cDCD organ donation pathway of Romagna Local Health Authority: strategic planning, organizational management, and results

Abstract

The introduction of pathways to enrol deceased donors after cardio-circulatory confirmation of death (donation after circulatory death, DCD) is expanding in many countries to face the shortage of organs for transplantation. The implementation of normothermic regional reperfusion (NRP) with warm oxygenated blood is a strategy to manage in-situ the organs of DCD donors. This approach, an alternative to in-situ cold preservation, and followed by prompt retrieval and cold static storage and/or ex-vivo machine perfusion (EVMP), could be limited to abdominal organs (A-NRP) or extended to the thorax (thoraco-abdominal, TA-NRP. NRP is also referred to as extracorporeal interval support for organ retrieval (EISOR). The use of EISOR is increasing in Europe, even if variably regulated. A-NRP has been demonstrated to be effective in decreasing the risk associated with transplantation of abdominal organs from DCD donors, and was recommended by the European Society for Organ Transplantation (ESOT) in a recent consensus document. We aim to explain how we select the candidates for DCD, to describe our regionalized model for implementing EISOR provision, and to introduce the health care professionals involved in this complex process, with their strictly defined roles, responsibilities, and boundaries. Finally, we report the results of our program, recruiting cDCD donors over a large network of hospitals, all pertaining to a Local Health Authority (Azienda Unità Sanitaria Locale, AUSL) in Romagna, Italy.

Fig. 1

Modified Maastricht Classification for DCD donors (Kootstra et al., Thuong et al.), and potential for enrolment in the network of hospitals pertaining to the Local Health Authority of the Romagna Area. DCD donation after cardio-circulatory determination of death, CA cardiac arrest, ECPR extracorporeal cardiopulmonary resuscitation, ECLS extracorporeal life support, WLST withdrawal of life sustaining treatment, ICU intensive care unit, OR operating room

Fig. 2

Identification of cDCD donor and evolving definitions during assessment for suitability. Only a fraction of the donors move to the subsequent phase, as the pathway might be interrupted at any stage due to emerging awareness of clinical findings or opposition to organ donation. cDCD controlled donation after cardio-circulatory determination of death, WLST withdrawal of life sustaining treatment, BI brain injury, DND donation after neurological determination of death, WIT warm ischemia time, NRP normothermic regional perfusion, ISP in situ perfusion, EVMP ex-vivo machine perfusion, referral center; TX transplantation

Fig. 3

Simplified graphic of major teams involved in cDCD organ donation pathway and their main tasks; random order. cDCD controlled donation after cardio-circulatory determination of death, ICU intensive care unit, WLST withdrawal of life sustaining treatment, PT procurement team, COP local hospital procurement team, CAP local health authority procurement team, ECLS extracorporeal life support, NRP normothermic regional perfusion, CRT regional transplant referral center, TX transplantation

Fig. 4

Service mapping of cDCD donor pathway for procedures occurring in the referral center. cDCD controlled donation after cardio-circulatory determination of death, PT procurement team; ECLS extracorporeal life support, WLST withdrawal of life sustaining treatment, TX transplantation, EMS emergency medical system, NRP normothermic regional perfusion, OR operating room, N&HCPs nursing and allied healthcare professionals, ICU intensive care unit

Fig. 5

Service mapping of cDCD donor pathway for procedures occurring in the referring center. cDCD controlled donation after cardio-circulatory determination of death, PT procurement team; ECLS extracorporeal life support, WLST withdrawal of life sustaining treatment, TX transplantation, EMS emergency medical system, NRP normothermic regional perfusion, OR operating room, N&HCPs nursing and allied healthcare professionals, ICU intensive care unit

Fig. 6

Map of the Emilia Romagna Region, Italy; Romagna area is highlighted in red. The hospitals included in the Local Health Authority Network are depicted; hospitals that have procured DCD donors, to date, are listed from A to D according to the date of first DCD donor enrollment; potential referring center that did not procure DCD donors, to date, are listed from E to G in alphabetical order. DCD donation after cardio-circulatory determination of death, cDCD controlled DCD

Fig. 7

cDCD donors enrolled in the hospital pertaining to the Local Health Authority of the Romagna Area. Four out of seven hospitals procured donors, to date. A: cases per year/per hospital. B: total cases per year. C: total cases per hospital. cDCD controlled donation after circulatory death. Hospitals are listed from A to D according to the date of first DCD donor enrolment. * For 2016, data from September 1 to December 31; for 2022, data from January 1 to August 31. § For 2021, numbers could have been impacted by first waves of Coronavirus 2019 pandemic

Fig. 8

DND donors enrolled in the hospital pertaining to the Local Health Authority of the Romagna Area. Six out of seven hospital procured donors, to date. A total cases per year. B total cases per hospital. Hospitals that have procured DCD donors, to date, are listed from A to D according to the date of first DCD donor enrolment; potential referring center that did not procure DCD donors, to date, are listed from E to F in alphabetical order. DND controlled donation after circulatory death, DCD donation after cardio-circulatory determination of death. * For 2016, data from September 1 to December 31; for 2022, data from January 1 to August. § For 2021, numbers could be impacted by first waves of Coronavirus 2019 pandemic