North Devon District Hospital Annual Report 2010-2011 · North Devon District Hospital Annual...

North Devon District Hospital Annual Report 2010-2011

Contents

Professional Development Programme for Organ Donation March 2011

1

Executive Summary ................................................................................................................ 3


2

Message from the Organ Donation Committee Chair ............................................................. 4 Progress Report from the Clinical Lead for Organ Donation (CLOD) ..................................... 5 Progress report from the Specialist Nurse for Organ Donation (SNOD)................................. 6 Feedback from the Organ Donation Committee ..................................................................... 6 Committee Members............................................................................................................... 8 Strategy & Vision .................................................................................................................... 9 Performance Variances and Action Plans ............................................................................ 11 Organ Donation Rates/ Potential Donor Audit Benchmarking .............................................. 12 Local Initiatives ..................................................................................................................... 13 Future Development Plans ................................................................................................... 14 Possible risks/ pressures ...................................................................................................... 15 Hospital Organ Donation Team Structure............................................................................. 16

Annex 1 – Audit of Potential Organ Donors Annex 2 – Tissue Donation Glossary NHS BT – National Health Service Blood and Transplant CLOD – Clinical Lead Organ Donation SNOD – Specialist Nurse Organ Donation ICU – Intensive Care Unit ED – Emergency Department MAU – Medical Assessment Unit NDDH – North Devon District Hospital


3

Executive Summary North Devon District Hospital Trust and their Organ Donation Committee have had a good first year with solid foundations laid to build on for the future. With this in mind our overarching aim is to ensure all organ donors are indentified and referred and that the option of Organ and or Tissue Donation becomes the normal part of the end of life care that is provided at North Devon District Hospital. The close working relationship with the Specialist Nurses in Organ Donation and support from National Health Service Blood and Transplant has enabled us to move this forward and as a consequence, this will ensure that we play our part in increasing Organ Donation by 50% by 2013. The positive impact of this will not only be seen nationally but will also ensure our local transplant waiting list population will benefit, by reducing the time waiting for a transplant and nationally will go to help prevent 3 people from dying every day.


4

Message from the Organ Donation Committee Chair

The Organ Donation Committee was formed in February 2010 according to the recommendations outlined in the Organ Taskforce Report, ‘Organs for Transplant’

Our aim has been to raise awareness within the Trust and externally and to increase the number of successful organ donor retrievals. From a standing start, we have made a number of significant achievements in our first year.

Establishment of a number of Trust policies and procedures Donation Policy, Terms of Reference, etc as outlined later.

Attendance by the Chair and Clinical Lead, Dr Andrew Walder, at the year long programme of Master Classes organised by NHS BT and delivered in Bristol by Deloitte.

Engagement with and training of staff to raise awareness and influence increased identification and conversion of potential donors.

A concentrated publicity campaign during organ donation week. Press, radio, various giveaways, payslip reminders, displays etc

The aim was to increase awareness and to encourage more people to go on to the register and to agree to donation for themselves and loved ones.

At the outset, the Trust was rather behind others in the South West in terms of activity and organisational support for organ donation. However, over the last few months we have addressed this and have been successful in exceeding the target set for us by NHS BT. We have no recorded missed opportunities in 2010/11. Further, visiting retrieval teams have praised our staff for their professionalism and helpful attitude.

This is a small acute hospital with limited opportunities for organ retrieval but overall, this has been a successful first year and we have established a good basis from which to progress.

I am grateful for the backing of the Chair, Chief Executive and Medical Director and the support offered by many others including Jacquie Spencer and Sally Holmes, our two hard working Specialist Nurse Consultants in Organ Donation.

June Lake, Chair, Organ Donation Committee


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Progress Report from the Clinical Lead for Organ Donation (CLOD) This year was focussed on laying the foundations for long term success in achieving the targets set by the Nation Health Service Blood and Transplant. The Trust Organ Donation Committee was formed and has been successfully running under June Lake’s chairmanship with input from all involved departments and has helped to share expertise and develop a working strategy for the “Making change Happen” agenda.

I have had extensive training in the Personal Development Programme run by National Health Service Blood Transfusion in Bristol on a whole range of topics from organ donor management to dealing with the press. These sessions have focussed on helping us to maximise the potential for organ donation in our Trust and to develop our own criteria for considering potential candidates for organ donation. We have met our organ donation target this year (see appendix 1).

I have been teaching as many medical staff as possible about the considerable changes in highlighting the need for organ donation and the process involved – I have focused on A&E personnel to ensure that we highlight all potential donors in the A&E as there could be a potential to increase organ donation activity. (Sessions with new juniors in their induction programme, medical and surgical governance days, A&E teaching programme, etc)

The potential organ donor audit has helped us to identify and overcome local barriers to success and it also informs us as to how to best improve the Trusts performance in this area. As part of this we have developed a local identification and referral criteria.

The Trust is also performing well in the tissue donation audit (see Appendix 2).

In the coming year we plan to build on our progress so far by continuing the education programme across the hospital and providing information and encouragement to all those who have the opportunity to initiate the process of considering organ donation.

Dr Andrew Walder, Clinical Lead Organ Donation The Trust appointed the Clinical Lead in April 2009. This position is funded by NHSBT for 1 PA a week.


6

Progress report from the Specialist Nurse for Organ Donation (SNOD)

The Specialist Nurse Organ Donation has been linked to North Devon District Hospital for over 3 years via the Intensive Care Unit. This was then extended in line with the task force recommendations in September 2009, when I became the linked SNOD within the Trust. The post was handed over to Jacquie Spencer who filled the role of SNOD for approximately 12 months but following internal promotion North Devon District Hospital has been handed back to me and I have been fully embraced by the ITU and the rest of the Trust as the resident SNOD and have received my honoury contract

During the year since a SNOD became resident, part-time, we have undertaken the following initiatives:

• Regular teaching both formal and informal within Intensive Care Unit (ICU), Emergency

Department (ED) and Theatres

• Collecting Potential Donor Audit data from ICU & ED

• Updating and producing policies for organ donation

• Ensuring that education and information resources are up to date

• Worked closely with the Clinical lead for Organ Donation and the Chair

• Redeveloped the deceased patient checklist with the ED and ICU and the Mortuary Staff

so that the question of Tissue Donation is raised where organ donation is not

appropriate.

• Reporting quarterly to the Trust Organ Donation Committee

Sally Holmes, Specialist Nurse Organ Donation

Feedback from the Organ Donation Committee


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The organ donation committee meets quarterly and has representatives from across the Trust, inc Medical Director, Tissue donation team, ED, MAU, Theatres, Palliative care and ICU.

The committee is chaired by a Trust Non Executive Director and is attended by the Clinical Lead for Organ Donation (CLOD) and the Specialist Nurse for Organ Donation (SNOD). The committee is supported by the Directorate Manager for Anaesthetics, Theatres and Critical Care.

The committee has focussed on the following areas in the past year –

Ensuring that the committee itself had the correct membership, terms of reference and commitment from the Trust.

Development and ratification of the Trust Organ Donation Policy.

A publicity campaign for national transplant week.

Monitoring Trust training and staff awareness related to organ donation.

Reviewing the results of audits and activity figures and recommending actions as appropriate.

Sharon Bates Divisional Manager Anaesthetics, Theatres, Critical Care, Cancer Services & Patient Access


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Committee Members Mrs June Lake Chair and Non Executive Director

Dr Andrew Walder Clinical Lead for Organ Donation

Dr Alison Diamond Medical Director

Dr Fionn Bellis Consultant, Emergency Dept

Jacquie Spencer Donor Transplant Team Manager

Sally Holmes Donor Transplant Co-ordinator

Alison Tollafield Sister - ICU

Jo Hope Emergency Services Matron

Helen Pope Sister - ED

Donna Knight Senior Nurse/Matron - ICU

Sarah Weston SN ED

Andrea Johns Theatres

Mezzi Franklin Palliative Care

Lesley Calcutt Palliative Care

Helen Wilson SN MAU

Claire Smith Senior Tissue Co-ordinator, Bristol

Leanne Sarney Senior Tissue Co-ordinator, Bristol

Katherine Allen Communications

Sharon Bates Divisional Manager Anaesthetics, Theatres, Critical

Care, Cancer Services & Patient Access, Vice Chair

Maria Snell Clerical Support


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Strategy & Vision Mission Statement: To make the option of organ donation a normal part of end of life care that we provide here at NDDH for all our patients, their relatives and carers.

To make donation usual, not unusual

Strategy and Vision:

To achieve 100% referral of potential donors by removing barriers and creating smooth

pathways.

To enable a culture of patient and family care that recognises respect for their wishes, gives

ongoing support and acknowledges their generosity

To achieve comprehensive understanding and support for organ donation with key players both within and outside of the Trust. Work effectively and efficiently with all parties to ensure that the organ donation and retrieval process is smooth for the families and organisations involved.

To have a high level of staff awareness and education regarding organ donation across the Trust but with particular focus to the key areas of ED, MAU and ICU. Particular Accomplishments/ Highlights/ Actions delivered over the last year


10

We have formed and now have a well functioning organ Donation Committee. We have a strong leadership within the Trust and close working with the Specialist Nurse Organ Donation. We have exceeded out targets set by NHSBT and have completed 3 successful heart beating organ donation retrievals, with feedback from the national team that the organisation of the retrieval and the involvement of the NDHT staff were good. Within the ICU we have formulated a minimal referral criteria which has been agreed by all the ICU clinicians and it is working well as the Potential Donor Audit shows we have not missed any potential organ donors. During national transplant week July 2010 we increased publicity with a stand in the hospital restaurant, and extra publicity in the main entrance of the Hospital. We also attached an Organ Donor Registration leaflet to every member of NDHT staff’s payslip that month to increase the awareness amongst our staff.


11

Performance Variances and Action Plans Using the Task Force recommendations, the committee took the view that the first year of work should focus on:

Establishing and understanding the current organ donation activity.

Building relationships with essential individuals and departments. Formalise the processes of the Organ Donation Committee and its place within North Devon District Hospital Trust. Education and raising awareness.

Identifying blockages in the process.

Developing appropriate policies where needed.

Developing and learning new skills necessary to leading change and negotiating.


12

Organ Donation Rates/ Potential Donor Audit Benchmarking As a Trust we are not being currently benchmarked against others but with the implementation of Key Performance Indicators in early 2011, this will become an important guide to performance When the Organ Donation Committee was relaunched in it current structure last February, the Potential Organ Donor Audit revealed that in 2008/2009 there had only been 1 Brain Stem Dead donor and that there was 2 missed potential donors following cardiac death.

On review of the potential donor audit 2009/2010 this shows that there had been no donations following brain stem death and no donations following cardiac death. There had also been a further 4 referrals for assessment of suitability for organ donation. One was assessed as suitable but the family withdrew consent following the explanation of the time frames involved. There still remains one missed potential donor and there was no family refusal.

During the year 2010-2011 there were 3 proceeding donors following Brain Stem Death Testing and 2 further referrals that were declined by the family. I am happy to report there have been no missed potential donors during this year.

Overall there has been a significant increase in donation activity within the trust.

Sally Holmes SNOD


13

Local Initiatives During 2010/11 we have

Participated in National Transplant Week in July, inc press and radio coverage

Organ Donation Messages on the Trust TV monitors in foyer etc

Organ Donation Leaflet displays – internal and external

Promotion in the Patient Advice and Liaison (PALs) office and the Raleigh Galley Restaurant

Staff awareness training including supporting staff to attend national European Transplant Coordinators conference in Cardiff and our local Society of Devon Intensive Therapist annual conference at Saunton Sands

We are in the process of planning the memorial sculpture for donors and we will have publicity related to this, when complete.


14

Future Development Plans As a Committee we will continue to build on the positive work that we have completed during the last year.

Recognising the size of the organisation and our local population figures we acknowledge that it is likely that levels of organ donors may remain relatively low, however as an organisation our aim is to never miss any potential donors for reasons other than family choice or clinical necessity.

We are currently finalising our work plan for 2011/12 .


15

Possible risks/ pressures We are aware that the ever increasing pressures on the Critical Care Beds may at times question our ability to facilitate the organ donation process but with close working practices and escalation policies in place with Theatres, we would hope that this risk can be managed satisfactorily.

Hospital Organ Donation Team Structure

Donation Committee Chair

June Lake

Trust Donation Committee Representation from Key

Areas in the Trust

Clinical Lead Organ Donation

Dr Andrew Walder

Specialist Nurse-Organ Donation

Sally Holmes/ Jacquie Spencer

Health Professionals and departments throughout

Trust

Health Professionals and departments throughout

Trust

Appendix 1


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17


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19


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22


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Appendix 2

Tissue Donation

A break down of where the tissue referrals were made and by which healthcare group.

A comparison of other Trusts & Hospices for tissue donors

0

20

40

60

80

100

120

BRI

Fren

chay

RUH

WGH YD

HM

PKND

DHSM

DND

Hos

pT H

osp

Y Hos

pB H

osp

Othe

r

Non Proceeding referrals

Donors


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