Prototype of a computerized scale for the active search for potential organ donors 1

ABSTRACT Objective: to develop a prototype of a computerized scale for the active search for potential organ and tissue donors. Method: methodological study, with the analysis of 377 electronic medical records of patients who died due to encephalic death or cardiorespiratory arrest in the intensive care units of a tertiary hospital. Among the deaths due to cardiorespiratory arrest, the study aimed to identify factors indicating underreported encephalic death cases. The Acute Physiology and Chronic Health Evaluation II and Sepsis Related Organ Failure Assessment severity indexes were applied in the protocols. Based on this, a scale was built and sent to five experts for assessment of the scale content, and subsequently, it was computerized by using a prototyping model. Results: 34 underreported encephalic death cases were identified in the medical records of patients with cardiorespiratory arrest. Statistically significant differences were found in the Wilcoxon test between the scores of hospital admissions in the intensive care unit and the opening of the encephalic death protocol for both severity indexes. Conclusion: the prototype was effective for identifying potential organ donors, as well as for the identification of the degree of organ dysfunction in patients with encephalic death.


Introduction
The organ donation and transplantation process consists of actions that make it possible to transform Potential Donors (PD), patients with Encephalic Death (ED) protocols, into effective organ and/or tissue donors, aiming at transplantation (1) . The clinical criteria for ED are set out in the Resolution 1480/1997 of the Federal Council of Medicine and, in order to identify patients who meet these criteria, a daily intensive search should be carried out in Intensive Care Units (ICUs) and emergency units (2)(3) .
Despite the need for active search and mandatory reporting of PD, underreporting of potential donors is among the main causes of non-effectiveness of the donation and transplantation of organs and tissues from a deceased donor. Added to this there is the inadequate structure of the hospitals for the diagnosis of ED and care/ maintenance provided to PD, as well as the refusal of the relatives to authorize the donation (4)(5) .
According to the Brazilian Transplant Registry (BTR), in 2016 there was a slight increase in the actual organs donor notification rates (6) . In 2015 (7) , there were  (6) . There are still 34,147 people waiting for organ transplants (7) .
In order to increase the number of transplants from a deceased donor, it is necessary not only to identify the PD, but also to perform it early because ED process culminates in pathophysiological changes resulting from the inactivation of pressure, hormonal and respiratory control centers, which can cause the circulatory collapse and make the donation and transplant process unfeasible (8) .
In this scenario, it is desirable to implement information systems that ensure an active search for the notification and maintenance of PD in the health services throughout the country, using computerized resources capable of identifying data in electronic medical records of critical patients who meet the established criteria for organ and tissue donation. The objective of this study was to develop a prototype of a computerized scale for the active search for potential organ and tissue donors.

Method
It is a methodological study. The study was carried out in a high complexity hospital, a reference in renal and cardiac transplants, located in the South of Brazil.
The study consisted of 377 electronic medical records of patients who died in 2014 in the Adult Intensive Care Units (A-ICU), aged between 18 and 80 years (age limit for solid organ donation). Data collection was carried out from September to October 2015.
The variables collected from all medical records were: age, sex, diagnosis and length of hospitalization.
The medical records of patients with Cardiopulmonary Arrest (CPA) were analyzed in terms of clinical evolution in order to identify encephalic death, brain death, coma with areflexia and/or description of clinical signs of encephalic death, in accordance with current legislation (2) for identification of underreported ED cases. Medical records that had at least three clinical signs of ED and for which there was no search for potential organ donors were considered as underreported ED cases.
The Sepsis Related Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) prognostic indexes were applied in the medical records of patients with ED.
These prognostic indexes or severity indexes evaluate the clinical and laboratory data of the patients, as well as indicate the degree of organic dysfunction, expressed as a numerical value (9) . The APACHE II calculation is obtained through the sum of three items: age, physiological variables (temperature, mean arterial pressure, heart rate, respiratory rate, oxygenation, arterial pH, sodium, potassium, creatinine, hematocrit and leukocytes) and chronic disease diagnosis (10) . The SOFA index is estimated by means of a scoring system, ranging from 1 to 4 points, based on the evaluation of six organic systems: respiratory, hepatic, cardiovascular, renal, central nervous system and coagulation (9) . SOFA and APACHE II scores were calculated on ICU admission, opening of ED protocol, proper ED diagnosis, and on the day of occurrence of CPA, if the latter has occurred before the conclusion of the protocol.
After identifying the feasibility of obtaining these data from patients' medical records, the first version

Results
In total, 377 electronic medical records of patients who died in the ICU of the institution under study were analyzed to identify the feasibility of obtaining data that enabled an active search for ED cases, as well as underreporting of PD who have had CPA and showed clinical signs of ED.
It was found that 346 (91.8%) deaths occurred due to CPA and 31 (8.2%) due to ED. In the characterization of the deaths due to CPA, it was evidenced that the majority were male (58.7%); aged equal to or greater than 65 years (49.5%), with a mean age of 60.

-APACHE II † -Fill the information below:
Glasgow Coma Scale: It should be noted that the suggestion to include the available data into EPR (marital status, mother's name, father's name and spouse's name) was not accepted, since such information does not correspond to the main purpose of the daily active search and leads to an increase in application time.
Regarding item 3, it was requested to include the RASS scale, so the health service could choose between

-APACHE II † -Fill the information below:
Mean arterial pressure: Arterial partial pressure of O2 (PaO 2 ):  to asleep and unresponsive patients (13) . The RASS scale, with scores ranging from +4 (combative) to -5 If sedation is discontinued and the patient maintains arreflexia and GCS with a value equal to 3, the opening of an ED protocol must be initiated (14) . however, it is a scale of difficult application, and for this reason, the health professional must be qualified to apply it (16) .
GCS is the most widely used scoring system at the international level for evaluating comatose patients under intensive care, with the aim of standardizing clinical observations in adults with neurological damage associated with alterations of consciousness. Its score ranges from 3 to 15, and score 3 is compatible with brain death, when associated to the evaluation of other parameters (14)(15)(16) .
The application of Ramsay or RASS scales for the internationally known Spanish model for Organ Donation and Transplantation, which was based on two basic principles: organization and continuos adaptation to the new knowledge produced in this area (19) .
Spain is one of the countries that have stood out for the use of quality instruments capable of defining the theoretical capacity of organ donation, according to the type of hospital, of detecting possible losses of donors during the donation process, and of analyzing the causes of these losses, identifying which hospital factors have an impact on the donation process. In Brazil, effective instruments to measure and evaluate the donation and transplantation process are needed (18) .
In this way, the scale for the active search for  (20) .
In the results of this study, it was observed that several patients presented CPA without determination of ED, which prevents the organ allocation process.
In addition, the values of the APACHE II and SOFA severity indexes showed a statistically significant difference between the scores at ICU admission and at the opening of the ED protocol, by means of the application of the Wilcoxon test. This difference not only represents the worsening of the condition, but also a physiological dysfunction that can cause CPA in the PD.
Severity and organ dysfunction scoring systems, such as APACHE II and SOFA, have been widely used and validated in various settings and populations (21) . The calculation of ED rate in a health institution is one of the main obstacles to the detection of PD worldwide. In Brazil, estimation of potential donors is calculated according to the population rate of a given area, to the different hospital indexes, and to the percentages of deaths in ICUs (18) .
The estimated incidence of ED is 60 cases per million inhabitants per year, which corresponds to 12% of the deaths occurred in intensive care units of large general hospitals (22) . Adding the number of underreported cases, 34, to the number of patients with ED, 33, 67 notifications are obtained, ie, a result that far exceeded the 12% estimate, reaching 14.4%.
This may be the specific estimate of potential donors at the study institution.
It is worth mentioning that, importing the data registered in the EPR may be a limiting factor for the effectiveness of the active search scale in terms of identification of PD due to the repetition of the information provided by EPR. This may be due to the possible existence of unreliable data for the clinical neurological examination or unreliable scores obtained in APACHE II and SOFA. In addition, the scale has not been submitted to the validation process, a future stage that will be developed for the continuation of this study.

Conclusion
The prototype was efficient to identify potential It is expected that this scale can be used in other institutions, with a view to improving the identification and maintenance of potential donors, with an impact on the reduction of losses due to underreporting cases and inadequate maintenance of potential donors, thus allowing a greater effectiveness in the supply of organs for transplantation.