Is there an association between consent rates in Swiss hospitals and critical care staffs' attitudes towards organ donation, their knowledge and confidence in the donation process?

This study investigated the critical care staff's attitude, knowledge and involvement with donation, skills and confidence with donation-related tasks and their association with consent rates at the hospital level. In 2015, we conducted a cross-sectional survey among critical care staff of hospitals involved in organ donation using an anonymous online questionnaire with a response rate of 56.4% (n = 2799). The hospital level consent rate was obtained from the Swiss Monitoring of Potential Donors database (2013-2015). For each hospital, we calculated a mean score for each predictor of interest of the Hospital Attitude Survey and investigated the association with hospital consent rates with generalized linear mixed-effect models. In univariable analysis, one score point increase in doctors' confidence resulted in a 66% (95% CI: 45%-80%) reduction in the odds to consent, and one score point increase in nurses' attitudes resulted in a 223% (95% CI: 84%-472%) increase in the odds to consent. After simultaneously adjusting for all major predictors found in the crude models, only levels of education of medical and nursing staff remained as significant predictors for hospital consent rates. In Switzerland, efforts are needed to increase consent rates for organ donation and should concentrate on continuous support as well as specific training of the hospital staff involved in the donation process.

Deceased organ donation activity and efficiency in Switzerland between 2008 and 2017: achievements and future challenges.

BACKGROUND: Various actions have been taken during the last decade to increase the number of organs from deceased donors available for transplantation in Switzerland. This study provides an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. In addition, it puts the evolution of the Swiss donation program's efficiency in relation to the situation in the neighboring countries. METHODS: This study is an analysis of prospective registry data, covering the period from 1 January 2008 to 31 December 2017. It includes all actual deceased organ donors (ADD) in Switzerland. Donor data were extracted from the Swiss Organ Allocation System. The "donor conversion index" (DCI) methodology and data was used for the comparison of donation program efficiency in Switzerland, Germany, Austria, Italy and France. RESULTS: During the study period there were 1116 ADD in Switzerland. The number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). The reintroduction of the donation after cardiocirculatory death (DCD) program in 2011 resulted in the growth of annual percentages of DCD donors, reaching a maximum of 27% in 2017. The total number of organs transplanted from ADD was 3763 (3.4 ± 1.5 transplants per donor on average). Of these, 48% were kidneys (n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352) and 7% pancreata or pancreatic islets (n = 249). The donation program efficiency assessment showed an increase of the Swiss DCI from 1.6% in 2008 to 2.7% in 2017 (+ 69%). The most prominent efficiency growth was observed between 2012 and 2017. Even though Swiss donation efficiency increased during the study period, it remained below the DCI of the French and Austrian donation programs. CONCLUSION: Swiss donation activity and efficiency grew during the last decade. The increased donation efficiency suggests that measures implemented so far were effective. The lower efficiency of the Swiss donation program, compared to the French and Austrian programs, may likely be explained by the lower consent rate in Switzerland. This issue should be addressed in order to achieve the goal of more organs available for transplantation.

Extended-criteria donors in lung transplantation in Switzerland: an evaluation of two adapted lung donor scores.

AIM: Various scoring systems aim to assess the quality of organs donated for transplantation on the basis of patient characteristics, clinical examination and laboratory results. How well such scoring systems reflect the practice in lung transplantation in Switzerland has never been studied. Therefore, we evaluated two scoring systems for their ability to predict whether or not donor lungs are accepted by the two Swiss lung transplant centres. METHODS: We retrospectively analysed patient data of adult deceased organ donors in Switzerland between 1 July 2007 and 30 June 2014. Included were all donors from whom at least one organ was transplanted. We evaluated two lung donor quality scores, the multicentre-developed Eurotransplant donor score (EDS), and the single-centre-developed Zurich donor score (ZDS). Both scores were slightly adapted to be applicable to Swiss deceased organ donor data. We evaluated whether these scores can predict whether lungs were transplanted or refused by Swiss transplant centres, using univariate logistic regression. We further assessed their discriminative power by calculating the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 635 donors included in our analysis, 295 (46%) were accepted as lung donors by one of the two lung transplant centres in Switzerland. Our analysis showed that both scores can predict whether or not a donor lung is likely to be accepted for transplantation in Switzerland. As the score value of a donor increases, the odds of the lung being transplanted significantly decreases (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.51-0.65 for the adapted EDS; OR 0.35, 95% CI 0.28-0.43 for the adapted ZDS). This effect is slightly more pronounced in the adapted ZDS than in the adapted EDS. The discriminatory power of the scores from the AUC was 0.719 (95% CI 0.680-0.758) for the adapted EDS, and 0.723 (95% CI 0.681-0.760) for the adapted ZDS, which for both was deemed fair discrimination. CONCLUSIONS: Both scoring systems are able to predict whether or not donor lungs are accepted by the two Swiss lung transplant centres. As an alternative to adapting an established scoring system, a national lung quality score could be derived de novo. This could be based on a logistic regression analysis including the most relevant donor characteristics. However, such a new score would need to be validated on an independent sample and ideally tested for its predictive value in terms of post-transplantation outcome.

Evolution of Deceased Organ Donation Activity Versus Efficiency Over a 15-year Period: An International Comparison.

BACKGROUND: The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs. METHODS: This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the United States. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons. RESULTS: According to the DCI and of the countries included in the study, Spain, France, and the United States had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally. CONCLUSIONS: Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.

Attitudes towards organ donation and relation to wish to donate posthumously.

BACKGROUND: Organs donated for transplantation remain a scarce resource in Switzerland. One of the reasons for this situation is the high percentage of patients or families who refuse to consent to donation. This study aimed to provide an overview of attitudes towards organ donation among Swiss residents, including any intention to donate organs after death, and whether they had already declared their wish and/or communicated it to anyone. METHODS: A representative poll investigating the attitude of the Swiss population towards deceased organ donation was conducted between 16 and 28 March 2015. Survey data were collected in 1000 structured telephone interviews. Participants consisted of residents aged 15 years and over from all Swiss regions, and covering the German, French and Italian language areas. RESULTS: Of the 1000 survey participants, 92% stated that they have a very positive (58%) or quite positive (33%) attitude towards organ donation, while 6% have a very negative (2%) or quite negative (4%) view. Some 81% of respondents said that they would be willing to donate their organs after death, and 9% expressed a wish not to become a donor. A total of 53% of participants said that they had already communicated or documented whether they wish to donate. CONCLUSION: Our study highlights the importance of continuing to raise awareness about the importance of communicating wishes, both in written form and to family members, and suggests that more work is needed to reap the benefits of the substantial support for organ donation among the Swiss population.

International collaboration and organ exchange in Switzerland.

BACKGROUND: Organ exchange among organ procurement organisations (OPOs) serves three main purposes: firstly, it reduces the loss of donor organs for which there is no suitable recipient on the waiting list of an OPO; secondly, it improves the odds of specific patient groups for receiving a matching donor organ; thirdly, it allows an optimised donor-recipient match, due to an expansion of the donor and recipient pool. However, only few published studies provide figures for the significance of international organ sharing. This study aims to assess the impact of organ imports on the Swiss transplant activity. METHODS: We retrospectively analysed the data related to international organ exchange and its impact on the Swiss transplant activity. Information about organs from deceased donors offered by foreign OPOs was extracted from the Swiss Organ Allocation System for the period from 1 January 2009 to 31 December 2013. RESULTS: During the study period, 1028 organs were offered by foreign OPOs for allocation to patients needing transplantation in Switzerland. Of all organs offered, 35.9% originated from the Agence de la Biomédecine (France) and 25.6% from the National Health Service Blood and Transplant (United Kingdom). Totally 137 organs (13.3%) were accepted by the Swiss transplant centres for transplantation. These imported organs account for 7.2% of the transplants performed between 2009 and 2013. The impact of imported organs on the transplant activity was largest for the liver (14.2%), followed by heart (8.9%), lung (6.3%) and kidney (4.0%). CONCLUSIONS: Our study showed that international organ exchange substantially contributed to the Swiss transplant activity during the period analysed. The collaboration between OPOs can be life-saving, especially for paediatric patients and selected adult transplant candidates. More patients might benefit from organ sharing if the standards for international collaboration could be further harmonised.

Swiss Monitoring of Potential Organ Donors (SwissPOD): a prospective 12-month cohort study of all adult ICU deaths in Switzerland.

BACKGROUND: The Swiss Monitoring of Potential Organ Donors (SwissPOD) was initiated to investigate the causes of the overall low organ donation rate in Switzerland. The objective of our study was an assessment of the donation after brain death (DBD) process in Swiss adult intensive care units (ICUs), and to provide an overview of the donation efficiency as well as of the reasons for non-donation. METHODS: SwissPOD is a prospective cohort study of all deaths in Swiss ICUs and accident and emergency departments. This study is an analysis of SwissPOD data of all patients who deceased in an adult ICU between 1 September 2011 and 31 August 2012. RESULTS: Out of 3,667 patients who died in one of the 79 adult ICUs participating in SwissPOD, 1,204 were possible, 198 potential, 133 eligible, and 94 utilised DBD donors. The consent rate was 48.0% and the conversion rate 47.5%. In 80.0% of cases, the requests for donation took place before brain death was diagnosed, resulting in a similar proportion of consents and objections as when requests were made after brain death diagnosis. CONCLUSIONS: Despite the low donation rate, Swiss adult ICUs are performing well in terms of the conversion rate, similar to major European countries. The refusal rate is among the highest in Europe, which clearly has a negative impact on the donation rate. Optimising the request process seems to be the most effective means of increasing the donation rate.

Organ donation in Switzerland--an analysis of factors associated with consent rate.

BACKGROUND AND AIM: Switzerland has a low post mortem organ donation rate. Here we examine variables that are associated with the consent of the deceased's next of kin (NOK) for organ donation, which is a prerequisite for donation in Switzerland. METHODS AND ANALYSIS: During one year, we registered information from NOK of all deceased patients in Swiss intensive care units, who were approached for consent to organ donation. We collected data on patient demographics, characteristics of NOK, factors related to the request process and to the clinical setting. We analyzed the association of collected predictors with consent rate using univariable logistic regression models; predictors with p-values <0.2 were selected for a multivariable logistic regression. RESULTS: Of 266 NOK approached for consent, consent was given in 137 (51.5%) cases. In multivariable analysis, we found associations of consent rates with Swiss nationality (OR 3.09, 95% CI: 1.46-6.54) and German language area (OR 0.31, 95% CI: 0.14-0.73). Consent rates tended to be higher if a parent was present during the request (OR 1.76, 95% CI: 0.93-3.33) and if the request was done before brain death was formally declared (OR 1.87, 95% CI: 0.90-3.87). CONCLUSION: Establishing an atmosphere of trust between the medical staff putting forward a request and the NOK, allowing sufficient time for the NOK to consider donation, and respecting personal values and cultural differences, could be of importance for increasing donation rates. Additional measures are needed to address the pronounced differences in consent rates between language regions.

Heart allocation and transplantation in Switzerland since the introduction of the Swiss Organ Allocation System (SOAS).

OBJECTIVE: To provide an overview of heart allocation and transplantation in Switzerland since the introduction of the Swiss Organ Allocation System (SOAS). METHODS: This study is a retrospective analysis of SOAS data related to heart transplantation between 1 July 2007 and 30 June 30 2013. RESULTS: During the study period, 300 patients were newly waitlisted for a heart transplant in Switzerland, 199 were transplanted and 52 deceased while on the waiting list. Of the 723 hearts offered by Swisstransplant to the three university hospitals with a heart transplantation programme (Bern, Lausanne and Zurich), 199 (27.5%) were transplanted. Of these, 183 (92.0%) were procured in Switzerland and 16 (8.0%) were offered by a foreign organ procurement organisation. Fifty-two hearts were transplanted to patients who were listed in urgent status, equalling an urgent transplant rate of 26.1%. Whereas the overall waiting list mortality was 19.0%, it was as high as 31.8% in patients older than 60 years. CONCLUSIONS: Our study showed a growing Swiss heart transplant waiting list, as significantly more patients were newly waitlisted than transplanted. Compared with the international data, the acceptance rate of heart offers and the rate of urgent transplantations were relatively low, while the waiting list mortality was higher. The fact that the mortality was highest in candidates aged 60 and above suggests that the new generation of ventricular assist devices as destination therapy should be considered as an alternative to transplantation in selected patients.

Patient characteristics of deceased organ donors in Switzerland 1998-2008.

BACKGROUND: Transplantation today faces two major issues: organ shortage, and the increasing age of deceased donors. The former leads to growing waiting lists and, as a consequence, to a higher mortality of patients in need of an organ. The latter results in an augmentation of the proportion of organs from so called extended criteria donors, which, in the past, have been associated with inferior outcomes. METHODS: Retrospective analysis of the patient characteristics of all deceased organ donors in Switzerland from 1 January 1998 to 31 December 2008. A total of 1004 patient records of brain-dead organ donors (59.4% male, 40.6% female) were analysed for demographic data and causes of death. RESULTS: The average donor age increased from 43.8 ± 16.9 years in 1998 to 51.7 ± 18.0 years in 2008 (+27.6%; p <0.05). When comparing 2008 with 1998, cerebral haemorrhage accounts for 52.8% of the causes of death in 2008 (+16.7 percentage points), whereas the proportion of cranio-cerebral trauma decreased by 22 percentage points to 16.9%. The largest group of donors are the 16-55 year-olds with a 50% quota in 2008 (-23.6% compared with 1998). During the study period, the ≥65 year-old group had a 216.2% growth rate, and it accounts 26.6% of the donors in 2008 (p <0.05). CONCLUSIONS: A shift in the causes of death significantly increased the average age of donors, and transplantation medicine is confronted with a growing number of extended criteria donors. Nevertheless, 10-year survival of transplant recipients is better than ever before.

Assessing the potential of international organ exchange--the Swiss experience.

OBJECTIVE: Little is known about the impact of international organ exchange on national transplant programmes. This study evaluates the relevance of hearts and lungs offered by the European Organ Exchange Organisations to Swisstransplant, Switzerland's national organ procurement organisation. METHODS: The study is a retrospective analysis of donor characteristics of 290 hearts and 199 lungs, offered by the European Organ Exchange Organisations between 1 January 2004 and 31 December 2008 to Swisstransplant. It assesses the responses (acceptance/reasons for refusal) from the Swiss heart and lung transplant centres. RESULTS: Among the 290 hearts offered by the foreign transplant organisations, eight (2.8%) were accepted by a Swiss transplant centre. This corresponds to 5.8% of the Swiss heart transplant activity during the observation period. In the lung group (n = 199), five (2.5%) were accepted, equalling 2.8% of the transplant activity. As for the reasons for refusal, approximately one-fifth and one-sixth of both the heart and lung offers were refused for medical and logistic reasons, respectively. For more than half of the offers, there was either no compatible recipient on the Swiss waiting list, or the reason for refusal was not specified. Notably, 47.6% of the offers in the heart group and 46.7% of the lung offers originated from donors aged less than 16 years. CONCLUSIONS: International organ exchange is a very valuable and effective way to allocate a maximum of medically suitable organs to recipients on the waiting list. Organ exchange is lifesaving, especially in children, and also in patients with rare blood groups. A professional structure within the national organ procurement organisations, and a close cooperation between them on an international level, is crucial to achieve organ exchange on a high-quality level in Europe.

Organ transplantation in Switzerland: impact of the new transplant law on cold ischaemia time and organ transports.

BACKGROUND: On 1 July 2007 a new transplant law came into force in Switzerland. The principal item of this new law is the change from centre-oriented allocation to patient-oriented national allocation of organs. The aim of the present study is to assess the impact on cold ischaemia time (CIT) and transport requirements. METHODS: From 1 July 2006 to 30 June 2008 168 brain-dead donors were registered by Swisstransplant in Switzerland. Donors have been analysed in a retrospective cohort study design. Donor characteristics, transportation requirements and CIT were assessed from the Necroreport. RESULTS: 74 donors (44%) were allocated in the period before the introduction of the new law (period A) and 94 donors (56%) after the new law. Donor characteristics were similar. In period A, 114 organs (37.9%) were allocated within the procurement centre, compared to 54 organs (15.5%) in period B. Transport time for liver and kidney was remarkably longer in period B. Overall, CITs remained largely stable except for a significant increase of nearly 115 minutes in the liver graft median CIT (p <0.01). CONCLUSIONS: The new Swiss transplant law clearly entails an increase in the frequency of organ transports. Overall CIT is not affected. However, liver transplantation is afflicted by an increase in transports and CIT. This may affect mid-term outcome and should therefore be followed closely.