Tasks and responsibilities of the

German organ procurement organization DSO

Technical Assistance for Alignment in Organ Donation1st International Symposium

Crowne Plaza İstanbul, 29 of May 2014

Axel Rahmel MD

th

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

Contents

Finances in Organ Donation and Transplantation

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

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-CentersWaiting list Organ donation procedure Transplantation

AllocationStiftung Eurotransplant

Leiden / Niederlande

OPODeutsche Stiftung Organtransplantationsince June 2000

Eurotransplant

DSO

Tran

spla

nt-c

ente

rs

Stakeholder in Organ Donation Process

TT-Labs

Transplant Centers

Hospitals

Eurotransplant (NL)

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

The German Procurement Organisation (DSO)

The DSO has the responsibility to organise organ procurement in every German hospital (regulated by German Transplant Act)

is the national organ procurement organisation

GermanyResidents: 82,4 mill.Federal States: 16

DSO7 regions

80 coordinators (nurses / physicians)

Hospitals with ICU: 1.346Transplant 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

On the spot support

during organ donation

process

Any time

(365 days / 24 hours)

Process time ≤ 12 h

Contracts

693 contracts with procurement surgeons181 contracts with consultants for brain

death diagnosis 45 contracts with transplantation-centres

Pathology / Immunology 12 contracts for HLA-typing

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

Organization of the organ donation process in Germany

The Organ Donation Process Primary or

secondary brain injury

Causes of Death of Organ Donors

84 % Atraumatic causes of death

Killed in road traffic

130

78

56

0

20

40

60

80

100

120

140

Verkehrstote/pmp 2008

USASpanienDeutschland

2010: 3657 Verkehrstote

Reduced mortality after stroke

Organ Donation in Germany (Age of Organ Donors)

Primary or secondary brain

injuryDiagnosis of brain death

The Organ Donation Process

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

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)

The Organ Donation Process

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)Family

discussion

The Organ Donation Process

Written wish to donate

Next of kin

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!

Therapy

Grieving Process

Death (Brain death)

Decision

Accompany the Decision Process

Reasons for Refusal (%)

Next of kin discordant

Death not accepted

Religious reason

Others

Unknown

Negative attitude towards organ donation known

Deceased person´s attitude not known

Damage to bodily integrity

%

%

%

%

%

%

%

n = 2520

Reasons for Consent (%)

6,3

26,4 1,3

44,8

5,3

15,8

Desire to make sence of the sudden death of a loved oneKnowing someone who needs a transplant or benefied from a organ donationOther reason

Unknown

Positive attitude towards organ donation known

Altruistic motives(compassion) %

%

%

%

n = 4669

44,8 %

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)Family

discussion

Medical examination of the deceased

patient

The Organ Donation Process

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

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)Family

discussion

Medical examination of the deceased

patientData transfer to Eurotransplant

for organ allocation

The Organ Donation Process

Report & Update Procurement

Allocation & XMRequest Transplant

• Medical history• Admission• Procurement

OrdersTransports

Notification

DIAG LAB ICD OPS

MNTMED

med. Evaluation

HTD AttorneyRelatives

Legal prerequisite

Processing donor- & organinformation

ET-Interface

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

Medical examination of the deceased

patient

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)Family

discussion

Data transfer to Eurotransplant

for organ allocation

Organ harvesting

The Organ Donation Process

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

Primary or secondary brain

injuryDiagnosis of brain death

Reporting of potential donor to OPO (DSO)Family

discussion

Medical examination of the deceased

patientData transfer to Eurotransplant

for organ allocation

Organ harvesting

Organ transport

The Organ Donation Process

Establishing an air transport network responsible for the organisation of all national and international transports of organ retrieval teams and organs.

DSO: Air transport - extrarenal 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

Organ harvesting

Organ transport

Transplantation

Data transfer to Eurotransplant

for organ allocation

Medical examination of the deceased

patient

Family discussion

Reporting of potential donor to OPO (DSO)

Diagnosis of brain death

Primary or secondary brain

injury

The Organ Donation Process

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

SOP (Standard Operation Procedure)

5

4

1

2

3

Development and Implemantation of Standard Operating Procedures (SOP) together with DSO Coordinators and inclusion of contact persons from the hospital

Information materials for professionals

CD-ROM

Guidelines

www.dso.de

Manuals

Annual reports

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

Finances in Organ Donation and Transplantation

Health insurance company

of the organ-

recipient

Lump sum per Tx

registration-lump sum

organ removal (DSO)

§ 11 TPG

DRGs

donor-hospital

organ allocation (ET)

§ 12 TPG

refund

organ transplantation

(TPZ)

§ 10 TPG

Organisational flat rate

DSO does not recieve an entire budget sum but recieves a lump-compensation 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 non-renal organs.

Compensation mechanisms if the fixed number of cases is not reached or exeeded.

DSO: Budgeting systematics

Example: Allowances Surgeons

Special cases:Kidneys en bloc: 820,00 €Split liver, if both splits are transplanted: 1.640,00 €

1 organ (individual kidney, liver or pancreas) € 820,00

2 organs € 1.640,00

3 organs € 2.460,004 organs € 3.280,005 organs € 4.100,00

If no organ has eventually been transplanted € 290,00

Allowance for abdominal retrieval teams

DSO: Air transport - extrarenal organsAir 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!