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Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 19-24

Seth-donation of organs and tissues (S-DOT) score: A scoring system for the assessment of hospitals for best practices in organ donation after brain death

Fortis Organ Retrieval and Transplant, Fortis Memorial Research Institute, Gurugram, Haryana, India

Date of Submission17-Sep-2019
Date of Acceptance05-Jan-2020
Date of Web Publication31-Mar-2020

Correspondence Address:
Dr. Avnish Kumar Seth
Fortis Organ Retrieval and Transplant, Fortis Memorial Research Institute, Gurugram - 122 002, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_49_19

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Background: A need was felt to have a simple scoring system for the objective assessment of hospitals for preparedness for donation after brain death (DBD). Materials and Methods: Eighteen tertiary care transplanting hospitals in India were scored on 20 parameters (Seth-Donation of Organs and Tissues [S-DOT] score). An independent observer scored each parameter as 2, 1, or 0 with a maximum score of 40. The loopholes in organ donation (OD) were addressed by monthly interactions and hospitals re-assessed at 6 months by the same observer. Statistical analysis was performed with the Wilcoxon signed-ranks test. Results: The median S-DOT score at baseline was 13.5 (range 3–33). On correlating baseline score with donations over preceding 4 years, 1 hospital with score >30 (good) had 17 donations, 8 hospitals with a score 15–29 (satisfactory) had 19 donations, whereas none of the 9 hospitals with score <15 (unsatisfactory) had a donation. After 6 months, S-DOT score improved for all hospitals to a median of 23.5 (range 4–37) with a median increase of 6.7 (range 1–22), P < 0.001. Four hospitals with a score >30 had 6 donations, 9 hospitals with score 15–29 had 7 donations whereas none of the 5 hospitals with score <15 had any donation. Conclusion: S-DOT score may be a useful tool for the objective assessment and improvement of hospitals on best practices in DBD. A score of >30 was frequently associated with OD, while a score <15 could consistently identify hospitals that did not have any donation.

Keywords: Best practices, brain death, organ donation

How to cite this article:
Seth AK, Singh T. Seth-donation of organs and tissues (S-DOT) score: A scoring system for the assessment of hospitals for best practices in organ donation after brain death. Indian J Transplant 2020;14:19-24

How to cite this URL:
Seth AK, Singh T. Seth-donation of organs and tissues (S-DOT) score: A scoring system for the assessment of hospitals for best practices in organ donation after brain death. Indian J Transplant [serial online] 2020 [cited 2020 Jul 6];14:19-24. Available from: http://www.ijtonline.in/text.asp?2020/14/1/19/281768

  Introduction Top

It is estimated by the WHO that 135,860 organ transplants were carried out in 2016 worldwide from deceased and living donors.[1] This number, however, caters to only 10% of the estimated requirement. There are close to 27,000 deceased donors annually, the majority being a result of donation after brain death (DBD).[2] Donation after circulatory death (DCD) constitutes significantly to the donor pool in some countries such as Spain, the US, and the UK. India follows an opt-in system for organ donation (OD) and majority of deceased donors are DBD. Even though the Transplantation of Human Organs Act was passed in 1994, there was very little deceased OD activity for several years. The revision in the Act in 2011 and the Rules of 2014 brought about much-needed change including the mandatory declaration of brain death (BD). OD rate has doubled over the past 5 years to 0.65 per million population in 2018. Data from the National Organ and Tissue Transplant Organization indicate that a total of 875 individuals donated their organs in 2018. Deceased OD now accounts for >32% of liver transplants and 15% of the kidney transplants in the country. While there is the reason for optimism, it is estimated that <5% of patients who need a transplant actually manage to get one.[3],[4],[5],[6],[7],[8]

There are three arms to a successful OD program, namely suitable legislation, an aware population and a robust medical system. Even as the first two components have now been addressed fairly, there is a systematic failure of recognition or declaration of BD in critical care units (CCUs) across the country. The critical care teams, often untrained or poorly motivated, are reluctant to go the extra mile to ensure donor optimization and OD. The “required request“ spelt out in the Transplantation of Human Organs and Tissues Rules 2014, that mandates counseling of families of all patients with BD for OD, is seldom adhered to.[4],[5],[6],[7],[8]

A need was felt, to create a simplified, objective system for hospitals for the assessment and quantification of parameters that are deemed essential for deceased OD and encourage best practices.

  Materials and Methods Top

Twenty parameters [Table 1] were identified for the objective assessment of hospitals to determine preparedness for deceased OD. These covered the structure, process and outcomes related to DBD including attitude toward OD, identification and reporting of the potential donor, declaration of BD, transplant coordination (TC) and counseling, donor optimization, awareness activities, liaison, tissue donation, and audit. An independent expert from outside the hospital scored each parameter as 2, 1 or 0, with 2 being the best possible score. Eighteen tertiary care transplanting hospitals from a leading healthcare chain in the country were scored for these parameters. The total of these parameters, with a maximum possible score of 40, called Seth-Donation of Organs and Tissues (S-DOT) score was then calculated. Parameters scored as 0 or 1 enabled the program managers to identify the weak areas. Experts in OD then interacted with the Organ Donation Committee (ODC) of each hospital to address the loopholes. The ODC comprised the Chief of Critical Care, Chief of Medical Administration, and the Chief of Nursing. The interaction was monthly in the form of on-site visits or over Skype. The hospitals were assessed and scored again after 6 months by the interaction between the same independent expert observer and ODCs. Data were analyzed using the SPSS (version 22) manufactured by IBM and the Wilcoxon signed-ranks test was used for statistical analysis. The study was exempt from approval from the ethics board.
Table 1: Assessment indicators and grading of Seth-Donation of Organs and Tissues Score

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The subjects enrolled in the study are dead, so no consent required. The study has been approved by Institutional ethics committee of Fortis Memorial Research Institute, Gurugam, Haryana (Ethics Committee registration no: ECR/223/Inst/HR/2013/RR-16).

  Results Top

The median S-DOT score at primary assessment was 13.5 (range 3–33). Based on the primary score of each hospital, OD data over the previous 4 years was retrospectively reviewed. One hospital with score >30 (good) had 17 donations, 8 hospitals with a score 15–29 (satisfactory) had 19 donations, whereas none of the 9 hospitals with a score <15 (unsatisfactory) had a donation. After 6 months of implementation of best practice patterns, an improvement in the S-DOT scores was noted for all hospitals to a median of 23.5 (range 4–37). The increase was found to highly significant statistically (median 6.7, range 1–22, P < 0.001) [Table 2].
Table 2: Variations in Seth-Donation of Organs and Tissues score over 6 months, and impact on organ donation

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A significant improvement in the S-DOT score leading to improvement in the category was seen in 8 hospitals. Of these, 4 hospitals improved from unsatisfactory to satisfactory, 1 hospital improved from unsatisfactory to good, whereas 3 hospitals improved from satisfactory to good. These results are depicted pictorially in [Figure 1].
Figure 1: Total Seth-Donation of Organs and Tissues score of 18 hospitals: Baseline and at 6 months

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During the study period, 4 hospitals with score >30 had 6 ODs, 9 hospitals with score 15–29 had 7 donations, whereas none of the 5 hospitals with score <15 had any donation. Of critical interest is the increase in the number of ODs during the study period. From a cumulative 36 ODs in 48 months (at an average of 0.7/month) in the period preceding the study, the number of ODs increased to 14 in 6 months (2.1/month). Also noteworthy is the fact that 13 hospitals attained the threshold S-DOT score of 15, as against only 9 at the initiation of the study, and all 4 hospitals had their first OD during the study period. The parameters most amenable for intervention were reporting of possible BDs by critical care teams, availability of trained reliever for TC, implementation of donor optimization protocol, initiation of a facility for pledging organs, and the number of cornea donations. The least change was observed in the attitude of neurology and neurosurgery team toward OD, availability of dedicated room for counseling of families and liaison with local police and postmortem authorities.

Details of changes in individual parameters of the S-DOT Score are depicted in [Figure 2] and [Table 3].
Figure 2:Changes in individual parameters of the Seth-Donation of Organs and Tissues score

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Table 3: Changes in Seth-Donation of Organs and Tissues parameters over the study period

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  Discussion Top

In countries struggling to establish a meaningful deceased OD program, most hospitals do not have defined pathways for the identification and maintenance of brain dead donors or trained workforce to approach the families for OD.[2],[3],[4],[5],[6],[7],[8]

Given that the process of successful OD is challenging, resource intensive, and multifactorial, we proceeded to identify 20 key areas where intervention is required. A positive attitude toward deceased OD by the hospital administration and clinicians is the key. OD does not happen on its own. It is a process that has to be driven and passes through three stages. First, the transplant teams tend to push the program because of the felt need. In the second stage, the hospital administration steps in, pushed by a motivated OD proponent, to monitor the progress, and ensure that possible BDs are brought to the notice of the TC and the family counseled. The third stage is when the process is well established and self-driven by the critical care teams. The involvement and commitment of senior administration toward the cause is a vital prerequisite. Patients with severe neurological damage are hospitalized under the care of neurosurgeons and neurophysicians. It is crucial to have them on board as their consent for going ahead with the process of declaration of BD and counseling the family for OD is mandatory. The privilege and timing of informing the family about BD lies with the treating team and the baton is seamlessly passed on to the CCU and TCs for donor maintenance (DM), counseling, and documentation for OD. Teaching films on the diagnosis of BD are best made with the help of neurophysicans and neurosurgeons and this simple step often provides the necessary ownership to the OD program.

Since our pilot focused on India, it is important to be cognizant of the determinants of the transplant programs in the country.[4],[7],[8] Health is a state subject in India. Only 15 out of 29 states and 6 of 9 Union Territories have adopted the Transplantation of Human Organs Act of 1994 or the Transplantation of Human Organs and Tissues Act 2011, thus limiting the declaration of BD. The Appropriate Authority of these states approves a panel of doctors from each hospital who are certified to participate in the process of declaration of BD. Four members from the BD Committee (BDC) need to examine the patient twice over a minimum interval of 6 h to confirm the diagnosis. The members of BDC need to be updated as there is a constant movement of concerned specialists, especially in private hospitals.

The OD program has to be driven by CCUs. In our setting, the initial reluctance was seen to stem from a lack of knowledge and experience at conducting tests for BD, especially the apnea test. Besides workshops on the declaration of BD and DM, a clinical lead in organ donation (CLOD) was designated for these hospitals. The CLOD acted as a single point of contact for issues related to the declaration of BD and DM. All concerned must understand that the option for OD is a part of excellence in end of life care rather than a spectacular event.

Constituting the ODC is a step aligned with the second phase of setting up an OD program. The nursing supervisor often sends out a daily morning report on admissions, discharges, notifiable diseases, deaths, etc., Inclusion of possible BD, ODs and cornea donations in the daily report goes a long way in sensitizing the system. Lack of reporting of possible BDs is the Achilles heel of the OD program in India. To call a patient 99% dead instead of informing the family clearly about BD and the irreversible nature of the same lets many an opportunity slip by. Allowing a family to grieve for their loved one after BD provides a window for the counseling team to step in and try to make a difference before the heart comes to a standstill. While the law mandates that every hospital that carries out organ transplantation must have a TC, there is an acute shortage of workforce in this field. In addition to a full time dedicated TC, every effort must be made to train resources like junior hospital administrators, nursing staff, and personnel from NGOs so that in the absence of TC during leave, the process does not come to a standstill. In our experience, initial counseling is best done by a group of experts from treating unit, CCU, TC, nursing supervisor trained in cornea donation and hospital administration. The counseling team must have access to a dedicated counseling room. This space must display material on the need for organ and tissue donation in the country, its legality, and the hundreds of previous examples. Leaving the family for a couple of minutes in a room like that makes the task of the counseling team much easier.

It is important that every organization drafts a standard operating procedure (SOP) for compliance. This SOP must clearly spell out the process of OD to be followed, should be readily available and updated annually. The staff should be well versed in the same so that all legal requirements, documentation, and the DM protocol are readily available.

OD and transplantation are not possible in India without the involvement of the police. All patients with road accidents are medico-legal and police clearance is mandatory before proceeding with organ retrieval. Once retrieved, organs like the heart are transported rapidly by using “green corridors“ provided by the traffic police. Constant interaction, education and acknowledgment of the work done by the police and postmortem authorities is required so that there are no issues in police clearance and priority is accorded for postmortem for organ donors.

Continuous education and sensitization of the general public are also imperative. It becomes very difficult for a grieving family to accept the concept of death with a beating heart. Leaflets answering Frequently asked questions (FAQs) on the same should be available in all waiting areas and the process of pledging and donating ones organs explained. The law now mandates that a board on “required request“ be placed in the waiting areas of CCUs. The process of OD stands on a tripod created by legislation, public awareness and best hospital practices. Staff from organ transplant units must join the TCs in organizing awareness programs by way of ground events or social media. Counseling for cornea donation in the absence of a contraindication should be a part of the end of life care. By counseling for tissues after every death, the staff and the whole system gets sensitized to dealing with grieving families. In fact, the Ramakrishna Protocol suggested that asking for the corneas should precede asking for organs after BD in India. A monthly audit on possible BDs and why they did not convert into a donation help in identifying and closing the loopholes. The audits also are a good time to organize an “OD huddle“ to celebrate the hard work done by various departments after a successful donation.

From our study, two factors have emerged clearly. One, strategies toward identifying and implementing best practices can significantly impact rates of deceased OD. Two, the impact of these strategies can be evident in as few as 6 months. The interventions, however, did not prove to be uniformly effective across all parts of the country. Hospitals located in poorly performing states such as Punjab and West Bengal continued to struggle, a reflection of the apathy toward OD in these states.

So far benchmarking in OD programs has concentrated on donors per million population (DPMP). The authors have repeatedly questioned the reliability of using DPMP as a measure of organ and tissue donation program performance.[9] Matesanz et al. evaluated the processes that could potentially improve OD in Spain.[10],[11],[12] They concluded that the process of DBD was structured into three phases: referral of possible donors to CCUs from outside units, management of possible DBDs within the CCUs and obtaining consent for OD. Indicators to assess performance in each phase were constructed and the factors influencing these indicators were studied to ensure that comparable groups of hospitals could be established. However, they did not discuss the interventions in the hospitals that could drastically increase the rate of OD. The Organ Donation European Quality System provides a robust assessment of organ procurement performance for hospitals.[13],[14] Its specific objectives primarily identify quality criteria and quality indicators in three types of OD namely DBD, DCD and living donation. As many as 131 quality criteria and 31 quality indicators developed have proven to be helpful in self-assessment and external audits of transplant programs. Similarly, in an attempt to devise a strategy to standardize the donation process and to optimize outcomes, a RAND modified three-round Delphi approach was used to build consensus about preexisting norms. A set of 65 key interventions and 11 quality indicators for the management of a potential donor after BD were found to be key for quality improvement programs, specific to Belgium.[14] However, these exhaustive tools are applicable more to assess quality indicators in programs that are up and running and may not be applicable to countries struggling to start a DBD program.

  Conclusion Top

The S-DOT score is a useful tool for the objective assessment and improvement of hospitals on best practices in DBD. It can help identify processes and sub-processes that require intervention. A score of >30 was frequently associated with DBD, while a score <15 could consistently identify hospitals that did not have any donation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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