In-house coordination project for organ and tissue procurement: social responsibility and promising results 1

Abstract Objectives: to report the results of evaluation regarding changes in the number of potential donor referrals, actual donors, and conversion rates after the implementation of an in-house organ and tissue donation for transplantation coordination project. Methods: epidemiological study, both retrospective and transversal, was performed with organ donation data from the Secretariat of Health for the State and the in-house organ donation coordination project of a beneficent hospital. The data was compared using nonparametric statistical Mann-Whitney test, and the Student's t-test, considering a significance level of 5% (p <0.05). Results: there were statistically significant differences (p < 0.05), before and after the implementation of the project on the number of potential donor notification/month (3.05 - 4.7 ), number of actual donor/month (0.78 to 1.60) and rate of conversion ( 24.7 to 34.8 %). The hospitals 1, 2, 7 and 8 had significant results in potential donor, actual donor or conversion rate. Conclusion: the presence of an in-house coordinator is promising and beneficial, the specialist is important to change the indicators of efficiency, which consequently reduces the waiting lists for organ transplants.


Introduction
In Brazil, the organ and tissue donation and transplantation's national system was implemented in 1997 by the law No. 9,434 and the decree No. 2,268 (1)(2) . After this federal regulation some states started to create specific rules and resolutions to deal with this topic locally. In São Paulo, the local organizational and operational structure of the organ donation and transplant system was determined by the resolution SS No. 103/1997 (3) . Therefore, it was established the organ donation model adopted there, which was based on the North-American's model of Organ Procurement Organization.
The Organ Procurement Organization is based on regionalized professional support for hospitals to administrate the entire organ donation process. This support is provided by external expert nurses and/ or physicians. However, it is known that in-house committees for organ donation and transplantation allow a better organization of the organ donation process.
The Spanish model, which preaches the presence of an organ and tissue donor coordinator (OTDC) in these in-house committees for organ donation, facilitates the early identification of potential organ donors, and provides an adequate family support. This structure also allows better communication amongst all the structures of the organ donation and transplantation system, consequently improving quantitatively and qualitatively the organ donation (4)(5) .
Therefore, the state of São Paulo made some changes in its organ donation system and adopted some particularities of the Spanish model. From this point, São Paulo's organ donation system became a blend of the north-American's and the Spanish's models. This new model incorporated the in-house committees for organ donation. In Brazil, the in-house committees are classified by the number of deaths per year in their hospitals. The type I refer from 0 to 200, the type II above 200 and type III above 1,000 deaths per year (6) . This committee is composed by a multidisciplinary team and usually has a nurse as coordinator (7) .The activity of nurses in the organ donation and transplantation field is regulated by the Conselho Federal de Enfermagem from the identification of the potential organ donor to the release of the body for the family to the funeral ceremonies (8) . Although the nurses possess legal support to work with organ donation, in Brazil the majority of nurses do not perform this activity exclusively. These nurses usually work in acute care and along with this position they perform the organ donation activities. This prevents the hospital from achieving their potential for organ donation, since the nurses are not exclusive for managing the whole process.
In order to address this problem, some initiatives arose in the state of São Paulo. One of them was implemented in 2008 as a partnership among one beneficent hospital in São Paulo, the National Transplant System, and the Secretariat of Health for the State of São Paulo. This beneficent hospital has developed a project of in-house organ and tissue donation for transplantation coordination for public hospitals. This was a pioneer project that hired a specialist nurse to act in public hospitals as an OTDC, at no cost to these hospitals. The The study population was made up based on the potential donor referrals and number of actual donors, from the state of São Paulo, with a sample before and after the nursing specialist's arrival at nine public hospitals.
The arrival of the specialist nurses was considered as the intervention in the nine hospitals. The specialist nurses' work was to identify potential organ donors, improve the organ donor maintenance, and provide family support. project at the beneficent hospital. All nine hospitals provide high complexity care, including treatment for cases of trauma, neurology or neurosurgery.
For the purpose of patterning the terms within the scientific nomenclature, the terms "potential donor referrals" and "number of actual donors" will be replaced herein by: potential donor after brain death (PDBD is a person whose clinical condition is suspected to fulfill brain death criteria); and actual donor after brain death (ADBD is a consented eligible donor in whom an operative incision was made with the intent of organ recovery for the purpose of transplantation) (9) .
The data was collected during a single occasion and it was separated into two groups: one before the

Discussion
The results presented in this article are positive and  (11) .
We can argue that the proper functioning of an in-house committee is pretty important for the improvement of numbers of effective donors (12) . By the results presented we can understand that the inhouse committees for organ and tissue donation for transplantation improve the processes involved in organ donation. These committees ensure better quality and quantity of organs supplied to the country's public transplant system (13)(14)(15) . What can be seen by the statistical significant difference in the number of brain death notifications after the arrival of the specialist nurse in the hospitals studied and also in the effective donors generated for the transplant state system. The consequence of these numbers would reduce the waiting lists for transplantation, through increasing the possibility of equity, which is one of the guiding principles of the Brazilian public health system. After an organ transplant the patient will be able to return to the labor market, since many rely on state benefits, such as pensions, to subsist during the pre-transplantation phase. Beyond that, studies indicate that indirect costs of a patient in the transplant waiting list are higher than the organ transplant procedure (16)(17) .
These increasing results presented in numbers of brain death notification and effective donors can be The main strength of this study was the long term analysis performed amongst the hospitals. However, this was the unique initiative for organ donation of this type in the state of São Paulo at the time of the study. There was no control group, constituting a limitation of the study. Future studies must be multicenter with a larger number of hospitals and comparing the data long term.
Even so, this study is pioneer in Brazil and demonstrated the importance of the specialist nurse as an OTDC to improve the organ donation process.

Conclusion
The report presented in this study showed that the presence of an organ tissue donor coordinator (specialist nurse) is beneficial and socially promising. We observed a clear improvement in the number of brain death notifications in the period after the implementation of the project. Even so, this represents a daily challenge for in-house coordinators, since the diagnosis of brain death is a medical expertise and it is known to still have many cases of underreporting.
This simple fact of increasing brain death notifications create greater possibilities for effective donors, ensuring both the right of diagnosis of brain death to the patient and the right to decision of the families of the deceased. In this scenario, the OTDC improves the family embracement because there is a unique team for this work.
Finally, a more careful government attention on the policies will be necessary, especially for those that rule the organ donation and transplantation processes.
Furthermore, funding alternatives for payment of the costs with this important professional need to be found.