Technical Assistance for Alignment in Organ Donation
1st International Symposium
Tasks and responsibilities
of the
German organ procurement organization
DSO
Crowne Plaza İstanbul, 29 th of May 2014
Axel Rahmel MD
Contents
1
Legal Framework
2
The German Procurement Organisation (DSO)
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
1
Legal Framework
2
The German Procurement Organisation (DSO
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
The legal basis
German Transplantation Act (adopted in 1997)
• Regulates organ donation, allocation and transplantation from
deceased and living donors
• Informed consent (opt-in)
• Brain death: complete and irreversible
loss of all brain function
• No donation after cardiac death (DCD)!
• First amendment on 4th September 2007
• Second amendment on 1st August 2012
Transplantation act – shared responsibilities
Transplant-Centers
Waiting list
Organ donation procedure
Transplantation
OPO
Deutsche Stiftung
Organtransplantation
since June 2000
Allocation
Stiftung Eurotransplant
Leiden / Niederlande
DSO
Stakeholder in Organ Donation Process
Hospitals
TT-Labs
Transplant Centers
Eurotransplant (NL)
1
Legal Framework
2
The German Procurement Organisation (DSO
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
The German Procurement Organisation (DSO)
is the national organ procurement organisation
The DSO has the responsibility to organise organ procurement in
every German hospital (regulated by German Transplant Act)
Germany
Residents: 82,4 mill.
Federal States: 16
DSO
7 regions
80 coordinators
(nurses / physicians)
Hospitals with ICU: 1.346
Transplant Centers: 47
Cooperation with hospitals
• Appropriate communication path
- Donor referral (suitability of donor/support)
• Support in determination of brain death
• Examinations / therapy regarding
- organ function
- diagnosis of infection
- tumor diagnosis
- immunological parameters
• Data transfer to allocation authority
• Organization of
- transport of organs/teams
Contracts
693 contracts with procurement surgeons
181 contracts with consultants for brain
death diagnosis
45 contracts with transplantation-centres
Pathology / Immunology
12 contracts for HLA-typing
1
Legal Framework
2
The German Procurement Organisation (DSO
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
Organization of the organ donation process in Germany
The Organ Donation Process
Primary or secondary
brain injury
Causes of Death of Organ Donors
Killed in road traffic
140
130
USA
Spanien
Deutschland
120
100
80
60
40
78
56
20
2010: 3657 Verkehrstote
0
Verkehrstote/pmp 2008
Reduced mortality after stroke
Organ Donation in Germany (Age of Organ Donors)
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Detection of brain death and confirmation
Brain death protocol
• According to the guidelines of the
federal medical counsil
• 2 qualified doctors not involved in
transplantation have to confirm
independently brain death
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Family
discussion
Written wish to donate
Next of kin
Accompany the Decision Process
Therapy
Decision
Death (Brain death)
Grieving Process
To accompany the decision means:
Competent partner with time, goal, kowledge and emotion
• Ask helpful and prudent open question, build bridges
• Reflect together
• Provide information and guarantees
• Avoid after decision-dissonance!
Reasons for Refusal (%)
Next of kin discordant
Damage to
bodily integrity
Death not accepted
Religious reason
%
%
%
Deceased person´s
attitude not known
Others
%
%
%
Negative attitude towards
organ donation known
n = 2520
%
Unknown
Reasons for Consent (%)
Desire to make sence
of the sudden death of
a loved one
15,8 %
Altruistic motives
(compassion)
26,4
1,3
5,3 %
%
6,3 %
%
44,8
44,8
n = 4669
Knowing someone who
needs a transplant or
benefied from a organ
donation
Other reason
Unknown
Positive attitude towards
organ donation known
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Family
discussion
Medical examination
of the deceased patient
Medical and behavioural history
Standardised questionnaires should be used to obtain the following
information:








clinical history and pre-existing diseases
behavioral risk and previous medical treatment
history of chemical and/or radiation exposure, previous and current
medication
travel history or overseas/out-of-country residency
recent history of any immunization with live vaccines
risk of transmitting prion disease
information about congenital or inherited disorders
other relevant family medical history
Standardized medical history
www.edqm.eu
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Family
discussion
Medical examination
of the deceased patient
Data transfer to
Eurotransplant for
organ allocation
Processing donor- & organinformation
Relative
s
HTD
Notification
Attorne
y
Legal prerequisite
Allocation & XMRequest
Transplant
ET-Interface
med. Evaluation
Report & Update
Procurement
• Medical history
DIAG
LAB
MED
Transports
ICD
MNT
OPS
• Admission
• Procurement
Orders
Key Features
 Different userprofiles
 Documentation according to the process
 Standardized diagnostics and procedures
 Timerelated information
 Calculator for laboratory values
 Modification history
 Validation and businessrules
 Interfaces for medical and administative information
 Data-Warehouse retrieval and reporting
 New attributes easy to add - parameter model
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Family
discussion
Medical examination
of the deceased patient
Organ
harvesting
Data transfer to
Eurotransplant for
organ allocation
Organization of the organ procurement
Organisational framework
• Number of participating teams
• Transport routes and times
• Scheduling
• Weather conditions
• Experience of the teams
• Coordination between the teams
• Waiting time at the OT
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Family
discussion
Organ
transport
Medical examination
of the deceased patient
Organ
harvesting
Data transfer to
Eurotransplant for
organ allocation
DSO: Air transport - extrarenal organs
Establishing an air transport network responsible for the organisation
of all national and international transports of organ retrieval teams and
organs.
Main goals and principles:
 quality, safety and economic efficiency
 medical necessities, CIT
 consideration of transport distance
 avoiding „empty“ flights
 rare use of cost-intensive jets
trustworthy und competent partners
The Organ Donation Process
Primary or secondary
brain injury
Diagnosis of brain
death
Reporting of potential
donor to OPO (DSO)
Transplantation
Family
discussion
Organ
transport
Medical examination
of the deceased patient
Organ
harvesting
Data transfer to
Eurotransplant for
organ allocation
1
Legal Framework
2
The German Procurement Organisation (DSO
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
SOP (Standard Operation Procedure)
Development and Implemantation of Standard Operating Procedures (SOP) together
with DSO Coordinators and inclusion of contact persons from the hospital
1
2
3
4
5
Information materials for professionals
Guidelines
Manuals
Annual reports
CD-ROM
www.dso.de
1
Legal Framework
2
The German Procurement Organisation (DSO
3
The Organ Donation Process
4
Tasks of hospitals
5
Finances in Organ Donation and Transplantation
Finances in Organ Donation and Transplantation
Lump sum
per Tx
organ removal
(DSO)
refund
donor-hospital
§ 11 TPG
Health
insurance
company
of the
organrecipient
registration
-lump sum
organ allocation
(ET)
§ 12 TPG
DRGs
organ
transplantation
(TPZ)
§ 10 TPG
DSO: Budgeting systematics
Organisational flat rate
DSO does not recieve an entire budget sum but recieves a lumpcompensation for every transplanted organ, negotiated yearly.
In the year 2013, the organisational flat rate is 8.460 € per transplanted
organ. 4.000 transplantations are assumed.
DSO covers all costs theat occur during the donation process as well as
structural costs with this flat. DSO has contracts with organ retrieval
surgeons, neurologists, labs beside the own staff.
Exeptions: refund of costs to the donor hospitals and flight costs for nonrenal organs.
Compensation mechanisms if the fixed number of cases is not reached
or exeeded.
Example: Allowances Surgeons
Allowance for abdominal retrieval teams
1 organ (individual kidney, liver or pancreas)
€
2 organs
€ 1.640,00
3 organs
€ 2.460,00
4 organs
€ 3.280,00
5 organs
€ 4.100,00
If no organ has eventually been transplanted
€
Special cases:
Kidneys en bloc: 820,00 €
Split liver, if both splits are transplanted: 1.640,00 €
820,00
290,00
DSO: Air transport - extrarenal organs
Air transport of extrarenal organs
In 2013, the lump sum for an air transport of an extrarenal organ is
7.652 € per transplanted organ for which a separate flight is carried out.
Unsuccessful operations are included in the lump sum and will noch be
refunded separately. The lump sum is based on the assumption that 880
air transports will be carried out in 2013.
If the number of 880 flights is exeeded 50 % of the additional proceeds
will be refunded to payers. If the number of flights is lower than 880
flights 50 % of the lacking revenues will be refunded by the payers.
Thank you for your attention!