title: Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance.
abstract: BACKGROUND
  The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA.
  
  
  METHODS
  The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12-24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1-4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6-8 ml/kg, positive end-expiratory pressure 8-10 cmH2O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA.
  
  
  RESULTS
  There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed.
  
  
  CONCLUSIONS
  A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor.
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil. glauco.w@brturbo.com.br.|Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil. glauco.w@brturbo.com.br.|Organización Nacional de Trasplantes, Madrid, Spain. glauco.w@brturbo.com.br.|Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil. glauco.w@brturbo.com.br.|Hospital Municipal São José, Joinville, Santa Catarina, Brazil. glauco.w@brturbo.com.br.|, Rua Doutor Plácido Gomes, 500 Bairro Anita Garibaldi, 89.202-050, Joinville, Santa Catarina, Brazil. glauco.w@brturbo.com.br.
authors.forename: Glauco A
authors.initials: GA
authors.lastname: Westphal
authors.affiliation: Organización Nacional de Trasplantes, Madrid, Spain.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Coll
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.
authors.forename: Rafael L
authors.initials: RL
authors.lastname: de Souza
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.
authors.forename: Silvana
authors.initials: S
authors.lastname: Wagner
authors.affiliation: Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.
authors.forename: Artur
authors.initials: A
authors.lastname: Montemezzo
authors.affiliation: Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.
authors.forename: Fernanda Carolina
authors.initials: FC
authors.lastname: Cani de Souza
authors.affiliation: Universidade da Região de Joinville, Joinville, Santa Catarina, Brazil.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Torres
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.
authors.forename: Stefan
authors.initials: S
authors.lastname: Halla
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.
authors.forename: Tiago C
authors.initials: TC
authors.lastname: Carnin
authors.affiliation: Centro Hospitalar Unimed de Joinville, Joinville, Santa Catarina, Brazil.
authors.forename: Míriam C
authors.initials: MC
authors.lastname: Machado
authors.affiliation: Hospital Regional Homero de Miranda Gomes, São José, Santa Catarina, Brazil.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Berbigier
authors.affiliation: Hospital São Francisco, Concórdia, Santa Catarina, Brazil.
authors.forename: Fernando
authors.initials: F
authors.lastname: Busetto
authors.affiliation: Hospital Municipal São José, Joinville, Santa Catarina, Brazil.
authors.forename: Ivonei
authors.initials: I
authors.lastname: Bittencourt
authors.affiliation: Hospital Santa Isabel, Blumenau, Santa Catarina, Brazil.
authors.forename: Karine
authors.initials: K
authors.lastname: Gerent
authors.affiliation: Hospital Marieta Konder Bornhausen, Itajaí, Santa Catarina, Brazil.
authors.forename: Bruno S
authors.initials: BS
authors.lastname: de Souza
authors.affiliation: Hospital e Maternidade São José, Jaraguá do Sul, Santa Catarina, Brazil.
authors.forename: Manoel
authors.initials: M
authors.lastname: Tassinari
authors.affiliation: Central de Transplantes do Estado de Santa Catarina, Florianópolis, Santa Catarina, Brazil.
authors.forename: Joel
authors.initials: J
authors.lastname: de Andrade
mesh_terms: D000293:Adolescent; D000328:Adult; D001926:Brain Death / Q000175:diagnosis; D000066491:Clinical Decision-Making / Q000379:methods*; D002985:Clinical Protocols; D006040:Goals; D006323:Heart Arrest / Q000175:diagnosis / Q000517:prevention & control*; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D058996:Quality Improvement / Q000592:standards; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000379:methods / Q000592:standards*; D055815:Young Adult
keywords: Checklist; Donor management; Donor management goals; Organ donor; Organ transplantation