Never Declared Brain Dead Potential Organ Donors-An Additional Source of Donor Organs?

CONTEXT: Patients never declared brain dead may represent an additional source of donor organs. OBJECTIVE: To determine the number of likely brain dead potential donors who are never declared brain dead and to compare them with brain dead and donation after cardiac death potential organ donors. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective chart review of all catastrophically brain-injured patients referred to a single-organ procurement organization (OPO) over a 4-year period. This study identified 159 likely brain dead potential organ donors, 902 brain dead potential organ donors, and 357 potential donation after circulatory death donors over a 4-year period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: This study did not predetermine outcome measures before data collection because the study group, likely brain dead potential organ donors, had not previously been described. RESULTS: Likely brain dead potential donors were significantly older than brain dead potential donors ( P < .0001) but were otherwise not different demographically. They were more likely to be a late referral to the OPO ( P < .0001) and less likely to be in the donor registry ( P < .0001). The most commonly identified factors associated with a failure to declare brain death were an unwillingness to continue supportive care by the family, premention of donation, a nontimely imminent death referral, known prior objection to donation, terminal instability, and a lack of cooperation with the OPO.

Increasing demands for quality measurement.

Measurement of health care quality and patient safety is rapidly evolving, in response to long-term needs and more recent efforts to reform the US health system around "value." Development and choice of quality measures is now guided by a national quality strategy and priorities, with a public-private partnership, the National Quality Forum, helping determine the most worthwhile measures for evaluating and rewarding quality and safety of patient care. Yet there remain a number of challenges, including diverse purposes for quality measurement, limited availability of true clinical measures leading to frequent reliance on claims data with its flaws in determining quality, fragmentation of measurement systems with redundancy and conflicting conclusions, few high-quality comprehensive measurement systems and registries, and rapid expansion of required measures with hundreds of measures straining resources. The proliferation of quality measures at the clinician, hospital, and insurer level has created challenges and logistical problems. Recommendations include raising the bar for qualtiy measurements to achieve transformational rather than incremental change in the US quality measurement system, promoting a logical set of measures for the various levels of the health system, leaving room for internal organizational improvement, harmonizing the various national and local quality measurement systems, anchoring on National Quality Forum additions and subtractions of measures to be applied, reducing reliance on and retiring claims-based measures as quickly as possible, promoting comprehensive measurement such as through registries with deep understanding of patient risk factors and outcomes, reducing attention to proprietary report cards, prompt but careful transition to measures from electronic health records, and allocation of sufficient resources to accomplish the goals of an efficient, properly focused measurement system.

Case report: probable transmission of vaccine strain of yellow fever virus to an infant via breast milk.

The 17D yellow fever vaccine is a live-virus vaccine that has been in use since the 1940s. The incidence of encephalitis after yellow fever vaccination among young infants is much higher than among children older than nine months of age. Until recently, avoidance of vaccination by breastfeeding women who have received yellow fever vaccine had been based on theoretical grounds only. We report the probable transmission of vaccine strain of yellow fever virus from a mother to her infant through breastfeeding.

"If the glove fits": Hospital-wide universal gloving is associated with improved hand hygiene and may reduce Clostridioides difficile infection.

OBJECTIVE: To determine whether a hospital-wide universal gloving program resulted in increased hand hygiene compliance and reduced inpatient Clostridioides difficile infection (CDI) rates. DESIGN: We carried out a multiple-year before-and-after quasi-experimental quality improvement study. Gloving and hand hygiene compliance data as well as hospital-acquired infection rates were prospectively collected from January 1, 2015, to December 31, 2017, by secret monitors. SETTINGS: The University of Rochester Strong Memorial Hospital, an 849-bed quaternary-care teaching hospital. PATIENTS: All adult inpatients with the exception of patients in the obstetrics unit. INTERVENTIONS: A hospital-wide universal gloving protocol was initiated on January 1, 2016. RESULTS: Hand hygiene compliance increased from 68% in 2015 reaching an average of 88% by 2017 (P < .0002). A 10% increase in gloving per unit was associated with a 1.13-fold increase in the odds of hand hygiene (95% credible interval, 1.12-1.14). The rates of CDI decreased from 1.05 infections per 1,000 patient days in 2015 to 0.74 in 2017 (P < .04). CONCLUSION: A universal gloving initiative was associated with a statistically significant increase in both gloving and hand hygiene compliance. CDI rates decreased during this intervention.

Pediatric organ donation: a national survey examining consent rates and characteristics of donor hospitals.

OBJECTIVE: To characterize the eligible pediatric donor pool in the United States by age, consent rate, location, and cause of donor loss. STUDY DESIGN: Survey. SETTING: Organ procurement organizations in the United States. PATIENTS: Pediatric patients who suffered brain death in the United States in 2005 and who were medically suitable for organ donation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We determined the number of patients, age < or =17 yrs, who were eligible for organ donation and the consent rate by age. Each hospital in which donation occurred was characterized by the presence of a pediatric intensive care unit (PICU), a pediatric critical care medicine (PCCM) fellowship, solid organ transplant programs, and level I trauma programs. Additional information was obtained on the number of donation after cardiac death donors and eligible donors lost due to medical examiner refusals and deterioration before organ recovery. The number of reported eligible pediatric donors in 2005 was 1330. The consent rate was 69.2% with higher consent rates in eligible donors 12 yrs of age and older. Eligible donors were spread across a large number of hospitals with few having ten or more eligible donors. Variability exists among hospitals in consent rate and number of donors per 100 PICU beds. The presence of a level I trauma program and/or a PCCM fellowship was associated with higher numbers of donors per 100 PICU beds. Ninety-four eligible donors were lost before recovery of organs due to medical examiner denials or cardiac arrest. Donation after cardiac death accounted for 37 donors. CONCLUSIONS: Overall pediatric consent rates were 69.2% but varied by age. Eligible donors were found most often in hospitals with level I trauma programs or PCCM fellowship programs. Few hospitals had >10 eligible donors in a 12-month period. This study is the first to describe in detail the U.S. pediatric donor population.

Donation after cardiac death in pediatric critical care.

OBJECTIVE: To describe the unmet need for pediatric organs, the history of donation after cardiac death (DCD), implementation of DCD policies in children's hospitals, and the current U.S. experience with DCD in children. DESIGN: Review of existing literature and national data regarding DCD. SETTING: Three children's hospitals and a national organ procurement network. PATIENTS: Nationwide review of pediatric candidates for transplantation and pediatric DCD donors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Interest in DCD has greatly increased over the past several years due to limited organ availability for transplantation. Leading medical groups have evaluated and endorsed DCD, and more hospitals are offering DCD as part of end-of-life care options for dying patients and to increase donation. Children's hospitals need to evaluate this concept and develop ethically sound polices to meet the needs of patients and families. Preliminary reports regarding organ function from DCD donors are promising, and DCD is increasing. CONCLUSIONS: The widening gap between the need for organs and the availability of organs from brain-dead donors has led to a resurgence of both interest in and use of organs donated after cardiac death. Children's hospitals need to explore DCD as an option in select circumstances to serve grieving families who would like to donate and to increase organ availability for transplantation. DCD programs are dependent on input and support from critical care providers.

The impact of electronic health record implementation and use on performance of the Surgical Care Improvement Project measures.

OBJECTIVE: To examine the impact of electronic health record (EHR) deployment on Surgical Care Improvement Project (SCIP) measures in a tertiary-care teaching hospital. DATA SOURCES: SCIP Core Measure dataset from the CMS Hospital Inpatient Quality Reporting Program (March 2010 to February 2012). STUDY DESIGN: One-group pre- and post-EHR logistic regression and difference-in-differences analyses. PRINCIPAL FINDINGS: Statistically significant short-term declines in scores were observed for the composite, postoperative removal of urinary catheter and post-cardiac surgery glucose control measures. A statistically insignificant improvement in scores for these measures was noted 3 months after EHR deployment. CONCLUSION: The transition to an EHR appears to be associated with a short-term decline in quality. Implementation strategies should be developed to preempt or minimize this initial decline.

First case of Zika virus infection in a returning Canadian traveler.

A woman who recently traveled to Thailand came to a local emergency department with a fever and papular rash. She was tested for measles, malaria, and dengue. Positive finding for IgM antibody against dengue and a failure to seroconvert for IgG against dengue for multiple blood samples suggested an alternate flavivirus etiology. Amplification of a conserved region of the non-structural protein 5 gene of the genus Flavivirus yielded a polymerase chain reaction product with a matching sequence of 99% identity with Zika virus. A urine sample and a nasopharygeal swab specimen obtained for the measles investigation were also positive for this virus by reverse transcription polymerase chain reaction. Subsequently, the urine sample yielded a Zika virus isolate in cell culture. This case report describes a number of novel clinical and laboratory findings, the first documentation of this virus in Canada, and the second documentation from this region in Thailand.

Achieving the HIV and AIDS National Strategic Plan: A practical calculator for local target setting in district health facilities.

The South African HIV National Strategic Plan (NSP) aims to provide access to appropriate treatment, care and support to 80% of the HIV-infected population by 2011. By mid-2008, highly active antiretroviral treatment (HAART) was being dispensed to about half the HIV-infected population in need. Reaching the NSP targets will require full mobilisation of all of South Africa's health facilities. While the NSP has broad political and programmatic support from the Department of Health and civil society, and managers are able to recite the national targets, it has been difficult for these managers to relate the targets to their own geographical areas of responsibility. National, regional and district targets for HIV care have been set from South Africa's relatively good census, modelling and epidemiological data. However, few practical tools are available to help clinicians and managers understand their facility's actual contribution to the district regional and national NSP targets for each step of the HIV care pathway (HIV testing, CD4 testing, HAART referral and initiation). The calculation of HAART initiation targets is complicated by the anticipated additional demand for treatment that will be generated by a change in the recommended CD4-count threshold for initiation of treatment.4 Accordingly, we provide a data-based tool that is readily available, and that district and facility managers can use to calculate their annual steady-state HIV testing, CD4 testing and HAART initiation requirements. These calculated values can be used for local and regional planning and to assess and improve current performance at facility level.