO through an internal survey and interviews. As a quality improvement project, the McGill University Health Centre Research Ethics Board granted an exemption letter for ethics review. Collaboration was sought from each ODO administrator through Canadian Blood Services’ Donation and Transplant Administrators Advisory Committee.

In this ES of current DA practices among Canadian ODOs, we found that the frequency, methods, and scope of these DAs were variable across jurisdictions. The primary reasons for conducting DAs across all ODOs are to estimate donor potential, evaluate system performance, identify MDOs, and inform quality improvement initiatives. Reporting DA results was frequently done to ODO quality improvement/patient safety committees (73%) and feedback in various forms was often, but not universally, provided to health care professionals (64%). Only one ODO provided public reporting aligned with current standards of increasing transparency with the public. Organ donation organizations collected differing minimum data sets using divergent DD and methodology for calculating donation metrics. Our aim was to understand current practices to inform development of a national deceased donation data strategy and not to compare ODO.

When comparing our data to the ES previously undertaken by the DDDWG, we noted that DAs in Canada continue to be predominately conducted by staff with informal training. Nevertheless, there is improved standardization in DA practices with twice as many ODO reporting the use of standard operating procedures (SOPs) in 2019 (comparison data obtained 27 March 2019 through personal communication with Karen Hornby, BScN, MS, Research Support Services Program, Trillium Gift of Life Network, Toronto, ON, Canada).

It is not surprising that we found variability between ODOs given that oversight of health care in Canada resides at the provincial level. This differs in comparison with high-performing organ donation and transplantation (ODT) systems with timely performance of systemwide DAs like the UK, where health care is managed nationally under the National Health Service. The lack of consistent timeliness of performing DAs in Canada is likely explained by limitations in human resources (e.g., limited staff, staff turnover, competing demands, staff off site), inconsistency of electronic health records, and lack of automation, namely an electronic donation system used nationwide. Under these conditions, it is difficult to build expertise in performing DAs and to have consistent, accurate, and timely data to drive improvement. In an era of increased transparency and patient/family engagement in health care, public reporting of ODT data from DAs would be the goal; it is no wonder that, given our findings, only one ODO is doing so.

Published DA standardization initiatives have been associated with an increase in donor identification and referral, thereby reducing MDOs over time.^9,10 A systematic approach to medical chart reviews is deemed to be the most accurate method to estimate potential donor pools; however, this requires standardized data collection tools and protocols for training chart abstractors and measures of interrater reliability to optimize data accuracy and precision.^4,5 An example of regional and international standardization initiative is the Donor Action program.¹¹ This program, led by a group of professional organizations with experience in organ procurement from Europe and the USA, provides tools, resources, and guidelines for conducting DA. This allows for assessment of hospital-specific organ donation potential and the identification of bottlenecks along the donation pathway, including DAs used to identify MDOs. After one year of implementing the Donor Action program, an average increase of 53% in aggregated donation rates was reported by eight countries and sustained after two years at 33% in 11 European hospitals.^12,13 Importantly, consistently applied quality improvement initiatives and the cost to implement them can outweigh the cost of treatment alternatives, such as dialysis in patients with end-stage renal disease.¹²

To further evolve and standardize a national approach to DAs in Canada, we need to harmonize and implement a national deceased donation minimum data set, DD, and donation metrics. Next, the DA process should be standardized and supported by a DA trigger to inform scope, training for those conducting DAs, and timely reporting and feedback of audit findings. Finally, to evolve to a high-performing ODT system, we recommend that DAs be performed in all emergency departments and ICUs where mechanical ventilation is available. Encouragingly, most Canadian hospitals with ventilatory capacity were being audited. Additional elements of a high-performing system include publicly reported donation rates and that a single, national electronic donation data system be implemented. Only one ODO had public reporting in 2019, but importantly, five provinces had legislation in place around mandatory reporting on deceased donor metrics to the provincial Ministries of Health, advancing the argument for regular standardized DAs at the national level. Given the significant variability reported in donor audit practices, national collaboration will be required to report, analyze, and reduce MDOs. Concurrent work is underway by our group and others to achieve these objectives. Important facilitators to this work are the willingness and motivation of all ODOs to collaborate on this project and certain ODOs being high performers in DAs who can guide others to also be successful.

Our results are limited by the self-reporting nature of the study design. In addition, we did not verify or observe practices reported by ODOs. Furthermore, our understanding is limited by the questions we asked and how they were interpreted. For accuracy, we sought to clarify responses with ODO representatives during the interview process. Importantly, where practices were not harmonized throughout a province, ODO representatives who participated in the ES responded in consideration of their local context and we recognize there may be an underestimation of the variability in practices. As a result, we may have an incomplete picture of each ODO’s practices in data collection, adjudication, and training. We expect that certain practices may also have evolved since the ES was undertaken, as some ODOs were already planning quality assurance and SOP development projects. We do not know how these may have evolved during the COVID-19 pandemic.

Canadian ODOs deceased DA practices remain fragmented and lack consistency in methodology, timeliness, definitions used, metrics calculated, and reporting. Consequently, there are significant challenges in tracking MDOs and developing quality improvement initiatives to reduce them. This variability underscores the need for a national DA strategy to harmonize DD metrics and establish a deceased donation minimum data set. This would allow accurate assessment of ODT system performance and inform quality improvement activities to better serve patients at the end of life who are denied the opportunity to donate and those on the transplant waitlist.