This past month, a new Organ Preservation Unit began responding to specific 9-1-1 calls in Manhattan. Its ultimate goal is to boost kidney donations in New York City and perhaps beyond. Previously, donations in the city have come from registered donors who were declared brain dead while hospitalized. This new pilot program, which began Dec. 1 and will last for five months, expands the potential donor pool and will test protocols carefully developed by a multidisciplinary team over three years.
The program, which is funded by a $1.5 million federal Health Resources and Services Administration (HRSA) grant, is limited to 9-1-1 calls made in Manhattan between the hours of 4 p.m. and midnight, adults between the ages of 18 and 60, and previously registered donors who experience cardiac arrest at home or another residence. In addition, family members must consent before a donor is included in the program.
“The lack of available organs for donation has for a long time been a problem, and there have been many people who have looked at how to expand the pool of available organs,” said Bradley Kaufman, MD, division medical director for the New York City Fire Department, which is participating in the pilot. Kaufman said a 2006 report by the Institute of Medicine that described several ways of expanding the pool of available organs suggested including donor candidates who died from circulatory determination of death in addition to those who died after being declared brain dead.(1)
“Currently, there’s no system in place to enable those people who die from cardiac arrest while outside the hospital to be able to donate their organs. In our system, I’ve frequently been faced with this situation where I’m on the scene with the EMTs and paramedics, and we try everything possible to resuscitate a patient. Despite that, we are unable to, resuscitation is terminated, and the person is pronounced dead. The family may say, ‘He wanted to be an organ donor.’ And what we would tell them is, ‘Sorry, there’s no system in place to make that happen.’”
Making it happen
An interagency team within New York City that includes the fire and police departments, medical examiner, New York City Health and Hospitals Corporation, Bellevue Hospital and New York Organ Donor Network, has worked on developing protocols for several years. According to Kaufman, the New York City pilot is the first of its kind in the U.S., though similar programs currently exist in Spain and France.
Kaufman says safeguards that are built into the system will ensure that the focus continues to be preserving the life at hand.
“Here in New York City, we like to think we use the most advanced resuscitation techniques possible, and we’ll continue to do that,” Kaufman said. “Our main priority is caring for the patient. Hopefully we get a return of spontaneous circulation; that’s the goal. Sometimes, for a variety of reasons, we transport the patient with ongoing resuscitative efforts. And other times, we, the rescuing crew, terminate the resuscitation in the field as ordered by the online medical control physician. None of that changes.”
Kaufman said they’ve created a “firewall” between the rescue processes and the organ donation processes. The responding EMS crews have not changed how they treat cardiac arrest patients. The EMS crews that respond to potential cardiac arrest 9-1-1 calls are not aware of the dedicated Organ Preservation Unit’s activities, and the organ preservation team only presents itself when the patient meets very stringent inclusion criteria and after all resuscitative efforts have been exhausted and the patient has been pronounced dead.
The Organ Preservation Unit is staffed by two specially trained EMTs, a physician from Bellevue Hospital and a family services specialist from the New York Organ Donor Network. A New York Police Department detective will respond in a separate vehicle to confirm that there is not a crime scene requiring preservation. This team monitors the radio frequencies for patients in cardiac arrest. They also review the computer-aided dispatch data to see if the patient likely meets the inclusion criteria (aged 18–60 with no evidence of trauma, criminal activity or certain medical conditions), and they check the New York State Registry of Consent to confirm the patient is a registered organ donor.
If a patient dies of cardiac arrest at their home or another residence, meets all the other inclusion criteria and is a registered donor, the organ preservation team approaches the family to discuss the patient’s wishes. Even if the patient is registered, the family must consent. Once the scene is cleared by the deputy chief medical examiner, the physician will inject the patient with Heparin, and the team will perform one minute of chest compressions to circulate the Heparin in the deceased patient’s system.
The team will then transport the potential donor to a designated hospital, where they will be placed on a localized bypass machine and undergo tests. If all goes well, their kidneys could be recovered within approximately four hours. The current pilot is only evaluating kidney donation. However, according to the New York Organ Donor Network, a single organ donor could potentially save up to eight lives or improve the lives of up to 50 people with other organ or tissue needs.
Testing the protocols
“The sole goal of the pilot is to test the processes,” Kaufman said. “The pilot has been designed to be extremely conservative with the age criteria, the medical criteria, the first personal consent criteria. So there likely won’t be any people who meet all this criteria. We’re just testing the process. Can we get the unit out there? Can they screen the calls appropriately? Can they get the team together? Can the police get there on time? And so on.”
If the pilot proves successful, i.e., the processes work as designed, Kaufman said the criteria, such as catchment area and time of day, will likely be expanded to potentially include more donors.
The three years it took to develop the pilot culminated in the Nov. 29 launch, said Elaine Berg, MPA, FACHE, president and chief executive officer of the New York Organ Donor Network. “We held numerous focus groups and meetings with all kinds of community groups all around Manhattan and, particularly, in the Bellevue area to elicit from them what their feelings about this were, first of all, and to educate them about the program. There was a lot of work done prior to the launch over the last few years with the communities,” said Berg. “We had a lot of press coverage, and it was all very positive, because we answered the questions honestly; we were straightforward.”
Kaufman said the EMTs who work on the Organ Preservation Unit received intensive training on the “patient direction issues that they’re going to face as well as the unique processes they have to follow.” He said eight to 10 EMTs are currently trained, and when they’re working a shift on the OPU, they do not respond to any other calls.
In addition to working through the clinical questions of how to transport and treat a body to preserve the organs, Berg said a bioethicist worked closely with the group to examine the ethical questions posed by identifying potential organ donors in the prehospital setting. “We didn’t know how to do this because it’s never been done before,” she said.
Currently, 2.3 million people who live in New York state are on the organ donor registry, Berg said, and many more believe they’re on the registry but aren’t. An estimated 18 people die every day in the U.S. waiting for an organ transplant, according to the New York Organ Donor Network.
“There are so few donors because we can only become donors if we die in a hospital under certain circumstances,” Berg said. “This project, theoretically, has the capacity to really increase the number of donors. It’s a new way to honor and acknowledge the wishes of people who really want to save lives after they’ve died.”
To learn more about the New York Organ Donor Network, visit www.donatelifeny.org.
1. Institute of Medicine of the National Academies. www.iom.edu/Reports/2006/Organ-Donation-Opportunities-for-Action.aspx.