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The article studies the impact of meeting donor management goals (DMG) at several time points during the organ donation process on the number of organs transplanted per donor (OTPD) in the U.S.' United Network for Organ Sharing Region 5. The study involved nine DMGs representing normal cardiovascular, pulmonary, renal and endocrine end points. It finds that the donor hospital management of patients with catastrophic brain injuries, before the intent to donate is known, affects outcomes.

Background: Identification of strategies to improve organ donor use remains imperative. Despite the association between hospital volume and outcomes for many common disease processes, there have been no studies that assess the impact of organ donor hospital volume on organ yield.Study Design: A prospective observational study of all deceased organ donors managed by 10 organ procurement organizations across United Network for Organ Sharing regions 4, 5, and 6 was conducted from February 2012 to June 2015. To study the impact of hospital volume on organ yield, each donor was placed into a hospital-volume quartile based on the number of donors managed by their hospital. Stepwise logistic regression was used to identify the independent effect of hospital volume on the primary outcomes measure of having ≥4 organs transplanted per donor.Results: Data from 4,427 donors across 384 hospitals were collected and hospitals were assigned quartiles based on their volume of deceased donors. Hospitals managed a mean ± SD of 3.3 ± 5.2 donors per hospital per year. After adjusting for age, ethnicity, donor type, blood type, BMI, creatinine, and organ procurement organization/donor service area, being managed in hospitals within the highest volume quartile remained a positive independent predictor of ≥4 organs transplanted per donor (odds ratio = 1.52; 95% CI 1.29 to 1.79; p < 0.001).Conclusions: Deceased organ donor hospital volume impacts organ yield, with the highest-volume centers being 52% more likely to achieve ≥4 organs transplanted per donor. Efforts should be made to share practices from these higher-volume centers and consideration should be given to centralization of donor care. [ABSTRACT FROM AUTHOR]

The shortage of organs available for transplantation has become a national crisis. The Department of Health and Human Services established performance benchmarks for timely notification, donation after cardiac death (DCD), and conversion rates (total donors/eligible deaths) to guide organ procurement organizations and donor hospitals in their attempts to increase the number of transplantable organs. In January 2007, an organ donor council (ODC) with an ongoing performance improvement case review process was created at a Level I trauma center. A critical care devastating brain injury protocol and a DCD policy were instituted. Best performance benchmarks were evaluated before and after establishment of the ODC. At our center, the total number of referrals increased from 96 in 2006 to 139 in 2007 and 143 in 2008. Timely notification rate increased from 64 per cent in 2006 to 83 per cent in 2007 and 2008 (P < 0.01). DCD rate increased from 0 per cent in 2006 to 13 per cent in 2007 (P = 0.06) and 10 per cent in 2008 (P = 0.09). Conversion rate increased from 53 per cent in 2007 to 78 per cent in 2008 (P = 0.05) and 73 per cent in 2009 (P = 0.16). Organs transplanted per eligible death trended upward from 1.80 in 2007 to 2.54 in 2009 (P = 0.20). As a consequence, the establishment of a multidisciplinary ODC and performance improvement initiative demonstrated improved donation outcomes. [ABSTRACT FROM AUTHOR]

Importance: The shortage of organs available for transplant has led to the use of expanded criteria donors (ECDs) to extend the donor pool. These donors are older and have more comorbidities and efforts to optimize the quality of their organs are needed., Objective: To determine the impact of meeting a standardized set of critical care end points, or donor management goals (DMGs), on the number of organs transplanted per donor in ECDs., Design, Setting, and Participants: Prospective interventional study from February 2010 to July 2013 of all ECDs managed by the 8 organ procurement organizations in the southwestern United States (United Network for Organ Sharing Region 5)., Interventions: Implementation of 9 DMGs as a checklist to guide the management of every ECD. The DMGs represented normal cardiovascular, pulmonary, renal, and endocrine end points. Meeting the DMG bundle was defined a priori as achieving any 7 of the 9 end points and was recorded at the time of referral to the organ procurement organization, at the time of authorization for donation, 12 to 18 hours later, and prior to organ recovery., Main Outcomes and Measures: The primary outcome measure was 3 or more organs transplanted per donor and binary logistic regression was used to identify independent predictors with P < .05., Results: There were 671 ECDs with a mean (SD) number of 2.1 (1.3) organs transplanted per donor. Ten percent of the ECDs had met the DMG bundle at referral, 15% at the time of authorization, 33% at 12 to 18 hours, and 45% prior to recovery. Forty-three percent had 3 or more organs transplanted per donor. Independent predictors of 3 or more organs transplanted per donor were older age (odds ratio [OR] = 0.95 per year [95% CI, 0.93-0.97]), increased creatinine level (OR = 0.73 per mg/dL [95% CI, 0.63-0.85]), DMGs met prior to organ recovery (OR = 1.90 [95% CI, 1.35-2.68]), and a change in the number of DMGs achieved from referral to organ recovery (OR = 1.11 per additional DMG [95% CI, 1.00-1.23])., Conclusions and Relevance: Meeting DMGs prior to organ recovery with ECDs is associated with achieving 3 or more organs transplanted per donor. An increase in the number of critical care end points achieved throughout the care of a potential donor by both donor hospital and organ procurement organization is also associated with an increase in organ yield.

Background: Cirrhosis is known to be a significant risk factor for morbidity and mortality following trauma such that its presence is a requirement for trauma center transfer. The impact of trauma center level on post-injury survival in cirrhotic patients has not been well studied., Methods: The National Trauma Databank (version 7) was used to identify patients admitted with cirrhosis as a preexisting comorbidity. Patients who were dead on arrival, died in the emergency department, or had missing trauma center information were excluded. Our primary outcome measure was overall mortality stratified by admission trauma center level. Logistic regression analysis was used to derive adjusted mortality results., Results: A total of 3,395 patients met inclusion criteria (0.16% of all National Trauma Databank patients). Patients admitted to a Level I center were more likely to be younger and minorities, experience penetrating injuries, and require immediate operative intervention despite similar Injury Severity Scores (ISS). Overall mortality was lower at Level I centers compared with other centers (10.3% vs. 14.0%, p = 0.001). After logistic regression, Level I centers were associated with significantly lower mortality compared with non-Level I centers (adjusted odds ratio, 0.70; 95% confidence interval, 0.53-0.89; p = 0.004)., Conclusion: The mortality for cirrhotic patients admitted to a Level I trauma center was significantly less compared with those admitted to non-Level I centers. The etiology of this improved outcome needs to be identified and transmitted to non-Level I centers., Level of Evidence: Epidemiologic study, level III.

Background: Oesophageal trauma is uncommon. The aim of this study was to conduct a descriptive analysis of penetrating oesophageal trauma and determine risk factors for oesophageal related complications and mortality in the National Trauma Data Bank (NTDB)., Methods: Patients with penetrating oesophageal trauma from Levels 1 and 2 trauma centres in the NTDB (2007 and 2008) that specified how complication and comorbidity data were recorded were selected. Data collected included age, injury severity score (ISS), abbreviated injury scores (AIS), lengths of stay (LOS) and ventilation days, systolic blood pressure (SBP) in the emergency department (ED), comorbidities, oesophageal related procedures, and oesophageal related complications. Univariate and multivariable analyses were conducted to identify significant predictors of oesophageal-related complications and mortality in patients with LOS>24 h., Results: 227 patients from 107 centres were studied. The mean number of patients per centre was 2 (range 1-15). Overall mortality was found to be 44% with 92% of these deaths in less than 24 h. In patients with LOS>24 h, 62% had primary repair, 13% drainage, 4% resection, 1% diversion, and 20% unspecified. No significant difference in mortality was found in patients with oesophageal related complications. The time to first oesophageal related procedure was not significantly different in those with oesophageal related complications or those who died. Significant predictors of oesophageal related complications were age and AIS of the abdomen or pelvic contents ≥3 and the only significant predictor of mortality was ISS., Conclusions: Most deaths in penetrating oesophageal trauma occur in the first 24 h due to severe associated injuries. Primary repair was the most common intervention, followed by drainage and resection. Oesophageal related complications were not found to significantly increase mortality and time to first oesophageal related procedure did not affect outcomes in this subset of patients from the NTDB., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: There is a national shortage of organs available for transplantation. Implementation of preset donor management goals (DMGs) to improve outcomes is recommended, but uniform practices and data are lacking. We hypothesized that meeting DMGs before organ procurement would result in more organs transplanted per donor (OTPD)., Methods: The eight organ procurement organization in United Network for Organ Sharing Region 5 selected 10 critical care end points as DMGs. Each organ procurement organization submitted retrospective data from 40 standard criteria donors. "DMGs met" was defined as achieving any eight DMGs before procurement. The primary outcome was ≥4 OTPD. Binary logistic regression was used to determine independent predictors of ≥4 OTPD with a p<0.05., Results: Three hundred twenty standard criteria donors had 3.6±1.6 OTPD. Donors with DMGs met had more OTPD (4.4 vs. 3.3, p<0.001) and were more likely to have ≥4 OTPD (70% vs. 39%, p<0.001). Independent predictors of ≥4 OTPD were age (odds ratio [OR]=0.94), serum creatinine (OR=0.65), thyroid hormone use (OR=2.0), "DMGs met" (OR=4.4), and achieving the following individual DMGs: central venous pressure 4 mm Hg to 10 mm Hg (OR=1.9), ejection fraction>50% (OR=4.0), Pao2:FIO2>300 (OR=4.6), and serum sodium 135 to 160 mEq/L (OR=3.4)., Conclusions: Meeting DMGs before procurement resulted in more OTPD. Donor factors and critical care end points are independent predictors of organ yield. Prospective studies are needed to determine the true impact of each DMG on the number and function of transplanted organs.

Background: Data regarding pre-existing comorbidities is often poorly recorded in trauma registries, and reports of their impact on outcomes are conflicting. Additionally, many previous reports, when conducting data analysis, do not reliably account for differences in case and control cohorts. Our objective was to identify a subset of patients with reliable comorbidity and complication data in the National Trauma Data Bank (NTDB) in order to determine the impact of select chronic organ system dysfunction on morbidity and mortality using case-control methodology., Study Design: We analyzed a refined dataset from NTDB 7.1 (2002 to 2006) containing admissions to Level 1 and 2 trauma centers, which specified using chart abstraction to document comorbidities and complications. Patients with a history of cirrhosis, dialysis, HIV, and warfarin therapy were compared with a 2:1 case-matched control group. Data regarding age; Injury Severity Score (ISS); ventilator, ICU, and hospital lengths of stay; complications; and mortality were obtained. Pearson's chi-square, Fisher's exact test, and the t-test were used to compare demographics and outcomes of each comorbidity group. A p value < 0.05 was considered significant., Results: After case-control matching, pre-existing cirrhosis, dialysis, and warfarin therapy were found to be risk factors for both complications and mortality; HIV/AIDS was found to be a risk factor only for complications., Conclusions: Chronic hepatic failure, end-stage renal disease, immunodeficiency, and acquired coagulopathy are associated with higher resource use, complication rates, and mortality in a refined subset of NTDB patients., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)