ARTICLE IN BRIEF
A review of hospital-based practices for determining brain death finds that wide-ranging disparities exist nearly five years after the release of the 2010 practice parameters set by the American Academy of Neurology.
Many hospitals have not yet fully incorporated the AAN's 2010 updated practice guidelines for determining brain death, according to a review of policies at approximately 80 percent of hospitals in the United States.
In response to the new report, several neurocritical care experts who were not involved with the review called for a mechanism to ensure greater accountability for these practices, including the possibility of monitoring by the Joint Commission.
The AAN's Quality Standards Subcommittee issued an updated evidence-based guideline in 2010 after a 2005-2006 survey found wide-ranging differences in how facilities adhered to the original 1995 AAN guidance prerequisites and testing methods, including those for apnea and ancillary tests.
“Hospitals are getting better with the AAN guidelines, but there is still work to be done,” said the lead study author David M. Greer, MD, FAAN, a professor of neurology and vice chairman of the department of neurology at Yale University School of Medicine in New Haven, CT.
In the new study, published online ahead of print December 28 in JAMA Neurology, researchers at several major hospitals sought to determine whether the updated 2010 recommendations had achieved greater uniformity in brain death policies. Using current hospital protocols provided by 52 organ procurement organizations, they reviewed and analyzed available data from June 26, 2012, to July 1, 2015.
The investigators evaluated policies in five areas, including who is qualified to determine brain death; the necessary prerequisites for testing, including body temperature, apnea; and details of the clinical examination.
A total of 508 policies were reviewed, which represented a majority of hospitals equipped for brain death evaluations; of these, 492 provided sufficient data for the analysis.
In addition to differences among policies in specifying all aspects of clinical examinations, apnea testing, and specifying appropriate ancillary tests and how they should be performed, the researchers found that 56.2 percent of policies failed to specify the recommended benchmark for blood pressure, and 79.4 percent failed to specify the lowest body temperature for such determinations.
Among the notable findings, just 33.1 percent of hospitals required specific expertise in neurology or neurosurgery in determining brain death, and only 43.1 percent specifically required an attending physician to make a determination of brain death. A total of 150 policies made no mention of who could make such a determination.
The study found that attending physicians, most with neuroscience expertise, do make decisions about brain death, but many policies still allow more junior physicians to make such decisions. There was also significant variation in the number of examinations required as well as waiting periods between examinations when multiple examinations are required.
In addition to ensuring the absence of confounding conditions, some hospitals do not test for lower brainstem function, as well as for specific tests for apnea testing, including PCO2 levels specified in AAN's report. Also, some hospitals do not include specifics of approved ancillary testing of patients or have unapproved and/or non-validated ancillary tests in their policies.
Dr. Greer said that because no legitimate false-positive determinations of brain death have surfaced to date, physicians and administrators might feel reassured that their policies are working and making policy changes is unnecessary.
“The AAN's 2010 revision of the parameter made a serious effort to make brain death determination simple and straightforward, offering clear guidance about how to approach difficult situations and when to pursue ancillary testing,” including online checklists and sample policies, specific instructions, and how-to videos, Dr. Greer said.
The Subcommittee understood that there would be practice differences in different countries and regions, he added, but why these changes remain an issue with hospitals in the US is not clear.
PRACTICE AUDITS ARE NEEDED
One important factor that may be hindering wider incorporation of AAN's practice parameter is that no government or state accreditation organization holds hospitals responsible for following these recommendations, said Dr. Greer, and if local proponents do not advocate for changes, making revisions may not be a priority for hospitals, or does not occur at all.
“I think that until most major hospital accreditation organizations, such as the Joint Commission, mandate up-to-date adherence to these recommendations they remain voluntary. Until then, physicians are encouraged to work with their information technology groups to incorporate checklists, detailed protocols, and order sets into electronic medical record systems to make the brain death determination more streamlined and straightforward,” he noted. “I feel it is incumbent on neurologists to take a greater leadership role.”
WHO MAKES THE CALL?
Experts who were not involved with the study also expressed concerns about the variation in practices. “What is most concerning to me is that there is no insecurity where there should be,” Gene Sung, MD, MPH, director of the neurocritical care and stroke division at Keck School of Medicine of the University of Southern California, Los Angeles, told Neurology Today. The biggest issue, he noted, is that there are often no clear standards at some hospitals on who can determine brain death.
Changing practices is often a difficult process requiring multiple approaches, and it remains unclear if the AAN recommendations have reached all practitioners, he noted. “Clearly other groups need to get involved.”
The study's findings should serve as a call for action to all hospital accrediting bodies to demand that policies are consistent with AAN criteria.
Dr. Sung is currently leading an effort through the World Federation of Societies of Intensive and Critical Care Medicine and the World Congress of Neurology to address the issue.
“If worse comes to worse, there may be a need for Joint Commission oversight,” he said.
ACCURATE DIAGNOSES NEEDED
Joseph J. Fins, MD, chief of the division of medical ethics and a professor of medical ethics in neurology at Weill Cornell Medical College in New York City, said that there appears to be some unresolved ambivalence and a sense of ambiguity in brain death.
“This seems somewhat counterintuitive, but I think this is true not just among the public, but also among medical professions who may be hesitant to make these decisions.”
“It is possible that that current study was conducted too soon to account for the slow pace of practice changes,” he told Neurology Today, adding that bureaucracy at most hospitals often makes adopting new guidelines a prolonged process. Yet even if hospital policies are consistent with AAN practice parameters, they may not be implemented in practice, he said.
He also agreed with others interviewed here that it would be helpful if the Joint Commission stepped in, because they have clear authority over hospital accreditation.
“The AAN practice parameters are the gold standard, and if the Joint Commission surveyed cases, they would have to admit there is a problem. This new study has identified the problem, but it will probably take an accrediting organization like the Joint Commission to truly address the issue.”
EXPERTS: ON DISPARITIES IN DETERMINING BRAIN DEATH